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Petitgas C, Seugnet L, Dulac A, Matassi G, Mteyrek A, Fima R, Strehaiano M, Dagorret J, Chérif-Zahar B, Marie S, Ceballos-Picot I, Birman S. Metabolic and neurobehavioral disturbances induced by purine recycling deficiency in Drosophila. eLife 2024; 12:RP88510. [PMID: 38700995 PMCID: PMC11068357 DOI: 10.7554/elife.88510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024] Open
Abstract
Adenine phosphoribosyltransferase (APRT) and hypoxanthine-guanine phosphoribosyltransferase (HGPRT) are two structurally related enzymes involved in purine recycling in humans. Inherited mutations that suppress HGPRT activity are associated with Lesch-Nyhan disease (LND), a rare X-linked metabolic and neurological disorder in children, characterized by hyperuricemia, dystonia, and compulsive self-injury. To date, no treatment is available for these neurological defects and no animal model recapitulates all symptoms of LND patients. Here, we studied LND-related mechanisms in the fruit fly. By combining enzymatic assays and phylogenetic analysis, we confirm that no HGPRT activity is expressed in Drosophila melanogaster, making the APRT homolog (Aprt) the only purine-recycling enzyme in this organism. Whereas APRT deficiency does not trigger neurological defects in humans, we observed that Drosophila Aprt mutants show both metabolic and neurobehavioral disturbances, including increased uric acid levels, locomotor impairments, sleep alterations, seizure-like behavior, reduced lifespan, and reduction of adenosine signaling and content. Locomotor defects could be rescued by Aprt re-expression in neurons and reproduced by knocking down Aprt selectively in the protocerebral anterior medial (PAM) dopaminergic neurons, the mushroom bodies, or glia subsets. Ingestion of allopurinol rescued uric acid levels in Aprt-deficient mutants but not neurological defects, as is the case in LND patients, while feeding adenosine or N6-methyladenosine (m6A) during development fully rescued the epileptic behavior. Intriguingly, pan-neuronal expression of an LND-associated mutant form of human HGPRT (I42T), but not the wild-type enzyme, resulted in early locomotor defects and seizure in flies, similar to Aprt deficiency. Overall, our results suggest that Drosophila could be used in different ways to better understand LND and seek a cure for this dramatic disease.
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Affiliation(s)
- Céline Petitgas
- Genes Circuits Rhythms and Neuropathology, Brain Plasticity Unit, CNRS, ESPCI Paris, PSL Research UniversityParisFrance
- Metabolomic and Proteomic Biochemistry Laboratory, Necker-Enfants Malades Hospital and Paris Cité UniversityParisFrance
| | - Laurent Seugnet
- Integrated Physiology of the Brain Arousal Systems (WAKING), Lyon Neuroscience Research Centre, INSERM/CNRS/UCBL1BronFrance
| | - Amina Dulac
- Genes Circuits Rhythms and Neuropathology, Brain Plasticity Unit, CNRS, ESPCI Paris, PSL Research UniversityParisFrance
| | - Giorgio Matassi
- Dipartimento di Scienze Agroalimentari, Ambientali e Animali, University of UdineUdineItaly
- UMR “Ecology and Dynamics of Anthropogenic Systems” (EDYSAN), CNRS, Université de Picardie Jules VerneAmiensFrance
| | - Ali Mteyrek
- Genes Circuits Rhythms and Neuropathology, Brain Plasticity Unit, CNRS, ESPCI Paris, PSL Research UniversityParisFrance
| | - Rebecca Fima
- Genes Circuits Rhythms and Neuropathology, Brain Plasticity Unit, CNRS, ESPCI Paris, PSL Research UniversityParisFrance
| | - Marion Strehaiano
- Genes Circuits Rhythms and Neuropathology, Brain Plasticity Unit, CNRS, ESPCI Paris, PSL Research UniversityParisFrance
| | - Joana Dagorret
- Genes Circuits Rhythms and Neuropathology, Brain Plasticity Unit, CNRS, ESPCI Paris, PSL Research UniversityParisFrance
| | - Baya Chérif-Zahar
- Genes Circuits Rhythms and Neuropathology, Brain Plasticity Unit, CNRS, ESPCI Paris, PSL Research UniversityParisFrance
| | - Sandrine Marie
- Laboratory of Metabolic Diseases, Cliniques Universitaires Saint-Luc, Université catholique de LouvainBrusselsBelgium
| | - Irène Ceballos-Picot
- Metabolomic and Proteomic Biochemistry Laboratory, Necker-Enfants Malades Hospital and Paris Cité UniversityParisFrance
| | - Serge Birman
- Genes Circuits Rhythms and Neuropathology, Brain Plasticity Unit, CNRS, ESPCI Paris, PSL Research UniversityParisFrance
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2
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Leow EH, Chong SL, Tan ES, Koh AL, Cham BWM, Yap CJY, Ng YH. Adenine phosphoribosyl transferase (APRT) deficiency and a novel sequence variant in APRT with phenotypic diversity and a literature review. Nephrology (Carlton) 2023; 28:649-654. [PMID: 37619970 DOI: 10.1111/nep.14232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023]
Abstract
Adenine phosphoribosyl transferase (APRT) deficiency is an autosomal recessive disorder and a rare cause of urolithiasis due to mutations in APRT (OMIM #102600). APRT deficiency results in increased urinary excretion of 2,8-dihydroxyadenine (DHA) which can cause urolithiasis and kidney failure. However, with prompt diagnosis, patients with APRT deficiency can be treated with xanthine oxidoreductase inhibitors which decrease urinary DHA excretion and improve outcomes. We report a pair of siblings, an 11-year-old brother and his 14-year-old sister with compound heterozygous variants c.270del (p.Lys91Serfs*46) and c.484_486del (p.Leu162del) in APRT with variable clinical presentation of APRT deficiency. The brother presented at 17 months of age with urolithiasis and severe acute kidney injury. His elder sister remained well and asymptomatic with normal kidney function and did not develop renal calculi. Brownish disk or sphere-like crystals with both concentric and radial markings were reported on urine microscopy in the sister on screening. The sister's diagnosis was confirmed with further laboratory evidence of absent red cell lysate APRT activity with corresponding elevated levels of urinary DHA. In conclusion, we identified a novel mutation in the APRT gene in a pair of siblings with greater phenotypic severity in the male.
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Affiliation(s)
- Esther Huimin Leow
- Nephrology Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Siew Le Chong
- Nephrology Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Ee Shien Tan
- Genetics Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Ai Ling Koh
- Genetics Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Breana Wen Min Cham
- Genetics Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Celeste Jia Ying Yap
- Nephrology Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yong Hong Ng
- Nephrology Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
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Rashid I, Verma A, Tiwari P, D’Cruz S. A deficiência de adenina fosforibosiltransferase leva à disfunção do aloenxerto renal em receptores de transplante renal: uma revisão sistemática. J Bras Nefrol 2022. [DOI: 10.1590/2175-8239-jbn-2021-0283pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Resumo Antecedentes: A deficiência de adenina fosforibosiltransferase (APRT) tem grandes implicações na sobrevida do enxerto em pacientes transplantados renais. Esta revisão sistemática investigou o padrão diagnóstico, a abordagem de tratamento e os desfechos do transplante renal entre pacientes transplantados renais com deficiência de adenina fosforibosiltransferase. Material e métodos: Os artigos que relatam sobre a enzima APRT e a disfunção do aloenxerto renal foram recuperados do PubMed/Medline, ScienceDirect, Biblioteca Cochrane e bancos de dados do Google Acadêmico. Utilizou-se a análise descritiva para extrair inferências. Resultados: Foram incluídos participantes que receberam 39 enxertos, a maioria dos quais provenientes de doadores vivos seguidos por doadores falecidos e doadores cadáveres. Foi relatado tempo de sobrevida do enxerto superior a 6 meses em 23 (76,7%) pacientes, enquanto outros 7 (23,3%) pacientes tiveram tempo de sobrevida do enxerto inferior a 6 meses. Apenas 4 (13,3%) pacientes apresentaram deficiência de APRT antes do transplante. Após acompanhamento, um terço dos pacientes, 10 (33,3%) apresentaram função do enxerto estável, 1 paciente teve perda do aloenxerto, 8 (26,6%) pacientes apresentaram função retardada do enxerto, enquanto os 11 (36,6%) pacientes restantes tiveram disfunção crônica do enxerto renal. Conclusões: A deficiência de APRT é uma causa subestimada e reversível de nefropatia cristalina que leva à disfunção do aloenxerto renal ou à perda total do aloenxerto. Os resultados deste estudo pedem a inclusão desta condição no diagnóstico diferencial de nefropatia cristalina, mesmo na ausência de um histórico de nefrolitíase.
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Affiliation(s)
- Ishfaq Rashid
- National Institute of Pharmaceutical Education and Research, India
| | - Ashish Verma
- National Institute of Pharmaceutical Education and Research, India
| | - Pramil Tiwari
- National Institute of Pharmaceutical Education and Research, India
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Rashid I, Verma A, Tiwari P, D’Cruz S. Adenine phosphoribosyl transferase deficiency leads to renal allograft dysfunction in kidney transplant recipients: a systematic review. J Bras Nefrol 2022; 44:403-416. [PMID: 35635787 PMCID: PMC9518620 DOI: 10.1590/2175-8239-jbn-2021-0283en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/22/2022] [Indexed: 11/22/2022] Open
Abstract
Background: Adenine phosphoribosyl transferase (APRT) deficiency has great implications on graft survival in kidney transplant patients. This systematic review investigated the diagnostic pattern, treatment approach, and kidney transplant outcomes among kidney transplant patients with adenine phosphoribosyl transferase deficiency. Material and methods: Articles reporting the APRT enzyme deficiency and kidney allograft dysfunction were retrieved from PubMed/Medline, ScienceDirect, Cochrane library and Google scholar databases. Descriptive analysis was used to draw inferences. Results: The results from 20 selected studies covering 30 patients receiving 39 grafts had an average age of 46.37 years are presented. Graft survival time of more than 6 months was reported in 23 (76.7%) patients, while other 7 (23.3%) patients had graft survival time of less than 6 months. Only 4 (13.3%) patients had APRT deficiency before transplantation. After follow-up, one-third of the patients 10 (33.3%) had stable graft function, 1 patient had allograft loss, 8 (26.6%) patients had delayed graft function while the remaining 11 (36.6%) patients had chronic kidney graft dysfunction. Conclusions: APRT deficiency is an under-recognized, treatable condition that causes reversible crystalline nephropathy, leading to loss of allograft or allograft dysfunction. The study results showed that inclusion of genetic determination of APRT deficiency in the differential diagnosis of crystalline nephropathy, even in the absence of a history of nephrolithiasis, can improve renal outcomes and may improve allograft survival.
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Affiliation(s)
- Ishfaq Rashid
- National Institute of Pharmaceutical Education and Research, India
| | - Ashish Verma
- National Institute of Pharmaceutical Education and Research, India
| | - Pramil Tiwari
- National Institute of Pharmaceutical Education and Research, India
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Singh P, Harris PC, Sas DJ, Lieske JC. The genetics of kidney stone disease and nephrocalcinosis. Nat Rev Nephrol 2022; 18:224-240. [PMID: 34907378 DOI: 10.1038/s41581-021-00513-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 12/15/2022]
Abstract
Kidney stones (also known as urinary stones or nephrolithiasis) are highly prevalent, affecting approximately 10% of adults worldwide, and the incidence of stone disease is increasing. Kidney stone formation results from an imbalance of inhibitors and promoters of crystallization, and calcium-containing calculi account for over 80% of stones. In most patients, the underlying aetiology is thought to be multifactorial, with environmental, dietary, hormonal and genetic components. The advent of high-throughput sequencing techniques has enabled a monogenic cause of kidney stones to be identified in up to 30% of children and 10% of adults who form stones, with ~35 different genes implicated. In addition, genome-wide association studies have implicated a series of genes involved in renal tubular handling of lithogenic substrates and of inhibitors of crystallization in stone disease in the general population. Such findings will likely lead to the identification of additional treatment targets involving underlying enzymatic or protein defects, including but not limited to those that alter urinary biochemistry.
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Affiliation(s)
- Prince Singh
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Peter C Harris
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,Division of Molecular Biology and Biochemistry, Mayo Clinic, Rochester, MN, USA
| | - David J Sas
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.,Division of Pediatric Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA. .,Division of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
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PCSK9 promotes arterial medial calcification. Atherosclerosis 2022; 346:86-97. [DOI: 10.1016/j.atherosclerosis.2022.01.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 01/14/2022] [Accepted: 01/19/2022] [Indexed: 12/18/2022]
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Koyun M, Sancaktar M, Aksoy GK, Çomak E, Kaçar A, Adar M, Berdeli A, Akman S. A rare cause of urolithiasis in an infant: Answers. Pediatr Nephrol 2021; 36:2067-2068. [PMID: 33459934 DOI: 10.1007/s00467-020-04910-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/17/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Mustafa Koyun
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Nephrology, Akdeniz University, 07070, Antalya, Turkey.
| | - Muhammet Sancaktar
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Nephrology, Akdeniz University, 07070, Antalya, Turkey
| | - Gülşah Kaya Aksoy
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Nephrology, Akdeniz University, 07070, Antalya, Turkey
| | - Elif Çomak
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Nephrology, Akdeniz University, 07070, Antalya, Turkey
| | - Ayla Kaçar
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Nephrology, Akdeniz University, 07070, Antalya, Turkey
| | - Mehtap Adar
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Nephrology, Akdeniz University, 07070, Antalya, Turkey
| | - Afig Berdeli
- Faculty of Medicine, Department of Pediatrics, Molecular Medicine Laboratory, Ege University, Izmir, Turkey
| | - Sema Akman
- Faculty of Medicine, Department of Pediatrics, Division of Pediatric Nephrology, Akdeniz University, 07070, Antalya, Turkey
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Lau NKC, Ng SKW, Chan IHS, Ng KS, Kwok JSS. Urinary bladder stone due to adenine phosphoribosyltransferase deficiency: first genetically confirmed case in a Chinese patient. Pathology 2019; 51:557-561. [PMID: 31201003 DOI: 10.1016/j.pathol.2019.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 02/20/2019] [Accepted: 02/28/2019] [Indexed: 11/15/2022]
Affiliation(s)
| | - Selina Ka Wai Ng
- Department of Paediatrics and Adolescent Medicine, Kwong Wah Hospital, Hong Kong
| | | | - Kwan Shun Ng
- Department of Pathology, Kwong Wah Hospital, Hong Kong
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9
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Hyperuricemia in Children and Adolescents: Present Knowledge and Future Directions. J Nutr Metab 2019; 2019:3480718. [PMID: 31192008 PMCID: PMC6525889 DOI: 10.1155/2019/3480718] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/09/2019] [Indexed: 02/07/2023] Open
Abstract
Recent evidence suggests that hyperuricemia is an important condition in children and adolescents, particularly in association with noncommunicable diseases. This review aims to summarize our current understanding of this condition in pediatric patients. An analysis of serum uric acid reference values in a healthy population indicates that they increase gradually with age until adolescence, with differences between the sexes arising at about 12 years of age. This information should be taken into consideration when defining hyperuricemia in studies. Gout is extremely rare in children and adolescents, and most patients with gout have an underlying disease. The major causes of hyperuricemia are chronic conditions, including Down syndrome, metabolic or genetic disease, and congenital heart disease, and acute conditions, including gastroenteritis, bronchial asthma (hypoxia), malignant disorders, and drug side effects. The mechanisms underlying the associations between these diseases and hyperuricemia are discussed, together with recent genetic information. Obesity is a major cause of hyperuricemia in otherwise healthy children and adolescents. Obesity is often accompanied by metabolic syndrome; hyperuricemia in obese children and adolescents is associated with the components of metabolic syndrome and noncommunicable diseases, including hypertension, insulin resistance, dyslipidemia, and chronic kidney disease. Finally, strategies for the treatment of hyperuricemia, including lifestyle intervention and drug administration, are presented.
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Jiménez Herrero MC, Petkov Stoyanov V, Gutiérrez Sánchez MJ, Martín Navarro JA. Litiasis due to 2,8-dihydroxyadenine, usefulness of the genetic study. Nefrologia 2019; 39:206-207. [PMID: 30389108 DOI: 10.1016/j.nefro.2018.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 05/07/2018] [Accepted: 08/02/2018] [Indexed: 11/28/2022] Open
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Runolfsdottir HL, Palsson R, Agustsdottir IM, Indridason OS, Edvardsson VO. Long-term renal outcomes of APRT deficiency presenting in childhood. Pediatr Nephrol 2019; 34:435-442. [PMID: 30443743 PMCID: PMC6349544 DOI: 10.1007/s00467-018-4109-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/28/2018] [Accepted: 09/28/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Adenine phosphoribosyltransferase (APRT) deficiency is a hereditary purine metabolism disorder that causes kidney stones and chronic kidney disease (CKD). The purpose of this study was to examine the course of APRT deficiency in patients who presented in childhood. METHODS The disease course of 21 (35%) patients in the APRT Deficiency Registry of the Rare Kidney Stone Consortium, who presented with manifestations of APRT deficiency and/or were diagnosed with the disorder before the age of 18 years, was studied. The effect of pharmacotherapy on renal manifestations and outcomes was thoroughly assessed. RESULTS Fourteen children were placed on allopurinol, 100 (25-200) mg/day, at the age of 2.6 (0.6-16.5) years. Six of these patients had experienced kidney stone events and three had developed acute kidney injury (AKI) prior to allopurinol treatment. During 18.9 (1.7-31.5) years of pharmacotherapy, stones occurred in two patients and AKI in three. Six adult patients started allopurinol treatment, 200 (100-300) mg/day, at age 29.8 (20.5-42.4) years. Five of these patients had experienced 28 stone episodes and AKI had occurred in two. Stone recurrence occurred in four patients and AKI in two during 11.2 (4.2-19.6) years of allopurinol therapy. Lack of adherence and insufficient dosing contributed to stone recurrence and AKI during pharmacotherapy. At latest follow-up, estimated glomerular filtration rate (eGFR) was 114 (70-163) and 62 (10-103) mL/min/1.73 m2 in those who initiated treatment as children and adults, respectively. All three patients with CKD stages 3-5 at the last follow-up were adults when pharmacotherapy was initiated. CONCLUSION Timely diagnosis and treatment of APRT deficiency decreases renal complications and preserves kidney function.
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Affiliation(s)
| | - Runolfur Palsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland. .,Internal Medicine Services, Landspitali-The National University Hospital of Iceland, Hringbraut 101, Reykjavik, Iceland.
| | - Inger M Agustsdottir
- Children’s Medical Center, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland
| | - Olafur S Indridason
- Division of Nephrology, Internal Medicine Services, Landspitali–The National University Hospital of Iceland, Reykjavik, Iceland
| | - Vidar O Edvardsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland. .,Children's Medical Center, Landspitali-The National University Hospital of Iceland, Hringbraut 101, Reykjavik, Iceland.
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13
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Huq A, Nand K, Juneja R, Winship I. APRT deficiency: the need for early diagnosis. BMJ Case Rep 2018; 2018:bcr-2018-225742. [DOI: 10.1136/bcr-2018-225742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive disorder which leads to accumulation of poorly soluble 2,8-dihydroxyadenine in kidneys resulting in nephrolithiasis as well as chronic kidney disease from crystal nephropathy. This report describes a 55-year-old previously fit man who presented with shortness of breath and the investigative pathway that eventually led to a diagnosis of APRT deficiency. Early diagnosis has aided in timely institution of allopurinol, thereby improving his renal function and possibility of weaning off renal replacement therapy. Genetic testing has enabled early identification of other family members at risk and prevention of renal failure by commencing xanthine oxidoreductase (XOR) inhibitors. The issues surrounding kidney donation by a member of this family are also discussed. This case represents the importance of awareness and recognition of the signs and symptoms of this rare condition, complications of which can be easily prevented by early institution of XOR inhibitor therapy.
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Marra G, Taroni F, Berrettini A, Montanari E, Manzoni G, Montini G. Pediatric nephrolithiasis: a systematic approach from diagnosis to treatment. J Nephrol 2018; 32:199-210. [DOI: 10.1007/s40620-018-0487-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/21/2017] [Indexed: 01/26/2023]
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Edvardsson VO, Runolfsdottir HL, Thorsteinsdottir UA, Sch Agustsdottir IM, Oddsdottir GS, Eiriksson F, Goldfarb DS, Thorsteinsdottir M, Palsson R. Comparison of the effect of allopurinol and febuxostat on urinary 2,8-dihydroxyadenine excretion in patients with Adenine phosphoribosyltransferase deficiency (APRTd): A clinical trial. Eur J Intern Med 2018; 48:75-79. [PMID: 29241594 PMCID: PMC5817015 DOI: 10.1016/j.ejim.2017.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 09/30/2017] [Accepted: 10/09/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Adenine phosphoribosyltransferase (APRT) deficiency is a rare, but significant, cause of kidney stones and progressive chronic kidney disease. The optimal treatment has not been established. The purpose of this pilot study was to compare the effect of the xanthine oxidoreductase inhibitors allopurinol and febuxostat on urinary 2,8-dihydroxyadenine (DHA) excretion in APRT deficiency patients. MATERIALS AND METHODS Patients listed in the APRT Deficiency Registry of the Rare Kidney Stone Consortium, currently receiving allopurinol therapy, were invited to participate. The trial endpoint was the 24-h urinary DHA excretion following treatment with allopurinol (400mg/day) and febuxostat (80mg/day). Urinary DHA was measured using a novel ultra-performance liquid chromatography - electrospray tandem mass spectrometry assay. RESULTS Eight of the 10 patients invited completed the study. The median (range) 24-h urinary DHA excretion was 116 (75-289) mg at baseline, and 45 (13-112) mg after 14days of allopurinol therapy (P=0.036). At the end of the febuxostat treatment period, 4 patients had urinary DHA below detectable limits (<20ng/mL) compared with none of the participants following allopurinol treatment (P=0.036). The other 4 participants had a median 24-h urinary DHA excretion of 13.2 (10.0-13.4) mg at the completion of febuxostat therapy (P=0.036). CONCLUSION Urinary DHA excretion in APRT deficiency patients decreased with conventional doses of both allopurinol and febuxostat. Febuxostat was, however, significantly more efficacious than allopurinol in reducing DHA excretion in the prescribed doses. This finding, which may translate into improved outcomes of patients with APRT deficiency, should be confirmed in a larger sample.
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Affiliation(s)
- Vidar O Edvardsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland; Children's Medical Center, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.
| | | | - Unnur A Thorsteinsdottir
- Faculty of Pharmaceutical Sciences, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Inger M Sch Agustsdottir
- Children's Medical Center, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - G Steinunn Oddsdottir
- Department of Clinical Biochemistry, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Finnur Eiriksson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland; ArcticMass, Reykjavik, Iceland
| | - David S Goldfarb
- Nephrology Section, New York University Langone Medical Center, New York, NY, USA
| | - Margret Thorsteinsdottir
- Faculty of Pharmaceutical Sciences, School of Health Sciences, University of Iceland, Reykjavik, Iceland; ArcticMass, Reykjavik, Iceland
| | - Runolfur Palsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland; Division of Nephrology, Internal Medicine Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.
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Balasubramaniam GS, Arenas-Hernandez M, Escuredo E, Fairbanks L, Marinaki T, Mapplebeck S, Sheaff M, Almond MK. Adenine phosphoribosyltransferase deficiency in the United Kingdom: two novel mutations and a cross-sectional survey. Clin Kidney J 2016; 9:800-806. [PMID: 27994857 PMCID: PMC5162415 DOI: 10.1093/ckj/sfw093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 08/04/2016] [Indexed: 11/18/2022] Open
Abstract
Background Adenine phosphoribosyltransferase deficiency is an inborn error of metabolism that can cause kidney disease from crystalline nephropathy or kidney stones. Methods We present three cases from a single centre with varied presentations to illustrate how increasing awareness led to better patient identification. We then undertook a cross-sectional survey of all the patients identified from the Purine Research Laboratory in the UK since 1974. Results Our index case presented with recurrent nephrolithiasis and was diagnosed on stone analysis, the second case presented with acute kidney injury and the third case was identified from a biopsy undertaken for acute on chronic kidney injury. Genetic studies identified two novel mutations. Twenty patients were retrospectively identified. The mean age at diagnosis was 25 years (range 2–70); eight were <20 years, seven were 20–40 years and five were >40 years. Five of the 20 patients were deceased, 3 after end-stage renal disease (ESRD). Twelve have normal renal function, one had CKD stage 3, one had severe kidney disease and one was on dialysis. Conclusions Adenine phosphoribosyltransferase deficiency presents in a wide spectrum in all age groups. Patients can be completely asymptomatic and kidney disease may be incorrectly attributed to other conditions. Outcome is poor in late diagnosis and there is a high prevalence of ESRD. Patients with unexplained renal stone disease or deterioration in kidney function should be considered for screening. Identification and surveillance of patients in the UK can improve. There is now a rare disease registry with meetings organized that include patients, families and health care providers to improve awareness.
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Affiliation(s)
- Gowrie S Balasubramaniam
- Department of Renal Medicine, Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, Southend SO0 0RY, UK
| | | | - Emilia Escuredo
- Purine Research Laboratory, St Thomas' Hospital, Westminister Bridge Road, London, UK
| | - Lynette Fairbanks
- Purine Research Laboratory, St Thomas' Hospital, Westminister Bridge Road, London, UK
| | - Tony Marinaki
- Purine Research Laboratory, St Thomas' Hospital, Westminister Bridge Road, London, UK
| | - Sarah Mapplebeck
- Department of Biochemistry, Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, Southend, UK
| | - Michael Sheaff
- Department of Pathology, Barts and the London Hospital, Royal London Hospital, Whitechapel Road, Whitechapel, London, UK
| | - Michael K Almond
- Department of Renal Medicine, Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, Southend SO0 0RY, UK
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Thorsteinsdottir M, Thorsteinsdottir UA, Eiriksson FF, Runolfsdottir HL, Agustsdottir IMS, Oddsdottir S, Sigurdsson BB, Hardarson HK, Kamble NR, Sigurdsson ST, Edvardsson VO, Palsson R. Quantitative UPLC-MS/MS assay of urinary 2,8-dihydroxyadenine for diagnosis and management of adenine phosphoribosyltransferase deficiency. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1036-1037:170-177. [PMID: 27770717 PMCID: PMC5445224 DOI: 10.1016/j.jchromb.2016.09.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 09/09/2016] [Accepted: 09/13/2016] [Indexed: 10/21/2022]
Abstract
Adenine phosphoribosyltransferase (APRT) deficiency is a hereditary disorder that leads to excessive urinary excretion of 2,8-dihydroxyadenine (DHA), causing nephrolithiasis and chronic kidney disease. Treatment with allopurinol or febuxostat reduces DHA production and attenuates the renal manifestations. Assessment of DHA crystalluria by urine microscopy is used for therapeutic monitoring, but lacks sensitivity. We report a high-throughput assay based on ultra-performance liquid chromatography coupled to tandem mass spectrometry (UPLC-MS/MS) for quantification of urinary DHA. The UPLC-MS/MS assay was optimized by a chemometric approach for absolute quantification of DHA, utilizing isotopically labeled DHA as an internal standard. Experimental screening was conducted with D-optimal design and optimization of the DHA response was performed with central composite face design and related to the peak area of DHA using partial least square regression. Acceptable precision and accuracy of the DHA concentration were obtained over a calibration range of 100 to 5000ng/mL on three different days. The intra- and inter-day accuracy and precision coefficients of variation were well within ±15% for quality control samples analyzed in replicates of six at three concentration levels. Absolute quantification of DHA in urine samples from patients with APRT deficiency was achieved wihtin 6.5min. Measurement of DHA in 24h urine samples from three patients with APRT deficiency, diluted 1:15 (v/v) with 10mM ammonium hydroxide (NH4OH), yielded a concentration of 3021, 5860 and 10563ng/mL and 24h excretion of 816, 1327 and 1649mg, respectively. A rapid and robust UPLC-MS/MS assay for absolute quantification of DHA in urine was successfully developed. We believe this method will greatly facilitate diagnosis and management of patients with APRT deficiency.
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Affiliation(s)
| | | | - Finnur F Eiriksson
- University of Iceland, Reykjavik, Iceland; ArcticMass, Reykjavik, Iceland.
| | | | - Inger M Sch Agustsdottir
- Childreńs Medical Center, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.
| | - Steinunn Oddsdottir
- Department of Clinical Biochemistry, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.
| | - Baldur B Sigurdsson
- ArcticMass, Reykjavik, Iceland; Center for Biomedicine, European Academy of Bolzano/Bozen, Bolzano, Italy.
| | | | | | | | - Vidar O Edvardsson
- University of Iceland, Reykjavik, Iceland; Childreńs Medical Center, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.
| | - Runolfur Palsson
- University of Iceland, Reykjavik, Iceland; Division of Nephrology, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.
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Doré B, Meria P. A great contributor to the French urological science: Michel Daudon. CR CHIM 2016. [DOI: 10.1016/j.crci.2014.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Chong SL, Ng YH. Obstructive uropathy and severe acute kidney injury from renal calculi due to adenine phosphoribosyltransferase deficiency. World J Pediatr 2016; 12:243-5. [PMID: 26684317 DOI: 10.1007/s12519-015-0073-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 12/09/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Adenine phosphoribosyltransferase (APRT) deficiency is an uncommon genetic cause of chronic kidney disease due to crystalline nephropathy. METHODS A case of a Chinese boy with APRT deficiency presenting with severe acute kidney injury secondary to obstructive uropathy from multiple renal calculi was reviewed. RESULTS The patient underwent staged removal of the calculi. Infrared spectrometry of the renal calculi showed 2,8-dihydroxyadenine. APRT deficiency was confirmed with abolished APRT enzyme activity in red blood cells. He was started on allopurinol and low purine diet with complete resolution of the residual calculi. CONCLUSION APRT deficiency should be considered in patients with multiple radiolucent renal calculi.
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Affiliation(s)
- Siew Le Chong
- Department of Pediatrics (Nephrology Service), KK Women's and Children's Hospital, Singapore, Singapore
| | - Yong Hong Ng
- Department of Pediatrics (Nephrology Service), KK Women's and Children's Hospital, Singapore, Singapore.
- , 100 Bukit Timah Road, Singapore, 229899, Singapore.
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An unusual cause of pink diapers in an infant: Questions and Answers. Pediatr Nephrol 2016; 31:575, 577-80. [PMID: 25823987 PMCID: PMC4591217 DOI: 10.1007/s00467-015-3072-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 02/11/2015] [Accepted: 02/12/2015] [Indexed: 10/23/2022]
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Runolfsdottir HL, Palsson R, Agustsdottir IM, Indridason OS, Edvardsson VO. Kidney Disease in Adenine Phosphoribosyltransferase Deficiency. Am J Kidney Dis 2015; 67:431-8. [PMID: 26724837 DOI: 10.1053/j.ajkd.2015.10.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 10/15/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND Adenine phosphoribosyltransferase (APRT) deficiency is a purine metabolism disorder causing kidney stones and chronic kidney disease (CKD). The course of nephrolithiasis and CKD has not been well characterized. The objective of this study was to examine long-term kidney outcomes in patients with APRT deficiency. STUDY DESIGN An observational cohort study. SETTING & PARTICIPANTS All patients enrolled in the APRT Deficiency Registry of the Rare Kidney Stone Consortium. OUTCOMES Kidney stones, acute kidney injury (AKI), stage of CKD, end-stage renal disease, estimated glomerular filtration rate (eGFR), and changes in eGFR. MEASUREMENTS Serum creatinine and eGFR calculated using creatinine-based equations. RESULTS Of 53 patients, 30 (57%) were females and median age at diagnosis was 37.0 (range, 0.6-67.9) years. Median duration of follow-up was 10.3 (range, 0.0-31.5) years. At diagnosis, kidney stones had developed in 29 (55%) patients and 20 (38%) had CKD stages 3 to 5, including 11 (21%) patients with stage 5. At latest follow-up, 33 (62%) patients had experienced kidney stones; 18 (34%), AKI; and 22 (42%), CKD stages 3 to 5. Of 14 (26%) patients with stage 5 CKD, 12 had initiated renal replacement therapy. Kidney stones recurred in 18 of 33 (55%) patients. The median eGFR slope was -0.38 (range, -21.99 to 1.42) mL/min/1.73m(2) per year in patients receiving treatment with an xanthine dehydrogenase inhibitor and -5.74 (range, -75.8 to -0.10) mL/min/1.73m(2) per year in those not treated prior to the development of stage 5 CKD (P=0.001). LIMITATIONS Use of observational registry data. CONCLUSIONS Progressive CKD and AKI episodes are major features of APRT deficiency, whereas nephrolithiasis is the most common presentation. Advanced CKD without a history of kidney stones is more prevalent than previously reported. Our data suggest that timely therapy may retard CKD progression.
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Affiliation(s)
| | - Runolfur Palsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland; Division of Nephrology, Internal Medicine Services, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Inger M Agustsdottir
- Children's Medical Center, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Olafur S Indridason
- Division of Nephrology, Internal Medicine Services, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland
| | - Vidar O Edvardsson
- Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland; Children's Medical Center, Landspitali-The National University Hospital of Iceland, Reykjavik, Iceland.
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Bollée G, Cochat P, Daudon M. Recurrence of crystalline nephropathy after kidney transplantation in APRT deficiency and primary hyperoxaluria. Can J Kidney Health Dis 2015; 2:31. [PMID: 26380104 PMCID: PMC4570695 DOI: 10.1186/s40697-015-0069-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 07/24/2015] [Indexed: 01/25/2023] Open
Abstract
Purpose of review To provide transplant physicians with a summary of the pathogenesis and diagnosis of adenine phosphoribosyl transferase (APRT) deficiency and primary hyperoxaluria and, focussed on kidney transplantation, and to discuss interventions aimed at preventing and treating the recurrence of crystalline nephropathy in renal transplant recipients. Source of information Pubmed literature search. Setting Primary hyperoxaluria and APRT deficiency are rare inborn errors of human metabolism. The hallmark of these diseases is the overproduction and urinary excretion of compounds (2,8 dihydroxyadenine in APRT deficiency, oxalate in primary hyperoxaluria) that form urinary crystals. Although recurrent urolithiasis represents the main clinical feature of these diseases, kidney injury can occur as a result of crystal precipitation within the tubules and interstitium, a condition referred to as crystalline nephropathy. Some patients develop end-stage renal disease (ESRD) and may become candidates for kidney transplantation. Since kidney transplantation does not correct the underlying metabolic defect, transplant recipients have a high risk of recurrence of crystalline nephropathy, which can lead to graft loss. In some instances, the disease remains undiagnosed until after the occurrence of ESRD or even after kidney transplantation. Key messages Patients with APRT deficiency or primary hyperoxaluria may develop ESRD as a result of crystalline nephropathy. In the absence of diagnosis and adequate management, the disease is likely to recur after kidney transplantation, which often leads to rapid loss of renal allograft function. Primary hyperoxaluria, but not APRT deficiency, becomes a systemic disease at low GFR with oxalate deposition leading to malfunction in non-renal organs (systemic oxalosis). We suggest that these diagnoses should be considered in patients with low glomerular filtration rate (GFR) and a history of kidney stones. In APRT deficiency, stones may be confused with uric acid stones, unless specialized techniques are used (infrared spectroscopy or X-ray crystallography for urinary crystals or stone analysis; Fourier transform infrared microscopy for crystals in kidney biopsy). Where these are unavailable, and for confirmation, the diagnosis can be made by measurement of enzyme activity in red blood cell lysates or by genetic testing. In patients with primary hyperoxaluria, levels of urinary and plasma oxalate; and the presence of nearly pure calcium oxalate monohydrate in stones, which often also have an unusually pale colour and unorganized structure, increase diagnostic suspicion. Molecular genetic testing is the criterion measure. Lifelong allopurinol therapy, with high fluid intake if appropriate, may stabilize kidney function in APRT deficiency; if ESRD has occurred or is near, results with kidney transplantation after initiation of allopurinol are excellent. In primary hyperoxaluria recognized before ESRD, pyridoxine treatment and high fluid intake may lead to a substantial decrease in urinary calcium oxalate supersaturation and prevent renal failure. In non-responsive patients or those recognized later in their disease, liver transplantation cures the underlying defect and should be considered when the GFR falls below 30 ml/min/1.73 m2; in those which or near ESRD, liver transplantation and intensive dialysis before kidney transplantation may be considered to reduce the total body oxalate burden before kidney transplantation. Limitations The availability of diagnostic tests varies between countries and centres. Data on long term outcomes after kidney transplantation are limited, especially for APRT deficiency patients. Implications Increasing transplant physicians knowledge of APRT deficiency and primary hyperoxaluria should enable them to implement adequate diagnostic and therapeutic interventions, thereby achieving good outcomes after kidney transplantation.
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Affiliation(s)
- Guillaume Bollée
- Division of Nephrology and Research Centre of the Centre Hospitalier de l'Université de Montréal and Université de Montréal, Montréal, Québec Canada ; Division of Nephrology, Hôpital Notre Dame, 1560 Sherbrooke Street East, Montreal, QC H2L 4 M1 Canada
| | - Pierre Cochat
- Centre de Référence des Maladies Rénales Rares, Hospices Civils de Lyon and Université Claude-Bernard Lyon 1, Lyon, France
| | - Michel Daudon
- Service d'Explorations Fonctionnelles, AP-HP, Hôpital Tenon, Paris, France
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Brilland B, Augusto JF, Croue A, Subra JF, Sayegh J. A rare case of primary non-function of renal allograft due to adenine phosphoribosyltransferase deficiency. Int Urol Nephrol 2015; 47:1589-91. [PMID: 26253830 DOI: 10.1007/s11255-015-1077-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 07/30/2015] [Indexed: 11/28/2022]
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Abstract
Primary disease recurrence after renal transplantation is mainly diagnosed by examination of biopsy samples, but can also be associated with clinical symptoms. In some patients, recurrence can lead to graft loss (7-8% of all graft losses). Primary disease recurrence is generally associated with a high risk of graft loss in patients with focal segmental glomerulosclerosis, membranous proliferative glomerulonephritis, primary hyperoxaluria or atypical haemolytic uraemic syndrome. By contrast, disease recurrence is associated with a limited risk of graft loss in patients with IgA nephropathy, renal involvement associated with Henoch-Schönlein purpura, antineutrophil cytoplasmic antibody-associated glomerulonephritis or lupus nephritis. The presence of systemic diseases that affect the kidneys, such as sickle cell anaemia and diabetes mellitus, also increases the risk of delayed graft loss. This Review provides an overview of the epidemiology, pathophysiology and management of primary disease recurrence in paediatric renal graft recipients, and describes the overall effect on graft survival of each of the primary diseases listed above. With appropriate management, few paediatric patients should be excluded from renal transplantation programmes because of an increased risk of recurrence.
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Ceballos-Picot I, Daudon M, Harambat J, Bensman A, Knebelmann B, Bollée G. 2,8-Dihydroxyadenine urolithiasis: a not so rare inborn error of purine metabolism. NUCLEOSIDES NUCLEOTIDES & NUCLEIC ACIDS 2015; 33:241-52. [PMID: 24940675 DOI: 10.1080/15257770.2013.853780] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Adenine phosphoribosyltransferase (APRT) deficiency is a rare inherited metabolic disorder that leads to the formation and hyperexcretion of 2,8-dihydroxyadenine (DHA) into urine. The low solubility of DHA results in precipitation and formation of urinary crystals and kidney stones. The disease can be present as recurrent urolithiasis or nephropathy secondary to crystal precipitation into renal parenchyma (DHA nephropathy). The diagnostic tools available, including stone analysis, crystalluria, and APRT activity in red blood cells, make the diagnosis easy to confirm when APRT deficiency is suspected. However, the lack of recognition of this metabolic disorder frequently resulted in a delay in diagnosis and treatment with grave consequences. The early recognition and treatment of APRT deficiency are of crucial importance to prevent irreversible loss of renal function. This review summarizes the genetic and metabolic mechanisms underlying DHA stones formation and chronic kidney disease, along with the issues of diagnosis and management of APRT deficiency. Moreover, we report the mutations in the APRT gene responsible for APRT deficiency in 51 French patients (43 families) including 22 pediatric cases (18 families) among the 64 patients identified in the biochemistry laboratories of Necker Hospital, Paris (1978-2013).
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Affiliation(s)
- Irène Ceballos-Picot
- a Université Paris Descartes, Assistance Publique Hôpitaux de Paris, Laboratoire de Biochimie Métabolomique et protéomique, Hôpital Necker-Enfants Malades , Paris , France
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Bollée G, Daudon M, Ceballos-Picot I. Adenine phosphoribosyltransferase deficiency: Leave no stone unturned. World J Clin Urol 2014; 3:218-226. [DOI: 10.5410/wjcu.v3.i3.218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Revised: 06/04/2014] [Accepted: 07/29/2014] [Indexed: 02/06/2023] Open
Abstract
Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive disease leading to generation of large amounts of 2,8-dihydroxyadenine (DHA). DHA is excreted in urine, where it precipitates into crystals due to its low solubility. DHA crystals can aggregate into stones or cause injury to the renal parenchyma (DHA nephropathy). Recurrent urolithiasis and DHA nephropathy are the two clinical manifestations of APRT deficiency. Diagnosis of APRT deficiency can be made during childhood as well as adulthood. Diagnosis mainly relies on the recognition of DHA in stones or urine crystals. Measurement of APRT activity and genetic testing are useful for confirmation of diagnosis, for family screening and should be considered in difficult cases of urolithiasis or crystalline nephropathy. Allopurinol therapy is the cornerstone of treatment and is highly effective in preventing recurrence of stones and kidney disease. High fluid intake and dietary modifications are also recommended. Early diagnosis and treatment are of paramount importance to prevent renal damage. Unfortunately, diagnosis of APRT deficiency is often overlooked and irreversible renal failure still occurs in a substantial proportion of patients. Clinicians must be alert to the possibility of APRT deficiency and consider the appropriate diagnostic tests in certain cases. This review discusses the genetic and biochemical mechanisms of APRT deficiency, and the issues of diagnosis and management.
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Zaidan M, Palsson R, Gall ECL, Garstka A, Maggiore U, Deteix P, Battista M, Gagné ER, Ceballos-Picot I, Van Huyen JPD, Legendre C, Daudon M, Edvardsson VO, Knebelmann B, Knebelmann B. Recurrent 2,8-dihydroxyadenine nephropathy: a rare but preventable cause of renal allograft failure. Am J Transplant 2014; 14:2623-32. [PMID: 25307253 PMCID: PMC4560835 DOI: 10.1111/ajt.12926] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/16/2014] [Accepted: 07/01/2014] [Indexed: 01/25/2023]
Abstract
Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive enzyme defect of purine metabolism that usually manifests as 2,8-dihydroxyadenine (2,8-DHA) nephrolithiasis and more rarely chronic kidney disease. The disease is most often misdiagnosed and can recur in the renal allograft. We analyzed nine patients with recurrent 2,8-DHA crystalline nephropathy, in all of whom the diagnosis had been missed prior to renal transplantation. The diagnosis was established at a median of 5 (range 1.5-312) weeks following the transplant procedure. Patients had delayed graft function (n=2), acute-on-chronic (n=5) or acute (n=1) allograft dysfunction, whereas one patient had normal graft function at the time of diagnosis. Analysis of allograft biopsies showed birefringent 2,8-DHA crystals in renal tubular lumens, within tubular epithelial cells and interstitium. Fourier transformed infrared microscopy confirmed the diagnosis in all cases, which was further supported by 2,8-DHA crystalluria, undetectable erythrocyte APRT enzyme activity, and genetic testing. With allopurinol therapy, the allograft function improved (n=7), remained stable (n=1) or worsened (n=1). At last follow-up, two patients had experienced allograft loss and five had persistent chronic allograft dysfunction. 2,8-DHA nephropathy is a rare but underdiagnosed and preventable disorder that can recur in the renal allograft and may lead to allograft loss.
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Affiliation(s)
- Mohamad Zaidan
- Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France,Paris Descartes University, Sorbonne Paris Cité, Paris, France,INSERM U1151, Institut Necker Enfants Malades, Département « Biologie cellulaire », Paris, France
| | - Runolfur Palsson
- Division of Nephrology, Internal Medicine Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland,Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | | | - Antoine Garstka
- Department of Nephrology, Huriez Hospital, CHRU de Lille, Lille, France
| | - Umberto Maggiore
- Department of Nephrology, Parma University Hospital, Parma, Italy
| | - Patrice Deteix
- Department of Nephrology, Gabriel-Montpied Hospital, CHU de Clermont-Ferrand, France
| | - Michele Battista
- Departments of Clinical and Experimental Medicine, Nephrology and Transplantation and International Research Centre Autoimmune Diseases (IRCAD) of the Amedeo Avogadro University, Maggiore Hospital, Novara, Italy
| | - Eve-Reine Gagné
- Division of Nephrology, CHUS, FMSS, Sherbrooke University, Québec, Canada
| | - Irène Ceballos-Picot
- Paris Descartes University, Sorbonne Paris Cité, Paris, France,Department of Metabolic Biochemistry, Necker Hospital, APHP, Paris, France
| | - Jean-Paul Duong Van Huyen
- Paris Descartes University, Sorbonne Paris Cité, Paris, France,Department of Pathology, Necker Hospital, APHP, Paris, France
| | - Christophe Legendre
- Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France,Paris Descartes University, Sorbonne Paris Cité, Paris, France,INSERM U1151, Institut Necker Enfants Malades, Département « Biologie cellulaire », Paris, France
| | - Michel Daudon
- Department of Clinical Physiology, Tenon Hospital, APHP, Paris, France
| | - Vidar O. Edvardsson
- Division of Nephrology, Internal Medicine Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland,Division of Pediatric Nephrology, Children's Medical Center, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Bertrand Knebelmann
- Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris, France,Paris Descartes University, Sorbonne Paris Cité, Paris, France,INSERM U1151, Institut Necker Enfants Malades, Département « Biologie cellulaire », Paris, France
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Giraudon A, Richard E, Godron A, Bouty A, Dobremez E, Barat P, Blouin JM, Llanas B, Harambat J. [Clinical and biochemical characterization of childhood urolithiasis]. Arch Pediatr 2014; 21:1322-9. [PMID: 25287140 DOI: 10.1016/j.arcped.2014.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 06/29/2014] [Accepted: 08/27/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Urolithiasis is rare in children, but the incidence has increased over the past few decades. This study aims at describing the clinical and biochemical characteristics, etiology, and treatment of urolithiasis in children. METHODS This was a retrospective study of all children under 16 years of age seen at the Bordeaux University Children's Hospital with a diagnosis of urolithiasis. The diagnosis was confirmed either radiologically or clinically by the expulsion of the stone. RESULTS A total of 186 children with a diagnosis of urolithiasis between 1994 and 2012 were included. The median age at diagnosis was 7.4 years. The male-to-female ratio was 1.9. The estimated annual incidence was around 5.5/100,000 children under 15 years of age in the past 5 years. The main presenting feature was nonspecific abdominal pain (71%). Metabolic calculi accounted for 48% of the patients with idiopathic hypercalciuria as the main cause. Genetic diseases accounted for 15% of cases. The proportion of infectious calculi was estimated at 33% and decreased in the past two decades. Stone fragments were sent for analysis in 86 children, and calcium oxalate was the major component (37%), followed by calcium phosphate (33%), purine (9%), and struvite (8%). At least 26% of patients experienced recurrence of stone passage. CONCLUSION This retrospective study highlighted changes in characteristics of pediatric urolithiasis over time. Childhood-onset urolithiasis requires complete etiological work-up so that a metabolic cause with a high risk of recurrence does not go unrecognized.
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Affiliation(s)
- A Giraudon
- Unité de néphrologie-endocrinologie, service de pédiatrie, hôpital Pellegrin-Enfants, CHU de Bordeaux, 33076 Bordeaux, France; Service de pédiatrie, centre hospitalier de Pau, 64000 Pau, France
| | - E Richard
- Laboratoire de biochimie, hôpital Pellegrin, CHU de Bordeaux, 33076 Bordeaux, France; Biothérapies des maladies génétiques et cancers, U1035, université de Bordeaux, 33000 Bordeaux, France
| | - A Godron
- Unité de néphrologie-endocrinologie, service de pédiatrie, hôpital Pellegrin-Enfants, CHU de Bordeaux, 33076 Bordeaux, France
| | - A Bouty
- Service de chirurgie pédiatrique, hôpital Pellegrin-Enfants, CHU de Bordeaux, 33076 Bordeaux, France
| | - E Dobremez
- Service de chirurgie pédiatrique, hôpital Pellegrin-Enfants, CHU de Bordeaux, 33076 Bordeaux, France
| | - P Barat
- Unité de néphrologie-endocrinologie, service de pédiatrie, hôpital Pellegrin-Enfants, CHU de Bordeaux, 33076 Bordeaux, France
| | - J-M Blouin
- Laboratoire de biochimie, hôpital Pellegrin, CHU de Bordeaux, 33076 Bordeaux, France; Biothérapies des maladies génétiques et cancers, U1035, université de Bordeaux, 33000 Bordeaux, France
| | - B Llanas
- Unité de néphrologie-endocrinologie, service de pédiatrie, hôpital Pellegrin-Enfants, CHU de Bordeaux, 33076 Bordeaux, France
| | - J Harambat
- Unité de néphrologie-endocrinologie, service de pédiatrie, hôpital Pellegrin-Enfants, CHU de Bordeaux, 33076 Bordeaux, France.
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Balasubramaniam S, Duley JA, Christodoulou J. Inborn errors of purine metabolism: clinical update and therapies. J Inherit Metab Dis 2014; 37:669-86. [PMID: 24972650 DOI: 10.1007/s10545-014-9731-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 05/27/2014] [Accepted: 06/02/2014] [Indexed: 12/20/2022]
Abstract
Inborn errors of purine metabolism exhibit broad neurological, immunological, haematological and renal manifestations. Limited awareness of the phenotypic spectrum, the recent descriptions of newer disorders and considerable genetic heterogeneity, have contributed to long diagnostic odysseys for affected individuals. These enzymes are widely but not ubiquitously distributed in human tissues and are crucial for synthesis of essential nucleotides, such as ATP, which form the basis of DNA and RNA, oxidative phosphorylation, signal transduction and a range of molecular synthetic processes. Depletion of nucleotides or accumulation of toxic intermediates contributes to the pathogenesis of these disorders. Maintenance of cellular nucleotides depends on the three aspects of metabolism of purines (and related pyrimidines): de novo synthesis, catabolism and recycling of these metabolites. At present, treatments for the clinically significant defects of the purine pathway are restricted: purine 5'-nucleotidase deficiency with uridine; familial juvenile hyperuricaemic nephropathy (FJHN), adenine phosphoribosyl transferase (APRT) deficiency, hypoxanthine phosphoribosyl transferase (HPRT) deficiency and phosphoribosyl-pyrophosphate synthetase superactivity (PRPS) with allopurinol; adenosine deaminase (ADA) and purine nucleoside phosphorylase (PNP) deficiencies have been treated by bone marrow transplantation (BMT), and ADA deficiency with enzyme replacement with polyethylene glycol (PEG)-ADA, or erythrocyte-encapsulated ADA; myeloadenylate deaminase (MADA) and adenylosuccinate lyase (ADSL) deficiencies have had trials of oral ribose; PRPS, HPRT and adenosine kinase (ADK) deficiencies with S-adenosylmethionine; and molybdenum cofactor deficiency of complementation group A (MOCODA) with cyclic pyranopterin monophosphate (cPMP). In this review we describe the known inborn errors of purine metabolism, their phenotypic presentations, established diagnostic methodology and recognised treatment options.
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Affiliation(s)
- Shanti Balasubramaniam
- Metabolic Unit, Princess Margaret Hospital, Roberts Road, Subiaco, Perth, WA, 6008, Australia
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Kaartinen K, Hemmilä U, Salmela K, Räisänen-Sokolowski A, Kouri T, Mäkelä S. Adenine phosphoribosyltransferase deficiency as a rare cause of renal allograft dysfunction. J Am Soc Nephrol 2014; 25:671-4. [PMID: 24459232 DOI: 10.1681/asn.2013090960] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Adenine phosphoribosyltransferase deficiency is a rare autosomal recessive disorder manifesting as urolithiasis or crystalline nephropathy. It leads to the generation of large amounts of poorly soluble 2,8-dihydroxyadenine excreted in urine, yielding kidney injury and in some patients, kidney failure. Early recognition of the disease, institution of xanthine analog therapy to block the formation of 2,8-dihydroxyadenine, high fluid intake, and low purine diet prevent CKD. Because of symptom variability and lack of awareness, however, the diagnosis is sometimes extremely deferred. We describe a patient with adenine phosphoribosyltransferase deficiency who was diagnosed during evaluation of a poorly functioning second kidney allograft. This report highlights the risk of renal allograft loss in patients with undiagnosed adenine phosphoribosyltransferase deficiency and the need for improved early detection of this disease.
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Edvardsson VO, Goldfarb DS, Lieske JC, Beara-Lasic L, Anglani F, Milliner DS, Palsson R. Hereditary causes of kidney stones and chronic kidney disease. Pediatr Nephrol 2013; 28:1923-42. [PMID: 23334384 PMCID: PMC4138059 DOI: 10.1007/s00467-012-2329-z] [Citation(s) in RCA: 157] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 09/13/2012] [Accepted: 09/17/2012] [Indexed: 01/27/2023]
Abstract
Adenine phosphoribosyltransferase (APRT) deficiency, cystinuria, Dent disease, familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC), and primary hyperoxaluria (PH) are rare but important causes of severe kidney stone disease and/or chronic kidney disease in children. Recurrent kidney stone disease and nephrocalcinosis, particularly in pre-pubertal children, should alert the physician to the possibility of an inborn error of metabolism as the underlying cause. Unfortunately, the lack of recognition and knowledge of the five disorders has frequently resulted in an unacceptable delay in diagnosis and treatment, sometimes with grave consequences. A high index of suspicion coupled with early diagnosis may reduce or even prevent the serious long-term complications of these diseases. In this paper, we review the epidemiology, clinical features, diagnosis, treatment, and outcome of patients with APRT deficiency, cystinuria, Dent disease, FHHNC, and PH, with an emphasis on childhood manifestations.
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MESH Headings
- Adenine Phosphoribosyltransferase/deficiency
- Adenine Phosphoribosyltransferase/genetics
- Animals
- Child
- Cystinuria/diagnosis
- Cystinuria/epidemiology
- Cystinuria/genetics
- Cystinuria/therapy
- Dent Disease/diagnosis
- Dent Disease/epidemiology
- Dent Disease/genetics
- Dent Disease/therapy
- Genetic Predisposition to Disease
- Heredity
- Humans
- Hypercalciuria/diagnosis
- Hypercalciuria/epidemiology
- Hypercalciuria/genetics
- Hypercalciuria/therapy
- Hyperoxaluria, Primary/diagnosis
- Hyperoxaluria, Primary/epidemiology
- Hyperoxaluria, Primary/genetics
- Hyperoxaluria, Primary/therapy
- Kidney Calculi/diagnosis
- Kidney Calculi/epidemiology
- Kidney Calculi/genetics
- Kidney Calculi/therapy
- Metabolism, Inborn Errors/diagnosis
- Metabolism, Inborn Errors/epidemiology
- Metabolism, Inborn Errors/genetics
- Metabolism, Inborn Errors/therapy
- Nephrocalcinosis/diagnosis
- Nephrocalcinosis/epidemiology
- Nephrocalcinosis/genetics
- Nephrocalcinosis/therapy
- Phenotype
- Prognosis
- Renal Insufficiency, Chronic/diagnosis
- Renal Insufficiency, Chronic/epidemiology
- Renal Insufficiency, Chronic/genetics
- Renal Insufficiency, Chronic/therapy
- Renal Tubular Transport, Inborn Errors/diagnosis
- Renal Tubular Transport, Inborn Errors/epidemiology
- Renal Tubular Transport, Inborn Errors/genetics
- Renal Tubular Transport, Inborn Errors/therapy
- Risk Factors
- Urolithiasis/diagnosis
- Urolithiasis/epidemiology
- Urolithiasis/genetics
- Urolithiasis/therapy
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Bollée G, Harambat J, Bensman A, Knebelmann B, Daudon M, Ceballos-Picot I. Adenine phosphoribosyltransferase deficiency. Clin J Am Soc Nephrol 2012; 7:1521-7. [PMID: 22700886 DOI: 10.2215/cjn.02320312] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Complete adenine phosphoribosyltransferase (APRT) deficiency is a rare inherited metabolic disorder that leads to the formation and hyperexcretion of 2,8-dihydroxyadenine (DHA) into urine. The low solubility of DHA results in precipitation of this compound and the formation of urinary crystals and stones. The disease can present as recurrent urolithiasis or nephropathy secondary to crystal precipitation into renal parenchyma (DHA nephropathy). The diagnostic tools available-including stone analysis, crystalluria, and APRT activity measurement-make the diagnosis easy to confirm when APRT deficiency is suspected. However, the disease can present at any age, and the variability of symptoms can present a diagnostic challenge to many physicians. The early recognition and treatment of APRT deficiency are of crucial importance for preventing irreversible loss of renal function, which still occurs in a non-negligible proportion of cases. This review summarizes the genetic and metabolic mechanisms underlying stone formation and renal disease, along with the diagnosis and management of APRT deficiency.
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Affiliation(s)
- Guillaume Bollée
- Association pour l'Utilisation du Rein Artificiel and Inserm U970, Paris, France.
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