1
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Sas DJ, Mara K, Mehta RA, Seide BM, Banks CJ, Danese DS, McGregor TL, Lieske JC, Milliner DS. Natural history of urine and plasma oxalate in children with primary hyperoxaluria type 1. Pediatr Nephrol 2024; 39:141-148. [PMID: 37458799 PMCID: PMC11044200 DOI: 10.1007/s00467-023-06074-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/13/2023] [Accepted: 06/22/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND Primary hyperoxaluria type 1 (PH1) is a rare, severe genetic disease causing increased hepatic oxalate production resulting in urinary stone disease, nephrocalcinosis, and often progressive chronic kidney disease. Little is known about the natural history of urine and plasma oxalate values over time in children with PH1. METHODS For this retrospective observational study, we analyzed data from genetically confirmed PH1 patients enrolled in the Rare Kidney Stone Consortium PH Registry between 2003 and 2018 who had at least 2 measurements before age 18 years of urine oxalate-to-creatinine ratio (Uox:cr), 24-h urine oxalate excretion normalized to body surface area (24-h Uox), or plasma oxalate concentration (Pox). We compared values among 3 groups: homozygous G170R, heterozygous G170R, and non-G170R AGXT variants both before and after initiating pyridoxine (B6). RESULTS Of 403 patients with PH1 in the registry, 83 met the inclusion criteria. Uox:cr decreased rapidly over the first 5 years of life. Both before and after B6 initiation, patients with non-G170R had the highest Uox:cr, 24-h Uox, and Pox. Patients with heterozygous G170R had similar Uox:cr to homozygous G170R prior to B6. Patients with homozygous G170R had the lowest 24-h Uox and Uox:cr after B6. Urinary oxalate excretion and Pox tend to decrease over time during childhood. eGFR over time was not different among groups. CONCLUSIONS Children with PH1 under 5 years old have relatively higher urinary oxalate excretion which may put them at greater risk for nephrocalcinosis and kidney failure than older PH1 patients. Those with homozygous G170R variants may have milder disease. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- David J Sas
- Division of Pediatric Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
| | - Kristin Mara
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Ramila A Mehta
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Barbara M Seide
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Carly J Banks
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | | | | | - John C Lieske
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Dawn S Milliner
- Division of Pediatric Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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2
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Martin-Higueras C, Borghese L, Torres A, Fraga-Bilbao F, Santana-Estupiñán R, Stefanidis CJ, Tory K, Walli A, Gondra L, Kempf C, Gessner M, Habbig S, Eifler L, Schmitt CP, Rüdel B, Bartram MP, Beck BB, Hoppe B. Multicenter Long-Term Real World Data on Treatment With Lumasiran in Patients With Primary Hyperoxaluria Type 1. Kidney Int Rep 2024; 9:114-133. [PMID: 38312792 PMCID: PMC10831356 DOI: 10.1016/j.ekir.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/28/2023] [Accepted: 10/02/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction The RNA interference (RNAi) medication lumasiran reduces hepatic oxalate production in primary hyperoxaluria type 1 (PH1). Data outside clinical trials are scarce. Methods We report on retrospectively and observationally obtained data in 33 patients with PH1 (20 with preserved kidney function, 13 on dialysis) treated with lumasiran for a median of 18 months. Results Among those with preserved kidney function, mean urine oxalate (Uox) decreased from 1.88 (baseline) to 0.73 mmol/1.73 m2 per 24h after 3 months, to 0.72 at 12 months, and to 0.65 at 18 months, but differed according to vitamin B6 (VB6) medication. The highest response was at month 4 (0.55, -70.8%). Plasma oxalate (Pox) remained stable over time. Glomerular filtration rate increased significantly by 10.5% at month 18. Nephrolithiasis continued active in 6 patients, nephrocalcinosis ameliorated or progressed in 1 patient each. At last follow-up, Uox remained above 1.5 upper limit of normal (>0.75 mmol/1.73 m2 per 24h) in 6 patients. Urinary glycolate (Uglyc) and plasma glycolate (Pglyc) significantly increased in all, urine citrate decreased, and alkali medication needed adaptation. Among those on dialysis, mean Pox and Pglyc significantly decreased and increased, respectively after monthly dosing (Pox: 78-37.2, Pglyc: 216.4-337.4 μmol/l). At quarterly dosing, neither Pox nor Pglyc were significantly different from baseline levels. An acid state was buffered by an increased dialysis regimen. Systemic oxalosis remained unchanged. Conclusion Lumasiran treatment is safe and efficient. Dosage (interval) adjustment necessities need clarification. In dialysis, lack of Pox reduction may relate to dissolving systemic oxalate deposits. Pglyc increment may be a considerable acid load requiring careful consideration, which definitively needs further investigation.
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Affiliation(s)
- Cristina Martin-Higueras
- German Hyperoxaluria Center, c/o Kindernierenzentrum Bonn, Germany
- Institute of Biomedical Technology, University of La Laguna, Tenerife, Spain
| | | | - Armando Torres
- Institute of Biomedical Technology, University of La Laguna, Tenerife, Spain
- Department of Nephrology, Hospital Universitario de Canarias, Tenerife, Spain
| | - Fátima Fraga-Bilbao
- Department of Pediatrics, Hospital Universitario de Canarias, Tenerife, Spain
| | - Raquel Santana-Estupiñán
- Department of Nephrology, Hospital Universitario de Gran Canaria Doctor Negrín, Gran Canaria, Spain
| | | | - Kálmán Tory
- Pediatric Center, MTA Center of Excellence, Semmelweis University; Budapest, Hungary & MTA-SE Lendulet Nephrogenetic Laboratory, Hungarian Academy of Sciences, Budapest, Hungary
| | - Adam Walli
- Wisplinghoff Laboratory, Cologne, Germany
| | - Leire Gondra
- Pediatric Nephrology Department, Cruces University Hospital, UPV/EHU, Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Caroline Kempf
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Disorders, Charité Universitätsmedizin Berlin, Germany
| | | | - Sandra Habbig
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, Cologne, Germany
| | - Lisa Eifler
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department of Pediatrics, Cologne, Germany
| | - Claus P. Schmitt
- Division of Pediatric Nephrology, University Hospital Heidelberg, Germany
| | | | - Malte P. Bartram
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Bodo B. Beck
- Institute of Human Genetics, University Hospital Cologne, Germany
| | - Bernd Hoppe
- German Hyperoxaluria Center, c/o Kindernierenzentrum Bonn, Germany
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3
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Lemoine S, Dahan P, Haymann JP, Meria P, Almeras C. 2022 Recommendations of the AFU Lithiasis Committee: Medical management - from diagnosis to treatment. Prog Urol 2023; 33:911-953. [PMID: 37918992 DOI: 10.1016/j.purol.2023.08.004] [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: 06/30/2023] [Revised: 07/27/2023] [Accepted: 08/01/2023] [Indexed: 11/04/2023]
Abstract
The morphological-compositional analysis of urinary stones allows distinguishing schematically several situations: dietary, digestive, metabolic/hormonal, infectious and genetic problems. Blood and urine testing are recommended in the first instance to identify risk factors of urinary stone disease in order to avoid recurrence or progression. The other objective is to detect a potential underlying pathology associated with high risk of urinary stone disease (e.g. primary hyperparathyroidism, primary or enteric hyperoxaluria, cystinuria, distal renal tubular acidosis) that may require specific management. Lifestyle-diet measures are the basis of the management of all stone types, but pharmacological treatments may be required. METHODOLOGY: These recommendations were developed using two methods: the Clinical Practice Recommendation (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU 2022] and their adaptability to the French context.
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Affiliation(s)
- S Lemoine
- Hospices Civils de Lyon, SFNDT, SP, Lyon, France
| | - P Dahan
- Nephrology Department, Clinique Saint-Exupéry, SFNDT, Toulouse, France
| | - J P Haymann
- Inserm, UMRS 1155 UPMC, Tenon Hospital, SP, Paris, France; Service d'Explorations Fonctionnelles Multidisciplinaires, Tenon Hospital, Paris, France
| | - P Meria
- Service d'Urologie, Hôpital Saint Louis, AP-HP-Centre Université Paris Cité, Paris, France
| | - C Almeras
- UroSud, clinique La Croix du Sud, Quint-Fonsegrives, France.
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4
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Mandrile G, Beck B, Acquaviva C, Rumsby G, Deesker L, Garrelfs S, Gupta A, Bacchetta J, Groothoff J. Genetic assessment in primary hyperoxaluria: why it matters. Pediatr Nephrol 2023; 38:625-634. [PMID: 35695965 PMCID: PMC9842587 DOI: 10.1007/s00467-022-05613-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/23/2022] [Accepted: 04/29/2022] [Indexed: 01/21/2023]
Abstract
Accurate diagnosis of primary hyperoxaluria (PH) has important therapeutic consequences. Since biochemical assessment can be unreliable, genetic testing is a crucial diagnostic tool for patients with PH to define the disease type. Patients with PH type 1 (PH1) have a worse prognosis than those with other PH types, despite the same extent of oxalate excretion. The relation between genotype and clinical phenotype in PH1 is extremely heterogeneous with respect to age of first symptoms and development of kidney failure. Some mutations are significantly linked to pyridoxine-sensitivity in PH1, such as homozygosity for p.G170R and p.F152I combined with a common polymorphism. Although patients with these mutations display on average better outcomes, they may also present with CKD stage 5 in infancy. In vitro studies suggest pyridoxine-sensitivity for some other mutations, but confirmatory clinical data are lacking (p.G47R, p.G161R, p.I56N/major allele) or scarce (p.I244T). These studies also suggest that other vitamin B6 derivatives than pyridoxine may be more effective and should be a focus for clinical testing. PH patients displaying the same mutation, even within one family, may have completely different clinical outcomes. This discordance may be caused by environmental or genetic factors that are unrelated to the effect of the causative mutation(s). No relation between genotype and clinical or biochemical phenotypes have been found so far in PH types 2 and 3. This manuscript reviews the current knowledge on the genetic background of the three types of primary hyperoxaluria and its impact on clinical management, including prenatal diagnosis.
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Affiliation(s)
- Giorgia Mandrile
- Medical Genetics Unit and Thalassemia Center, San Luigi University Hospital, University of Torino, Orbassano, TO, Italy
| | - Bodo Beck
- Institute of Human Genetics, Center for Molecular Medicine Cologne, and Center for Rare and Hereditary Kidney Disease, University Hospital of Cologne, CologneCologne, Germany
| | - Cecile Acquaviva
- Service de Biochimie Et Biologie Moléculaire, Hospices Civils de Lyon, UM Pathologies Héréditaires du Métabolisme Et du Globule Rouge, Lyon, France
| | - Gill Rumsby
- Department of Clinical Biochemistry, University College London Hospitals NHS Foundation Trust | UCLH, Kintbury, UK
| | - Lisa Deesker
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Sander Garrelfs
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands
| | - Asheeta Gupta
- Department of Nephrology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Justine Bacchetta
- Reference Center for Rare Renal Diseases, Pediatric Nephrology-Rheumatology-Dermatology Unit, Hospices Civils de Lyon, Femme Mere Enfant Hospital, Lyon 1 University, Bron, France
| | - Jaap Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands.
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5
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Abstract
Oxalate homeostasis is maintained through a delicate balance between endogenous sources, exogenous supply and excretion from the body. Novel studies have shed light on the essential roles of metabolic pathways, the microbiome, epithelial oxalate transporters, and adequate oxalate excretion to maintain oxalate homeostasis. In patients with primary or secondary hyperoxaluria, nephrolithiasis, acute or chronic oxalate nephropathy, or chronic kidney disease irrespective of aetiology, one or more of these elements are disrupted. The consequent impairment in oxalate homeostasis can trigger localized and systemic inflammation, progressive kidney disease and cardiovascular complications, including sudden cardiac death. Although kidney replacement therapy is the standard method for controlling elevated plasma oxalate concentrations in patients with kidney failure requiring dialysis, more research is needed to define effective elimination strategies at earlier stages of kidney disease. Beyond well-known interventions (such as dietary modifications), novel therapeutics (such as small interfering RNA gene silencers, recombinant oxalate-degrading enzymes and oxalate-degrading bacterial strains) hold promise to improve the outlook of patients with oxalate-related diseases. In addition, experimental evidence suggests that anti-inflammatory medications might represent another approach to mitigating or resolving oxalate-induced conditions.
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Affiliation(s)
- Theresa Ermer
- Department of Surgery, Division of Thoracic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Lama Nazzal
- Department of Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Maria Clarissa Tio
- Division of Nephrology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Sushrut Waikar
- Department of Medicine, Section of Nephrology, Boston University, Boston, MA, USA
| | - Peter S Aronson
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT, USA
| | - Felix Knauf
- Department of Internal Medicine, Section of Nephrology, Yale School of Medicine, New Haven, CT, USA.
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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6
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Grottelli S, Annunziato G, Pampalone G, Pieroni M, Dindo M, Ferlenghi F, Costantino G, Cellini B. Identification of Human Alanine-Glyoxylate Aminotransferase Ligands as Pharmacological Chaperones for Variants Associated with Primary Hyperoxaluria Type 1. J Med Chem 2022; 65:9718-9734. [PMID: 35830169 PMCID: PMC9340776 DOI: 10.1021/acs.jmedchem.2c00142] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
![]()
Primary hyperoxaluria type I (PH1) is a rare kidney disease
due
to the deficit of alanine:glyoxylate aminotransferase (AGT), a pyridoxal-5′-phosphate-dependent
enzyme responsible for liver glyoxylate detoxification, which in turn
prevents oxalate formation and precipitation as kidney stones. Many
PH1-associated missense mutations cause AGT misfolding. Therefore,
the use of pharmacological chaperones (PCs), small molecules that
promote correct folding, represents a useful therapeutic option. To
identify ligands acting as PCs for AGT, we first performed a small
screening of commercially available compounds. We tested each molecule
by a dual approach aimed at defining the inhibition potency on purified
proteins and the chaperone activity in cells expressing a misfolded
variant associated with PH1. We then performed a chemical optimization
campaign and tested the resulting synthetic molecules using the same
approach. Overall, the results allowed us to identify a promising
hit compound for AGT and draw conclusions about the requirements for
optimal PC activity.
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Affiliation(s)
- Silvia Grottelli
- Department of Medicine and Surgery, University of Perugia, P.le L. Severi 1, 06132 Perugia, Italy
| | - Giannamaria Annunziato
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Gioena Pampalone
- Department of Medicine and Surgery, University of Perugia, P.le L. Severi 1, 06132 Perugia, Italy
| | - Marco Pieroni
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Mirco Dindo
- Department of Medicine and Surgery, University of Perugia, P.le L. Severi 1, 06132 Perugia, Italy
| | - Francesca Ferlenghi
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Gabriele Costantino
- Department of Food and Drug, University of Parma, Parco Area delle Scienze 27/A, 43124 Parma, Italy
| | - Barbara Cellini
- Department of Medicine and Surgery, University of Perugia, P.le L. Severi 1, 06132 Perugia, Italy
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7
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Belostotsky R, Frishberg Y. Catabolism of Hydroxyproline in Vertebrates: Physiology, Evolution, Genetic Diseases and New siRNA Approach for Treatment. Int J Mol Sci 2022; 23:ijms23021005. [PMID: 35055190 PMCID: PMC8779045 DOI: 10.3390/ijms23021005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 11/16/2022] Open
Abstract
Hydroxyproline is one of the most prevalent amino acids in animal proteins. It is not a genetically encoded amino acid, but, rather, it is produced by the post-translational modification of proline in collagen, and a few other proteins, by prolyl hydroxylase enzymes. Although this post-translational modification occurs in a limited number of proteins, its biological significance cannot be overestimated. Considering that hydroxyproline cannot be re-incorporated into pro-collagen during translation, it should be catabolized following protein degradation. A cascade of reactions leads to production of two deleterious intermediates: glyoxylate and hydrogen peroxide, which need to be immediately converted. As a result, the enzymes involved in hydroxyproline catabolism are located in specific compartments: mitochondria and peroxisomes. The particular distribution of catabolic enzymes in these compartments, in different species, depends on their dietary habits. Disturbances in hydroxyproline catabolism, due to genetic aberrations, may lead to a severe disease (primary hyperoxaluria), which often impairs kidney function. The basis of this condition is accumulation of glyoxylate and its conversion to oxalate. Since calcium oxalate is insoluble, children with this rare inherited disorder suffer from progressive kidney damage. This condition has been nearly incurable until recently, as significant advances in substrate reduction therapy using small interference RNA led to a breakthrough in primary hyperoxaluria type 1 treatment.
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8
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Sas DJ, Magen D, Hayes W, Shasha-Lavsky H, Michael M, Schulte I, Sellier-Leclerc AL, Lu J, Seddighzadeh A, Habtemariam B, McGregor TL, Fujita KP, Frishberg Y. Phase 3 trial of lumasiran for primary hyperoxaluria type 1: A new RNAi therapeutic in infants and young children. Genet Med 2021; 24:654-662. [PMID: 34906487 DOI: 10.1016/j.gim.2021.10.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Primary hyperoxaluria type 1 (PH1) is a rare, progressive, genetic disease with limited treatment options. We report the efficacy and safety of lumasiran, an RNA interference therapeutic, in infants and young children with PH1. METHODS This single-arm, open-label, phase 3 study evaluated lumasiran in patients aged <6 years with PH1 and an estimated glomerular filtration rate >45 mL/min/1.73 m2, if aged ≥12 months, or normal serum creatinine, if aged <12 months. The primary end point was percent change in spot urinary oxalate to creatinine ratio (UOx:Cr) from baseline to month 6. Secondary end points included proportion of patients with urinary oxalate ≤1.5× upper limit of normal and change in plasma oxalate. RESULTS All patients (N = 18) completed the 6-month primary analysis period. Median age at consent was 50.1 months. Least-squares mean percent reduction in spot UOx:Cr was 72.0%. At month 6, 50% of patients (9/18) achieved spot UOx:Cr ≤1.5× upper limit of normal. Least-squares mean percent reduction in plasma oxalate was 31.7%. The most common treatment-related adverse events were transient, mild, injection-site reactions. CONCLUSION Lumasiran showed rapid, sustained reduction in spot UOx:Cr and plasma oxalate and acceptable safety in patients aged <6 years with PH1, establishing RNA interference therapies as safe, effective treatment options for infants and young children.
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Affiliation(s)
- David J Sas
- Division of Pediatric Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| | - Daniella Magen
- Pediatric Nephrology Institute, Rambam Health Care Campus, Haifa, Israel
| | - Wesley Hayes
- Department of Paediatric Nephrology, Great Ormond Street Hospital, London, United Kingdom
| | | | - Mini Michael
- Division of Pediatric Nephrology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, TX
| | - Indra Schulte
- Department of Pediatric Nephrology, University of Bonn, Bonn, Germany
| | - Anne-Laure Sellier-Leclerc
- Hôpital Femme Mère Enfant and Centre d'Investigation Clinique Inserm, Hospices Civils de Lyon, ERKnet, Bron, France
| | | | | | | | | | | | - Yaacov Frishberg
- Division of Pediatric Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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9
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Poyah P, Bergman J, Geldenhuys L, Wright G, Walsh NM, Hull P, Roche K, West ML. Primary Hyperoxaluria Type 1 (PH1) Presenting With End-Stage Kidney Disease and Cutaneous Manifestations in Adulthood: A Case Report. Can J Kidney Health Dis 2021; 8:20543581211058931. [PMID: 34840803 PMCID: PMC8613886 DOI: 10.1177/20543581211058931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/13/2021] [Indexed: 11/17/2022] Open
Abstract
Rationale: Primary hyperoxaluria (PH) is a rare autosomal recessive disorder more commonly diagnosed in children or adolescents. Owing to its rarity and heterogeneous phenotype, it is often underrecognized, resulting in delayed diagnosis, including diagnosis after end-stage kidney disease (ESKD) has occurred or recurrence after kidney-only transplantation. Case Presentation: A 40-year-old Caucasian Canadian woman with a history of recurrent nephrolithiasis since age 19 presented with ESKD and cutaneous symptoms. She had no known prior kidney disease and no family history of kidney disease or nephrolithiasis. Diagnosis: A diagnosis of primary hyperoxaluria type 1 (PH1) due to homozygous splice donor mutation (AGXT c.680+1G>A) was made with kidney and cutaneous pathology demonstrating calcium oxalate deposition and ultrasound suggestive of nephrocalcinosis. Interventions: She was initiated on frequent, high-efficiency, high-flux conventional hemodialysis and oral pyridoxine. Lumasiran was added 11 months later, after she developed bilateral swan-neck deformities. Outcomes: After 14 months of high-intensity dialysis and 3 months of lumasiran, there have been no signs of renal recovery, and extra-renal involvement has increased with progressive swan-neck deformities, reduced cardiac systolic function, and pulmonary hypertension. The patient has been waitlisted for kidney-liver transplantation. Teaching Points: This case report describes an adult presentation of PH1. The case highlights the importance of timely workup of metabolic causes of recurrent nephrolithiasis or nephrocalcinosis in adults which can be a presenting sign of PH and genetic testing for PH to facilitate early diagnosis and treatment especially in the era of novel therapeutics that may alter disease course and outcomes. The case also demonstrates the value of testing for PH in adults presenting with unexplained ESKD and a history of recurrent nephrolithiasis or nephrocalcinosis due to implications for organ transplantation strategy and presymptomatic family screening.
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Affiliation(s)
- Penelope Poyah
- Department of Medicine, Dalhousie University, Halifax, NS, Canada.,Division of Nephrology, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Joel Bergman
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Laurette Geldenhuys
- Department of Pathology, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Glenda Wright
- Department of Pathology, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Noreen M Walsh
- Department of Medicine, Dalhousie University, Halifax, NS, Canada.,Department of Pathology, Dalhousie University and Nova Scotia Health Authority, Halifax, NS, Canada
| | - Peter Hull
- Department of Medicine, Dalhousie University, Halifax, NS, Canada.,Division of Clinical Dermatology & Cutaneous Science, Nova Scotia Health Authority, Halifax, NS, Canada
| | - Kristina Roche
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Michael L West
- Department of Medicine, Dalhousie University, Halifax, NS, Canada.,Division of Nephrology, Nova Scotia Health Authority, Halifax, NS, Canada
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