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Evans W, Richardson-May J, Arora R. Multimodal Imaging in Unusual Alport Retinopathy. Cureus 2024; 16:e52768. [PMID: 38389645 PMCID: PMC10882256 DOI: 10.7759/cureus.52768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Alport syndrome, a rare genetic condition, can manifest various ocular abnormalities. This case report presents a unique instance of Alport syndrome where bilateral reduced visual acuity led to cataract surgery and subsequent central serous chorioretinopathy due to steroid treatment. By utilizing multiple imaging modalities, we aim to illustrate classical and atypical findings, addressing a literature gap and sharing our experience for educational purposes.
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Affiliation(s)
- William Evans
- Ophthalmology, Salisbury District Hospital, Salisbury, GBR
| | | | - Rashi Arora
- Ophthalmology, Salisbury District Hospital, Salisbury, GBR
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Greenstein VC, Castillejos DS, Tsang SH, Lee W, Sparrow JR, Allikmets R, Birch DG, Hood DC. Monitoring Lesion Area Progression in Stargardt Disease: A Comparison of En Face Optical Coherence Tomography and Fundus Autofluorescence. Transl Vis Sci Technol 2023; 12:2. [PMID: 37126335 PMCID: PMC10153573 DOI: 10.1167/tvst.12.5.2] [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] [Received: 12/12/2022] [Accepted: 03/23/2023] [Indexed: 05/02/2023] Open
Abstract
Purpose To compare longitudinal changes in en face spectral domain-optical coherence tomography (SD-OCT) measurements of ellipsoid zone (EZ) and retinal pigment epithelium (RPE) loss to changes in the hypoautofluorescent and hyperautofluorescent (AF) areas detected with short-wavelength (SW)-AF in ABCA4-associated retinopathy. Methods SD-OCT volume scans were obtained from 20 patients (20 eyes) over 2.6 ± 1.2 years (range 1-5 years). The EZ, and RPE/Bruch's membrane boundaries were segmented, and en face slab images generated. SubRPE and EZ slab images were used to measure areas of atrophic RPE and EZ loss. These were compared to longitudinal measurements of the hypo- and abnormal AF (hypoAF and surrounding hyperAF) areas. Results At baseline, the en face area of EZ loss was significantly larger than the subRPE atrophic area, and the abnormal AF area was significantly larger than the hypoAF area. The median rate of EZ loss was significantly greater than the rate of increase in the subRPE atrophic area (1.2 mm2/yr compared to 0.5 mm2/yr). The median rate of increase in the abnormal AF area was significantly greater than the increase in the hypoAF area (1.6 mm2/yr compared to 0.6 mm2/yr). Conclusions En face SD-OCT can be used to quantify changes in RPE atrophy and photoreceptor integrity. It can be a complementary or alternative technique to SW-AF with the advantage of monitoring EZ loss. The SW-AF results emphasize the importance of measuring changes in the hypo- and abnormal AF areas. Translational Relevance The findings are relevant to the selection of outcome measures for monitoring ABCA4-associated retinopathy.
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Affiliation(s)
- Vivienne C. Greenstein
- Department of Ophthalmology, Harkness Eye Institute, Columbia University, New York, NY, USA
| | - David S. Castillejos
- Department of Ophthalmology, Harkness Eye Institute, Columbia University, New York, NY, USA
| | - Stephen H. Tsang
- Department of Ophthalmology, Harkness Eye Institute, Columbia University, New York, NY, USA
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Winston Lee
- Department of Ophthalmology, Harkness Eye Institute, Columbia University, New York, NY, USA
- Department of Genetics and Development, Columbia University Medical Center, New York, NY, USA
| | - Janet R. Sparrow
- Department of Ophthalmology, Harkness Eye Institute, Columbia University, New York, NY, USA
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Rando Allikmets
- Department of Ophthalmology, Harkness Eye Institute, Columbia University, New York, NY, USA
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, USA
| | | | - Donald C. Hood
- Department of Ophthalmology, Harkness Eye Institute, Columbia University, New York, NY, USA
- Department of Psychology, Columbia University, New York, NY, USA
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Jauregui R, Nuzbrokh Y, Su PY, Zernant J, Allikmets R, Tsang SH, Sparrow JR. Retinal Pigment Epithelium Atrophy in Recessive Stargardt Disease as Measured by Short-Wavelength and Near-Infrared Autofluorescence. Transl Vis Sci Technol 2021; 10:3. [PMID: 33505770 PMCID: PMC7794276 DOI: 10.1167/tvst.10.1.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 11/10/2020] [Indexed: 12/16/2022] Open
Abstract
Purpose To compare the detection of retinal pigment epithelium (RPE) atrophy in short-wavelength (SW-AF) and near-infrared autofluorescence (NIR-AF) images in Stargardt disease (STGD1) patients. Methods SW-AF and NIR-AF images (115 eyes from 115 patients) were analyzed by two independent graders. Hypoautofluorescent (hypoAF) areas, indicative of RPE atrophy, were measured, and the two modalities were compared. Results Patients were segregated into four groups: nascent (6 [5%]), widespread (21 [18%]), discrete (55 [48%]), and chorioretinal atrophy (33 [29%]). The areas of hypoAF were larger in NIR-AF compared to SW-AF images in discrete (3.9 vs. 2.2 mm2, P < 0.001) and chorioretinal atrophy (12.7 vs. 11.4 mm2, P = 0.015). Similar findings were observed qualitatively in nascent and widespread atrophy patients. Using the area linear model (ALM), lesion area increased at similar rates in SW-AF and NIR-AF images of discrete atrophy (0.20 vs. 0.32 mm2/y, P = 0.275) and chorioretinal atrophy (1.30 vs. 1.74 mm2/y, P = 0.671). Using the radius linear model (RLM), the lesion effective radius also increased similarly in SW-AF and NIR-AF images in discrete (0.03 vs. 0.05 mm2/y, P = 0.221) and chorioretinal atrophy (0.08 vs. 0.10 mm2/y, P = 0.754) patients. Conclusions NIR-AF reveals a larger area of RPE atrophy in STGD1 patients compared to SW-AF images, but rates of lesion enlargement in the two modalities are similar. Translational Relevance Measurements of RPE atrophy by AF imaging are crucial for monitoring STGD1 disease progression and given our findings we advocate greater use of NIR-AF for patients.
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Affiliation(s)
- Ruben Jauregui
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA.,Jonas Children's Vision Care, New York, NY, USA
| | - Yan Nuzbrokh
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA.,Jonas Children's Vision Care, New York, NY, USA
| | - Pei-Yin Su
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
| | - Jana Zernant
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
| | - Rando Allikmets
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA.,Department of Pathology & Cell Biology, Columbia University Medical Center, New York, NY, USA
| | - Stephen H Tsang
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
| | - Janet R Sparrow
- Department of Ophthalmology, Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, NY, USA
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Gupta V, Jamil M, Luthra S, Puthalath AS. Alport syndrome with bilateral simultaneous anterior and posterior lenticonus with severe temporal macular thinning. BMJ Case Rep 2019; 12:e229554. [PMID: 31420426 PMCID: PMC6700549 DOI: 10.1136/bcr-2019-229554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2019] [Indexed: 11/04/2022] Open
Abstract
Alport syndrome (AS) is a hereditary disease with various modes of inheritance, X-linked being the the most common. Anterior lenticonus is the characteristic abnormality along with perimacular and peripheral fleck retinopathy. Our two cases of AS had simultaneous anterior and posterior lenticonus with severe temporal macular thinning on optical coherence tomography with no specific renal symptomatology and were diagnosed as AS without any invasive renal biopsy. First patient was a 19-year-old man who presented with compound myopia due to bilateral anterior and posterior lenticonus with perimacular fleck retinopathy and lozenge sign and bilateral moderate sensorineural hearing loss (SNHL). Second patient was a 24-year-old man who presented with difficulty in vision due to bilateral anterior and posterior lenticonus with bilateral severe SNHL. Our cases emphasise the crucial role of an ophthalmologist in diagnosing AS before the onset of renal symptoms and prompting further nephrological work-up in the patient or the carrier.
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Affiliation(s)
- Vinita Gupta
- Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mahsa Jamil
- Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Saurabh Luthra
- Ophthalmology, Drishti Eye Institute, Dehradun, Uttarakhand, India
| | - Athul S Puthalath
- Ophthalmology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Nam KY, Kim BJ, Kim JH, Kang TS, Cho HK, Chung IY, Park JM, Han YS. Fundus Albipunctatus Diagnosed in a 9-year-old Female. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2019. [DOI: 10.3341/jkos.2019.60.10.999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Ki Yup Nam
- Department of Ophthalmology, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Bum Jun Kim
- Department of Ophthalmology, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Ji Hye Kim
- Department of Ophthalmology, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Tae Seen Kang
- Department of Ophthalmology, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Hyun Kyung Cho
- Department of Ophthalmology, Gyeongsang National University Changwon Hospital, Changwon, Korea
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Jinju, Korea
| | - In Young Chung
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Jinju, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
| | - Jong Moon Park
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Jinju, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
| | - Yong Seop Han
- Department of Ophthalmology, Gyeongsang National University Changwon Hospital, Changwon, Korea
- Department of Ophthalmology, Gyeongsang National University College of Medicine, Jinju, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
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Greenstein VC, Nunez J, Lee W, Schuerch K, Fortune B, Tsang SH, Allikmets R, Sparrow JR, Hood DC. A Comparison of En Face Optical Coherence Tomography and Fundus Autofluorescence in Stargardt Disease. Invest Ophthalmol Vis Sci 2017; 58:5227-5236. [PMID: 29049723 PMCID: PMC5642378 DOI: 10.1167/iovs.17-22532] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Purpose To compare morphologic changes on en face images derived from wide-field swept-source optical coherence tomography (ssOCT) to hypo- and hyperautofluorescent (hypoAF, hyperAF) areas on short-wavelength autofluorescence (SW-AF), and near-infrared (NIR)-AF in recessive Stargardt disease (STGD1). Methods Wide-field ssOCT cube scans were obtained from 16 patients (16 eyes). Averaged B-scans and SW-AF images were obtained using Spectralis HRA+OCT. NIR-AF images were obtained from 6 eyes. The inner/outer segment (IS/OS), OS/RPE, and RPE/Bruch's membrane boundaries were segmented, and en face slab images generated. A subRPE slab image was used to measure the abnormal RPE area, and an IS/OS slab image, the IS/OS junction loss area. These were compared to hypo- and abnormal SW-AF areas, and hypoNIR-AF areas. A preRPE(OS) slab image was used to evaluate the spatial and intraretinal locations of flecks. Results For all eyes, RPE atrophy was visualized as a central hyperreflective area on the subRPE slab, and IS/OS junction loss as an abnormal reflective area on the IS/OS slab; the latter was significantly larger (P = 0.04). There was good agreement between the hyperreflective area on the subRPE slab image and hypoSW-AF area, and between the abnormal reflective area on the IS/OS slab and hypo-hyperSW-AF area; the hypoNIR-AF area indicated that the hyperreflective area on the subRPE slab underestimated RPE atrophy. The spatial locations of hyperreflective flecks on the en face preRPE(OS) slab image corresponded to those on the SW-AF images. Conclusions Wide-field en face OCT imaging has the potential to be a clinically useful tool for the management of STGD1.
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Affiliation(s)
| | - Jason Nunez
- Department of Psychology, Columbia University, New York, New York, United States
| | - Winston Lee
- Department of Ophthalmology, Columbia University, New York, New York, United States
| | - Kaspar Schuerch
- Department of Ophthalmology, Columbia University, New York, New York, United States
| | - Brad Fortune
- Devers Eye Institute, Portland, Oregon, United States
| | - Stephen H Tsang
- Department of Ophthalmology, Columbia University, New York, New York, United States.,Department of Pathology & Cell Biology, Columbia University, New York, New York, United States
| | - Rando Allikmets
- Department of Ophthalmology, Columbia University, New York, New York, United States.,Department of Pathology & Cell Biology, Columbia University, New York, New York, United States
| | - Janet R Sparrow
- Department of Ophthalmology, Columbia University, New York, New York, United States.,Department of Pathology & Cell Biology, Columbia University, New York, New York, United States
| | - Donald C Hood
- Department of Ophthalmology, Columbia University, New York, New York, United States.,Department of Psychology, Columbia University, New York, New York, United States
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Neriyanuri S, Rao C, Raman R. STRUCTURAL AND FUNCTIONAL CHARACTERIZATION OF BENIGN FLECK RETINA USING MULTIMODAL IMAGING. Retin Cases Brief Rep 2017; 11:186-190. [PMID: 28301857 DOI: 10.1097/icb.0000000000000324] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE To report structural and functional features in a case series of benign fleck retina using multimodal imaging. METHODS Four cases with benign fleck retina underwent complete ophthalmic examination that included detailed history, visual acuity, and refractive error testing, FM-100 hue test, dilated fundus evaluation, full field electroretinogram, fundus photography with autofluorescence, fundus fluorescein angiography, and swept-source optical coherence tomography. RESULTS Age group of the cases ranged from 19 years to 35 years (3 males and 1 female). Parental consanguinity was reported in two cases. All of them were visually asymptomatic with best-corrected visual acuity of 20/20 (moderate astigmatism) in both the eyes. Low color discrimination was seen in two cases. Fundus photography showed pisciform flecks which were compactly placed on posterior pole and were discrete, diverging towards periphery. Lesions were seen as smaller dots within 1500 microns from fovea and were hyperfluorescent on autofluorescence. Palisading retinal pigment epithelium defects were seen in posterior pole on fundus fluorescein angiography imaging; irregular hyper fluorescence was also noted. One case had reduced cone responses on full field electroretinogram; the other three cases had normal electroretinogram. On optical coherence tomography, level of lesions varied from retinal pigment epithelium, inner segment to outer segment extending till external limiting membrane. CONCLUSION Functional and structural deficits in benign fleck retina were picked up using multimodal imaging.
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Affiliation(s)
- Srividya Neriyanuri
- *Elite School of Optometry, Chennai, India;†Birla Institute of Science and Technology, Pilani, India; and‡Shri Bhagwan Mahaveer Vitreoretinal services, Sankara Nethralaya, Chennai, India
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Sodi A, Mucciolo DP, Cipollini F, Murro V, Caporossi O, Virgili G, Rizzo S. En face OCT in Stargardt disease. Graefes Arch Clin Exp Ophthalmol 2016; 254:1669-79. [PMID: 26743751 DOI: 10.1007/s00417-015-3254-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 12/15/2015] [Accepted: 12/21/2015] [Indexed: 11/25/2022] Open
Abstract
PURPOSE To evaluate the structural features of the macular region by enface OCT imaging in patients with clinical diagnosis of Stargardt disease, confirmed by the detection of ABCA4 mutations. METHODS Thirty-two STGD patients were included in the study for a total of 64 eyes. All patients received a comprehensive ophthalmological examination, color fundus photography, fundus auto-fluorescence imaging and OCT. Five OCT scans were considered: ILM and RPE scans (both automatically obtained from the instrument), above-RPE slab, photoreceptor slab and sub-RPE slab (these last three manually obtained). RESULTS ILM scans showed evident radial folds on the retinal surface in 8/64 eyes (12.5 %). In 6 of the 7 patients, these vitreo-retinal interface abnormalities were unilateral. The photoreceptor slab showed some macular alterations ranging from dis-homogeneous, hypo-reflective abnormalities (7/64 eyes, 11 %) to a homogeneous, well-defined, roundish, hypo-reflective area (17/64 eyes, 27 %) in all the eyes. The sub-RPE slab showed a centrally evident, hyper-reflective abnormality in 58/64 eyes (90.6 %). Superimposing the sub-RPE slab over the images corresponding to the photoreceptor slab, the area of the photoreceptor atrophy sharply exceeded that of the RPE atrophy (44/46 eyes, 96 %). CONCLUSION Enface OCT proved to be a clinically useful tool for the management of STGD patients, illustrating in vivo the structural abnormalities of the different retinal layers.
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Affiliation(s)
- Andrea Sodi
- Careggi Teaching Hospital , Eye Clinic, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Dario Pasquale Mucciolo
- Careggi Teaching Hospital , Eye Clinic, University of Florence, Largo Brambilla 3, 50134, Florence, Italy.
| | - Francesca Cipollini
- Careggi Teaching Hospital , Eye Clinic, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Vittoria Murro
- Careggi Teaching Hospital , Eye Clinic, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Orsola Caporossi
- Careggi Teaching Hospital , Eye Clinic, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Gianni Virgili
- Careggi Teaching Hospital , Eye Clinic, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
| | - Stanislao Rizzo
- Careggi Teaching Hospital , Eye Clinic, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
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Skorczyk-Werner A, Pawłowski P, Michalczuk M, Warowicka A, Wawrocka A, Wicher K, Bakunowicz-Łazarczyk A, Krawczyński MR. Fundus albipunctatus: review of the literature and report of a novel RDH5 gene mutation affecting the invariant tyrosine (p.Tyr175Phe). J Appl Genet 2015; 56:317-27. [PMID: 25820994 PMCID: PMC4543405 DOI: 10.1007/s13353-015-0281-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 02/26/2015] [Accepted: 03/05/2015] [Indexed: 12/17/2022]
Abstract
Fundus albipunctatus (FA) is a rare, congenital form of night blindness with rod system impairment, characterised by the presence of numerous small, white-yellow retinal lesions. FA belongs to a heterogenous group of so-called flecked retina syndromes. This disorder shows autosomal recessive inheritance and is caused mostly by mutations in the RDH5 gene. This gene encodes the enzyme that is a part of the visual cycle, the 11-cis retinol dehydrogenase. This study is a brief review of the literature on FA and a report of the first molecular evidence for RDH5 gene mutation in a Polish patient with this rare disorder. We present a novel pathogenic RDH5 gene mutation in a 16-year-old female patient with symptoms of night blindness. The patient underwent ophthalmological examinations, including colour vision testing, fundus photography, automated visual field testing, full-field electroretinography (ERG) and spectral optical coherent tomography (SOCT). The patient showed typical FA ERG records, the visual field was constricted and fundus examination revealed numerous characteristic, small, white-yellowish retinal lesions. DNA sequencing of the RDH5 gene coding sequence (exons 2–5) enabled the detection of the homozygous missense substitution c.524A > T (p.Tyr175Phe) in exon 3. This is the first report of RDH5 gene mutation that affects the invariant tyrosine, one of the most conserved amino acid residues in short-chain alcohol dehydrogenases/reductases (SDRs), crucial for these enzymes’ activity. The location of this substitution, together with its predicted influence on the protein function, indicate that the p.Tyr175Phe mutation is the cause of FA in our patient.
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Affiliation(s)
- Anna Skorczyk-Werner
- Department of Medical Genetics, Poznan University of Medical Sciences, 8, Rokietnicka Street, 60-806, Poznań, Poland,
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Kruegel J, Rubel D, Gross O. Alport syndrome--insights from basic and clinical research. Nat Rev Nephrol 2012; 9:170-8. [PMID: 23165304 DOI: 10.1038/nrneph.2012.259] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In 1927, Arthur C. Alport first published his description of a triad of symptoms in a family with hereditary congenital haemorrhagic nephritis, deafness and ocular changes. A few years after his death, this group of symptoms was renamed Alport syndrome. To this day, Alport syndrome still inevitably leads to end-stage renal disease and the need for renal replacement therapy, starting in young adulthood. During the past two decades, research into this rare disease has focused on the effects of mutations in collagen type IV and the role of changes in podocytes and the glomerular basement membrane that lead to early kidney fibrosis. Animal models of Alport syndrome also demonstrate the pathogenetic importance of interactions between podocytes and the extracellular matrix. Such models might also help researchers to answer basic questions about podocyte function and the development of fibrosis, and to develop new therapeutic approaches that might be of use in other kidney diseases. In this Review, we discuss the latest basic and clinical research on Alport syndrome, focusing on the roles of podocyte pathology and the extracellular matrix. We also highlight early diagnosis and treatment options for young patients with this disorder.
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Affiliation(s)
- Jenny Kruegel
- Department of Nephrology and Rheumatology, University Medicine Göttingen, Robert-Koch-Straße 40, 37075 Göttingen, Germany
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