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Monich AG, Bissler JJ, Barreto FC. Tuberous Sclerosis Complex and the kidneys: what nephrologists need to know. J Bras Nefrol 2024; 46:e20240013. [PMID: 38991206 PMCID: PMC11239183 DOI: 10.1590/2175-8239-jbn-2024-0013en] [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: 01/18/2024] [Accepted: 04/24/2024] [Indexed: 07/13/2024] Open
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disease characterized by the development of hamartomas in the central nervous system, heart, skin, lungs, and kidneys and other manifestations including seizures, cortical tubers, radial migration lines, autism and cognitive disability. The disease is associated with pathogenic variants in the TSC1 or TSC2 genes, resulting in the hyperactivation of the mTOR pathway, a key regulator of cell growth and metabolism. Consequently, the hyperactivation of the mTOR pathway leads to abnormal tissue proliferation and the development of solid tumors. Kidney involvement in TSC is characterized by the development of cystic lesions, renal cell carcinoma and renal angiomyolipomas, which may progress and cause pain, bleeding, and loss of kidney function. Over the past years, there has been a notable shift in the therapeutic approach to TSC, particularly in addressing renal manifestations. mTOR inhibitors have emerged as the primary therapeutic option, whereas surgical interventions like nephrectomy and embolization being reserved primarily for complications unresponsive to clinical treatment, such as severe renal hemorrhage. This review focuses on the main clinical characteristics of TSC, the mechanisms underlying kidney involvement, the recent advances in therapy for kidney lesions, and the future perspectives.
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Affiliation(s)
- Aline Grosskopf Monich
- Universidade Federal do Paraná, Departamento de Clínica Médica, Programa de Pós-Graduação em Medicina Interna e Ciências da Saúde, Curitiba, PR, Brazil
- Hospital Universitário Evangélico Mackenzie, Serviço de Nefrologia, Curitiba, PR, Brazil
| | - John J. Bissler
- University of Tennessee, Health Science Center, Le Bonheur Children's Hospital, Department of Pediatrics, Memphis, TN, USA
- Le Bonheur Children's Hospital, Children's Foundation Research Institute, Memphis, TN, USA
- St. Jude Children’s Research Hospital, Pediatric Medicine Department, Memphis, TN, USA
| | - Fellype Carvalho Barreto
- Universidade Federal do Paraná, Departamento de Clínica Médica, Programa de Pós-Graduação em Medicina Interna e Ciências da Saúde, Curitiba, PR, Brazil
- Universidade Federal do Paraná, Departamento de Clínica Médica, Serviço de Nefrologia, Curitiba, PR, Brazil
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Pietrobon A, Stanford WL. Tuberous Sclerosis Complex Kidney Lesion Pathogenesis: A Developmental Perspective. J Am Soc Nephrol 2023; 34:1135-1149. [PMID: 37060140 PMCID: PMC10356159 DOI: 10.1681/asn.0000000000000146] [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: 10/04/2022] [Accepted: 03/27/2023] [Indexed: 04/16/2023] Open
Abstract
The phenotypic diversity of tuberous sclerosis complex (TSC) kidney pathology is enigmatic. Despite a well-established monogenic etiology, an incomplete understanding of lesion pathogenesis persists. In this review, we explore the question: How do TSC kidney lesions arise? We appraise literature findings in the context of mutational timing and cell-of-origin. Through a developmental lens, we integrate the critical results from clinical studies, human specimens, and genetic animal models. We also review novel insights gleaned from emerging organoid and single-cell sequencing technologies. We present a new model of pathogenesis which posits a phenotypic continuum, whereby lesions arise by mutagenesis during development from variably timed second-hit events. This model can serve as a conceptual framework for testing hypotheses of TSC lesion pathogenesis, both in the kidney and in other affected tissues.
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Affiliation(s)
- Adam Pietrobon
- The Sprott Centre for Stem Cell Research, Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Institute of Systems Biology, Ottawa, Ontario, Canada
| | - William L. Stanford
- The Sprott Centre for Stem Cell Research, Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Institute of Systems Biology, Ottawa, Ontario, Canada
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Bissler JJ, Batchelor D, Kingswood JC. Progress in Tuberous Sclerosis Complex Renal Disease. Crit Rev Oncog 2023; 27:35-49. [PMID: 36734871 DOI: 10.1615/critrevoncog.2022042857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Tuberous sclerosis complex (TSC) is an autosomal dominant disorder that affects both fetal development and postnatal tissue growth, resulting in altered brain structures and a tumor predisposition syndrome. Although every organ system is affected by the disease, kidney involvement is a leading cause of death in adults with TSC. Over the past decade, significant progress has been made in understanding the renal disease. This review focuses on the cystic and solid renal lesions in TSC, including their pathobiology and treatment.
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Affiliation(s)
- John J Bissler
- Department of Pediatrics, University of Tennessee Health Science Center and Le Bonheur Children's Hospital, Memphis, TN 38105; Children's Foundation Research Institute (CFRI), Le Bonheur Children's Hospital, Memphis, TN 38105; Pediatric Medicine Department, St. Jude Children's Research Hospital, Memphis, TN 38105
| | - Dinah Batchelor
- Johns Hopkins All Children's Hospital, St. Petersburg, FL 33702
| | - J Christopher Kingswood
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Centre, St. Georges University of London, London, United Kingdom
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Ritter DM, Fessler BK, Ebrahimi-Fakhari D, Wei J, Franz DN, Krueger DA, Trout AT, Towbin AJ. Prevalence of thoracoabdominal imaging findings in tuberous sclerosis complex. Orphanet J Rare Dis 2022; 17:124. [PMID: 35292049 PMCID: PMC8922878 DOI: 10.1186/s13023-022-02277-x] [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: 11/05/2021] [Accepted: 03/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background Tuberous sclerosis complex (TSC) results in neurodevelopmental phenotypes, benign tumors, and cysts throughout the body. Recent studies show numerous rare findings in TSC. Guidelines suggest routine abdominal and chest imaging to monitor these thoracoabdominal findings, but imaging is not uniformly done across centers. Thus, the prevalence of many findings is unknown. To answer this, we categorized the clinical reads of 1398 thoracoabdominal scans from 649 patients of all ages in the Cincinnati Children’s Hospital TSC Repository Database. Results Typical TSC findings were present in many patients: kidney cysts (72%), kidney fat-containing angiomyolipomas (51%), kidney lipid-poor angiomyolipomas (27%), liver angiomyolipomas (19%), and lung nodules thought to represent multifocal micronodular pneumocyte hyperplasia (MMPH) (18%). While many features were more common in TSC2 patients, TSC1 patients had a higher prevalence of MMPH than TSC2 patients (24% versus 13%, p = 0.05). Many rare findings (e.g., lymphatic malformations and liver masses) are more common in TSC than in the general population. Additionally, most thoracoabdominal imaging findings increased with age except kidney cysts which decreased, with the 0–10 years age group having the highest percentage (69% 0–10 years, 49% 10–21 years, 48% 21 + years, p < 0.001). Finally, in our population, no patients had renal cell carcinoma found on abdominal imaging. Conclusions These results show that regular thoracoabdominal scans in TSC may show several findings that should not be ignored or, conversely, over-reacted to when found in patients with TSC. Female sex, TSC2 mutation, and age are risk factors for many thoracoabdominal findings. The data suggest novel interactions of genetic mutation with pulmonary nodules and age with renal cysts. Finally, in agreement with other works, these findings indicate that several rare thoracoabdominal imaging findings occur at higher rates in the TSC population than in the general population. This work supports obtaining detailed thoracoabdominal imaging in patients with TSC. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02277-x.
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Affiliation(s)
- David M Ritter
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Bailey K Fessler
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Daniel Ebrahimi-Fakhari
- Department of General Pediatrics, University Children's Hospital Muenster, Muenster, Germany
| | - Jun Wei
- The First Hospital of Yichang, Yichang, China
| | - David N Franz
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Darcy A Krueger
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander J Towbin
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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