1. Alport Syndrome Genetics and Diagnosis Martin Gregory, MD, PhD Professor of Medicine University of Utah Nothing to disclose

2. Modes of Inheritance X-linked (XLAS) –COL4A5 on chromosome Xq22 85% of cases Autosomal –COL4A3 or COL4A4 on chromosome 2q36-37 –Recessive (ARAS) 10-15% of cases –Autosomal Dominant (ADAS) 1-5% of cases Diseases mimicking AS –MYH9 disorders: Epstein and Fechtner syndromes

3. Giant Platelets in Fechtner Syndrome

4. Autosomal Dominant AS Rare, mild Vertical pattern of inheritance Male to male transmission Mutation in COL4A3 or COL4A4

5. Autosomal Recessive AS Uncommon Horizontal pattern of inheritance Consanguinity Mutations in COL4A3 or COL4A4 Parents are “carriers”: they have TBMN

6. X-linked AS Most common Vertical pattern of inheritance NO male to male transmission Mutations in COL4A5

7. Implications of Inheritance Patterns Need to be as sure as possible of mode of inheritance before drawing conclusions or advising families. Prediction is treacherous, and genetic counseling subtle. Both the chance that children will inherit the disorder and the likely severity of the syndrome vary with the type of AS

8. Copyright ©2010 American Society of Nephrology From the left of figure, Light weight solid line: large deletion, Dots: splice site mutation, Dash-Dot: small deletion, Heavy solid line: truncating mutation, Dash: missense mutation. Bekheirnia, M. R. et al. J Am Soc Nephrol 2010;21:876-883 Time to onset of ESRD associates with COL4A5 mutation type

9. Relevance of Specific Mutations in XLAS Large deletions and truncations cause the most severe phenotype. Splice-site mutations: intermediate severity Missense mutations: relatively mild disease. In US, but not Europe, mutations in the NC1 domain are more benign than those in the triple helical domain

10. Genetic Tests Available – COL4A5 Sequencing and deletion analysis –Expensive. Sensitivity > 80% for XLAS Targeted mutation analysis (Carrier detection) –Cheap. Use this once family’s mutation is known. Test for 3 common “Adult types” –Cheap. Use if family has one of these 3 mutations. –?use for screening certain groups Adults with dysmorphic hematuria and CKD. Alport syndrome with late-onset renal failure

11. “Adult-type” Mutations in the USA – Known gene carriers COL4A5 mutation ESRD age in males MaleFemaleTotal% of total L1649R3915022237248.6 C1564S32528113317.4 R1677Q501938577.5 G1170S381311243.1 c.2476delC441112233.0 G1234X42716233.0 16 others706313317.4 Total322443765100 Pont-Kingdon G et al. BMC Nephrology 2009; 10:38

12. Genetic Tests Available – COL4A3/4 COL4A3 and COL4A4 sequencing and deletion analysis –Expensive. Sensitivity >80% Use after COL4A5 mutation excluded or if inheritance suggests autosomal transmission Can use to diagnose ~40% of cases of TBMN

13. Before Genetic Testing Gather a complete family history, patient history, u/a. Make your best guess for mode of inheritance Is a mutation known in the family? Is genetic testing appropriate? Families making reproductive decisions To avoid kidney biopsy, or if diagnostic certainly is desired

14. Choice of an Appropriate Genetic Test Targeted analysis or Adult-type 3 mutation test if the mutation is known in the family If no mutation is known, usually start with sequencing, including deletion analysis in females May start with Adult-type 3 mutation test in families with renal failure in middle age COL4A3/4 sequencing if autosomal disease likely or if COL4A5 testing was negative

15. Now you Tell me … A lab test has 90% sensitivity and 99% specificity. The disease it tests for occurs in 1 in 50,000 people. A person in the population has a positive test. What is the likelihood that he has the disease tested for? 99% 90% 50% 10% <1%

16. Now you Tell me … A lab test has 90% sensitivity and 99% specificity. The disease it tests for occurs in 1 in 50,000 people. A person in the population has a positive test. What is the likelihood that he has the disease tested for? 99% 90% 50% 10% <1% Of people with the disease 90% will have a positive test Of people without the disease, 1% will have a positive test

17. Now you Tell me … A lab test has 90% sensitivity and 99% specificity. The disease it tests for occurs in 1 in 50,000 people. A person in the population has a positive test. What is the likelihood that he has the disease tested for? Test 100,000 people 1.8 true positives 99% 90% 50% 10% <1%

18. Now you Tell me … A lab test has 90% sensitivity and 99% specificity. The disease it tests for occurs in 1 in 50,000 people. A person in the population has a positive test. What is the likelihood that he has the disease tested for? Test 100,000 people 1.8 true positives 1,000 false positives Probability of disease 2/1002 = 0.2% 99% 90% 50% 10% <1%

19. Now you Tell me … A lab test has 90% sensitivity and 99% specificity. The disease it tests for occurs in 1 in 50,000 people. A person in the population has a positive test. What is the likelihood that he has the disease tested for? Test 100,000 people 1.8 true positives 1,000 false positives Probability of disease 2/1002 = 0.2% 99% 90% 50% 10% <1% A priori probability A posteriori

20. Now you Tell me … A lab test has 90% sensitivity and 99% specificity. The disease it tests for occurs in 1 in 50,000 people. A person in the population has a positive test. What is the likelihood that he has the disease tested for? Test 100,000 people 1.8 true positives 1,000 false positives Probability of disease 2/1002 = 0.2% 99% 90% 50% 10% <1% A priori probability A posteriori if test is + 0.002% 50% 98% 0.2% 98% 99.998%

21. Conclusions about Genetic Testing If a family has several males with ESRD, genetic testing will likely not improve prognostic accuracy. If the family is very small, the phenotype is likely severe. Before giving advice that may affect reproductive decisions, consider getting a genetic diagnosis for the prospective parent(s) involved (not just a diagnosis in the family). Only get a genetic diagnosis if it can change what you will do. Even very good tests may be misleading if misapplied