Alport Syndrome

Dr Mohit Naredi
 Contents
 History
 Background
 Pathophysiology
 Inheritance Patterns
 Clinical Findings
 Diagnosis
 Treatment
 Prognosis
History
 History
 Dr. Leonard Guthrie in 1902, described a family with
members who had hematuria.
 Arthur Frederick Hurst in 1923 described the
development of uremia in several members of this
family.
 In 1927, Dr. Cecil Alport followed 3 later generations
of the same family and he recognized that deafness was
a syndromic component and that the disorder tended to
be more severe in males than females.
 Subsequently, many more families were described and
the disease was named Alport Syndrome (AS) in 1961.
Background
 Background
 The incidence of AS is approximately 1 in 5000
births.
 In the US, accounts for approximately 2.3% of
children and 0.3% of adults with ESRD.
 In Europe, the incidence AS is greater and
accounts for 0.6% of patients with ESRD.
 In India, accounts for approximately 1.1% of
adults with ESRD.(Chugh et al)
Pathophysiology
 Pathophysiology
 AS is a primary basement membrane disorder arising
from mutations in genes encoding several members of
the type IV collagen family.

 Basement membranes are assembled through an

interweaving of type IV collagen with laminins and
sulfated proteoglycans.

 Six genes: COL4A1 to COL4A6 encode the six chains

of collagen IV, α1(IV) through α6(IV), respectively.
 Pathophysiology
 Each collagen IV chain has three domains:
 Short 7S domain at the N-terminal
 A long, collagenous domain occupying the midsection of the molecule
 Noncollagenous domain (NC1) positioned at the C terminal

 Despite the many potential permutations, the six collagen IV

chains only form three sets of triple helical molecules called
protomers: α1.α1.α2(IV), α3.α4.α5(IV) and α5.α5.α6(IV).
 Pathophysiology
 Two NC1 trimers unite to
form a hexamer.
 Four 7S domains form
tetramers with other
protomers
 The three protomers only
form three sets of hexamers
to form collagenous
networks:
 α1.α1.α2(IV) - α1.α1.α2(IV)
 α3.α4.α5(IV) – α3.α4.α5(IV)
 α1.α1.α2(IV) – α5.α5.α6(IV)
 Embryonic Development
 Recent evidence demonstrates that isoform switching
of type IV collagen becomes developmentally arrested
in patients with AS.
 In normal embryogenesis, oxidative and physical stress
stimulates the replacement of α1.α1.α2(IV) with
α3.α4.α5(IV) network.
 The cysteine-rich α3.α4.α5(IV) chains are thought to
enhance the resistance of GBM to proteolytic
degradation at the site of glomerular filtration.
 Thus, anomalous persistence of α1.α1.α2(IV) isoforms
confers an unexpected increase in susceptibility to
proteolytic enzymes, leading to basement membrane
splitting and damage.
Embryonic Development
Type IV collagen genes, α chains, and GBM specific isoforms.
(A) The six collagen IV genes (COL4A1 to COL4A6) located pairwise in a
head-to-head manner on three different chromosomes generate six
different alpha chains that have a globular noncollagenous domain at
their C-terminus
(B) Three chains form triple-helical molecules that can have different
combinations
(C) and

(D) Extracellularly, the triple-helical type IV collagen molecules form a

network by associating with each other at their ends so that two
molecules are cross-linked through their C-terminal globular domain
(NC1) and for trimers associated with each other at the N-termini.
In the embryonic GBM, the ubiquitous 1:1:2 trimer is the only isoform.
After birth, this isoform is gradually replaced by an 3:4:5 isoform , which is
more cross-linked through disulfide bonds within the collagenous regions
and more resistant to extracellular proteolysis. Defects in the 3:4:5 trimers
lead to TBMN or Alport syndrome, depending on the extensiveness
of alleles involved
Inheritance Patterns
 Inheritance Patterns
 Three genetic forms of AS exist:
 XLAS, which results from mutations in the COL4A5 gene
and accounts for 80-85% of cases.
 ARAS, which is caused by mutations in either the COL4A3
or the COL4A4 gene and is responsible for approximately
10-15% of cases.
 Rarely ADAS, which is also caused by a mutation in either
the COL4A3 or the COL4A4 gene accounts for the
remainder of cases.
 It is unclear why some heterozygous mutations cause
ARAS with progressive renal disease, while others are
associated with thin basement nephropathy, which is
typically benign.
 No mutations have been identified solely in the
COL4A6 gene.
 Inheritance Patterns
α Chain Genes Chromosome Tissue Distribution Mutation

α1(IV) COL4A1 13 Ubiquitous Unknown

α2(IV) COL4A2 13 Ubiquitous Unknown

GBM, tubular basement membrane, Descemet

α3(IV) COL4A3 2 membrane, Bruch membrane, anterior lens ARAS*/ADAS**
capsule, lungs, cochlea

GBM, TBM, Descemet membrane, Bruch membrane,

α4(IV) COL4A4 2 ARAS/ADAS
anterior lens capsule, lungs, cochlea

Epidermal basement membrane (EBM), Bowman’s

capsule (BC), GBM, distal TBM, Descemet
α5(IV) COL4A5 X XLAS†
membrane, Bruch membrane, anterior lens
capsule, lungs, cochlea

α6(IV) COL4A6 X BC, TBM, EBM Leiomyomatosis‡

*Autosomal recessive Alport syndrome, ** Autosomal dominant AS

† X-linked AS
‡ ARAS with mutations spanning COL4A5 and COL4A6 genes
 X Linked Mutations
 In the COL4A5 genes from the families with XLAS, more than
300 gene mutations have been reported.

 Most COL4A5 mutations are small and include missense

mutations, splice-site mutations, and small deletions where renal
failure and deafness occur after 30 years of age (adult form).

 Approximately 20% of the mutations are major rearrangements

at the COL4A5 locus (i.e., large deletions, reading frame shifts,
etc) in which patients are symptomatic before the age of 30
(juvenile form).

 A rare of deletion spanning COL4A5 and COL4A6 genes is

associated with a combination of XLAS and diffuse
leiomyomatosis.
 Autosomal Mutations
 To date, only 6 mutations in the COL4A3 gene and 12
mutations in the COL4A4 gene have been identified in
patients with ARAS.

 ARAS patients are either homozygous or compound

heterozygous for their mutations, and their parents are
usually asymptomatic carriers.

 ADAS is more rare than XLAS or ARAS and is a result

of a dominant negative mutation of the COL4A3 or
COL4A4 genes whose gene product acts
antagonistically to the wild-type allele.
Clinical Findings
 Clinical Findings
 In patients with XLAS, the disease is consistently
severe in males and female carriers are generally less
symptomatic.

 The female carrier variable phenotype is due to

lyonization by which only one X chromosome is active
per cell.

 In patients with ARAS, the disease is equally severe in

male and female homozygotes and the course is similar
to that of XLAS.

 In ADAS, the renal manifestations are typically milder

and present later than XLAS and ARAS.
 Renal Manifestations - Hematuria
 Gross or microscopic hematuria is the most common
and earliest manifestation.

 Microscopic hematuria is observed usually in the first

few years of life in all males and in 95% of females.

 Hematuria is usually persistent in males, whereas it can

be intermittent in females.

 Like IgA nephropathy, approximately 60-70% of

patients experience episodes of gross hematuria, often
precipitated by upper respiratory infection, during the
first 2 decades of life.
 Renal Manifestations - Proteinuria
 Proteinuria is usually absent in childhood but
eventually develops in males with XLAS and in
both males and females with ARAS.

 Significant proteinuria is infrequent in female

carriers with XLAS, but it may occur.

 Proteinuria usually progresses with age and can

be in the nephrotic range in as many as 30% of
patients.
 Renal Manifestations - ESRD
 The risk of progression of renal failure is highest
among males with XLAS and in both males and
females with ARAS.
 ESRD develops in virtually all males with XLAS,
usually between the ages of 16 and 35 years.
 Some evidence suggests that ESRD may occur even
earlier in ARAS, whereas renal failure has a slower
progression in ADAS.
 Approximately 90% of patients develop ESRD by age
40 years.
 The probability of ESRD in people younger than 30
years is significantly higher (90%) in patients with large
rearrangements of the COL4A5 gene compared to
those with minor mutations (50-70%).
 ESRD – Female Carriers
 The prognosis in females carriers with XLAS is usually
benign, and they develop ESRD at much lower rates.

 The reported probability of developing ESRD in female

carriers is 12% by age 40 years and 30% by age 60
years.

 Risk factors for progression to ESRD are episodes of

gross hematuria in childhood, hearing loss, nephrotic
range proteinuria, and diffuse GBM lamellations seen
on electron microscopy (EM).
 Hearing Deficits
 Bilateral sensorineural hearing loss is a characteristic
feature observed frequently, but not universally.

 May reflect impaired adhesion of the Organ of Corti

(which contain auditory sensory cells) to the basilar
membrane of the inner ear.

 About 50% of male patients with XLAS show

sensorineural deafness by age 25 years, and about 90% are
deaf by age 40 years.
 Hearing Deficits
 Hearing loss is never present at birth.
 Usually, hearing loss becomes apparent by late childhood or early
adolescence, generally before the onset of renal failure.
 Hearing impairment is always associated with renal involvement.
 Some families with AS have been found to have severe
nephropathy without hearing loss.
Ocular Findings – Anterior Lenticonus

 Conical protrusion of the central portion of the

lens into the anterior chamber.

 It is most marked anteriorly because it is the

region where the capsule is thinnest, the stresses
of accommodation are greatest, and the lens is
least supported.

 Occurs in approximately 15-20% of AS patients.

Ocular Findings – Anterior Lenticonus

 Pathognomonic feature if found.

 Not present at birth, but it develops and worsens with

increasing age leading to a slowly progressive
deterioration of vision.

 Not accompanied by eye pain, redness, night blindness

or defect in color vision.

 Can be complicated by cataract formation.

Ocular Findings – Anterior Lenticonus
 Ocular Findings – Dot and Fleck
Retinopathy
 The most common ocular manifestation of AS.
 Occurs in approximately 70% of males with
XLAS and about 10% female carriers.
 Small yellow or white granulations scattered
around the macula or periphery of the retina.
 Rarely observed in childhood, and it usually
becomes apparent at the onset of renal failure.
 Usually asymptomatic with no associated visual
impairment or night blindness.
Ocular Findings – Dot and Fleck Retinopathy
 XLAS with Leiomyomatosis
 Diffuse leiomyomatosis of the gastrointestinal, respiratory
and female genital tracts has been reported in some
families with AS (particularly esophagus and
tracheobronchial tree).

 Seen in 2-5% of patients and carriers of XLAS who have

deletions that involve COL4A5 and extend to the second
intron of the adjacent COL4A6 gene.

 Symptoms usually appear in late childhood and include

dysphagia, postprandial vomiting, substernal or epigastric
pain, recurrent bronchitis, dyspnea, cough, and stridor.
Diagnosis
 Diagnosis
 Historical information (family history, hearing loss,
visual disturbances, gross hematuria)

 Tissue biopsy often reveals ultrastructural abnormalities

and confirm diagnosis.

 Skin biopsy is less invasive than renal biopsy and

should be obtained first.

 Molecular genetic testing in equivocal biopsy cases,

patients in whom biopsy is contraindicated and
prenatal testing.
 Skin Biopsy

 The absence of α5(IV) chains in the epidermal basement membrane

on skin biopsy is diagnostic of XLAS.

 However, the absence of α5(IV) chains in the epidermal basement

membrane is observed in only 80% of males with XLAS.

 Therefore, the presence of α5(IV) chains in the epidermal basement

membrane does not rule out the diagnosis of XLAS.

 Furthermore, α3(IV) and α4(IV) chains are not found in the

epidermal basement membrane so skin biopsy can not be used for
the diagnosis of ARAS and ADAS.
 Skin Biopsy - IF

A, ARAS. Normal staining of EBM for α5(IV), indistinguishable from normal controls.
B, Female carrier of XLAS. Linear staining for α5(IV) on right side, loss of staining on left.
C, Male XLAS. No staining for α5(IV) of EBM.
Skin Biopsy - IF
Distribution of type IV collagen α5 chain
in dermo-epidermal basement membrane.
(A) Control skin.

(B) (B) Absence of α5 (IV) expression in

skin of a male affected with X-linked
Alport syndrome.
(C) (C) Segmental expression of the chain
in an affected female. Note the non-
specific labelling of the stratum
corneum with the anti-α5 antibody
 Renal Biopsy - Light Microscopy
 Light microscopy findings
are nonspecific.

 Can see focal and segmental

glomerular hypercellularity
of the mesangial and
endothelial cells.

 Renal interstitial foam cells

can be found and represent
lipid-laden macrophages
which can be seen in many
renal diseases.
 Renal Biopsy - IF
 Monoclonal antibodies directed against α3(IV), α4(IV), and
α5(IV) chains of type IV collagen can be used to evaluate the
GBM for the presence or absence of these chains.

 The absence of these chains from the GBM is diagnostic of AS

and has not been described in any other condition.
 Renal Biopsy - IF

A, TBMN with normal diffuse linear staining for α5(IV), indistinguishable from controls.
B, Female carrier of XLAS. Discontinuous staining of GBM and BC.
C, ARAS. No GBM staining, but BC and TBM preserved. α3(IV) staining negative (not shown).
D, Male XLAS. Staining for α5(IV) completely negative.
 Distribution of type IV collagen chains in kidney basement membranes.
Normal kidney: (A) Anti-α2(IV). (B) Anti-α3(IV). (C) Anti-α5(IV).
Male patient with X-linked Alport syndrome: (D) Anti-α1(IV). (E) Anti-α3(IV). (F) Anti-α5(IV).
Female patient with X-linked Alport syndrome: (G) Anti-α(5IV).
Patient with autosomal recessive Alport syndrome: (H) Anti-α3(IV). (I) Anti-α5(IV).
 Renal Biopsy - EM
 Earliest finding is thinning of GBM.
 Characteristic finding of longitudinal splitting of
lamina densa of GBM.
 May not be seen in young AS patients.
 The proportion of GBM that shows splitting
increases from 30% by age 10 to more than 90%
by age 30.

Rumpelt, HJ. Hereditary nephropathy: Correlation of clinical data with GBM alterations. Clin
Nephrol 1980; 13:203.
 Renal Biopsy - EM
(A) Marked irregularity in the GBM thickness with thick and split GBM segments contrasting with very thin ones (silver methenamine × 2700).
(B) Thickening and irregular contours of the GBM and splitting of the lamina densa (uranyl acetate and lead citrate × 5000).
(C) Irregular thickening of the GBM, podocyte hypertrophy, and effacement of foot processes along the thin GBM segments (uranyl acetate
and lead citrate × 3600).
(D) Thin GBM with diffuse effacement of foot processes (uranyl acetate and lead citrate × 4800).
 Renal Biopsy - EM

EM of patient with AS, arrows are pointing to the splitting and lamellation of the GBM.
 Renal Biopsy - EM

EM reveals GBM with lamellation (left) and another segment with thinning (right)
 Renal Biopsy - EM

A, EM of glomerular basement membrane, showing segments of thickening and thinning

with irregular contours.
B, Magnification of a thickened segment showing lamellation, electron-lucent areas and
electron-dense granules.
Treatment
 Treatment – Angiotensin Blockade
 It has been proposed, although unproven, that angiotensin
blockade may diminish the rate of proteinuria leading to
glomerulosclerosis and thereby disease progression.

 To date, only small uncontrolled trials have demonstrated the

effect of ACE inhibitors on reducing proteinuria in humans.

 Preemptive therapy with ACE inhibitors in an α3(IV) knockout

Alport mouse model prolonged lifespan until death from renal
failure by more than 100%.

 In the absence of more data, the use of ACE inhibitors is

reasonable in patients with Alport syndrome.

 Cohen, EP. In hereditary nephritis ACE inihibition decreases proteinuria and may slow the rate of progression. Am J Kidney Dis,
1996; 27:199.
 Gross, O et al. Preemptive ramipril therapy delays renal failure and reduces renal fibrosis in COL4A3-knockout mice with Alport
syndrome. KI 2003; 63: 438-446.
 Treatment - Cyclosporine
 Cyclosporine has also been studied in small
uncontrolled trials as well.

 One study of eight Alport males who received

cyclosporine for a mean duration of 8.4 years suggested
a slower progression to ESRD as compared to related
effected males.

 Another study demonstrated reduction in proteinuria,

however, 4 of 9 patients exhibited cyclosporine
nephrotoxicity.

 Callis, L et al. Long-term effects of cyclosporine A in Alport’s syndrome, KI 1999; 55: 1051-1056
 Charbit, M et al. Cyclosporine therapy in patients with Alport syndrome. Pediatric Nephrology 2007; 22:57-63.
 Treatment – Stem Cells
 Cell based therapies have shown some curative potential
in animal models, however, have yet to be tested in
humans.

 Two research groups have reported that treating mice

with wild-type bone marrow derived cells can improve
the disease in α3(IV) knockout Alport mice.

 The bone marrow stem cells differentiated into podocytes

which then secreted the missing α3(IV) chains in this
mouse model.

 Prodromidi, EI et al. Bone marrow-derived cells contribute to podocyte regeneration and amelioration of renal disease in a mouse
model of Alport syndrome. Stem Cells. 2006; 24: 2448-2455.
 Sugimoto H et al. Bone marrow–derived stem cells repair basement membrane collagen defects and reverse genetic kidney disease.
Proc Natl Acad Sci USA 2006; 103:7321-7326.
 Treatment – Renal Transplant
 AS is essentially cured with renal transplantation, and as
one would suspect unless the donor has the disease, AS
will not occur in the transplanted organ.

 The most significant and devastating, albeit rare,

complication of transplantation is antiglomerular
basement membrane nephritis.

 Approximately 3-5% of patients with Alport syndrome

who receive a transplant develop anti-GBM antibody to
the NC1 component of the α3(IV) chain.

 Post-transplant anti-GBM nephritis usually develops

within the first year of the transplant.
 Treatment – Renal Transplant
 For unclear reasons, certain patients are at very low risk for
developing post-transplant anti-GBM nephritis, including patients
with normal hearing, patients with late progression to ESRD, or
females with XLAS.

 Unlike de novo anti-GBM nephritis, pulmonary hemorrhage is

never observed because the patient's lung tissue does not contain
the antigen.

 Treatment with plasmapheresis and cyclophosphamide is usually

unsuccessful, and most patients lose the allograft.

 Retransplantation in most patients results in recurrence of anti-

GBM nephritis despite the absence of detectable circulating anti-
GBM antibodies before transplantation.
 Kashtan CE. Alport syndrome and thin glomerular basement membrane disease. J Am Soc Nephrol. 1998;9:1736.
Newer therapies such as antiprotease, chemokine receptor blockers, and statin or stem cell delivery have been suggested

 Blocking simultaneously at least MMP2, MMP3, and MMP9 in Col4a3−/− mice delays the progression of
the disease if treatment is given before development of GBM injury and occurrence of proteinuria in a
C57BL6 genetic background (Zeisberg et al., 2006).
 In addition, either an MMP12 inhibitor or CCR2 receptor antagonist attenuates the GBM thickening in
Col4a3−/− mice (Rao et al., 2006).
 It was also shown that chemokine receptor-1 blockade as well as statin treatment improves survival and
renal lesions in Alport mice (Ninichuk et al., 2005).
 Bone marrow transplantation of Col4a3−/− mice shows recruitment of bone marrow cells as future
podocytes and mesangial cells, (very) partial restoration of the expression of the α3-α4-α5(IV) network,
and clinical and histologic improvement (Floege et al., 2006; Prodromidi et al., 2006; Sugimoto et al.,
2006; Katayama et al., 2008).
 More recently, Sedrakyanet al. (2012) have shown that injection of amniotic fluid stem cells delays
progression of renal fibrosis in Alport mice.
 A recent study suggests that anti miR21 oligonucleotides prevent renal disease progression in mice
(Gomez et al., 2014).
 Reference
1. Alport’s Syndrome, Goodpasture’s Syndrome, and Type IV
Collagen. Billy G. Hudson, Ph.D., Karl Tryggvason, M.D.,
Ph.D., Munirathinam Sundaramoorthy, Ph.D., and Eric G.
Neilson, M.D. N Engl J Med 2003;348:2543-56.
Thank you.