Clinical Value of NPHS2 Analysis in Early- and Adult-Onset Steroid-Resistant Nephrotic Syndrome

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Clinical Value of NPHS2 Analysis in Early- and Adult-Onset Steroid-Resistant Nephrotic Syndrome Article Clinical Value of NPHS2 Analysis in Early- and Adult-Onset Steroid-Resistant Nephrotic Syndrome Sheila Santín,* Ba´rbara Tazo´n-Vega,* Irene Silva,* María A´ ngeles Cobo,† Isabel Gime´nez,‡ Patricia Ruíz,* Rafael García-Maset,‡ Jose´Ballarín,‡ Roser Torra,‡ and Elisabet Ars,* on behalf of the FSGS Spanish Study Group Summary Background and objectives To date, very few cases with adult-onset focal segmental glomerulosclerosis *Molecular Biology (FSGS) carrying NPHS2 variants have been described, all of them being compound heterozygous for the Laboratory, Fundacio´ p.R229Q variant and one pathogenic mutation. Puigvert, Universitat Auto`noma de Design, setting, participants, & measurements Mutation analysis was performed in 148 unrelated Spanish Barcelona, REDinREN, Instituto de patients, of whom 50 presented with FSGS after 18 years of age. Pathogenicity of amino acid substitutions Investigacio´n Carlos III, was evaluated through an in silico scoring system. Haplotype analysis was carried out using NPHS2 single Barcelona, Spain; nucleotide polymorphism and microsatellite markers. †Nephrology Department, Hospital Universitario de Results Compound heterozygous or homozygous NPHS2 pathogenic mutations were identified in seven Canarias, Tenerife, childhood-onset steroid-resistant nephrotic syndrome (SRNS) cases. Six additional cases with late child- Spain; and ‡Nephrology hood- and adult-onset SRNS were compound heterozygotes for p.R229Q and one pathogenic mutation, Department, Fundacio´ mostly p.A284V. p.R229Q was more frequent among SRNS cases relative to controls (odds ratio ϭ 2.65; Puigvert, Universitat ϭ Auto`noma de P 0.02). Significantly higher age at onset of the disease and slower progression to ESRD were found in Barcelona, REDinREN, patients with one pathogenic mutation plus the p.R229Q variant in respect to patients with two NPHS2 Instituto de pathogenic mutations. Investigacio´n Carlos III, Barcelona, Spain Conclusions NPHS2 analysis has a clinical value in both childhood- and adult-onset SRNS patients. For adult-onset patients, the first step should be screening for p.R229Q and, if positive, for p.A284V. These al- Correspondence: Dr. Roser Torra or Dr. leles are present in conserved haplotypes, suggesting a common origin for these substitutions. Patients car- Elisabet Ars, Fundacio´ rying this specific NPHS2 allele combination did not respond to corticoids or immunosuppressors and Puigvert, Cartagena 340- showed FSGS, average 8-year progression to ESRD, and low risk for recurrence of FSGS after kidney 350, 08025 Barcelona, ϩ transplant. Spain. Phone: 34 93 416 97 00; Fax: ϩ34 93 Clin J Am Soc Nephrol 6: 344–354, 2011. doi: 10.2215/CJN.03770410 416 97 30; E-mail: rtorra@fundacio- puigvert.es or ears@ Introduction onset familial cases of autosomal-recessive SRNS (5). fundacio-puigvert.es Nephrotic syndrome (NS) is characterized by edema, Nearly all patients with two NPHS2 pathogenic mu- massive proteinuria, hypoalbuminemia, and hyper- tations develop NS before the age of 6 years, present lipidemia. Clinically, NS has been divided into two mostly with FSGS, do not respond to immunosup- categories based on the response to steroid therapy: pressant treatment, reach ESRD before the end of the steroid-sensitive NS (SSNS) and steroid-resistant NS first decade of life, and have a reduced risk for recur- (SRNS) (1). In children and adults with SRNS, renal rence of FSGS after kidney transplant (8 versus 33%) histology typically shows focal segmental glomerulo- (13–19). In addition, Tsukaguchi et al. (20) reported sclerosis (FSGS), and 50 to 70% of patients progress to NPHS2 variants in 23% of late-onset familial cases and ESRD (2,3). In the last few years, mutations in genes in 2% of sporadic ones. In contrast, NPHS2 mutations encoding podocyte proteins have been identified in were not found in four large cohorts of adult-onset several forms of hereditary SRNS (4–10). cases published subsequently (21–24). Recently, Ma- To date, the main player in the genetic forms of chuca et al. (25) identified NPHS2 substitutions in 14% SRNS has been podocin, encoded by the NPHS2 gene of cases presenting with SRNS after 18 years of age. (11). Podocin is a 383-amino acid lipid-raft–associated Fifteen sporadic and 11 families with adult-onset protein localized at the slit diaphragm, where it is FSGS carrying NPHS2 variants have been reported required for the structural organization and regula- thus far, and affected individuals were compound tion of the glomerular filtration barrier. Its interaction heterozygous for a particular variant, p.R229Q, and with nephrin, NEPH1, CD2AP, and TRPC6 manage one pathogenic mutation, which was frequently the mechanosensation signaling, podocyte survival, cell p.A284V substitution among South American pa- polarity, and cytoskeletal organization (12). The tients. Although p.R229Q is one of the most common NPHS2 gene was identified 10 years ago in early- nonsynonymous NPHS2 variants in Caucasians (26), 344 Copyright © 2011 by the American Society of Nephrology www.cjasn.org Vol 6 February, 2011 Clin J Am Soc Nephrol 6: 344–354, February, 2011 NPHS2 in Childhood- and Adult-Onset SRNS, Santín et al. 345 its pathogenic role in SRNS is not clear because it is members. Unpublished missense mutations were observed with similar allele frequencies in SRNS and screened in 300 control chromosomes either by direct normal control subjects (5.13 and 3.75%, respectively) sequencing or by specific restriction enzyme diges- (17,18). Support for a functional role of this variant tion. comes from in vitro studies showing decreased neph- rin binding to mutant p.R229Q-podocin (20). Classification of Sequence Variants The goals of this study were (1) to assess the We developed an in silico scoring system to evalu- utility of NPHS2 testing in Spanish children and ate the pathogenicity of amino acid substitutions adults with SRNS or FSGS, (2) to determine (missense mutations) identified in the NPHS2 gene. whether the p.A284V pathogenic mutation and the This scoring system takes into consideration a num- p.R229Q variant occur on conserved haplotypes, (3) ber of in silico predictors (28–30) and population data. to evaluate genotype–phenotype correlation among We scored each of these factors, the sum of which patients with NPHS2 variants, focusing on adult resulted in an overall variant score (VS). These were Ն patients with FSGS, and (4) to study the association classified into four groups (30): VS 11 (highly likely ϭ Ն Յ with SRNS of the relatively common p.P20L, pathogenic, mutation group [MG] B); 10 VS 5 ϭ Ն Յ p.R229Q, and p.E264Q NPHS2 variants in a case- (likely pathogenic, MG C), 4 VS 0 (indetermi- ϭ Յ Ϫ control study. nate, MG I), and VS 1 (highly likely neutral, MG ϭ NV). Nonsense and frameshift mutations were classed as definitely pathogenic mutations (MG ϭ A) Materials and Methods because they are predicted to result in truncated pro- Patients teins. From a group of 239 Spanish patients with NS We considered “pathogenic mutations” to be those referred for NPHS2 mutation analysis, we selected sequence variants predicted to result in a truncated patients affected by SRNS (1,2) to evaluate NPHS2 protein (MG ϭ A) and those amino acid substitutions genotype–phenotype correlations. We excluded pa- not found in healthy controls, segregated with the tients with a potential underlying immune disorder disease in families, and expected to severely alter the defined by remission after steroid (n ϭ 37) or immu- ϭ ϭ protein sequence using in silico predictors (MG B). nosuppressive (n 18) therapy or late steroid resis- Missense substitutions classified as MG ϭ C or I were tance (n ϭ 7). Moreover, individuals with evidence of ϭ designated as “variants of unknown clinical signifi- autosomal-dominant disease (n 6), as well as those cance.” in whom we identified mutations in NPHS1, WT1, or ϭ TRPC6 (n 23), were excluded. Renal biopsy was Haplotype Analysis available in all patients with adult-onset NS and all We genotyped family members of patients carrying the showed FSGS. Secondary forms of FSGS were not p.R229Q variant and p.A284V mutation using NPHS2 mi- included. The cohort analyzed in this study thus rep- crosatellite markers (D1S3758, D1S3760, D1S215, D1S3759, resented 148 patients belonging to 139 families with and D1S2883). Haplotype construction was also carried SRNS. Patients originating from a consanguineous out using eight single nucleotide polymorphisms (SNPs): marriage (n ϭ 4) or those with an additional affected 5ЈUTR-52CϾG, 5ЈUTR-51GϾT(rs12406197), c.102GϾA sibling (n ϭ 8) were considered as familial cases. The (rs1079292), c.288CϾT(rs3738423), IVS3–21CϾT remaining 127 were sporadic SRNS cases. Age at on- (rs12401708), IVS7ϩ7AϾG, c.954TϾC(rs1410592), and set of NS, response to treatment, histopathologic find- c.1038AϾG(rs3818587). Moreover, three informative SNPs ings, progression to ESRD, and recurrence after kid- (5ЈUTR-51GϾT, IVS3–21CϾT, and c.954TϾC) were cho- ney transplantation were obtained (Table 1). We sen for further analysis in patients and controls carrying classified our population according to the age at onset the p.R229Q variant. of the disease in early childhood onset (0 to 5 years; 34.4 Ϯ 17.4 months, n ϭ 65), late childhood onset (6 to Statistical Analyses 17 years; 11.1 Ϯ 3.5 years, n ϭ 33), and adult onset Data are expressed as mean Ϯ SD. Comparisons (Ͼ18 years; 32.9 Ϯ 10.8 years, n ϭ 50). To calculate between two continuous variables were made using t mutation frequency, we used the number of families; tests. Genetic associations between NPHS2 variants when evaluating phenotype, we considered number and SRNS were assessed by comparing genotypic of patients. frequencies between patients and control subjects (matched by ethnicity and geography with the study cohort) using ␹2 or Fisher’s exact test. The odds ratio Mutation Analysis was calculated with 95% confidence interval. All tests Genomic DNA was isolated from peripheral blood were two-sided.
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