Original Investigation

Beyond Panel-Based Testing: Exome Analysis Increases Sensitivity for Diagnosis of Genetic Kidney Disease

Parker C. Wilson ,1 Latisha Love-Gregory,1 Meagan Corliss,2 Samantha McNulty,2 Jonathan W. Heusel,2,3 and Joseph P. Gaut1,4

Abstract Background Next-generation sequencing (NGS) is a useful tool for evaluating patients with suspected genetic kidney disease. Clinical practice relies on the use of targeted gene panels that are ordered based on patient presentation. We compare the diagnostic yield of clinical panel-based testing to exome analysis.

Methods In total, 324 consecutive patients underwent physician-ordered, panel-based NGS testing between December 2014 and October 2018. Gene panels were available for four clinical phenotypes, including atypical hemolytic uremic syndrome (n5224), nephrotic syndrome (n556), cystic kidney disease (n526), and Alport syndrome (n513). Variants were analyzed and clinical reports were signed out by a pathologist or clinical geneticist at the time of testing. Subsequently, all patients underwent retrospective exome analysis to detect additional clinically significant variants in kidney disease genes that were not analyzed as part of the initial clinical gene panel. Resulting variants were classified according to the American College of Medical Genetics and Genomics 2015 guidelines.

Results In the initial physician-ordered gene panels, we identified clinically significant pathogenic or likely pathogenic variants in 13% of patients (n542/324). CFHR3-CFHR1 homozygous deletion was detected in an additional 13 patients with aHUS without a pathogenic or likely pathogenic variant. Diagnostic yield of the initial physician-ordered gene panel was 20% and varied between groups. Retrospective exome analysis identified 18 patients with a previously unknown pathogenic or likely pathogenic variant in a kidney disease gene and eight patients with a high-risk APOL1 genotype. Overall, retrospective exome analysis increased the diagnostic yield of panel-based testing from 20% to 30%.

Conclusions These results highlight the importance of a broad and collaborative approach between the clinical laboratory and their physician clients that employs additional analysis when a targeted panel of kidney disease–causing genes does not return a clinically meaningful result. KIDNEY360 1: 772–780, 2020. doi: https://doi.org/10.34067/KID.0001342020

Introduction selected populations (8,14). This is an important dis- Next-generation sequencing (NGS) is as an important tinction because this approach significantly differs diagnostic tool for the characterization of kidney dis- from physician-ordered testing performed in real time ease (1). Targeted gene panels aid in the diagnosis of in an accredited clinical laboratory. With these caveats steroid-resistant nephrotic syndrome (NS) (2), nephro- in mind, Groopman et al. (8) reported that 9% of adults nophthisis (3), autosomal dominant polycystic kidney with CKD have a monogenic cause, encompassing 66 disease (4), atypical hemolytic uremic syndrome (aHUS) different disorders. Similarly, Lata et al. (14) identified (5,6), and congenital anomalies of the kidney and urinary a genetic cause for CKD in 24% of patients after select- tract (7). Renal biopsy is useful for evaluating patients ing for individuals with CKD of unknown cause or with suspected genetic kidneydisease,butitmayreveal family history of kidney disease. Interestingly, the nonspecific findings. A genetic diagnosis is critical for majority of monogenic disorders were detected as assessing risk in family members and may provide ther- singletons, which underscores the importance of a broad apeutic options for otherwise untreatable diseases (8–13). approach to genetic evaluation of kidney disease. Recent efforts have explored the utility of exome The selection of a genetic test is based on clinical sequencing in large populations of adults with CKD, assessment and family history. However, many kidney however, these studies were done retrospectively on diseases have overlapping clinical and pathologic

1Division of Anatomic and Molecular Pathology, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri 2Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri 3Department of Genetics, Washington University School of Medicine, St. Louis, Missouri 4Division of Nephrology, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri

Correspondence: Dr. Parker C. Wilson, Department of Pathology and Immunology, Washington University School of Medicine, 660 S. Euclid Avenue, CB 8118, St Louis, MO 63110. Email: [email protected]

772 Copyright © 2020 by the American Society of Nephrology www.kidney360.org Vol 1 August, 2020 KIDNEY360 1: 772–780, August, 2020 NGS Testing for Genetic Kidney Disease, Wilson et al. 773

phenotypes, complicating selection of the appropriate panel- with Picard (version 1.53). Single nucleotide variants were based test. Fortunately, many NGS-based targeted gene sets called with samtools (version 0.1.19) and insertions and are built on an exome backbone. This approach allows the deletions up to 21 bp were called using Unified Genotyper laboratory to use a single process for library preparation and (GATK version 1.2) and pindel (version 0.2.4). In silico func- sequencing followed by a customized informatics workflow tional prediction was performed with SIFT (version 5.0.2) and that extracts a subset of genes for clinical reporting. In the polyPhen-2 (version 2.2.2). Patients referred for aHUS genetic event an initial gene set returns no pathogenic or likely testing underwent additional multiplex ligation-dependent pathogenic variants, additional clinically relevant gene sets probe amplification to detect deletion of CFHR1-CFHR3 at can be “unmasked” and interrogated (5). Although there is an Cincinnati Children’s Hospital as previously described (5). abundance of archived genetic data that may or may not have implications for the patients’ health, there are currently no Variant Interpretation and Reporting guidelines on which patients should undergo additional re- Variant classifications were based on standards and view, which genes should be reviewed, or how frequently guidelines published by the American College of Medical this process should be repeated. Furthermore, new genes are Genetics and Genomics (ACMG) and the Association of implicated in renal disease on a regular basis (15–18). Molecular Pathology (20). Variant calls were reported using Human Genome Variation Society nomenclature (http:// www.hgvs.org/mutnomen) and variant attributes were ex- Materials and Methods amined using population databases, including the Exome Clinical Laboratory Workflow This study was approved by the Washington University Aggregation Consortium (ExAC version 0.3.1), Genome Aggregation Database (gnomAD version 2.1.0), the Na- School of Medicine Institutional Review Board and adheres ’ to the Declaration of Helsinki. All patients provided in- tional Center for Biotechnology Information s short genetic formed consent before clinical genetic testing. Clinical gene variations database (dbSNP version 135), the FH aHUS sets (Table 1) were ordered by licensed physicians and mutation database (http://www.fh-hus.org/v3.0), ClinVar performed in a College of American Pathologists (CAP)– (http://www.ncbi.nlm.nih.gov/clinvar/), the Human Gene accredited and Clinical Laboratory Improvement Amendments– Mutation Database public resource (http://www.hgmd.cf. certified laboratory. The data represent consecutive samples ac.uk/ac/index.php access 6/3/2018), and an internally cu- submitted to Genomics and Pathology Services at Wash- rated clinical-grade database of variants and interpretations ington University in Saint Louis between December 1, 2014 housed in the Clinical Genomics Workspace (PierianDx, St. and October 31, 2018. Library preparation for the NGS assay Louis, MO) (20,21). All results were reviewed by a pathol- began by fragmenting DNA to approximately 200 bp by ogist with subspecialty boards in molecular genetics from the American Board of Pathology, or a clinical laboratory ultrasonication, followed by end repair, A-tailing, and liga- fi tion to sequencing adapters. Libraries were prepared using geneticist certi ed in clinical molecular genetics and clinical the Agilent SureSelect XT Clinical Research Exome reagent, cytogenetics from the American Board of Medical Genetics and Genomics before release to the patient’s medical record. and sequenced using an Illumina (San Diego, CA) HiSeq2500 APOL1 fi in 23101-bp paired-end configuration. Analytic sensitivity, High-risk genotype was de ned as the presence of specificity, and reproducibility were established per the CAP a G1G1, G1G2, or G2G2 genotype (22). Diagnostic yield was defined as the presence of a pathogenic or likely pathogenic NGS-testing checklist (19). Alignment was performed with APOL1 CFHR3-CFHR1 Novoalign (version 2.08.02) and duplicates were marked variant, high-risk genotype, or ho- mozygous deletion in patients referred for aHUS testing.

Table 1. Clinical gene sets Retrospective Review of Extended Renal Gene Set We performed retrospective exome reanalysis of the variant Clinical Gene Sets call files for all patients using a curated list of genes implicated Atypical hemolytic uremic syndrome, thrombotic in renal disease (extended gene set in Supplemental Table 1) microangiopathy, and C3 glomerulopathy gene set (13 (8,14). Additional filtering criteria based on minor allele fre- CFHR3-CFHR1 genes and deletion status) quency in the gnomAD exome database, location of the variant ADAMTS13, C3, CD46, CFB, CFH, CFHR1, CFHR2, CFHR3, CFHR4, CFHR5, CFI, DGKE, and THBD; CFHR3-CFHR1 within the gene, annotation based on comparison with clinical deletion by multiplex ligation-dependent probe databases, and predicted in silico effects were used to enrich the amplification data set for variants more likely to be causative of disease Alport syndrome gene set (3 genes) COL4A3 COL4A4 COL4A5 (Supplemental Figure 1). Selected variants outside of the clin- , , and ically validated gene lists were confirmed by Sanger sequenc- Cystic disease and nephronophthisis gene set (23 genes) AHI1, CEP290, GLIS2, INVS, IQCB1, NEK8, NPHP1, NPHP3, ing before returning results to the patient record. NPHP4, RPGRIP1L, TMEM67, TTC21B, XPNPEP3, BICC1, CRB2, EYA1, HNF1B, PAX2, PKD1, PKD2, PKHD1, SIX5, and UMOD. Nephrotic syndrome and FSGS gene set (34 genes) Results ACTN4, ADCK4 (COQ8B), ANLN, APOL1, ARHGAP24, Patient Characteristics and Diagnostic Yield of Initial ARHGDIA, CD2AP, COL4A3, COL4A4, COL4A5, COQ2, Panel-Based NGS Testing for Suspected Genetic COQ6, CRB2, CUBN, EMP2, INF2, ITGA3, ITGB4, LAMB2, Kidney Disease LMX1B MEFV MYH9 MYO1E NEIL1 NPHS1 NPHS2 , , , , , , , In total, 324 patients received clinical, panel-based NGS PDSS2, PLCE1, PTPRO, SCARB2, SMARCAL1, TRPC6, TTC21B, and WT1. testing for suspected genetic kidney disease between December 1, 2014 and October 31, 2018 (Table 2). Among 774 KIDNEY360

patients with available clinical history, 78 had ESKD and 48 RNA level (28). In the second patient, exome reanalysis had undergone kidney transplant at the time of referral identified previously reported compound heterozygous (additional clinical information is provided in Supplemental mutations in SLC26A1 (p.S358L, p.T185M) associated with Table 2). ARF and calcium oxalate nephrolithiasis (29). The initial panel-based tests returned a clinically signif- Exome reanalysis detected an additional seven patients icant pathogenic or likely pathogenic variant in 42 patients with a high-risk APOL1 genotype in the absence of a path- (13%). An additional 101 (31%) patients had a variant of ogenic, likely pathogenic, or VUS. APOL1 high-risk geno- uncertain significance (VUS) with no pathogenic or likely type confers increased risk for ESKD and FSGS, but has not pathogenic variant. The proportion of patients with a path- been previously associated with aHUS (30). All seven ogenic or likely pathogenic variant was lowest in the aHUS patients were black and the three patients with available group (6%) and significantly higher in the NS/FSGS (14%), clinical history had ESKD. cystic disease and nephronophthisis (46%), and Alport syn- drome (30%) groups (Figure 1). Genetic Variants in Patients Referred for NS, FSGS, and Alport Syndrome Testing Genetic Variants in Patients Referred for aHUS Testing Genetic mutations in glomerular basement membrane aHUS is characterized by thrombotic microangiopathy proteins can lead to NS, FSGS, and Alport syndrome. In and mutations in complement pathway genes. In total, 224 total, 56 patients were referred for the NS/FSGS gene set patients were referred for aHUS panel-based testing. A total and 13 patients were referred for the Alport gene set. Initial of 18 patients had a clinically significant pathogenic or likely panel-based NGS testing for the NS/FSGS and Alport gene fi pathogenic variant detected in the initial aHUS gene set sets identi ed 12 patients with a pathogenic or likely path- (Table 3). The genes most commonly affected were CFH ogenic variant (Table 3). The genes most commonly affected NPHS1 n5 COL4A5 n5 NPHS2 n5 (n56), C3 (n54), and CD46 (n54). A total of 24 patients had were ( 3), ( 3), and ( 2). We fi NPHS1 homozygous loss of CFHR3-CFHR1 detected by multiplex identi ed a previously unreported pathogenic ligation-dependent probe amplification. We identified two frameshift variant (p.L16Gfs*3) in a 1-month-old girl with novel variants not previously reported in aHUS. CFH NS that is expected to result in loss of function. fi p.D1119E was identified in a 9-month-old boy with anemia, Exome reanalysis identi ed previously unknown patho- thrombocytopenia, bloody diarrhea, and an Escherichia coli– genic or likely pathogenic variants that resulted in a new fi positive stool sample. Similar variants (p.D1119G and genetic diagnosis in ve patients (Table 4). Two of these p.D1119N) have been reported in aHUS (23,24), and the patients were diagnosed with autosomal dominant condi- p.D1119G variant impairs the ability of CFH to bind C3b tions that have important implications for family members. fi and C3d (25,26). ADAMTS13 p.Q725* was identified in a 30- The rst patient had a strong family history of kidney UMOD year-old man with isolated thrombocytopenia. Heterozygous disease and a previously reported variant in nonsense variants in ADAMTS13 have been reported in parents (p.H175_R185del) that causes autosomal dominant tubu- of patients with congenital thrombocytopenic purpura and are lointerstitial kidney disease. The second patient was a 37- – associated with decreased ADAMTS13 activity (27). year-old man with ESKD and biopsy specimen proven Exome reanalysis identified a previously unknown path- FSGS that was presumed secondary to obesity. He had ogenic or likely pathogenic variant in 12 patients initially a strong family history of kidney disease and a novel het- PAX2 referred for panel-based aHUS testing (Table 4). These data erozygous variant in (p.G76R) that is located at the resulted in a new genetic diagnosis in eight patients and same position as a variant previously described in the confirmed the genetic cause of an existing clinical diagnosis context of renal coloboma syndrome (31). of autosomal dominant polycystic kidney disease (n53) or Laurence–Moon–Biedl syndrome (n51) in four patients. Genetic Variants in Patients Referred for Cystic Kidney Two patients that received a new genetic diagnosis were Disease and Nephronophthisis Testing newborns under evaluation for potential neonatal aHUS. In Cystic kidney disease and nephronophthisis are a spec- the first patient, exome reanalysis identified a previously trum of disorders that can have phenotypic overlap with reported homozygous nonsense mutation in REN (p.43*), congenital anomalies of the kidney and urinary tract. In which leads to absent renin expression at the protein and total, 26 patients were referred for the cystic kidney disease

Table 2. Patient demographics

Gene Set N Age in Years (SD) Gender Race and Ethnicity

aHUS 224 36.0 (19.1) 81 M, 143 F W, 139; B, 34; AS, 7; HIS, 21; OTH, 23 NS/FSGS 56 15.9 (15.1) 31 M, 25 F W, 24; B, 11; AS, 1; HIS, 5; OTH, 15 NPHP 26 20.4 (22.7) 13 M, 13 F W, 11; B, 6; HIS, 1; OTH, 8 Alport 13 29.9 (24.0) 5 M, 8 F W,8; B, 1; OTH, 4 Custom 5 40.2 (17.9) 3 M, 2 F W, 3; B, 2 Total 324 31.1 (20.6) 133 M, 191 F W, 185; B, 53; AS, 8; HIS, 27; OTH, 50

aHUS, atypical hemolytic uremic syndrome; M, male; F, female; W, white; B, black; AS, Asian; HIS, Hispanic; OTH, other; NS, nephrotic syndrome; NPHP, cystic renal disease and nephronophthisis. KIDNEY360 1: 772–780, August, 2020 NGS Testing for Genetic Kidney Disease, Wilson et al. 775

Referred for NGS for a Renal Disorder (n=324)

aHUS Gene Set Nephrotic Gene Nephronophthisis Alport Gene Set Custom Gene Set (n=224) Set (n=56) Gene Set (n=26) (n=13) (n=5)

Clinical Report Clinical Report Clinical Report Clinical Report Clinical Report (13 genes) (34 genes) (23 genes) (3 genes)

C3 (P:2, LP:2) CD46 (P:3, LP:1) INF2 (LP:2) NPHP4 (LP:1) CFB (LP:1) COL4A3 (LP:1) NPHS1 (P:2, LP:1) PKD1 (P:7, LP:2) CFH (P:2, LP:4) COL4A4 (LP:1) NPHS2 (P:2) PKHD1 (LP:1) VUS: 1 CFI (P:1, LP:1) COL4A5 (LP:2) WT1 (P:1) RPGRIP1L (LP:1) No Finding: 4 DGKE (P/P:1) VUS: 6 VUS: 31 VUS: 9 VUS: 54 No Finding: 3 No Finding: 17 No Finding: 5 Risk*: 24 No Finding: 139

Extended Set Extended Set Extended Set Extended Set Extended Set (309 genes) (309 genes) (309 genes) (309 genes) (309 genes)

ADAMTS13 (P:1, LP:1) NPHS2/LAMB2 (P/LP:1) COL4A4 (P/P:1) EYA1 (P:1) **TRPC6 (LP:1) PKD1 (LP:1) COL4A5 (P:1) ANKS6 (LP/LP:1) **APOL1 G1G2 (n=1) EYA1 (P:1) REN (P/P:1) PAX2 (LP:1) PBX1 (P:1) BBS10/CEP104 (LP/LP:1) SLC26A1 (P/LP:1) UMOD (P:1) WDR19 (LP/VUS:S) **This patient also had a WT1 (P:1) reported pathogenic APOL1 G1G1: 3 COL4A5 variant APOL1 G1G2: 4

Figure 1. | Expanding the gene panel increases sensitivity for detection of a clinically-significant variant. Clinical next-generation sequencing (NGS) for renal disorders: physician-ordered, panel-based clinical testing for suspected genetic kidney disease was performed on 324 consecutive patients for the following indications: (1) atypical hemolytic uremic syndrome (aHUS), thrombotic microangiopathy, and C3 glomerulopathy; (2) nephrotic syndrome and FSGS; (3) nephronophthisis and cystic kidney disease; (4) Alport syndrome; and (5) other. Clinical reports were generated for the initial gene panel and submitted to the patient medical record. Retrospective exome analysis identified additional clinically significant pathogenic and likely pathogenic variants defined by American College of Medical Genetics and Genomics criteria. P, pathogenic; LP, likely pathogenic; VUS, variants of uncertain significance. *Risk, homozygous deletion of CFHR3-CFHR1 are displayed as gene (assignment: number of patients) with “/” representing the presence of multiple variants (20). and nephronophthisis gene set. Initial panel-based testing Discussion identified 13 patients with a pathogenic or likely pathogenic In this study, we report our 4-year experience with NGS variant (Table 3). The majority of these patients had path- panel-based testing for suspected genetic kidney disease in ogenic or likely pathogenic variants in PKD1 (n59). a clinically validated laboratory. The initial physician- Exome reanalysis identified three patients with previously ordered clinical gene sets resulted in a genetic diagnosis unknown pathogenic or likely pathogenic variants resulting in in 64 of 324 patients. These results include pathogenic a new genetic diagnosis. The first patient was a 1-month-old (n523) and likely pathogenic (n519) variants in addition girl with congenital echogenic kidneys and compound het- to CFHR3-CFHR1 homozygous deletion in patients with erozygosity for a novel frameshift (p.L434fs) and previously aHUS (n522). Retrospective exome reanalysis of kidney reported splicing variant (c.1973-3C.G) in ANKS6 (32). The disease–related genes resulted in a clinically meaningful second patient was a 5-month-old boy with bilateral renal genetic diagnosis in an additional 26 patients. The retro- dysplasia and a heterozygous nonsense variant in PBX1 spective results included additional pathogenic or likely (p.Q48*). The third patient was a 3-year-old boy with con- pathogenic variants in kidney disease genes (n518) and genital absence of the left kidney and compound heterozy- eight patients with a high-risk APOL1 genotype. Our exome gosity for a novel frameshift variant (p.L92*) and previously reanalysis indicates that affected patients are likely to have reported missense variant (p.N273D) in WDR19 (33). pathogenic variants in genes that rarely cause kidney 776 KIDNEY360

Table 3. Pathogenic and likely pathogenic variants identified in physician-ordered gene set

Family Patient Gene Variant Genomic Coordinates (hg37) ACMG Novel Gene Set Historya

4 C3 p.R161W chr19:g.6718128G.A LP Yes aHUS No 66 C3 p.R1042L chr19:g.6694471C.A LP Yes aHUS No 123 C3 p.K65Q chr19:g.6719296T.G P Yes aHUS No 295 C3 p.K65Q chr19:g.6719296T.G P Yes aHUS No 2 CD46 p.C35Y chr1:g.207930365G.A LP Yes aHUS No 9 CD46 c.287-2A.G chr1:g.207930883A.G P Yes aHUS No 23 CD46 c.112712T.G chr1:g.207959029T.G P Yes aHUS No 35 CD46 c.287-2A.G chr1:g.207930883A.G P Yes aHUS No 313 CFB p.K323E chr6:g.31916220A.G LP Yes aHUS No 113 CFH p.D1119E chr1:g.196714993C.G LP No aHUS No 166 CFH p.R1210C chr1:g.196716375C.T LP Yes aHUS No 234 CFH p.R53H chr1:g.196642207G.A LP Yes aHUS No 298 CFH p.T956M chr1:g.196709833C.T LP Yes aHUS No 267 CFH c.349311G.A chr1:g.196715130G.A P Yes aHUS No 18 CFH c.61911G.A chr1:g.196646798G.A P Yes aHUS No 71 CFI p.I370N chr4:g.110670413A.T LP Yes aHUS No 304 CFI p.R474* chr4:g.110667387G.A P Yes aHUS No 85 DGKE p.W322*,p.W322* chr17:g.54926134G.A P Yes aHUS No 102 COL4A3 p.G695R chr2:g.228142227G.A LP Yes AS Yes 280 COL4A4 p.G478E chr2:g.227954610C.T LP Yes AS Yes 271 COL4A5 c.23111G.A chrX:g.107802384G.A P Yes AS Yes 264 COL4A5 c.431511G.A chrX:g.107929360G.A P Yes NPHP No 188 NPHP4 p.K424Rfs*7 chr1:g.5993238delT LP Yes NPHP Yes 244 PKD1 p.G3326D chr16:g.2149718C.T LP Yes NPHP Yes 252 PKD1 p.G1433R chr16:g.2160661C.T LP Yes NPHP Yes 250 PKD1 c.971211G.A chr16:g.2150166C.T P Yes NPHP Yes 273 PKD1 p.Q1203* chr16:g.2161561G.A P Yes NPHP No 176 PKD1 p.V2569Rfs*43 chr16:g.2143887_2143888insG P Yes NPHP No 190 PKD1 p.A3082Cfs*96 chr16:g.2152218_2152219delAT P Yes NPHP Yes 225 PKD1 p.L3834Cfs*111 chr16:g.2141819delG P No NPHP Yes 245 PKD1 p.Q2900* chr16:g.2153360G.A P Yes NPHP No 248 PKD1 p.L3999Wfs*40 chr16:g.2140892delA P No NPHP No 207 PKHD1 p.V1741M chr6:g.51889387C.T LP Yes NPHP No 233 RPGRIP1L p.D596Efs*5 chr16: LP No NPHP No g.53686809_53686823delinsAC 102 COL4A3 p.G695R chr2:g.228142227G.A LP Yes NS/ Yes FSGS 98 INF2 p.R177C chr14:g.105169653C.T LP Yes NS/ Yes FSGS 161 INF2 p.R177C chr14:g.105169653C.T LP Yes NS/ No FSGS 277 NPHS1 p.R743C chr19:g.36334481G.A LP Yes NS/ No FSGS 24 NPHS1 p.T847Rfs*57 chr19: P Yes NS/ No g.36333146_36333149delTTAG FSGS 213 NPHS1 p.L16Gfs*3 chr19:g.36342694_36342695insCC P No NS/ No FSGS 193 NPHS2 p.R138Q chr1:g.179530462C.T P Yes NS/ Yes FSGS 238 NPHS2 p.R291W chr1:g.179521740G.A P Yes NS/ No FSGS 216 WT1 p.H445R chr11:g.32414217T.C P Yes NS/ No FSGS

Variant pathogenicity assignments based upon American College of Medical Genetics and Genomics guidelines (20). ACMG, American College of Medical Genetics and Genomics; chr, chromosome; LP, likely pathogenic; aHUS, atypical hemolytic uremic syndrome; P, pathogenic; AS, Alport syndrome; NPHP, cystic renal disease and nephronophthisis; del, deletion; ins, insertion; NS, nephrotic syndrome. aFirst or second-degree relative with CKD or kidney transplant.

disease, because no two patients had a variant in the same in cases where pathogenic or likely pathogenic variants are gene. These data highlight the difficulty in designing a dis- not identified in the initial, clinically indicated gene set. ease-focused gene set for renal disorders that often have Furthermore, as new genes are added to our clinical gene overlapping clinical and pathologic phenotypes. sets, all patients that were tested before the addition of the In light of these findings, we are in the process of review- new gene will be interrogated for pathogenic variants. ing our testing paradigm that reflexes to an expanded panel Although there are currently no consensus guidelines, we KIDNEY360 1: 772–780, August, 2020 NGS Testing for Genetic Kidney Disease, Wilson et al. 777 a No No No No No No No No No No No Yes Yes No No Yes No No Yes Yes No Yes emolytic uremic syndrome; ADPKD, NS/FSGS aHUS aHUS AS NPHP aHUS aHUS aHUS aHUS NPHP aHUS aHUS aHUS aHUS aHUS NPHP GRHPR NS/FSGS, NPHP NS/FSGS AS NS/FSGS Biedl syndrome aHUS – Moon – microangiopathy membranes abnormalities, and hepatosplenomegaly GN cystic kidneys. enlarged, dysplastic right kidney loss Neonatal aHUS C Collapsing FSGS and thin basement T Cystic renal disease T Thrombocytopenia T T Congenital renal dysplasia C aHUS C G ESKD due to membranoproliferative A Laurence A Congenital ARF A aHUS A C Adult-onset FSGS TT ADPKD rule out aHUS ADPKD rule out aHUS T Nephrotic syndrome G G Congenital renal dysplasia and hearing A ADPKD rule out aHUS A ESKD due to C3 glomerulopathy and G Congenital absence left kidney and A . A A ...... chr4:g.983654G chr4:g.984938G chr1:g.3753972G chrX:107845113A chr4:g.88940651C chr4:g.88940651C chr4:g.39191386T chr16:g.2156891G chr16:g.2149956G chr4:g.39207283A chr8:g.72127681A chr10:102510464G chr9:g.101542538delA Congenital renal dysplasia, heart chr9:g.136307803C chr1:g.179530462C chr1:g.164529201C chr12:g.76740088G chr9:g.136291338G chr9:g.101530535G chr1:g.215814065G chr1:g.204131263G chr11:g.32413566G chr1:g.204131263G chr1:g.248813510A chr11:g.101375326T Genomic Coordinates (hg37) Clinical Diagnosis/Indication Initial Ordered Gene Set Family History T G c c b b c c . . 2A – p.L92* p.R43* p.R43* p.Q48* Variant p.Y226* p.Y559* p.S358L p.L513P p.N125S p.L434fs p.R213* p.R213* p.R989fs chr2:g.227917021_227917022delCT p.R989fs chr2:g.227917021_227917022delCT ESKD and thrombotic p.G107R p.R138Q p.T185M p.Q725* p.N273D p.R462W p.R3277C p.R4935* p.C1058fs chr3:g.49161980_49161981delCA Gross hematuria p.D187H p.A2375V c.1973-3C c.2042 p.H177_R185del chr16:g.20360068_20360094del FSGS WT1 REN PBX1 EYA1 EYA1 PKD2 PKD2 PKD1 PKD1 PAX2 BBS10 TRPC6 NPHS2 ANKS6 UMOD LAMB2 USH2A WDR19 CEP104 p.Q335* COL4A4 COL4A5 SLC26A1 ADAMTS13 ADAMTS13 ed in patients that underwent testing before the addition of ADAMTS13. fi 1 1 1 1 9 3 9 75 33 58 19 30 17 26 19 74 15 35 37 10 53 64 , , , , Variants were identi First or second-degree relative with CKD or kidney transplant. Variants are associated with an established clinical diagnosis. Patient Age (yr) Gene Table 4. Pathogenic and likely pathogenic variants identified in exome reanalysis 138 a b c 198 219 195 206 318 302 212 119 79 231 152 69 268 264 52 168 96 197 134 281 67 Variant pathogenicity assignments based upon American College of Medical Genetics and Genomics guidelines (20). chr, chromosome; aHUS, atypical h autosomal dominant polycystic kidney disease; AS, Alport syndrome; NPHP, cystic renal disease and nephronophthisis; NS, nephrotic syndrome. 778 KIDNEY360

believe that good laboratory practices should include ret- yield ranged from 30% to 54%, depending on disease cat- rospective review of negative cases on a semiannual to egory, and was higher in younger patients (0–14 years), yearly basis which comprised the majority of their population. An There is a wide spectrum of genetic testing options that important finding was that among the 54 patients with range from single gene to panel-based and whole-exome a genetic diagnosis, 13 patients had a change in clinical sequencing for both somatic and constitutional disorders diagnosis due to genetic testing. These data raise the pos- (34,35). Nephrology was a late adopter of clinical NGS sibility that had these patients initially received a narrow, testing and, as a result, relatively little is known about disease-focused panel; it is possible that their genetic di- the optimal approach to diagnosis of genetic kidney disease. agnosis would have been missed. Together with our data, We can draw from the experience of other specialties to these findings argue for a comprehensive approach and better understand how different modalities apply to diag- highlight the benefits of clinical NGS for kidney disease. nosis, prognosis, and precision medicine (34). To date, NGS-based testing will continue to be an important com- disease-focused panels have been the preferred approach ponent of the diagnostic workup in patients with a suspected for clinical applications; however, there are challenges to genetic component to their kidney disease and this study this approach that include development and validation of demonstrates the utility of variant reanalysis to improve separate panels for each disease process, constant updating diagnostic yield. of existing panels, and adherence to changing medical guidelines. These challenges have raised the question of Disclosures whether clinical testing should use a more comprehensive J. Gaut reports personal fees from BioLegend, grants from Na- approach like whole-exome or whole-genome sequencing tional Institutes of Health, and grants from Mid America Transplant (11,34). However, the benefits of a comprehensive approach Foundation, outside the submitted work. All remaining authors have to be weighed against their increased cost and turn- have nothing to disclose. around time, in addition to the increased likelihood of discovering VUS that may or may not be related to the Funding patient’s disease process. Currently, the majority of clinical None. laboratories rely on panel-based approaches for the diag- nosis of genetic kidney disease. An important caveat is that Acknowledgment “ ” laboratories often use an exome backbone for their clinical The results presented in this paper have not been published fi fl panels. This approach simpli es laboratory work ow by previously in whole or part, except in abstract format. employing a single library preparation, sequencing, and bioinformatics process for all patient samples, and is made possible by the decreasing cost of exome sequencing. The Author Contributions end result is that there is a large amount of unanalyzed M. Corliss, J. Gaut, L. Love-Gregory, S. McNulty, and P. Wilson genetic data that may contain clinically meaningful infor- reviewed and edited the manuscript and were responsible for data mation. A simple compromise might be to establish a work- curation, investigation, and methodology; J. Gaut, L. Love-Gregory, flow where the remaining genetic data is unmasked and S. McNulty, and P. Wilson were responsible for formal analysis and analyzed when the first disease-focused panel is negative. software; J. Gaut, L. Love-Gregory, and P. Wilson conceptualized Remaining challenges in the diagnosis of genetic kidney the study; J. Heusel, J. Gaut, L. Love-Gregory, and P. Wilson disease include difficulty in establishing the pathogenicity provided supervision; L. Love-Gregory and P. Wilson were re- of VUS and the detection of structural variants, which sponsible for visualization; P. Wilson wrote the original draft; and represent a minority of inherited kidney disease (2). The all authors were responsible for project administration, resources, difficulty with interpreting VUS will be partly resolved as and validation. clinical databases increase in size to include new patient populations and pathogenic variants. Supplemental Material However, there is a role for use of in silico computational This article contains supplemental material online at http://kidney360. prediction tools for assessing variant pathogenicity. In our asnjournals.org/lookup/suppl/doi:10.34067/KID.0001342020/-/ study, we used multiple in silico tools to predict the func- DCSupplemental. tional consequence of variants encountered in exome rean- Supplemental Table 1. Extended renal gene set. Supplemental Table 2. Patient demographics and clinical history. alysis. By limiting our investigation to variants with Supplemental Figure 1. Filtering strategy. a predicted damaging or deleterious effect, we were able to increase the likelihood that variants were assigned a likely pathogenic or pathogenic assertion under ACMG criteria References (36). One of the drawbacks of our approach is that we likely 1. Renkema KY, Stokman MF, Giles RH, Knoers NV: Next- missed clinically significant variants with a benign func- generation sequencing for research and diagnostics in kidney tional prediction. In silico analysis alone is insufficient to disease. Nat Rev Nephrol 10: 433–444, 2014 2. Sen ES, Dean P, Yarram-Smith L, Bierzynska A, Woodward G, assign pathogenicity and is lacking in sensitivity and spec- Buxton C, Dennis G, Welsh GI, Williams M, Saleem MA: Clinical ificity (35,37). A potential solution could be to design clin- genetic testing using a custom-designed steroid-resistant ne- ically validated functional assays to provide evidence for phrotic syndrome gene panel: Analysis and recommendations. pathogenicity. J Med Genet 54: 795–804, 2017 Recently, at least one group has published a case series 3. Schueler M, Halbritter J, Phelps IG, Braun DA, Otto EA, Porath JD, Gee HY, Shendure J, O’Roak BJ, Lawson JA, Nabhan MM, describing a comprehensive panel-based approach (approx- Soliman NA, Doherty D, Hildebrandt F: Large-scale targeted imately 200 genes) in a series of 127 patients (38). Diagnostic sequencing comparison highlights extreme genetic heterogeneity KIDNEY360 1: 772–780, August, 2020 NGS Testing for Genetic Kidney Disease, Wilson et al. 779

in nephronophthisis-related ciliopathies. J Med Genet 53: Ahn W, Canetta PA, Bomback AS, Appel GB, Antignac C, 208–214, 2016 Markowitz GS, Garcia CK, Kiryluk K, Sanna-Cherchi S, Gharavi 4. Rossetti S, Hopp K, Sikkink RA, Sundsbak JL, Lee YK, Kubly V, AG: Whole-exome sequencing in adults with chronic kidney Eckloff BW, Ward CJ, Winearls CG, Torres VE, Harris PC: disease: A pilot study [ published correction appears in Ann Intern Identification of gene mutations in autosomal dominant poly- Med 168: 308, 2018]. Ann Intern Med 168: 100–109, 2018 cystic kidney disease through targeted resequencing. J Am Soc 15. Gee HY, Zhang F, Ashraf S, Kohl S, Sadowski CE, Vega-Warner V, Nephrol 23: 915–933, 2012 Zhou W, Lovric S, Fang H, Nettleton M, Zhu JY, Hoefele J, Weber 5. Gaut JP, Jain S, Pfeifer JD, Vigh-Conrad KA, Corliss M, Sharma MK, LT, Podracka L, Boor A, Fehrenbach H, Innis JW, Washburn J, Levy Heusel JW, Cottrell CE: Routine use of clinical exome-based next- S, Lifton RP, Otto EA, Han Z, Hildebrandt F: KANK deficiency generation sequencing for evaluation of patients with thrombotic leads to podocyte dysfunction and nephrotic syndrome. J Clin microangiopathies. Mod Pathol 30: 1739–1747, 2017 Invest 125: 2375–2384, 2015 6. Bu F, Zhang Y, Wang K, Borsa NG, Jones MB, Taylor AO, 16. Bierzynska A, Soderquest K, Dean P,Colby E, Rollason R, Jones C, Takanami E, Meyer NC, Frees K, Thomas CP, Nester C, Smith RJH: Inward CD, McCarthy HJ, Simpson MA, Lord GM, Williams M, Genetic analysis of 400 patients refines understanding and Welsh GI, Koziell AB, Saleem MA; NephroS; UK study of Ne- implicates a new gene in atypical hemolytic uremic syndrome. phrotic Syndrome: MAGI2 mutations cause congenital nephrotic J Am Soc Nephrol 29: 2809–2819, 2018 syndrome. J Am Soc Nephrol 28: 1614–1621, 2017 7. Hwang DY, Dworschak GC, Kohl S, Saisawat P, Vivante A, Hilger 17. Braun DA, Sadowski CE, Kohl S, Lovric S, Astrinidis SA, Pabst WL, AC, Reutter HM, Soliman NA, Bogdanovic R, Kehinde EO, Tasic Gee HY, Ashraf S, Lawson JA, Shril S, Airik M, Tan W, Schapiro D, V, Hildebrandt F: Mutations in 12 known dominant disease- Rao J, Choi WI, Hermle T, Kemper MJ, Pohl M, Ozaltin F, Konrad causing genes clarify many congenital anomalies of the kidney M, Bogdanovic R, Bu¨scher R, Helmchen U, Serdaroglu E, Lifton and urinary tract. Kidney Int 85: 1429–1433, 2014 RP, Antonin W, Hildebrandt F: Mutations in nuclear pore genes 8. Groopman EE, Marasa M, Cameron-Christie S, Petrovski S, NUP93, NUP205 and XPO5 cause steroid-resistant nephrotic Aggarwal VS, Milo-Rasouly H, Li Y, Zhang J, Nestor J, Krithivasan syndrome. Nat Genet 48: 457–465, 2016 P, Lam WY, Mitrotti A, Piva S, Kil BH, Chatterjee D, Reingold R, 18. Vodopiutz J, Seidl R, Prayer D, Khan MI, Mayr JA, Streubel B, Bradbury D, DiVecchia M, Snyder H, Mu X, Mehl K, Balderes O, Steiß JO, Hahn A, Csaicsich D, Castro C, Assoum M, Mu¨ller T, Fasel DA, Weng C, Radhakrishnan J, Canetta P, Appel GB, Wieczorek D, Mancini GM, Sadowski CE, Le´vy N, Me´garbane´ A, Bomback AS, Ahn W, Uy NS, Alam S, Cohen DJ, Crew RJ, Dube Godbole K, Schanze D, Hildebrandt F, Delague V, Janecke AR, GK, Rao MK, Kamalakaran S, Copeland B, Ren Z, Bridgers J, Zenker M: WDR73 mutations cause infantile neurodegeneration Malone CD, Mebane CM, Dagaonkar N, Fellstro¨m BC, Haefliger and variable glomerular kidney disease. Hum Mutat 36: C, Mohan S, Sanna-Cherchi S, Kiryluk K, Fleckner J, March R, 1021–1028, 2015 Platt A, Goldstein DB, Gharavi AG: Diagnostic utility of exome 19. Aziz N, Zhao Q, Bry L, Driscoll DK, Funke B, Gibson JS, Grody sequencing for kidney disease. N Engl J Med 380: 142–151, 2019 WW, Hegde MR, Hoeltge GA, Leonard DG, Merker JD, 9. Mann N, Braun DA, Amann K, Tan W, Shril S, Connaughton DM, Nagarajan R, Palicki LA, Robetorye RS, Schrijver I, Weck KE, Nakayama M, Schneider R, Kitzler TM, van der Ven AT, Chen J, Voelkerding KV: College of American Pathologists’ laboratory Ityel H, Vivante A, Majmundar AJ, Daga A, Warejko JK, Lovric S, standards for next-generation sequencing clinical tests. Arch Ashraf S, Jobst-Schwan T, Widmeier E, Hugo H, Mane SM, Pathol Lab Med 139: 481–493, 2015 Spaneas L, Somers MJG, Ferguson MA, Traum AZ, Stein DR, 20. Richards S, Aziz N, Bale S, Bick D, Das S, Gastier-Foster J, Grody Baum MA, Daouk GH, Lifton RP, Manzi S, Vakili K, Kim HB, WW, Hegde M, Lyon E, Spector E, Voelkerding K, Rehm HL; Rodig NM, Hildebrandt F: Whole-exome sequencing enables ACMG Laboratory Quality Assurance Committee: Standards and a precision medicine approach for kidney transplant recipients. guidelines for the interpretation of sequence variants: A joint J Am Soc Nephrol 30: 201–215, 2019 consensus recommendation of the American College of medical 10. van der Ven AT, Connaughton DM, Ityel H, Mann N, Nakayama genetics and Genomics and the association for molecular M, Chen J, Vivante A, Hwang DY, Schulz J, Braun DA, Schmidt Pathology. Genet Med 17: 405–424, 2015 JM, Schapiro D, Schneider R, Warejko JK, Daga A, Majmundar 21. Sharma MK, Phillips J, Agarwal S, Wiggins WS, Shrivastava S, AJ, Tan W, Jobst-Schwan T, Hermle T, Widmeier E, Ashraf S, Amar Koul SB, Bhattacharjee M, Houchins CD, Kalakota RR, George B, A, Hoogstraaten CA, Hugo H, Kitzler TM, Kause F, Kolvenbach Meyer RR, Spencer DH, Lockwood CM, Nguyen TT, Duncavage CM, Dai R, Spaneas L, Amann K, Stein DR, Baum MA, Somers EJ, Al-Kateb H, Cottrell CE, Godala S, Lokineni R, Sawant SM, MJG, Rodig NM, Ferguson MA, Traum AZ, Daouk GH, Chatti V, Surampudi S, Sunkishala RR, Darbha R, Macharla S, Bogdanovic R, Stajic N, Soliman NA, Kari JA, El Desoky S, Fathy Milbrandt JD, Virgin HW, Mitra RD, Head RD, Kulkarni S, HM, Milosevic D, Al-Saffar M, Awad HS, Eid LA, Selvin A, Bredemeyer A, Pfeifer JD, Seibert K, Nagarajan R: Clinical Senguttuvan P, Sanna-Cherchi S, Rehm HL, MacArthur DG, Lek genomicist workstation. AMIA Jt Summits Transl Sci Proc 2013: M, Laricchia KM, Wilson MW, Mane SM, Lifton RP, Lee RS, Bauer 156–157, 2013 SB, Lu W, Reutter HM, Tasic V, Shril S, Hildebrandt F: Whole- 22. Lek M, Karczewski KJ, Minikel EV, Samocha KE, Banks E, Fennell exome sequencing identifies causative mutations in families with T, O’Donnell-Luria AH, Ware JS, Hill AJ, Cummings BB, congenital anomalies of the kidney and urinary tract. J Am Soc Tukiainen T, Birnbaum DP, Kosmicki JA, Duncan LE, Estrada K, Nephrol 29: 2348–2361, 2018 Zhao F, Zou J, Pierce-Hoffman E, Berghout J, Cooper DN, Deflaux 11. Vivante A, Hildebrandt F: Exploring the genetic basis of early-onset N, DePristo M, Do R, Flannick J, Fromer M, Gauthier L, Goldstein chronic kidney disease. Nat Rev Nephrol 12: 133–146, 2016 J, Gupta N, Howrigan D, Kiezun A, Kurki MI, Moonshine AL, 12. Braun DA, Schueler M, Halbritter J, Gee HY, Porath JD, Lawson Natarajan P, Orozco L, Peloso GM, Poplin R, Rivas MA, Ruano- JA, Airik R, Shril S, Allen SJ, Stein D, Al Kindy A, Beck BB, Cengiz Rubio V, Rose SA, Ruderfer DM, Shakir K, Stenson PD, Stevens C, N, Moorani KN, Ozaltin F, Hashmi S, Sayer JA, Bockenhauer D, Thomas BP, Tiao G, Tusie-Luna MT, Weisburd B, Won HH, Yu D, Soliman NA, Otto EA, Lifton RP, Hildebrandt F: Whole exome Altshuler DM, Ardissino D, Boehnke M, Danesh J, Donnelly S, sequencing identifies causative mutations in the majority of Elosua R, Florez JC, Gabriel SB, Getz G, Glatt SJ, Hultman CM, consanguineous or familial cases with childhood-onset increased Kathiresan S, Laakso M, McCarroll S, McCarthy MI, McGovern D, renal echogenicity. Kidney Int 89: 468–475, 2016 McPherson R, Neale BM, Palotie A, Purcell SM, Saleheen D, 13. Garg N, Zhang Y, Nicholson-Weller A, Khankin EV, Borsa NG, Scharf JM, Sklar P, Sullivan PF, Tuomilehto J, Tsuang MT, Watkins Meyer NC, McDermott S, Stillman IE, Rennke HG, Smith RJ, HC, Wilson JG, Daly MJ, MacArthur DG; Exome Aggregation Pavlakis M: C3 glomerulonephritis secondary to mutations in Consortium: Analysis of protein-coding genetic variation in factors H and I: Rapid recurrence in deceased donor kidney 60,706 humans. Nature 536: 285–291, 2016 transplant effectively treated with eculizumab. Nephrol Dial 23. Genovese G, Friedman DJ, Ross MD, Lecordier L, Uzureau P, Transplant 33: 2260–2265, 2018 Freedman BI, Bowden DW, Langefeld CD, Oleksyk TK, Uscinski 14. Lata S, Marasa M, Li Y, Fasel DA, Groopman E, Jobanputra V, Knob AL, Bernhardy AJ, Hicks PJ, Nelson GW, Vanhollebeke B, Rasouly H, Mitrotti A, Westland R, Verbitsky M, Nestor J, Slater Winkler CA, Kopp JB, Pays E, Pollak MR: Association of trypa- LM, D’Agati V, Zaniew M, Materna-Kiryluk A, Lugani F, Caridi G, nolytic ApoL1 variants with kidney disease in African Americans. Rampoldi L, Mattoo A, Newton CA, Rao MK, Radhakrishnan J, Science 329: 841–845, 2010 780 KIDNEY360

24. Richards A, Buddles MR, Donne RL, Kaplan BS, Kirk E, Venning 29.5% of cases of steroid-resistant nephrotic syndrome. J Am Soc MC, Tielemans CL, Goodship JA, Goodship TH: Factor H Nephrol 26: 1279–1289, 2015 mutations in hemolytic uremic syndrome cluster in exons 18-20, 33. Devriendt K, Matthijs G, Van Damme B, Van Caesbroeck D, a domain important for host cell recognition. Am J Hum Genet Eccles M, Vanrenterghem Y, Fryns JP, Leys A: Missense mutation 68: 485–490, 2001 and hexanucleotide duplication in the PAX2 gene in two un- 25. Bresin E, Rurali E, Caprioli J, Sanchez-Corral P, Fremeaux-Bacchi related families with renal-coloboma syndrome (MIM 120330). V, Rodriguez de Cordoba S, Pinto S, Goodship TH, Alberti M, Hum Genet 103: 149–153, 1998 Ribes D, Valoti E, Remuzzi G, Noris M; European Working Party 34. Hart TC, Gorry MC, Hart PS, Woodard AS, Shihabi Z, Sandhu J, on Complement Genetics in Renal Diseases: Combined com- Shirts B, Xu L, Zhu H, Barmada MM, Bleyer AJ: Mutations of the plement gene mutations in atypical hemolytic uremic syndrome UMOD gene are responsible for medullary cystic kidney disease influence clinical phenotype. J Am Soc Nephrol 24: 475–486, 2 and familial juvenile hyperuricaemic nephropathy. J Med Genet 2013 39: 882–892, 2002 26. Jokiranta TS, Jaakola VP, Lehtinen MJ, Pa¨repalo M, Meri S, 35. Gigante M, Caridi G, Montemurno E, Soccio M, d’Apolito M, Goldman A: Structure of complement factor H carboxyl-terminus Cerullo G, Aucella F, Schirinzi A, Emma F, Massella L, Messina G, reveals molecular basis of atypical haemolytic uremic syndrome. De Palo T, Ranieri E, Ghiggeri GM, Gesualdo L: TRPC6 mutations EMBO J 25: 1784–1794, 2006 in children with steroid-resistant nephrotic syndrome and atyp- 27. Kajander T, Lehtinen MJ, Hyva¨rinen S, Bhattacharjee A, Leung E, ical phenotype. Clin J Am Soc Nephrol 6: 1626–1634, 2011 Isenman DE, Meri S, Goldman A, Jokiranta TS: Dual interaction of 36. Hoff S, Halbritter J, Epting D, Frank V, Nguyen TM, van Reeuwijk factor H with C3d and glycosaminoglycans in host-nonhost J, Boehlke C, Schell C, Yasunaga T, Helmsta¨dter M, Mergen M, discrimination by complement. Proc Natl Acad Sci U S A 108: Filhol E, Boldt K, Horn N, Ueffing M, Otto EA, Eisenberger T, 2897–2902, 2011 Elting MW, van Wijk JA, Bockenhauer D, Sebire NJ, Rittig S, 28. Lotta LA, Garagiola I, Palla R, Cairo A, Peyvandi F: ADAMTS13 Vyberg M, Ring T, Pohl M, Pape L, Neuhaus TJ, Elshakhs NA, mutations and polymorphisms in congenital thrombotic throm- Koon SJ, Harris PC, Grahammer F, Huber TB, Kuehn EW, Kramer- bocytopenic purpura. Hum Mutat 31: 11–19, 2010 Zucker A, Bolz HJ, Roepman R, Saunier S, Walz G, Hildebrandt F, 29. Gribouval O, Gonzales M, Neuhaus T, Aziza J, Bieth E, Laurent Bergmann C, Lienkamp SS: ANKS6 is a central component of N, Bouton JM, Feuillet F, Makni S, Ben Amar H, Laube G, a nephronophthisis module linking NEK8 to INVS and NPHP3. Delezoide AL, Bouvier R, Dijoud F, Ollagnon-Roman E, Roume J, Nat Genet 45: 951–956, 2013 Joubert M, Antignac C, Gubler MC: Mutations in genes in the 37. Zhang W, Taylor SP, Ennis HA, Forlenza KN, Duran I, Li B, renin-angiotensin system are associated with autosomal recessive Sanchez JAO, Nevarez L, Nickerson DA, Bamshad M, Lachman renal tubular dysgenesis. Nat Genet 37: 964–968, 2005 RS, Krakow D, Cohn DH; University of Washington Center for 30. Gee HY, Jun I, Braun DA, Lawson JA, Halbritter J, Shril S, Nelson Mendelian Genomics: Expanding the genetic architecture and CP, Tan W, Stein D, Wassner AJ, Ferguson MA, Gucev Z, Sayer JA, phenotypic spectrum in the skeletal ciliopathies. Hum Mutat 39: Milosevic D, Baum M, Tasic V, Lee MG, Hildebrandt F: Mutations 152–166, 2018 in SLC26A1 cause nephrolithiasis. Am J Hum Genet 98: 38. Patrick AN, Cabrera JH, Smith AL, Chen XS, Ford HL, Zhao R: 1228–1234, 2016 Structure-function analyses of the human SIX1-EYA2 complex 31. Estrella MM, Parekh RS: The expanding role of APOL1 risk in reveal insights into metastasis and BOR syndrome. Nat Struct Mol chronic kidney disease and cardiovascular disease. Semin Biol 20: 447–453, 2013 Nephrol 37: 520–529, 2017 32. Sadowski CE, Lovric S, Ashraf S, Pabst WL, Gee HY, Kohl S, Received: March 16, 2020 Accepted: May 12, 2020 Engelmann S, Vega-Warner V, Fang H, Halbritter J, Somers MJ, “ Tan W, Shril S, Fessi I, Lifton RP, Bockenhauer D, El-Desoky S, See related editorial, Genetic Analysis in Kidney Disease: Kari JA, Zenker M, Kemper MJ, Mueller D, Fathy HM, Soliman Advancing Clinical Diagnosis and Research Discovery” on pages NA, Hildebrandt F; SRNS Study Group: A single-gene cause in 720–723. Supplemental Contents: Supplementary Table 1: Extended Renal Gene Set Supplementary Table 2: Patient Demographics and Clinical History Supplementary Figure 1: Filtering Strategy

Supplementary Table 1: Extended Renal Gene Set ACE ACTN4 ADAMTS13 ADCK4 AGT AGTR1 AGXT AHI1 ALG8 ALMS1 AMN ANKS6 ANLN AP2S1 APOA1 APOE APOL1 APRT AQP2 ARGHDIA ARHGAP24 ARL13B ARL6 ATP2A2 ATP6B1 ATP6V0A4 AVP AVPR2 BBS1 BBS10 BBS12 BBS2 BBS4 BBS5 BBS7 BBS9 BCS1L BICC1 BMP4 BRAF BRIP1 BSND C2orf86 C3 CA2 CACNA1S CASR CC2D2A CCDC28B CD151 CD2AP CD46 CDC5L CDKN1C CEP104 CEP164 CEP290 CFB CFH CFHR1 CFHR2 CFHR3 CFHR4 CFHR5 CFI CHD7 CHRM3 CLCKNB CLCN5 CLDN16 CLDN19 COL4A3 COL4A4 COL4A5 COL4A6 COQ2 COQ6 CPT2 CRB2 CREBBP CSPP1 CTNS CUBN CUL3 CYP11B1 CYP17A1 DGKE DHCR7 DLG3 DLL3 DNMT3B DSTYK EGF EIF2AK3 EMP2 ERCC4 ERCC8 ESCO2 ETFA ETFB ETFDH EYA1 FAN1 FANCA FANCB FANCC FANCD2 FANCE FANCF FANCG FANCI FANCL FANCM FGA FGF10 FGF20 FGF23 FGFR1 FGFR2 FGFR3 FN1 FOXC1 FOXC2 FOXF1 FRAS1 FREM1 FRTS FXYD2 GALNT3 GDNF GLA GLIS2 GPC3 GRHPR GSN H19 HNF1B HOXA1 HOXA13 HOXD13 HPSE2 HRAS HSD11B2 HSD17B4 ICK IKBKAP INF2 INPP5E INVS IQCB1 ITGA3 ITGB4 JAG1 JBTS15 KANK1 KANK2 KANK4 KCNJ10 KCNJ5 KCNQ1OT1 KLHL3 KRAS LAMB2 LCAT LMX1B LRIG2 LRP2 LRP4 LYZ MAGI2 MAP2K1 MAP2K2 MAX MCP MEFV MKKS MKS1 MLL2 MMACHC MMP1 MNX1 MRE11A MUC1 MUT MVK MYCN MYH9 MYO1E NEIL1 NEK8 NIPBL NKCC2 NLRP3 NOTCH2 NPHP1 NPHP3 NPHP4 NPHS1 NPHS2 NR3C2 NSD1 NUP107 NUP205 NUP93 OCRL OFD1 PAF1 PALB2 PAX2 PBX1 PDSS2 PEX1 PEX12 PEX14 PEX26 PEX5 PEX6 PHEX PKD1 PKD2 PKHD1 PLCE1 PROK2 PROKR2 PTEN PTPN11 PTPRO PVRL1 PXMP3 RECQL4 REN RET ROBO2 ROMK ROR2 RPGRIP1L SAC SALL1 SALL4 SCARB2 SCN4A SCNN1A SCNN1B SCNN1G SDCCAG8 SDHB SDHD SEMA3E SHH SIX1 SIX2 SIX5 SLC12A3 SLC22A12 SLC26A1 SLC26A4 SLC2A10 SLC34A1 SLC34A3 SLC3A1 SLC4A1 SLC4A4 SLC5A2 SLC7A9 SLC9A3R1 SLIT2 SMARCAL1 SMC1A SOX3 STRA6 SUCLA2 TFAP2A THBD TMEM127 TMEM216 TMEM237 TMEM67 TNFRSF1A TP63 TRAP1 TRIM32 TRPC6 TRPM6 TSC1 TSC2 TTC21B TTC8 TTR UBE3A UMOD UPK3A UQCRB UQCRQ USH2A VANGL1 VHL VIPAR VPS33B WDR19 WDR73 WFS1 WNK1 WNK4 WNT3 WT1 XDH XPNPEP3 XPO5 ZNF423

Supplementary Table 2 – Patient Demographics and Clinical History Patient ID Age Gender Race Gene Set Clinical History 1 25 M HIS aHUS 25M referred for aHUS genetic testing. Limited clinical history. 2 24 M W aHUS 24M with HUS and TTP referred for aHUS genetic testing. Limited clinical history. 3 41 F HIS aHUS 41F with aHUS and anemia referred for aHUS genetic testing. Limited clinical history. 4 45 F W aHUS 45F referred for aHUS genetic testing. Limited clinical history. 5 28 F OTH aHUS 28F referred for aHUS genetic testing. Limited clinical history. 6 36 F W aHUS 36F referred for aHUS genetic testing. Limited clinical history. 7 4 M OTH aHUS 4M referred for aHUS genetic testing. Limited clinical history. 8 28 M W aHUS 28M referred for aHUS genetic testing. Limited clinical history. 9 25 F HIS aHUS 25F with TMA referred for aHUS genetic testing. Limited clinical history. 10 63 F W aHUS 63F with ESRD 2/2 C3GN s/p transplant in 2016. disease onset 2006. No family history of kidney disease 11 30 M W aHUS 30M ESRD 2/2 C3GN dx 3/2017 s/p transplant in 5/2017. History of gout. Hyptertension dx at age 28 with CKD4 2/2 C3GN biopsy-confirmed. Family history of hypertension and diabetes in his sister but no kidney disease. 12 43 M W aHUS 43M with a family history of aHUS referred for aHUS genetic testing. Limited clinical history. 13 40 F W aHUS 40F with a family history of aHUS referred for aHUS genetic testing. Limited clinical history. 14 51 F AA aHUS 51F referred for aHUS genetic testing. Limited clinical history. 15 31 F HIS aHUS 31F referred for aHUS genetic testing. Limited clinical history. 16 24 F W aHUS 24F referred for aHUS genetic testing. Limited clinical history. 17 39 F OTH aHUS 39F referred for aHUS genetic testing. Limited clinical history. 18 46 M W aHUS 46M s/p kidney transplant in Aug 2016. Disease onset Mar 2010 with biopsy-confirmed TMA. Clinical dx of TTP. 19 13 F HIS aHUS 13F with C3GN referred for aHUS genetic testing. Limited clinical history. 20 39 M W aHUS 39M with ESRD 2/2 biopsy-proved TMA 21 1 F W nephrotic 21moF with nephrotic syndrome s/p transplant. Kidney biopsy showed minimal change disease. She had a positive ANA. No family history of kidney disease. 22 26 M HIS aHUS 26M with TMA and ARF referred for aHUS genetic testing. Limited clinical history. 23 50 F W aHUS 50F with TTP referred for aHUS genetic testing. Limited clinical history. 24 3 M OTH nephrotic 3M with nephrotic syndrome referred for nephrotic syndrome / FSGS genetic testing. Limited clinical history 25 61 M W aHUS 61M with ESRD 2/2 C3GN s/p transplant. No family history of kidney disease. 26 26 F W aHUS 26F with ESRD s/p transplant due to E.Coli-positive HUS at the age of 4. 27 24 M W aHUS 24M with ESRD 2/2 HUS s/p transplant. No family h/o kidney disease 28 25 F W aHUS 25F with a history of HUS at 18mo with renal function recovery until recently. 29 14 M W nephrotic 14M with nephrotic syndrome and FSGS s/p transplant at age 16. Family history of younger brother and father also with MCD. 30 18 F AA aHUS 18F with HUS and systemic vasculitis referred for aHUS genetic testing. Limited clinical history. 31 61 M W aHUS 61M referred for aHUS genetic testing. Limited clinical history. 32 37 F W aHUS 37F referred for aHUS genetic testing. Limited clinical history. 33 39 F AA aHUS 39F referred for aHUS genetic testing. Limited clinical history. 34 43 M W aHUS 43M with TTP referred for aHUS genetic testing. Limited clinical history. 35 27 F HIS aHUS 27F with HUS referred for aHUS genetic testing. Limited clinical history. 36 3 M OTH nephrotic 3M with nephrotic syndrome referred for nephrotic syndrome / FSGS genetic testing. Limited clinical history. 37 35 F W aHUS 35F with ESRD 2/2 C3GN and nephrotic syndrome during pregnancy with recurrence during her second pregnancy. During the first pregnancy she had endometritis and was treated for infection. Mother has a horseshoe kidney and mother and father both have HTN. Otherwise, no family history of kidney disease. 38 31 M AS aHUS 31M with ESRD and aHUS referred for aHUS genetic testing. Limited clinical history. 39 43 F AA aHUS 43F with ESRD 2/2 lupus s/p transplant June 2015. 40 48 F AA aHUS 48F with ESRD 2/2 sarcoidosis. 41 46 F W aHUS 46F referred for aHUS genetic testing. Limited clinical history. 42 65 F W aHUS 65F referred for aHUS genetic testing. Limited clinical history. 43 69 M W aHUS 69M referred for aHUS genetic testing. Limited clinical history. 44 21 F OTH aHUS 21F with ESRD 2/2 IGA nephropathy. No family history of kidney disease. 45 33 F AA aHUS 33F with ESRD 2/2 severe preeclampsia s/p transplant. Family history of nonobstructive cardiomyopathy and sudden cardiac death. 46 60 M W aHUS 60M referred for aHUS genetic testing. Limited clinical history. 47 24 F W aHUS 24F referred for aHUS genetic testing. Limited clinical history. 48 43 M OTH aHUS 24F referred for aHUS genetic testing. Limited clinical history. 49 39 M AA aHUS 39M with ESRD 2/2 HTN. No family history of kidney disease. 50 36 M AA aHUS 36M with ESRD 2/2 C3GN s/p kidney transplant. First transplant 2/2 FSGS diagnosed at age 18 and c/b recurrent FSGS. Transplant was from his mother. 51 20 F HIS aHUS 20F with lupus and C3GN referred for aHUS genetic testing. Limited clinical history. 52 35 F W aHUS 35F with a clinical diagnosis of Laurence-Moon syndrome (retinitis pigmentosa, obesity, possible hypogonadism) and a history of congenital nephrotic syndrome. She underwent kidney transplant which was complicated by thrombosis for which she received aHUS genetic testing. 53 2 F W aHUS 2F with clinical history of bloody diarrhea after traveling to Mexico received genetic aHUS testing. She is homozygous for CFHR3-1 deletion. 54 21 M W aHUS 21M with ESRD 2/2 IgA nephropathy and FSGS with a failed kidney transplant. He initially presented with gross hematuria. He is s/p transplant from his mother 55 25 F W aHUS 25F referred for aHUS genetic testing. Limited clinical history. 56 9 M W,AA aHUS 9M referred for aHUS genetic testing. Limited clinical history. 57 1 F HIS nephrotic 1F with nephrotic syndrome referred for nephrotic syndrome / FSGS genetic testing. Limited clinical history. 58 44 F W aHUS 44F with HUS, ARF, anemia, and thrombocytopenia. ADAMTS13 activity of 88%. No family history of kidney disease 59 32 M AA aHUS 32M referred for aHUS genetic testing. Limited clinical history. 60 19 F W aHUS 19F referred for aHUS genetic testing. Limited clinical history. 61 51 F W aHUS 51F referred for aHUS genetic testing. Limited clinical history. 62 23 M W aHUS 23M with biopsy-confirmed C3GN and proteinuria. 63 45 F W aHUS 45F with HUS referred for aHUS genetic testing. Limited clinical history. 64 47 F W aHUS 47F with ARF, hypocomplementemia, hemolysis referred for aHUS genetic testing. Limited clinical history. 65 64 M W aHUS 64M that presented with severe abdominal pain was found to have MAHA, thrombocytopenia, splenic infarct. ADAMTS13 activity was 70%. PMH of DM2, HTN, HPL, necrotizing pancreatitis unknown etiology. At age 54 he underwent pancreas resection c/b pancreatic insufficiency. Family history of MI and kidney cancer in father. 66 9 F W aHUS 9F referred for aHUS genetic testing. Limited clinical history. 67 64 M W oxalosis 64M with ESRD 2/2 renal dysplasia. Lost the first transplant to oxalosis. History of hearing loss since childhood. Mother died of parkinsons and father of heart disease. Brother and brother's children are in good health. 68 46 F AA aHUS 46F with ESRD 2/2 preeclampsia. History of bilateral upper body central vein stenosis. No family history of kidney disease. 69 12 F W aHUS 12F with ESRD 2/2 nephrotic syndrome referred for aHUS genetic testing. Patient presented at 7mo. Limited clinical history. 70 74 M W aHUS 74M referred for aHUS genetic testing. Limited clinical history. 71 23 M W aHUS 23M referred for aHUS genetic testing. Limited clinical history. 72 50 M W aHUS 50M ESRD of unknown etiology s/p kidney transplant jan 2016. He started dialysis at age 48 after presenting with presumed HUS / TTP. Family history of hyperlipidemia and hypertension but no kidney disease. 73 13 F W nephrotic 13F with steroid-resistant nephrotic syndrome. She had a kidney biopsy that showed minimal change disease. No hematuria or systemic symptoms. 74 34 F W aHUS 34F referred for aHUS genetic testing. Limited clinical history. 75 26 F W aHUS 26F referred for aHUS genetic testing. Limited clinical history. 76 3mo F OTH nephrotic 3moF with congenital nephrotic syndrome. Limited clinical history. 77 15 F W APOL1 15F with obesity, hypertension and a solitary right kidney cyst. 78 16 M AA nephrotic 16M with CKD and a kidney biopsy showing collapsing FSGS and is APOL1 G1G2. No history of hypertension or diabetes. No family history of kidney disease. RUS shows bilateral echogenic kidneys with no visible cysts. 79 26 F W aHUS 28F with ESRD 2/2 MPGN. Kidney biopsy was c/w secondary membranous. h/o positive ana and apls but no lupus. Kidney dz onset age 22. pt with mitral regurg. Famhx htn. She has multiple autoab including anti-cardiolipin. No h/o hearing loss. 80 71 M W aHUS 74M with immune mediated length-dependent axonal sensory neuropathy in the setting of positive TS-HDS antibodies, vasculitis, chronic kidney disease stage 4 and a free kappa light-chain monoclonal protein. He initially presented with a clinical diagnosis of aHUS made by kidney biopsy. At that time he had mild thrombocytopenia with a platelet count of ~100k and renal insufficiency. PMH significant for HTN and HPL. No family history of kidney disease. 81 22 M W aHUS 22M with ESRD 2/2 MPGN type 1 with a positive C3 nephritic factor s/p kidney transplant in 2016. 82 52 F W aHUS 52F referred for aHUS genetic testing. Limited clinical history. 83 30 M W aHUS 30M referred for aHUS genetic testing. Limited clinical history. 84 74 F W aHUS 74F with metastatic ovarian cancer that developed kidney injury and tma. Limited clinical hx. 85 14 M W aHUS 14M referred for aHUS genetic testing. Limited clinical history. 86 18 F OTH aHUS 18F with referred for aHUS genetic testing. Limited clinical history. 87 61 M AA aHUS 61M referred for aHUS genetic testing. Limited clinical history. 88 58 M W aHUS 58M with ESRD 2/2 biopsy-proven diabetic nephropathy. He underwent living-related kidney transplantation a Sep 2010. Developed chronic kidney disease following transplantation with FSGS on a kidney transplant biopsy. 89 48 M AA APOL1 48M referred for APOL1 genetic testing with nephrotic syndrome and CKD 2/2 FSGS, bilateral hip osteonecrosis, and a history of substance abuse. 90 26 F W aHUS 26F referred for aHUS genetic testing. Limited clinical history. 91 13 M AA nephrotic 13M with a history of nephrotic syndrome, facial swelling, hematuria and leukopenia. The patient had a 3mo history of a hyperpigmented rash on his chin. A kidney biopsy showed collapsing FSGS. RUS identified worsening bilateral nephrocalcinosis and parenchymal echogenicity. He has a family history of glomerulonephritis in his maternal grandmother, and lupus in his paternal grandmother. 92 13 F OTH aHUS,nephrotic 13F with steroid-resistant nephrotic syndrome. She initially presented with streptococcal pneumonia and developed HUS with multiorgan failure. Kidney biopsy results were consistent with MCD / FSGS. Family history of maternal great grandfather, maternal grandfather, and maternal great aunt with nephrotic syndrome. 93 31 F W aHUS 31F referred for aHUS genetic testing. Limited clinical history. 94 5 M AA nephrotic 4M with steroid-dependent nephrotic syndrome. His family history is significant for a maternal grandmother with lupus, and multiple paternal relatives with lupus and rheumatoid arthritis. Kidney biopsy was consistent with MCD. 95 9 F W nephrotic 6F with steroid-responsive biopsy-confirmed MCD c/b multiple relapses. Family histroy of kidney stones in her mother but otherwise no history of kidney disease. 96 9 F AA nephrotic 9F with persistent gross hematuria and biopsy showing FSGS with normal thickness gbm. She has a family history of ESRD in her mother 2/2 igan. She has 2 healthy siblings. 97 63 M AS aHUS 63M referred for aHUS genetic testing. Limited clinical history. 98 31 F W nephrotic 31F with FSGS. She initially presented at age 24 with proteinuria and has progressed to CKD3. She had a kidney biopsy at age 26 that showed FSGS and nephrocalcinosis. She has a strong family history of kidney disease and ESRD in her father who is s/p kidney transplant. 99 28 F W aHUS 31F with ESRD 2/2 MPGN type 1 now s/p kidney transplant at the age of 30. She has a history of Goodpastures syndrome with pulmonary hemorrhage at age 29. She does not have a family history of kidney disease. 100 24 M HIS aHUS 24M referred for aHUS genetic testing. Limited clinical history. 101 55 F W alport,nephroti 55F undergoing kidney donor evaluation for her c mother. She has a family history of ESRD in her mother and brother. Her father and sister have diabetes. 102 74 F W alport,nephroti 75F with a history of FSGS diagnosed by kidney c biopsy at age 72 s/p transplant. She has a history of ESRD and sub-nephrotic proteinuria with hearing loss and intermittent hematuria. Her brother has CKD and her mother has diabetes. Her sister has proteinuria. 103 19 M W alport,nephroti 19M with biopsy-proven FSGS. He has a family c history of ESRD in his father, brother, and paternal relatives. 104 23 M AS aHUS 23M with a history of C3GN. No family history of kidney disease. 105 14 F W nephrotic 14F with a history of rituximab-responsive FSGS. She presented at age 12 after a week of vomiting and diarrhea. She does not have a family history of kidney disease. 106 10 F W nephrotic 10F with ARF of unknown etiology. Presented with a 1 week history of fever, nausea, vomiting and diarrhea. RUS is normal. Her kidney function subsequently normalized. 107 16 F W nephrotic 16F with abdominal pain, constipation, and AKI. She has a history of recurrent UTI. No family history of kidney disease. 108 52 F AA aHUS 52F with a history of ESRD s/p kidney transplant at age 35 for hypertensive nephrosclerosis. She developed ESRD at age 29 following her 2nd pregnancy. CT abdomen showed atrophic bilateral kidneys with a 7mm cyst in the lower pole of the left kidney thought to be a hemorrhagic cyst. She does not have a family history of kidney disease. 109 34 F W nephrotic 34F evaluated for living kidney donation to her sister who has ESRD 2/2 obesity-related FSGS diagnosed at age 20. No other family members have a history of kidney disease. 110 41 M OTH nephrotic 41M referred for nephrotic/FSGS genetic testing. Limited clinical history. 111 24 F W aHUS 24F referred for aHUS genetic testing. Limited clinical history. 112 41 M W aHUS 41M with ESRD 2/2 biopsy-proved TMA attributed to HTN s/p kidney transplant. He does not have a family history of kidney disease. 113 1 M OTH aHUS 9mo with anemia, thrombocytopenia, and E.coli- positive blood diarrhea c/w HUS. 114 55 F AA aHUS 55F with a history of TMA referred for aHUS genetic testing. Limited clinical history. 115 34 F W aHUS 34F referred for aHUS genetic testing. Limited clinical history. 116 59 F HIS aHUS 59F referred for aHUS genetic testing. Limited clinical history. 117 69 F W aHUS 69F with biopsy findings of C3GN. She has a history of NASH-related cirrhosis. Her family history is significant for her mother with cirrhosis. 118 36 F W,HIS aHUS 36F referred for aHUS genetic testing. Limited clinical history. 119 17 M W alport 17M with gross hematuria. Normal serum creatinine and no proteinuria. Normal RUS. Renal biopsy normal in 2012. Family history significant for maternal uncle with a kidney transplant for unknown reason. 120 37 M W custom 37M with CKD 2/2 medullary cystic disease. Family history is significant for 3 brothers with kidney disease one of which received a kidney transplant. His mother died of leukemia and ARF but it is unclear if she had kidney disease. His maternal grandfather had kidney disease and so did at least 2 of his maternal grandfathers brothers. No family history of gout or hyperuricemia. Clinical suspicion for AD tubulointerstitial kidney disease. 121 29 F HIS aHUS 29F referred for aHUS genetic testing. Limited clinical history. 122 70 F OTH aHUS 70F from Jordan with CKD of unclear etiology. Kidney biopsy showed secondary FSGS with suspicion for TMA. Patient has HTN and DM2. She does not have a family history of kidney disease. 123 32 M W aHUS 32M with a history of nausea, vomiting, abdominal pain and ARF. No family history of kidney disease. 124 66 F W alport 66-year-old Caucasian female with past medical history of fibromyalgia, interstitial pulmonary fibrosis, hypertension, hypercholesterolemia, insomnia, fibromuscular dysplasia of the carotid, carotid artery occlusion and cerebrovascular accidents, arthritis, spinal stenosis and multiple abdominal surgeries. Her renal function has for the most part always been relatively normal, but she states that she has had microscopic hematuria for at least 10 years. She saw a nephrologist over 10 years ago who diagnosed her with Alport syndrome based on family history. A kidney biopsy was never done. Her father was reportedly diagnosed with Alport syndrome in his 50s and was initiated on dialysis at age 58. He ultimately passed from complications of end stage renal disease at age 59. The patient and her son report a very strong family history of kidney disease but upon further questioning, it does not appear to be a monogenic disorder. The patient has a sister who has kidney stones. She also has a granddaughter who had some form of a stent placed in her renal artery when she was relatively young and she has a great granddaughter who is 4 years old and being evaluated by a nephrologist currently for an "inflamed kidney." Other than her father, no family members were initiated on dialysis nor had history of early hearing loss. 125 39 M W aHUS 39M with ESRD 2/2 MPGN now s/p transplant. He was first diagnosed with CKD at age 15. No family history of kidney disease. 126 6 M AA aHUS 6M referred for aHUS genetic testing. Limited clinical history. 127 38 F AS aHUS 38F referred for aHUS genetic testing. Limited clinical history. 128 59 F W aHUS 59F with aHUS s/p plasmapheresis and eculizumab. She does not have a family history of kidney disease. 129 43 F W aHUS 43F referred for aHUS genetic testing. Limited clinical history. 130 39 F W aHUS 39F referred for aHUS genetic testing. Limited clinical history. 131 7 F W aHUS 7F referred for aHUS genetic testing. Limited clinical history. 132 13 F W aHUS 13F referred for aHUS genetic testing. Limited clinical history. 133 34 F W aHUS 34F with ESRD 2/2 IgA nephropathy and preeclampsia with TMA. No family history of kidney disease. 134 16 M W nephrotic,alpor 16M with "possible" ADPKD and hypertension. He t,nephronopthis has had renal cysts since the age of 10 and has is,custom since developed proteinuria and CKD3. A kidney biopsy showed FSGS. His mother does not have a history of kidney disease but his father's history is unknown. 135 18 F W aHUS 18F referred for aHUS genetic testing. Limited clinical history. 136 79 F W aHUS 79F referred for aHUS genetic testing. Limited clinical history. 137 35 F AA aHUS 35F with a history of urinary tract infections and nephrolithiasis that had an epidose of flank pain, dysuria and vomiting. Her serum creatinine rose to 3.8 and she had leukocytosis (32K), thrombocytopenia (4k) and hemolytic anemia. She improved after plasmapheresis. 138 75 F W aHUS 75F referred for aHUS genetic testing. Limited clinical history. 139 56 F W aHUS 56F referred for aHUS genetic testing. Limited clinical history. 140 22 F W aHUS 22F referred for aHUS genetic testing. Limited clinical history 141 57 F W aHUS/tma/c3 57F referred for aHUS genetic testing. She does not have a family history of kidney disease. 142 59 F AA aHUS 59F referred for aHUS genetic testing. Limited clinical history. 143 37 M AA aHUS 37M referred for aHUS genetic testing. Limited clinical history. 144 30 M W aHUS/tma/c3 30M donor evaluation for his sister who has pregnancy-associated aHUS. No other family members have a history of kidney disease. 145 22 M HIS aHUS 22M referred for aHUS genetic testing. Limited clinical history. 146 20 F W aHUS/tma/c3 20F with ESRD 2/2 HELLP. 147 49 M W aHUS/tma/c3 49M with ESRD 2/2 MPGN diagnosed at age 35. He had his 2nd kidney transplant at age 46. He has a history of nephrolithiasis at age 13 and demyelinating peripheral neuropathy treated with plasmapheresis and IVIG. He does not have a family history of kidney disease. 148 33 F OTH aHUS 33F referred for aHUS genetic testing. Limited clinical history. 149 17 F W nphp 17F referred for nephronophthisis genetic testing. She had hematuria and renal colic at age 14. She has a strong family history of kidney stones. She had a kidney biopsy that showed no significant abnormalities. RUS showed a small kidney stone and a small cyst in the left kidney. 150 34 M AA aHUS 34M referred for aHUS genetic testing. Limited clinical history 151 44 F W aHUS 44F referred for aHUS genetic testing. Limited clinical history. 152 74 M W aHUS/tma/c3 74M with a clinical diagnosis of PKD that is s/p transplant. 153 66 M AA aHUS 66M referred for aHUS genetic testing. Limited clinical history. 154 23 F AA aHUS 23F referred for aHUS genetic testing. Limited clinical history. 155 51 F W aHUS/tma/c3 51F with ESRD 2/2 multiple myeloma s/p transplant. 156 21 F AS aHUS 21F referred for aHUS genetic testing. Limited clinical history. 157 26 F OTH aHUS 26F referred for aHUS genetic testing. Limited clinical history. 158 7 F W aHUS/tma/c3 7F with blood diarrhea, anuria, AKI and HUS with prolonged dialysis and progression to CKD4. 159 4 M W nephrotic/fsgs 4M with a history of nephrotic syndrome onset at age 2. He ultimately achieved remission at age 6. Family history significant for RA (maternal GMA), thyroid disease (paternal aunt), DM and asthma but no kidney disease. Kidney biopsy showed partial FP effacement and differential includes MCD vs. FSGS. 160 4 M AA,W nephrotic/fsgs 4M referred for nephrotic syndrome / FSGS genetic testing. Limited clinical history. 161 71 M W nephrotic/fsgs 71M with ESRD s/p transplant at the age of 37 with a clinical diagnosis of Alport syndrome. 162 12 M HIS,W nephrotic/fsgs 12M with a history of proteinuria and thin glomerular basement membranes seen on kidney biopsy. 163 2 F W aHUS/tma/c3 2F with ARF 2/2 presumed HUS. She had a 2-day history of non-bloody diarrhea, nausea, and vomiting. She had anemia and thrombocytopenia. 164 31 F W aHUS 31F with nephrotic syndrome during her 2nd pregnancy and kidney biopsy findings of TMA. She has a history of hyperthyroidism and proteinuria during her first pregnancy that was not evaluated. She has progressed to CKD2. Her maternal grandmother has a history of kidney disease and thyroid disease and her mother and father have hypertension. 165 33 F AS aHUS/tma/c3 33F with ESRD 2/2 biopsy-confirmed IgA nephropathy s/p kidney transplant c/b TMA. 166 44 F W aHUS 44F referred for aHUS genetic testing. Limited clinical history. 167 74 F W aHUS 74F referred for aHUS genetic testing. Limited clinical history. 168 3 M OTH nphp 3M that presented with nephrotic syndrome and is now s/p kidney transplant. He had an absent left kidney and an enlarged right kidney by RUS with loss of corticomedullary differentiation. The clinical picture was suspicious for nephronophthisis. He has a nonsense mutation in WDR19. This gene is associated with nephronopthisis. 169 5 M OTH nephrotic/fsgs 5M with steroid-dependent nephrotic syndrome. He had disease onset at age 4. Kidney biopsy consistent with MCD. 170 48 M W aHUS 48M referred for aHUS genetic testing. Limited clinical history. 171 32 F AA aHUS 32F referred for aHUS genetic testing. Limited clinical history. 172 27 F W aHUS/tma/c3 30F with cystic fibrosis and esrd s/p bilateral lung transplant. She is homozygous for CFTR p.507_508del. She had an episode of AKI and kidney biopsy showed tma, which was attributed to cni toxicity that she was taking for her lung transplant. She has a history of encephalomalacia. 173 26 F AA aHUS 26F referred for aHUS genetic testing. Limited clinical history. 174 58 F W aHUS/tma/c3 58F with CKD4 of unknown etiology. She has no family history of kidney disease. RUS showed a small left kidney and both kidneys were echogenic. Patient received aHUS testing to exclude aHUS as a potential cause of her kidney disease prior to listing. 175 38 F W aHUS/tma/c3 40F with ESRD 2/2 congenital ureteral reflux s/p kidney transplant at age 37. She does not have a family history of kidney disease. 176 53 M W custom 53M with PKD s/p kidney transplant. Diagnosed at age 26. 177 1 M HIS nephrotic/fsgs 1M with nephrotic syndrome. 178 39 F W aHUS 39F referred for aHUS genetic testing. Limited clinical history. 179 17 F W nephrotic/fsgs 17F with proteinuria and FSGS. Disease onset at age 15. Her family history is significant for mixed connective tissue disease in her mother and kidney stones in her maternal grandmother. 180 14 F AA nphp 14F with polycystic left kidney and absent right kidney. She has a family history of ESRD in her father 2/2 FSGS who is s/p kidney transplant in his 30's. She has multiple half siblings who are healthy. 181 61 F W aHUS 61F with a history of aHUS/TTP and hypothyroidism. She developed AKI and was treated with dialysis, plasma exchange, and then eculizumab. 182 7 F W aHUS/tma/c3 7F with a history of hypoplastic LV s/p repair. She has a history of Evan's syndrome, T-cell lymphopenia, and CD46 deficiency. 183 10 M W nephrotic/fsgs 10M with steroid-resistant nephrotic syndrome. Disease onset at age 9. Family history significant for his sister with a "hole in her bladder" but otherwise no history of kidney disease. 184 69 F W aHUS/tma/c3 69F with ESRD 2/2 glomerulonephritis s/p transplant c/b post-transplant TMA. She was diagnosed with GN at age 22 and had her first transplant at age 31. Family history is significant for CKD in her father. 185 68 M W aHUS/tma/c3 68M with ESRD 2/2 MPGN and chronic TMA. He has a history of HCV and MGUS. He does not have a family history of kidney disease. 186 47 F W aHUS/tma/c3 47F referred for aHUS genetic testing. Limited clinical history. 187 53 M W aHUS/tma/c3 53M with ESRD 2/2 type 1 diabetic nephropathy s/p transplant at age 44. 188 10 M AA nphp,nephrotic 10M with ESRD 2/2 prune belly syndrome s/p /fsgs kidney transplant. His family history is significant for ESRD in his father. 189 21 M W aHUS/tma/c3 21M with ESRD 2/2 IgA nephropathy s/p kidney transplant. He has a family history of Marfan's, hypertension and diabetes. 190 42 M W custom 42M with PKD s/p transplant. His father also had PKD and received a transplant. 191 53 F AA aHUS/tma/c3 53F with CTD-associated pulmonary fibrosis s/p lung transplant. She has CKD3 of unclear etiology. She has a positive ANA, ENA and SSA-52. 192 35 F W aHUS/tma/c3 35F with CKD4 of unclear etiology. She has a history of ARF with thrombocytopenia and anemia and was treated for presumed aHUS. 193 6 F W nephrotic/fsgs 6F with FSGS. She has a family history of kidney disease in her maternal greatgrandmother and 2 brothers of the maternal greatgrandmother. Her mother and father do not have a history of kidney disease nor does the maternal grandfather. She has 3 siblings that are healthy. 194 12 F W aHUS/tma/c3 12F referred for aHUS genetic testing. Limited clinical history 195 1 M W aHUS/tma/c3 1wkM with congenital renal failure. 196 37 F W aHUS/tma/c3 37F with aHUS and choledocholithiasis s/p ERCP c/b pancreatitis. She subsequently developed thrombocytopenia, anemia and AKI. 197 37 M W nephrotic/fsgs 37M referred for genetic testing with the nephrotic syndrome / fsgs gene set due to concern for familial FSGS. 198 33 M W aHUS/tma/c3 33M with ESRD 2/2 PKD s/p transplant. His mother also has PKD. 199 15 F W aHUS/tma/c3 15F referred for aHUS genetic testing. Limited clinical history. 200 12 F W aHUS/tma/c3 12F with ESRD 2/2 Henoch Schonlein Purpura diagnosed at age 10 s/p kidney transplant. No family history of kidney disease. 201 20 M HIS nephrotic/fsgs 20M with CKD referred for nephrotic syndrome / FSGS genetic testing. Limited clinical history. 202 8 F OTH alport 8F with persistent hematuria and kidney biopsy with thin basement membranes. She has a family history of Alports syndrome. Maternal great uncle had deafness as a child and is s/p kidney transplant x2. He has 2 boys and a girl and they are all healthy. Maternal grandmother with intermittent hematuria s/p kidney biopsy. 203 2 F OTH nphp 2F with congenital echogenic kidneys with tiny cysts and bilateral pelviectasis. 204 17 M OTH nephrotic/fsgs 17M with FSGS referred for nephrotic syndrome / FSGS genetic testing. Limited clinical history. 205 2 F OTH aHUS/tma/c3 2F with a history of C3GN referred for aHUS genetic testing. Limited clinical history. 206 9 F AA aHUS/tma/c3,n 9F with a history of Denys-Drash syndrome. Kidney ephrotic/fsgs biopsy showed acute and chronic TMA with severe IFTA and glomerulosclerosis. She does not have a family history of kidney disease. 207 1 F OTH PKHD1 1F with a family history of PKD and normal kidney function and no evidence of renal cysts by RUS. 208 20 F W nephrotic/fsgs 20F with a history of nephrotic syndrome onset at age 2 and FSGS. 209 20 M AA nephrotic/fsgs 20M with ESRD 2/2 biopsy-proven FSGS s/p kidney transplant. No family history of kidney disease 210 43 F W aHUS/tma/c3 43F CKD4 2/2 HTN. History of necrotizing enterocolitis at birth, HBV, preeclampsia. Kidney biopsy showed arteriosclerosis. No family history of kidney disease. Patient referred for aHUS genetic testing to exclude aHUS as a potential etiology of her kidney disease because her sister is considering donation. 211 71 M W aHUS/tma/c3 71M with a history of biopsy-proven TMA after a raccoon bite. Family history of diabetes but no kidney disease. 212 1mo F W nphp 1moF with renal dysplasia born at 37wk. At 20 weeks gestation, noted mild renal dilatation, bilateral pelviectasis and echogenic kidneys with an AFI of 11 at that time. She was followed by MFM, fetal cardiologist and nephrology/urology at Mercy. Repeat prenatal ultrasound showed no renal cysts, no hydroureter and dilatation of renal pelvis. Small bladder noted intermittently on prenatal US. Postnatal US with bilateral echogenic kidneys, collecting system dilation, poor corticomedullary differentiation. Cardiac ECHO showed biventricular hypertrophy, flattened IVS, severe LVOT obstruction, small PFO and normal cardiac function. Liver US obtained and noted to have hepatosplenomegaly without evidence of biliary atresia. There is no family history of renal disease. 213 1mo F HIS nephrotic/fsgs 1moF referred for nephrotic syndrome / FSGS genetic testing. Limited clinical history. 214 37 M W aHUS/tma/c3,n 37M with ESRD 2/2 HTN and TMA s/p transplant at ephrotic/fsgs the age of 30 c/b FSGS. His mother and father have diabetes but there is no family history of kidney disease. 215 12 F OTH nphp 12F referred for nephronophthisis genetic testing. Limited clinical history. 216 5mo F W nephrotic/fsgs 5moF with Denys Drash Syndrome. The pelvic ultrasound showed a uterus (4 x 1.2 x 1.2 cm) and right ovary. She has clitoromegaly and undescended gonads. Her AMH was in the normal range for male and her CAH profile was normal. Her SRY was positive. She is 46XY. 217 15 M OTH nphp 15M with a multicystic right dysplastic kidney and type 1 diabetes. 218 3 M AA nephrotic/fsgs 3M with biopsy-proven FSGS, steroid-resistant nephrotic syndrome, fever, and hematuria. RUS shows nephromegaly. No family history of kidney disease. 219 58 F W aHUS/tma/c3 58F with ESRD 2/2 PKD. She has a family history of kidney disease in her father. 220 6 F HIS nphp 6F with multiple bilateral small renal cysts with normal kidney function and congenital deformity of her skull. 221 25 F W aHUS/tma/c3 25F with persistent proteinuria and kidney biopsy showing MPGN. No RUS. 222 23 M AA nephrotic/fsgs 23M presents for kidney donor evaluation. He has no past medical history. He has a family history of a brother with FSGS and maternal uncle with ESRD of unknown cause. 223 13 M W nephrotic/fsgs 13M with steroid-resistant nephrotic syndrome with disease onset at age 8. No family history of kidney disease. 224 37 F W custom 37F evaluated for living kidney donation for her sister who carries a diagnosis of cystinosis. The patient has no history of kidney disease. 225 61 M W nphp 61M with ESRD 2/2 PKD s/p kidney transplant. He has a family history of ESRD and aneurysms in his father. 226 25 F W aHUS/tma/c3 25F with biopsy-proven DDD and nephrotic syndrome. No family history of kidney disease 227 34 M W alport 34M with ESRD 2/2 hereditary nephritis. He had a transplant at age 24. He has a paternal uncle, nephew, and 2 cousins with biopsy-proven FSGS. 228 1 M OTH aHUS/tma/c3 1M previously healthy with new-onset seizures and hemolytic anemia concerning for TTP. He has no family history of bleeding or clotting disorders. 229 26 F HIS nephrotic/fsgs 26F with ESRD of unclear etiology. She has subsequently devloped CHF. She was diagnosed at age 23 when she presented with ARF. Her autoimmune workup was negative. The patients sister has a history of FSGS and her parents are both healthy. 230 1mo M AA nphp 1moM with renal dysfunction referred for nephronophthisis genetic testing. Limited clinical history. 231 19 M W aHUS/tma/c3 19M referred for genetic testing for aHUS with a clinical h/o tma and esrd. Patient was diagnosed with C3GN by kidney biopsy in 2002. Patient has a septated renal cyst in the right upper pole and multiple smaller cysts in the right lower pole by RUS and CT. Patients mother, father, 3 brothers, and sister do not have pkd. 232 61 M W aHUS/tma/c3 19M with ESRD and TMA referred for aHUS genetic testing. Limited clinical history. 233 71 M W nphp 71M with ESRD 2/2 PKD s/p kidney transplant. He started hemodialysis at age 70. He has a family history of kidney stones in his son, heart failure in his mother, and hypertension in his sister. 234 25 F W aHUS/tma/c3 25F with nausea, vomiting, fatigure, ARF and thrombocytopenia with elevated LDH. The constellation of findings at that time were consistent with a microangiopathic hemolytic anemia. She had normal ADAMTS13 activity. She has no family history suggestive of familial TTP. 235 31 F AA aHUS/tma/c3 31F with ESRD. She was first diagnosed at age 17 with ARF. Kidney biopsy findings were consistent with malignant hypertension-associated TMA. MRI of the abdomen showed that the patient's right kidney was 6.8 centimeters, left kidney was 11 centimeters without any hydronephrosis 236 38 M W aHUS/tma/c3 38M with ESRD 2/2 post-infectious GN s/p kidney transplant. He has no family history of kidney disease. 237 8 M W alport 8M with a history of gross hematuria at age 5-6 and a family history of Alport syndrome. His mother had genetic studies for Alport syndrome and was noted to have a normal heterozygous missense variant of unknown function in exon 29 of COL4A4. There is a family history of Alport syndrome in the maternal great grandfather, maternal grandmother, maternal aunt and cousins. They have had genetic tests and were diagnosed with COL4A5 (X-linked) mutations. 238 7 F W nephrotic/fsgs 7F with a history of FSGS referred for nehrotic syndrome / FSGS genetic testing. Limited clinical history. 239 16 F W alport,nphp 16F with CKD2 of unclear etiology, 2+ proteinuria, and hearing loss. Kidney biopsy was suboptimal but showed no significant abnormalities. She has a family history of diabetes but no kidney disease. RUS with bilateral kidneys 2SD below the mean in size. 240 19 M W aHUS/tma/c3 19M with ESRD 2/2 E.Coli+ HUS s/p kidney transplant. He does not have a family history of kidney disease 241 1 F W aHUS/tma/c3 1F with ARF and nephrotic syndrome diagnosed with aHUS. No family history of kidney disease. 242 10 F AA nephrotic/fsgs 5F early pubertal development with tanner stage 4 breasts and no pubic hair. Born at 24wks. History of "teeth root deformity" after birth. Kidney transplant 2/2 fsgs. Patient developed early diabetes. Has a pineal cyst. NS at age 6. history of bilateral inguinal hernia repair. Mother has 2 kidneys both on right side. Brother has keratoconus. Paternal grandfather has proteinuria. 243 16 F W nephrotic/fsgs 16F with proteinuria and immune complex GN. Autoimmune workup was negative. She does not have a family history of kidney disease. 244 3 F W nphp 3F with a history of cystic renal disease and macrocephaly. There is a history of multiple family members with a large head in paternal side. Mother's cousin had a renal transplant as a young adult due to hypertension. No family history of cystic kidney disease. Mother and father have had renal ultrasounds (at 30 years of age) - no cysts noted on renal U/S. Renal cysts in distant family member on dad's side. 245 31 F W nphp 31F with a history of PKD referred for nephronophthisis genetic testing. Limited clinical history. 246 55 M W aHUS/tma/c3 55M with ESRD 2/2 FSGS s/p kidney transplant c/b TMA. He has a history of kidney stones. He does not have a family history of kidney disease. 247 16 F AA nephrotic/fsgs 16F with ESRD of unclear etiology s/p kidney transplant. She first presented with severe anemia and ARF at age 13. She has a history of psychiatric illness treated with risperidone and benzotropine. 248 49 F W custom 49F with PKD referred for PKD1 and PKD2 genetic testing. Limited clinical history. 249 5 F W,AA nephrotic/fsgs 5F with steroid-resistant nephrotic syndrome and biopsy findings c/w MCD. She initially presented at age 3. She does not have a family history of kidney disease. 250 32 M OTH nphp 32M with PKD and nephrolithiasis. Family history is significant for ESRD in an aunt with diabetes as well as an uncle with FSGS on his paternal side, both were in their 50s and 60s. There is also a history of a hemorrhagic stroke on his paternal side. 251 2 F AA nphp 2F with CKD4 of unclear etiology. Kidney biopsy showed podocyte foot process effacement. PMH significant for hemoglobin SC disease and alpha thalassemia trait. RUS unremarkable. She does not have a family history of kidney disease. 252 15 M OTH nphp 15M with PKD and normal kidney function. He has a family history of PKD but not ESRD. 253 1 M AS nephrotic/fsgs 1M with nephrotic syndrome referred for nephrotic syndrome / FSGS genetic testing. Limited clinical history. 254 16 F AA nphp,nephrotic 16F with ESRD 2/2 obstructive uropathy s/p kidney /fsgs transplant. She does not have a family history of kidney disease. 255 9 M AA nphp,nephrotic 9M with a history of renal dysplasia and posterior /fsgs urethral valves leading to ESRD. No family history of kidney disease. 256 31 M AA aHUS/tma/c3 31M with ESRD 2/2 aHUS vs. small vessel vasculitis c/b TMA. He does not have a family history of kidney disease. 257 13 F W aHUS/tma/c3 13F with HUS admitted with abdominal pain, diarrhea, anemia, elevated LFTs, and ARF. She does not have a family history of kidney disease. 258 33 F W aHUS/tma/c3 33F with CF s/p bilateral lung transplant and CKD5. She has a brother with CF but no family history of kidney disease. 259 14 M OTH nephrotic/fsgs 14M with biopsy-proven steroid-resistant FSGS. He had his first symptoms at age 4. He has a history of kidney disease in his grandmother. 260 21 F AA nephrotic/fsgs 14F with nephrotic syndrome and biopsy-proven collapsing FSGS homozygous for APOL1 risk alleles. She does not have a family history of kidney disease. 261 14 F HIS aHUS/tma/c3 14F with CF s/p bilateral lung transplant c/b TMA. She has normal kidney function. She is adopted and her family history is unknown. 262 8 M W aHUS/tma/c3 8M with a history of hematuria and glomerulonephritis with a low C3. He does not have a family history of kidney disease. 263 15 M W aHUS/tma/c3 15M with a history of hypocomplementemia, proteinuria and DDD with FSGS diagnosed by kidney biopsy. 264 15 F AA alport 15F with FSGS and nephrotic syndrome. Retrospective review identified TRPC6 p.N125S, which has been implicated in autosomal dominant steroid resistant nephrotic syndrome and FSGS in children. The patient is also compound heterozygous for the APOL1 G1G2 risk alleles 265 19 F OTH alport 19F with biopsy-proven FSGS. She is adopted and family history is unknown. 266 8 M W nephrotic/fsgs 8M with nephrotic syndrome referred for nephrotic syndrome / FSGS genetic testing. Limited clinical history. 267 42 M HIS,W aHUS/tma/c3 42M with a history of aHUS. He has no family history of kidney disease. 268 5mo M W nphp 5moM with bilateral renal dysplasia with no cysts. He has a history of micrognathia, gynecomastia with mild galactorrhea, bilateral pneumothoraces at birth s/p bilateral needle thoracentesis, laryngomalacia, and cardiac echo showing a small PFO with L to R shunt, small muscular VSD with L to R shunt, right ventricular hypertrophy, and borderline dilated ascending aorta. No family history of kidney disease. 269 11 M W nephrotic/fsgs 11M with FSGS and nephrotic syndrome. He presented with nephrotic syndrome at age 4 and has had partial response to tacrolimus and rituximab. 270 35 F OTH nephrotic/fsgs 35F with ESRD 2/2 FSGS s/p kidney transplant at age 21. She does not have a family history of kidney disease. 271 4 M OTH alport 4M with microhematuria. His mother is a carrier of Alport syndrome and maternal grandfather had ESRD from Alport syndrome at 34. 272 69 M W aHUS/tma/c3 69M with ESRD 2/2 diabetic nephropathy s/p kidney transplant c/b TMA. He does not have a family history of kidney disease. 273 67 F OTH nphp 67F with PKD. She does not have a family history of kidney disease. 274 42 F OTH nephrotic/fsgs 42F with biopsy-proven FSGS, gout, and obesity. She has a family history of diabetes and hypertension. 275 35 F AA aHUS/tma/c3 35F with ESRD 2/2 HTN with kidney biopsy showing hypertension-associated TMA. Her aunt is on dialysis and her brother and sister have hypertension. 276 27 F OTH aHUS/tma/c3 27F with ESRD 2/2 biopsy-proven DDD. The patients paternal aunt had to have a native nephrectomy for an undetermined cause. 277 1mo M OTH nephrotic/fsgs 1moM with congenital nephrotic syndrome. He does not have a family history of kidney disease. 278 19 M W aHUS/tma/c3 19M with a history of AML c/b TMA. He does not have a family history of kidney disease. 279 19 M AA nephrotic/fsgs 19M with ESRD at age 10 2/2 nephrotic syndrome s/p transplant at age 15. His sister was born with 3 kidneys. 280 54 F OTH alport 54F with CKD3, proteinuria and biopsy-proven thin basement membrane disease. She has a family history of ESRD. 281 53 F OTH nephrotic/fsgs 53F with a strong family history of kidney disease due to FSGS. 282 56 M OTH nephrotic/fsgs 53M with ESRD 2/2 biopsy-proven FSGS at age 27. He has a family history of Bright's disease in his grandfather. 283 56 F OTH aHUS/tma/c3 56F with ESRD 2/2 DM2 and HTN s/p transplant at age 45 c/b TMA. She has no family history of kidney disease. 284 1 M W nphp 1wkM with renal dysplasia referred for nephronophthisis genetic testing. Limited clinical history. 285 18 F OTH aHUS/tma/c3 18F with lupus nephritis IV+V c/b TMA. She is adopted and family history is unknown. 286 15 M W nephrotic/fsgs 15M with nephrotic syndrome and kidney biopsy showing MCD. He does not have family history of kidney disease. 287 31 M W aHUS/tma/c3 31M with CKD5, hematuria and proteinuria with a kidney biopsy showing arteriosclerosis and TMA. He has a PMH of obesity, diabetes and NICM. 288 41 F AA aHUS/tma/c3 41F with proteinuria, hypertension and ARF with TMA. She does not have a family history of kidney disease. 289 5mo F HIS aHUS 5moF referred for aHUS genetic testing. Limited clinical history. 290 15 F HIS aHUS 15F with ESRD and possible aHUS or C3GN referred for aHUS genetic testing. Limited clinical history 291 52 M W aHUS 51M referred for aHUS genetic testing. Limited clinical history. 292 51 M AA aHUS 51M referred for aHUS genetic testing. Limited clinical history. 293 55 M W aHUS 55M referred for aHUS genetic testing. Limited clinical history. 294 76 F W aHUS 76F referred for aHUS genetic testing. Limited clinical history. 295 26 M AA aHUS 26M referred for aHUS genetic testing. Limited clinical history. 296 38 F W aHUS 38F with aHUS and TMA s/p transplant referred for aHUS genetic testing. Limited clinical history. 297 38 F AA aHUS 38F referred for aHUS genetic testing. Limited clinical history. 298 8 F W aHUS 8F referred for aHUS genetic testing. Limited clinical history. 299 36 F W aHUS 36F referred for aHUS genetic testing. Limited clinical history. 300 69 F HIS aHUS 69F with HUS and thrombocytopenia referred for aHUS genetic testing. Limited clinical history. 301 73 F W aHUS 73F with MAHA and aHUS referred for aHUS genetic testing. Limited clinical history. 302 30 M W aHUS 30M with thrombocytopenia referred for aHUS genetic testing. Limited clinical history. 303 15 F W aHUS 15F referred for aHUS genetic testing. Limited clinical history. 304 74 M W aHUS 74M with C3GN referred for aHUS genetic testing. Limited clinical history. 305 46 F AA aHUS 46F referred for aHUS genetic testing. Limited clinical history. 306 50 M AA aHUS 50M referred for aHUS genetic testing. Limited clinical history. 307 33 F W aHUS 33F with HUS referred for aHUS genetic testing. Limited clinical history. 308 31 F HIS aHUS 31F referred for aHUS genetic testing. Limited clinical history. 309 31 F OTH aHUS 31F referred for aHUS genetic testing. Limited clinical history. 310 53 F W aHUS 53F with HUS and TMA referred for aHUS genetic testing. Limited clinical history. 311 41 F W aHUS 41F referred for aHUS genetic testing. Limited clinical history. 312 3 F HIS aHUS 3F referred for aHUS genetic testing. Limited clinical history. 313 67 F W aHUS 67F referred for aHUS genetic testing. Limited clinical history. 314 27 F AA aHUS 27F referred for aHUS genetic testing. Limited clinical history. 315 4 M HIS aHUS 4M with aHUS and HTN referred for aHUS genetic testing. Limited clinical history. 316 10 F AA aHUS 10F referred for aHUS genetic testing. Limited clinical history. 317 69 M W aHUS 69M with ESRD 2/2 diabetic nephropathy s/p kidney transplant c/b TMA. He does not have a family history of kidney disease. 318 19 M OTH aHUS 19M referred for aHUS genetic testing. Limited clinical history. 319 59 M W aHUS 59M referred for aHUS genetic testing. Limited clinical history. 320 35 M HIS aHUS 35M referred for aHUS genetic testing. Limited clinical history. 321 36 F W aHUS 36F referred for aHUS genetic testing. Limited clinical history. 322 1 F HIS aHUS 1F referred for aHUS genetic testing. Limited clinical history. 323 57 F W aHUS 57F referred for aHUS genetic testing. Limited clinical history. 324 48 F AS aHUS 48F referred for aHUS genetic testing. Limited clinical history.