Rare diseases affecting the kidney
An approach with a few examples, prepared for the UK Renal Association's Advanced Nephrology Course. Clinical features of a handful of selected conditions in the pdf at the foot of the page.
Shortcut to this page: bit.ly/1xVFiSu
- Dr Google - 'oldest and best' (estab. 1997) Can be remarkably effective.
- scholar.google - intellectual Google, links to papers etc.
- PubMed - one of the astonishingly good free resources from NCBI (US). They've changed the world of science and medicine. Publicly funded for the benefit of the world by US taxes in a foresightful, liberating move - "thanks Obama*" (*actually 1988, the Reagan era; history). Register and log in automatically each time you visit for additional features.
- OMIM - Online Mendelian Inheritance in Man, one of many alternatives on the PubMed drop-down menu
- Professor Wikipedia - particularly good on genes and genetics. Usual cautions apply. Have you thought about editing it?
- rarerenal.org - diseases listed if there is a UK expert group and a Register. UK-relevant info about how to get testing done, management pathways. Great resource. Use it! Register your patients on Radar, become the local link?
- Gene Reviews (NCBI) many of these are outstanding, as good as many text books. There are exceptions, and not all diseases are covered.
- Gene Cards are technical but useful
- For patients, Genetics Home Reference (NIH) has good concise explanations, but quite dry
- There may be good professional or patient sites and some of these can be exceptional.
See for instance this Fabry example:
a-galactosidase deficiency leads to accumulation of glycoshpingolipid in lysosomes, primarily of endothelial cells. An important disease to diagnose, as now treatable by enzyme replacement, and a good example of the issues in managing lysosomal disorders, metabolic diseases, etc.
- Wikipedia on Fabry is particularly good
- Gene Reviews (NCBI) on Fabry is comprehensive and good
- Gene Card on the GLA gene is technical but useful; the database of mutations is for those with genetic experience or knowledge
- Cambridge site on lysosomal disorders
- For patients: two companies that market recombinant enzyme have produced patient info sites: fabrycommunity.com (Genzyme) and focusonfabry.co.uk (Shire)
- Genetics Home Reference (NIH) has good concise explanations, quite dry
The UK management guidelines 2012 from the now-defunct NHS Specialist Services, downloadable at the foot of this page, give an excellent guide to diagnosis and management. There are UK centres for Fabry Disease in London (Royal Free/UCL, GOSH), Salford, Birmingham (QE and BCH), Cambridge, but probably a need for more, or for a second tier of more local clinicians who are familiar with the condition.
Fabry is usually cared for by specialists in Metabolic Medicine in the UK. Most come from a Chemical Pathology background and don't have inpatient beds. The patients have diseases in many systems and local management is essential too. Some have significant or end stage renal disease. Nephrologists may be key providers and coordinators of care for many. (Metabolic Medicine curriculum)
Features of some of these summarised in the pdf dowloadable at the foot.
|Tuberous sclerosis||Autosomal dominant disease (TSC1 and 2 encoding hamartin, tuberin) causing lumps in brain, kidneys, skin (adenoma sebaceum), and in women, lung. Kidneys predominantly may become replaced, or develop large angiomyolipomas. They may have some cysts, or in a minority masses of cysts because of contiguous genes PKD1/TSC2. There is an excellent Wikipedia page on Tuberous Sclerosis and the Gene Review on TS is good too. The molecular basis of TS is uncontrolled activation of mTOR. So inhibitors of mTOR seem a natural therapeutic avenue. A little more info on clinical details in the pdf at the foot of the page|
|Birt Hogg Dube syndrome||Facial lesions can resemble Tuberous Sclerosis; renal oncocytomas; pneumothoraces. AD, variable features. Top quality info at bhdsyndrome.org|
|LCAT deficiency||Very rare autosomal recessive disorder causes loss of lecithin-cholesterol acyl transferase. Leads to accumulation of lipid deposits in cornea, glomerulus, and low HDL; cloudy cornea (fish eyes) and progressive proteinuric kidney disease seems common in complete deficiency. The best intro is again Genetics Home Reference, GHR on LCAT deficiency and also read GHR on partial LCAT deficiency which gives more molecular background. Autoimmune-caused enzyme deficiency has also been reported.|
|Methylmalonic acidaemia||there's a good Gene Review on MMA|
|Nail patella syndrome||A fascinating autosomal dominant condition in which AD mutations in the transcription factor LMX1B cause a series of features with considerable variation even within families. The characteristic nail and skeletal abnormalities are sometimes accompanied by proteinuric renal disease which may lead to ESRF; but LMX1B mutations are now being identified in patients with familial renal disease but without the characteristic non-renal features. A little more in the pdf at the foot of the page|
|Von Hippel Lindau||A complex topic and the Genetics Home Reference (GHR) page on VHL is a good intro. There is a very good Gene Review on VHL. The pathogenesis involves HIF (Hypoxia-inducible factor). Kidneypathology.com is good.|
- In the UK, the NIHR has established a Rare Diseases Translational Research Consortium, with Fellowships, grants etc. Info here and here.
- The Rare Renal initiative of the Renal Assoc and BAPN, has info on clinical pathways and advice for the UK at rarerenal.org, and oversees the renal rare disease registries (Radar).
Finally some recommended resources on other things
- Try any of our other edrep resources
- Radiopaedia has thousands of radiological images for your free re-use with attribution
- How to look at the glomerulus in a biopsy (6 minute video, ISN)