Alport syndrome (AS) is characterized by renal, cochlear, and ocular involvement. In the absence of treatment, renal disease progresses from microscopic hematuria to proteinuria, progressive renal insufficiency, and end-stage renal disease (ESRD) in all males with X-linked (XL) AS, and in all males and females with autosomal recessive (AR) AS. Progressive sensorineural hearing loss (SNHL) is usually present by late childhood or early adolescence. Ocular findings include anterior lenticonus (which is virtually pathognomonic), maculopathy (whitish or yellowish flecks or granulations in the perimacular region), corneal endothelial vesicles (posterior polymorphous dystrophy), and recurrent corneal erosion. In individuals with autosomal dominant (AD) AS, ESRD is frequently delayed until later adulthood, SNHL is also relatively late in onset and ocular involvement is rare.
Thin basement membrane nephropathy (TBMN) is characterized by persistent microscopic hematuria often first observed in childhood; progressive renal disease is relatively unusual and extrarenal abnormalities are rare.
The diagnosis of Alport syndrome and thin basement membrane nephropathy rests on:
- History and physical examination, which may include audiologic, renal, and ophthalmic evaluation;
- Detailed family history and possibly urinalyses on first- and second-degree relatives;
- Immunohistochemical analysis of basement membrane type IV collagen expression, using skin and/or renal biopsy specimens; and
- Examination of renal biopsy specimens by electron microscopy.
With these tools, the diagnosis can be confirmed in most cases. AS and many cases of TBMN are caused by mutation of the type IV collagen genes COL4A3, COL4A4, and COL4A5.
Treatment of manifestations: Alport syndrome: angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker in proteinuric individuals; potential living related donors must be evaluated carefully to avoid nephrectomy in an affected individual. Routine treatment of hypertension; renal transplantation for ESRD. Routine treatment of SNHL and cataracts; surgical intervention for symptomatic leiomyomas.
Prevention of secondary complications: Protect corneas of those with recurrent corneal erosions from minor trauma. Minimize exposure to loud noise.
Surveillance: Follow up of all individuals with Alport syndrome and thin basement membrane nephropathy with a nephrologist; monitoring of females with XLAS with measurement of blood pressure and renal function; audiologic evaluation of children with Alport syndrome every one to two years beginning at age six to seven years; monitoring of transplant recipients for development of anti-glomerular basement membrane antibody-mediated glomerulonephritis.
Evaluation of relatives at risk: Evaluate at-risk family members either by urinalysis or, if the pathogenic variant(s) in the family are known, by molecular genetic testing.
Three modes of inheritance are recognized for Alport syndrome: X-linked, autosomal recessive, and autosomal dominant. Currently, TBMN is known to be inherited in an autosomal dominant manner only.
- In families with X-linked inheritance, mothers heterozygous for a COL4A5 pathogenic variant have a 50% chance of transmitting the pathogenic variant in each pregnancy; sons who inherit the pathogenic variant will be affected with Alport syndrome and will eventually develop ESRD and, in most cases, deafness; daughters who inherit the pathogenic variant will typically have asymptomatic hematuria but may have more severe renal disease. Affected males will pass the pathogenic variant to all of their daughters and none of their sons.
- In families with autosomal recessive inheritance, the parents of an affected child are obligate heterozygotes and carry one mutant allele; at conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being a carrier who may or may not be symptomatic, and a 25% chance of being unaffected and not a carrier.
- In families with autosomal dominant inheritance, each child of an affected individual has a 50% chance of inheriting the pathogenic variant and having a collagen IV disorder (autosomal dominant AS or TBMN).
Molecular genetic testing for at-risk family members and prenatal testing for pregnancies at increased risk are possible if the pathogenic variant(s) in the family are known.
Pathogenic variants in COL4A3, COL4A4, or COL4A5 result in a spectrum of phenotypes from Alport syndrome to thin basement membrane nephropathy (TBMN) [Longo et al 2002], including X-linked Alport syndrome (XLAS), autosomal recessive Alport syndrome (ARAS), or autosomal dominant collagen IV disorders (autosomal dominant Alport syndrome [ADAS] and TBMN).
Alport syndrome should be suspected in an individual with the following clinical and pedigree features [Kashtan 2004]:
- Hematuria. In XLAS, 100% of affected males and more than 90% of affected females have microhematuria; 100% of males and females with ARAS have hematuria. Episodic gross hematuria is not unusual.
- Proteinuria, hypertension, and renal insufficiency develop with advancing age in all males with XLAS, and in all males and females with ARAS.
- Bilateral high-frequency sensorineural hearing loss (SNHL) typically becomes apparent by audiometry in late childhood or early adolescence in males with XLAS and in males and females with ARAS.
- In XLAS, SNHL eventually develops in 80%-90% of affected males as well as in some affected females; the incidence of SNHL in males and females with ARAS is probably similar to the incidence in males with XLAS.
- In some families with XLAS and in ADAS, SNHL may not be detectable until well into adulthood.
- Anterior lenticonus is pathognomonic of Alport syndrome. It occurs in 15%-20% of those with XLAS or ARAS and typically becomes apparent in late adolescence or early adulthood.
- Perimacular flecks occur in approximately 30% of individuals with Alport syndrome.
- Family history
- Family history positive for hematuria, deafness, and/or end stage renal disease is frequently seen.
- Family history of hematuria or renal failure may be negative because 10%-15% of males with XLAS have the disorder as the result of a de novo pathogenic variant and approximately 15% of affected individuals have ARAS.
TBMN should be suspected in an individual with the following clinical and pedigree features [Kashtan 2004]:
- Persistent hematuria without proteinuria
- Family history:
- Negative for renal failure
- Positive for hematuriaNote: Criterion may not be reliable because individuals eventually diagnosed as having TBMN are frequently unaware that they have relatives with hematuria.
Note: An individual suspected of having Alport syndrome or TBMN should be evaluated by either a pediatric or adult nephrologist (depending on age).
Males with XLAS; males and females with ARAS. Urinalysis typically shows hematuria (dozens to hundreds of erythrocytes per high-power microscope field). Overlap with normal results is minimal.
Female heterozygotes for XLAS. Approximately 95% of heterozygotes exhibit persistent or intermittent microhematuria (blood in the urine detectable only by microscope).
Both males and females with XLAS may have intermittent or constant gross hematuria.
Heterozygotes for ARAS. Approximately 50% of carriers of ARAS exhibit persistent or intermittent microhematuria.
Individuals with ADAS and TBMN. Urinalysis shows microscopic hematuria.
Immunohistochemical Analysis of Basement Membrane Type IV Collagen Expression
- Males with XLAS. In about 80% of males, incubation of a skin biopsy specimen with a monoclonal antibody directed against the collagen α5(IV) chain shows complete absence of staining of epidermal basement membranes. Approximately 20% of males show normal staining.
- Females heterozygous for XLAS. Approximately 60%-70% of heterozygous females exhibit discontinuous staining of the collagen α5(IV) chain [van der Loop et al 1999]. This is attributed to X-chromosome inactivation, by which it would be expected that one half of the basilar keratinocytes would express a normal collagen α5(IV) chain.
- Individuals with ARAS. All individuals have normal skin reactivity for the collagen α5(IV) chain.
- Individuals with ADAS and TBMN. All individuals have normal skin reactivity for the collagen α5(IV) chain.
- Males with XLAS typically show complete absence of immunostaining for the collagen α3(IV) chain, α4(IV) chain, and α5(IV) chain on renal biopsy.Approximately 20% of males with XLAS show normal staining of renal basement membranes for the collagen α3(IV) chain, α4(IV) chain, and α5(IV) chain.
- Females heterozygous for XLAS typically exhibit patchy loss of staining for the collagen α3, α4, and α5(IV) chains in GBMs and tubular basement membranes [Kashtan et al 1996]. Some heterozygous females exhibit normal staining for the collagen α3, α4, and α5(IV) chains in renal basement membranes.
- Individuals with ARAS show abnormalities of renal type IV collagen expression that differ from those of individuals with X-linked disease. Individuals with ARAS typically exhibit complete absence of staining for the collagen α3(IV) chain and α4(IV) chain. However, whereas their GBMs show no staining for the collagen α5(IV) chain, staining of Bowman's capsules and tubular basement membranes for the collagen α5(IV) chain is positive [Gubler et al 1995]. Some individuals with ARAS exhibit normal renal basement membrane staining for the collagen α3(IV) chain, α4(IV) chain, and α5(IV) chain.
- Individuals with ADAS and TBMN exhibit normal GBM staining for the collagen α3(IV) chain, α4(IV) chain, and α5(IV) chain.
Electron microscopy (EM)
- Normal. The normal glomerular capillary wall has a trilaminar appearance consisting of a homogeneous electron-dense layer (lamina densa) sandwiched between two electron-lucent layers (the laminae rara interna and externa).The outer (subepithelial) aspect of the glomerular capillary wall, where it abuts the foot processes of the glomerular visceral epithelial cells, is smooth and regular.A variety of techniques have been used to measure GBM width. The cut-off value in adults ranges from 250 nm to 330 nm, depending on technique. The cut-off value in children ranges from 200 nm to 250 nm, depending on technique (250 nm is within 2 SD of the mean at age 11 years).
- Alport syndrome. When diffusely present, the following three alterations are pathognomonic of Alport syndrome:
However, the earliest change in Alport syndrome is diffuse thinning of the glomerular capillary wall; thus, electron microscopy alone may not always be sufficient to differentiate Alport syndrome from thin basement membrane disease. (Marked variability in GBM width within a glomerulus in an individual with persistent microhematuria should raise suspicion of Alport syndrome.)
- The lamina densa appears to be split into multiple interlacing strands of electron-dense material, resembling basket-weaving.
- The lacunae between these strands are frequently occupied by round, electron-dense bodies (possibly entrapped cytoplasm).
- The glomerular capillary wall is diffusely thickened and its epithelial aspect is scalloped.
- TBMN. Most individuals with TBMN exhibit diffuse thinning of the lamina densa and of the GBM as a whole. The intraglomerular variability in GBM width is small in individuals with TBMN [Tiebosch et al 1989] and the GBM of individuals with TBMN remains attenuated over time, rather than undergoing the progressive thickening and multilamellation that is pathognomonic of Alport syndrome.Light and immunofluorescence microscopy are unremarkable in individuals with typical TBMN.
Establishing the Diagnosis
The diagnosis of Alport syndrome and thin basement membrane nephropathy (TBMN) is established in a proband with identification of pathogenic variant(s) in one of the genes listed in Table 1.
Molecular genetic testing approaches can include single-gene testing, use of a multi-gene panel, and more comprehensive genomic testing.
Single-gene testing. Sequence analysis is performed first followed by gene-targeted deletion/duplication analysis if no pathogenic variant is found.
The choice of which of the three genes to test first is based on family history, clinical findings, histopathology, and frequencies of Alport syndrome and thin basement membrane nephropathy.
- Alport syndrome
- Individuals with an X-linked family history (XLAS), test COL4A5 first.
- With a family history of either autosomal dominant or autosomal recessive inheritance, test COL4A3 first, followed by COL4A4.
- In those who do not have a family history of a similarly affected relative, test COL4A5 first, followed by COL4A3 and COL4A4
- In some individuals with a negative family history, only a single variant may be found in either COL4A3 or COL4A4. In such cases it may be difficult for the clinician to determine if the patient has a de novo dominant variant or a single autosomal recessive variant (with the other variant perhaps not detectable on today’s testing). In distinguishing between these two possibilities, note that a second undetected pathogenic variant in the proband is likely if:
- A parent has the pathogenic variant, but is asymptomatic or has only hematuria;
- A young individual has proteinuria and decreased renal function, deafness, anterior lenticonus, or perimacular flecks;
- An individual has abnormal collagen IV immunostaining in a renal biopsy specimen.
- Thin basement membrane nephropathy. Test COL4A3 and COL4A4.
A multi-gene panel that includes COL4A5, COL4A3, COL4A4, and other genes of interest (see Differential Diagnosis) may also be considered and is the preferred methodology in many centers. Note: The genes included in the panel and the diagnostic sensitivity of the testing used for each gene vary by laboratory and over time.
More comprehensive genomic testing (when available) including whole-exome sequencing (WES), whole mitochondrial sequencing (WMitoSeq), and whole-genome sequencing (WGS) may be considered if serial single-gene testing (and/or use of a multi-gene panel) fails to confirm a diagnosis in an individual with features of Alport syndrome or thin basement membrane nephropathy. Such testing may provide or suggest a diagnosis not previously considered (e.g., mutation of a different gene that results in a similar clinical presentation). For more information on comprehensive genome sequencing click here.
Digenic inheritance. Mencarelli et al  have described digenic inheritance of Alport syndrome in several families. The causative allelic variants may be in cis or in trans, and result in variable clinical features and transmission patterns.
In Alport syndrome and thin basement membrane nephropathy (TBMN), a spectrum of phenotypes ranging from progressive renal disease with extrarenal abnormalities (Alport syndrome) to isolated hematuria with a typically benign course (TBMN) is observed.
Alport syndrome has renal, cochlear, and ocular manifestations. Approximately 80% of Alport syndrome is X-linked; approximately 15% is autosomal recessive, and approximately 5% is autosomal dominant. Because Alport syndrome is predominantly an X-linked disorder, these manifestations are typically more severe in affected males. However, affected females with either XLAS or ARAS may have severe involvement as well. ADAS is typically a slowly progressive disorder; renal insufficiency and sensorineural hearing loss (SNHL) may not develop until relatively late in life.
Renal. The hallmark of Alport syndrome is microscopic hematuria (microhematuria). Males with XLAS have persistent microhematuria from early in life. Episodic gross hematuria can occur, especially during childhood. More than 90% of females with XLAS have microscopic hematuria, although it may be intermittent. Individuals with ARAS have persistent microhematuria, with no gender difference. Heterozygous carriers of a COL4A3 or COL4A4 pathogenic variant associated with ARAS have an estimated 50% incidence of persistent or intermittent microhematuria.
All males with XLAS develop proteinuria and, eventually, progressive renal insufficiency, which leads to end-stage renal disease (ESRD). Overall, an estimated 60% reach ESRD by age 30 years, and 90% by age 40 years [Jais et al 2000]. The rate of progression to ESRD is influenced by the nature of the COL4A5 pathogenic variant (see Genotype-Phenotype Correlations).
Approximately 12% of females with XLAS develop ESRD before age 40 years, increasing to 30% by age 60 years and 40% by age 80 years [Jais et al 2003].
Most individuals with ARAS develop significant proteinuria in late childhood or early adolescence and ESRD before age 30 years. Progression to ESRD occurs at a slower pace in individuals with ADAS (frequently delayed until later adulthood) than in those with XLAS or ARAS.
Cochlear. Hearing loss in Alport syndrome is never congenital. Diminished hearing is usually detectable by late childhood or early adolescence in boys with XLAS. In its early stages, the hearing deficit is detectable only by audiometry, with bilateral reduction in sensitivity to tones in the 2000- to 8000-Hz range. In affected males, the hearing loss is progressive and eventually extends to other frequencies, including those of conversational speech. Hearing loss is frequently identifiable by formal assessment of hearing in late childhood, but in some families is not detectable until relatively late in life.
SNHL develops in 80%-90% of males with XLAS by age 40 years [Jais et al 2000]. The course of the hearing loss depends on the pathogenic variant (see Genotype-Phenotype Correlations). Hearing impairment in members of families with Alport syndrome is always accompanied by evidence of renal involvement; no convincing evidence that deaf males lacking renal disease can transmit Alport syndrome to their offspring has been reported. In females with XLAS, hearing loss is less frequent and tends to occur later in life.
There do not appear to be gender differences in the incidence or course of hearing loss in ARAS. Individuals with ARAS typically exhibit juvenile onset of hearing loss. Hearing loss may be a very late development in individuals with ADAS.
A histologic study of cochleas in individuals with Alport syndrome suggests that defective adhesion of the organ of Corti to the basilar membrane may underlie the hearing deficit [Merchant et al 2004].
Ocular. Ocular lesions are common in Alport syndrome, occurring in 30%-40% of individuals with XLAS. The spectrum of ocular lesions appears to be similar in XLAS and ARAS. Ocular lesions appear to be relatively uncommon in ADAS.
- Anterior lenticonus, in which the central portion of the lens protrudes into the anterior chamber, is virtually pathognomonic in Alport syndrome. When present, anterior lenticonus is bilateral in approximately 75% of individuals. It is absent at birth, usually appearing during the second to third decade of life. Progressive distortion of the lens may occur, accompanied by increasing myopia. Lens opacities may be seen in conjunction with lenticonus, occasionally resulting from rupture of the anterior lens capsule.All reported individuals with anterior lenticonus who have been adequately examined have exhibited evidence of chronic nephritis and sensorineural hearing loss. It is far more common in affected males but can occur in females. The frequency of lenticonus in males with XLAS was 13% in one large series; its occurrence is related to the pathogenic variant (see Genotype-Phenotype Correlations).
- Maculopathy consisting of whitish or yellowish flecks or granulations in the perimacular region was found in approximately 14% of males with XLAS in a large series. The maculopathy does not appear to be associated with any visual abnormalities.
- Corneal endothelial vesicles (posterior polymorphous dystrophy) and recurrent corneal erosion may also be seen in individuals with Alport syndrome.
Like Alport syndrome, TBMN is characterized clinically by persistent microscopic hematuria often first observed in childhood. In some individuals, microhematuria is intermittent and may not be detected until adulthood. Episodic gross hematuria, frequently in association with upper respiratory infections, is not unusual. The hematuria of TBMN appears to be lifelong.
TBMN differs clinically from Alport syndrome in the following important respects:
- It is only rarely associated with extrarenal abnormalities.
- Proteinuria and hypertension and progression to ESRD are unusual.
- Gender differences in expression of TBMN are not apparent.
Although overt proteinuria and hypertension are unusual in TBMN, they have been described [van Paassen et al 2004]. Some of these cases may represent individuals who actually have Alport syndrome, and in whom the predominant abnormality of GBM is attenuation, rather than thickening and multilamellation.
Other glomerular disorders including IgA nephropathy and focal segmental glomerulosclerosis may co-occur in individuals with TBMN [Norby & Cosio 2005].
Genotype-Phenotype Correlations – XLAS
Risk for renal disease
- Large rearrangements and pathogenic nonsense and frameshift variants confer a 90% probability of end-stage renal disease (ESRD) before age 30 years, with 50% reaching ESRD by age 20 years [Jais et al 2000].
- In affected individuals with splice-site variants, the probability of ESRD before age 30 years is 70%, with 50% reaching ESRD by age 25 years.
- Missense variants are associated with only a 50% probability of ESRD before age 30 years and a renal half-life (the time it takes for 50% of the group to reach end stage, i.e., the need for dialysis or transplantation) of 32 years.
- In one study, COL4A5 missense variants that alter glycine and non-glycine residues in the 3' portion of were associated with earlier development of ESRD, compared with missense variants that alter glycine residues in the 5' portion of the gene [Gross et al 2002]. In another study, pathogenic variants at the 5' end of COL4A5 were associated with earlier ESRD, hearing loss, and ocular changes [Bekheirnia et al 2010].
Risk for deafness
- In individuals with large rearrangements of COL4A5 or nonsense, frameshift, or splice site variants, the risk for deafness is 50% at age ten years.
- In individuals with missense variants, the risk for deafness does not reach 50% until age 20 years.
Risk for anterior lenticonus. Anterior lenticonus occurs in approximately 15% of males with XLAS. Anterior lenticonus is almost entirely restricted to families with Alport syndrome with hearing loss and progression to ESRD before age 30 years. This observation is explained by the finding that lenticonus is significantly more common in individuals with a COL4A5 deletion or a small pathogenic variant resulting in a premature stop codon than in those with pathogenic missense or splice-site variants [Jais et al 2000].
Risk for diffuse leiomyomatosis
- All families in which XLAS cosegregates with diffuse leiomyomatosis exhibit large deletions that span the adjacent 5' ends of COL4A5 and COL4A6. These deletions involve varying lengths of COL4A5, but the COL4A6 breakpoint is always located in the second intron of the gene [Antignac & Heidet 1996].
- Leiomyomatosis does not occur in individuals with deletions of COL4A5 and COL4A6 that extend beyond intron 2 of COL4A6.
- Pathogenic variants of COL4A6 alone do not appear to cause Alport syndrome, a finding consistent with the absence of the α6(IV) chain from normal GBM.
Penetrance may be decreased in ADAS; at present, data are insufficient to draw a definitive conclusion.
The term “benign familial hematuria” is no longer used; it has been replaced with “thin basement membrane nephropathy.”
The prevalence of Alport syndrome has been estimated at 1:50,000 live births [Levy & Feingold 2000]. Data from several series suggest that approximately one fifth of children evaluated by pediatric nephrologists for isolated microhematuria receive a diagnosis of Alport syndrome. According to the United States Renal Data System (USRDS), approximately 0.2% of adults and 3% of children in the United States with ESRD carry a diagnosis of Alport syndrome.
TBMN of all causes is estimated to affect 1% of the population; the proportion caused by pathogenic variants in COL4A3 and COL4A4 is unknown.
Genetically Related (Allelic) Disorders
Alport syndrome with diffuse leiomyomatosis results from large deletions that span the adjacent 5' ends of COL4A5 and COL4A6 [Zhou et al 1993] (see Genotype-Phenotype Correlations). The association of Alport syndrome with diffuse leiomyomatosis of the esophagus and tracheobronchial tree has been reported in several dozen families [Antignac & Heidet 1996, Mothes et al 2002]. Symptoms usually appear in late childhood and include dysphagia, postprandial vomiting, retrosternal or epigastric pain, recurrent bronchitis, dyspnea, cough, and stridor. Affected females in these kindreds typically exhibit genital leiomyomas as well, causing clitoral hypertrophy with variable involvement of the labia majora and uterus. Bilateral posterior subcapsular cataracts also occur frequently in affected individuals.
AMME complex (Alport syndrome, intellectual disability [mental retardation], midface hypoplasia, and elliptocytosis) was described in two brothers shown to have a microdeletion of Xq22.3 involving all of COL4A5 and extending beyond its 3' end [Jonsson et al 1998, Meloni et al 2002].
Conditions with Hematuria
Alport syndrome most often presents in childhood, and thus must be differentiated from other causes of persistent (>6 months in duration) microhematuria in children.
- The first step in the evaluation of hematuria in children is to attempt to establish the source of the hematuria (renal/glomerular, renal/post-glomerular, post-renal).
- This often involves evaluation of urinary erythrocyte morphology by phase contrast microscopy, urinary calcium measurement, and/or renal ultrasound examination.
- Family history is an important component of the initial evaluation of the child with hematuria. When possible, obtaining urinalyses on first-degree relatives can also be informative.
- Once microhematuria is provisionally localized to the glomeruli, possible etiologies include a number of chronic glomerulopathies.
- In the child with no known family history of hematuria, the most likely diagnoses are IgA nephropathy, thin basement membrane nephropathy (TBMN), Alport syndrome, and membranoproliferative glomerulonephritis (see Dense Deposit Disease/Membranoproliferative Glomerulonephritis Type II).
- In the child with familial hematuria, the diagnostic possibilities narrow down to TBMN and Alport syndrome, although IgA nephropathy is occasionally familial.
Combined Nephritis and Deafness
Fechtner/Epstein syndrome. The eponym Fechtner syndrome refers to the association of hereditary nephritis, sensorineural deafness, cataracts, and the triad of the May-Hegglin anomaly (thrombocytopenia, large platelets, and characteristic leukocyte inclusions ["Döhle-like" bodies]). It is transmitted in an autosomal dominant manner. Epstein syndrome (the combination of nephritis, deafness, thrombocytopenia, and large platelets) and Fechtner syndrome were previously considered possible genetic variants of Alport syndrome. Some individuals with these disorders exhibit ultrastructural changes of the glomerular capillary wall reminiscent of those seen in individuals with Alport syndrome. However, these syndromes have been determined to be genetically distinct from Alport syndrome as both result from pathogenic variants in MYH9, the gene encoding myosin-9 [Seri et al 2000, Ghiggeri et al 2003, Kunishima et al 2003]. (See MYH9-Related Disorders.)
Evaluations Following Initial Diagnosis
To establish the extent of disease and needs in an individual diagnosed with Alport syndrome and thin basement membrane nephropathy (TBMN) the following evaluations are recommended:
- Evaluation of renal function
- Overt proteinuria (urine protein-creatinine ratio >0.2 or, in a child, 24-hour urine protein >4 mg/m2/hr) is an important indicator of renal disease progression in individuals with Alport syndrome and thin basement membrane nephropathy. Urine protein excretion should be assessed at the time of diagnosis and at least annually thereafter.
- In Alport syndrome and thin basement membrane nephropathy, decreased glomerular filtration and hypertension rarely appear before overt proteinuria. Once overt proteinuria has developed, renal function should be assessed periodically by serum creatinine concentration or other estimates of glomerular filtration rate (e.g., creatinine clearance or serum cystatin C levels) and blood pressure should be monitored.
- Hearing evaluation. High-frequency sensorineural deafness typically becomes detectable by audiogram in late childhood (age 6-10 years) in boys with XLAS and in boys and girls with ARAS.
- Ophthalmologic evaluation
- Assessment of ocular status is often unnecessary if the diagnosis of Alport syndrome is established by other means. The maculopathy is asymptomatic, and anterior lenticonus is also frequently asymptomatic.
- Individuals who experience acute corneal erosion should be seen by an ophthalmologist.
- Cardiac evaluation. Baseline evaluation including echocardiogram for aortic dilation in males with XLAS is indicated.
- Consultation with a clinical geneticist and/or genetic counselor
Treatment of Manifestations
Clinical practice recommendations for the treatment of individuals with Alport syndrome have been published [Kashtan et al 2013]. These recommendations encourage early detection of microalbuminuria and proteinuria through regular surveillance and early intervention aimed at suppressing proteinuria using angiotensin antagonists (click here for full text).
Renal. Hypertensive individuals should receive appropriate management.
Controlled clinical trials of therapy for Alport nephropathy have not been conducted. However, a retrospective analysis of a registry population suggested that early treatment with angiotensin blockade delays the onset of ESRD in human Alport syndrome [Gross et al 2012]. The angiotensin receptor blocker losartan has been shown to reduce proteinuria in children with Alport syndrome [Webb et al 2013]. Furthermore, angiotensin blockade has been shown to delay progression to ESRD in transgenic mice with ARAS [Gross et al 2003, Gross et al 2004]. Therefore, affected individuals are frequently treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers once proteinuria appears. This form of therapy is rarely associated with significant adverse effects. It is unknown whether the losartan therapy reduces the risk for aortic dilation in XLAS (as is being investigated for Marfan syndrome).
Renal transplantation is typically successful in individuals with Alport syndrome [Kashtan et al 1995, Byrne et al 2002]. Anti-GBM nephritis involving the renal allograft is a dramatic, but rare, complication occurring in an estimated 3% of males with Alport syndrome who have undergone transplantation [Kashtan 1999, Byrne et al 2002].
Prior to renal transplantation, males with XLAS should have a cardiac evaluation for aortic dilation [Kashtan et al 2010].
Special considerations apply to the selection of potential living related kidney donors for individuals with XLAS. The following discussion considers potential donors on the basis of gender and the presence or absence of hematuria:
- Male relative without hematuria. The optimal living related donor is a male who has a normal urinalysis and is therefore unaffected.
- Male relative with hematuria. A related male with hematuria probably has Alport syndrome, and cannot be a kidney donor.
- Female relative without hematuria. Female relatives who have normal urinalyses are probably unaffected, although approximately 5%-10% of females heterozygous for a COL4A5 pathogenic variant are asymptomatic. It is rare for asymptomatic females whose children are also asymptomatic to be heterozygous. Asymptomatic females can probably donate a kidney safely, but should be informed of their risk of having affected male children to whom they will not be able to donate a kidney. Genetic status can be confirmed or excluded by molecular genetic testing if the pathogenic variant in the family is known.
- Female relative with hematuria (i.e., heterozygous female). Females heterozygous for a COL4A5 pathogenic variant should only be considered as potential kidney donors if no asymptomatic living donors are available.
- The presence of proteinuria or sensorineural deafness is an absolute contraindication to kidney donation as these are risk factors for progression to ESRD.
- Heterozygous females younger than age 40 years should not be used as donors, even in the absence of proteinuria or deafness.
- Heterozygous females age 40 years or older who have normal renal function, blood pressure, and hearing and no proteinuria can be considered as donors because the risk of late progression to ESRD appears to be low in such individuals. However, the donor should be informed of the risk (albeit low) of late progression to ESRD.
Cochlear. Hearing aids should be prescribed when appropriate.
Ocular. The ocular manifestations of Alport syndrome rarely require specific ophthalmologic intervention.
Some individuals develop cataracts that interfere with vision; these should be extracted when necessary.
Diffuse leiomyomatosis. Symptomatic leiomyomas may require surgical intervention.
Prevention of Secondary Complications
Individuals who suffer recurrent corneal erosions may need to take measures (e.g., wearing goggles when riding a bicycle) to protect their corneas from minor trauma.
Exposure to loud noise should be minimized.
Clinical practice recommendations for the treatment and health surveillance of individuals with Alport syndrome have been published [Kashtan et al 2013].
Individuals with a diagnosis of Alport syndrome or thin basement membrane nephropathy should be followed by a nephrologist in addition to a primary care physician. Once overt proteinuria has developed, renal function should be assessed periodically by serum creatinine concentration or other estimates of glomerular filtration rate (e.g., creatinine clearance or serum cystatin C levels), and blood pressure should be monitored.
Although most females with XLAS exhibit only asymptomatic microhematuria, recent data indicate a significant risk for progression to ESRD [Jais et al 2003]. For this reason, all women with a diagnosis of Alport syndrome need to be monitored regularly for the development of proteinuria and hypertension.
Children with Alport syndrome should have audiologic evaluation every one to two years beginning at age six to seven years (see Hereditary Hearing Loss and Deafness Overview).
Periodic cardiac evaluation for aortic dilation for males with XLAS is appropriate.
Transplant recipients should be monitored for development of anti-glomerular basement membrane antibody-mediated glomerulonephritis.
Evaluation of Relatives at Risk
It is appropriate to evaluate family members at risk for Alport syndrome or thin basement membrane nephropathy in order to identify as early as possible those who would benefit from initiation of treatment and preventive measures.
- Males. A single urinalysis is sufficient in a male.
- Females. Several urinalyses should be performed in females before concluding that hematuria is absent.
- Molecular genetic testing. If the pathogenic variant(s) in the family are known, molecular genetic testing can be used to clarify the genetic status of at-risk family members. Molecular genetic testing is necessary to exclude heterozygosity in an at-risk female who does not have hematuria.
Relatives found to have proteinuria, hypertension, and/or a pathogenic variant should be referred to a nephrologist for further evaluation. In the absence of proteinuria or hypertension, relatives at risk should, at a minimum, have an annual urinalysis and measurement of blood pressure if molecular genetic testing is not available.
See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.
Therapies Under Investigation
Search ClinicalTrials.gov for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.
Genetic counseling is the process of providing individuals and families with information on the nature, inheritance, and implications of genetic disorders to help them make informed medical and personal decisions. The following section deals with genetic risk assessment and the use of family history and genetic testing to clarify genetic status for family members. This section is not meant to address all personal, cultural, or ethical issues that individuals may face or to substitute for consultation with a genetics professional. —ED.
Mode of Inheritance
Alport syndrome caused by mutation of COL4A5 is inherited in an X-linked manner (XLAS).
Alport syndrome caused by mutation of COL4A3 or COL4A4 can be inherited in an autosomal recessive (ARAS) or autosomal dominant manner (ADAS).
Thin basement membrane nephropathy (TBMN) caused by mutation of COL4A3 or COL4A4 has only been described as being inherited in an autosomal dominant manner.
Risk to Family Members – X-Linked Inheritance
Parents of a male proband
- The father of a male with XLAS will not have the disease nor will he be hemizygous for the COL4A5 pathogenic variant; therefore, he does not require further evaluation/testing.
- In a family with more than one affected male, the mother of an affected individual is an obligate heterozygote.
- If only one male in a family is affected, the likelihood that that individual's mother is heterozygous is 85%-90%. Approximately 10%-15% of male probands have XLAS as the result of a de novo pathogenic variant.
- The mother of a male known to have XLAS should have a urinalysis and/or molecular genetic testing if the pathogenic variant has been identified in the proband.
- The presence of microhematuria indicates that she is likely to be heterozygous for a COL4A5 pathogenic variant.
- If proteinuria or hypertension is present, she should be referred to a nephrologist for further evaluation.
- Molecular genetic testing is necessary to exclude the carrier state in an at-risk female who does not have hematuria.
- In the absence of proteinuria or hypertension, she should, at a minimum, have an annual urinalysis and measurement of blood pressure if molecular genetic testing has not excluded the carrier state.
Parents of a female proband
- The father or the mother of a female proband may have the COL4A5 pathogenic variant, or the proband may have a de novo pathogenic variant.
- Approximately 10%-15% of affected individuals have XLAS as the result of a de novo pathogenic variant.
- Evaluation of parents of a female proband with XLAS begins with urinalysis and proceeds as described for the mother of a male proband.
Sibs of a male proband. The risk to the sibs of a male proband depends on the genetic status of the mother:
- If the mother is heterozygous, each sib has a 50% chance of inheriting the COL4A5 pathogenic variant:
- Males who inherit the pathogenic variant will be affected.
- Females who inherit the pathogenic variant may or may not be symptomatic.
- If the mother is not heterozygous, the risk to sibs is low but greater than that of the general population because of the possibility of germline mosaicism.
Sibs of a female proband. The risk to the sibs of a female proband depends on the genetic status of the parents:
- If the mother is heterozygous, each sib has a 50% chance of inheriting the COL4A5 pathogenic variant:
- Males who inherit the pathogenic variant will be affected.
- Females who inherit the pathogenic variant may or may not be symptomatic.
- If the father has a pathogenic variant, all of his daughters will inherit the pathogenic variant and may or may not have symptoms. None of his sons will inherit the pathogenic variant.
- If neither parent has a pathogenic variant, the risk to sibs is low but greater than that of the general population because of the possibility of germline mosaicism.
Offspring of a male proband. Affected males transmit the COL4A5 pathogenic variant to all of their daughters and to none of their sons.
Offspring of a female proband. Women with a COL4A5 pathogenic variant have a 50% chance of transmitting the pathogenic variant to each child:
- Sons who inherit the pathogenic variant will be affected.
- Daughters will have a range of possible phenotypic expression.
Other family members of a proband. The male proband's maternal aunts may be at risk of being heterozygous and the aunts' offspring, depending on their gender, may be at risk of being heterozygous for the pathogenic variant or being affected.
Heterozygote (Carrier) Detection – X-Linked Inheritance
Molecular genetic testing for at-risk females who lack microhematuria requires prior identification of the pathogenic variant in the family.
Note: (1) Females are heterozygotes for this X-linked disorder and may develop clinical findings related to the disorder. (2) Identification of female heterozygotes requires either (a) prior identification of the pathogenic variant in the family or, (b) if an affected male is not available for testing, molecular genetic testing first by sequence analysis, and then, if a pathogenic variant is not identified, by methods to detect gross structural abnormalities.
Risk to Family Members – Autosomal Recessive Inheritance
Parents of a proband
- The parents of an affected child are obligate heterozygotes (i.e., carriers of one COL4A3 or COL4A4 pathogenic variant).
- Approximately 50% of heterozygotes (carriers) exhibit persistent or intermittent microhematuria. Carriers of ARAS rarely develop proteinuria, hypertension, or renal insufficiency.
Sibs of a proband
- At conception, each sib of an affected individual has a 25% chance of being affected, a 50% chance of being a carrier, and a 25% chance of being unaffected and not a carrier.
- Once an at-risk sib is known to be unaffected, the risk of his/her being a carrier is 2/3.
- Approximately 50% of carriers exhibit persistent or intermittent microhematuria. Carriers of ARAS rarely develop proteinuria, hypertension, or renal insufficiency.
Offspring of a proband. The offspring of an individual with ARAS are obligate heterozygotes (carriers) for a COL4A3 or COL4A4 pathogenic variant.
Other family members of a proband. Each sib of the proband's parents is at a 50% risk of being a carrier of a COL4A3 or COL4A4 pathogenic variant.
Carrier (Heterozygote) Detection – Autosomal Recessive Inheritance
Carrier testing of at-risk relatives is possible if the COL4A3 or COL4A4 pathogenic variants have been identified in the family.
Risk to Family Members – Autosomal Dominant Inheritance
Parents of a proband
- Most individuals diagnosed with ADAS or TBMN have an affected parent.
- A proband with an ADAS or TBMN may have the disorder as the result of a de novo COL4A3 or COL4A4 pathogenic variant. The proportion of cases caused by de novo pathogenic variants is unknown.
- Urinalysis is recommended for the evaluation of parents of a proband with an apparent de novo pathogenic variant and/or molecular genetic testing if the pathogenic variant has been identified in the proband.
Note: Although most individuals diagnosed with ADAS or TBMN have an affected parent, the family history may appear to be negative because of failure to recognize the disorder in family members, early death of the parent before the onset of symptoms, or late onset of the disease in the affected parent.
Sibs of a proband
- The risk to the sibs of a proband depends on the genetic the status of the parents.
- If a parent of the proband is affected, the risk is 50%.
- When the parents are clinically unaffected, the risk to the sibs of a proband appears to be low.
- No instances of germline mosaicism have been reported, although it remains a possibility.
Offspring of a proband. Offspring of an individual with ADAS or TBMN are at a 50% risk of inheriting the COL4A3 or COL4A4 pathogenic variant.
Other family members of a proband. The risk to other family members depends on the status of the proband's parents: if a parent is affected, his or her family members are at risk.
Related Genetic Counseling Issues
See Management, Evaluation of Relatives at Risk for information on evaluating at-risk relatives for the purpose of early diagnosis and treatment.
Screening of potential living related kidney donors. Most individuals with Alport syndrome who require kidney transplantation have X-linked disease. Both hemizygous males and heterozygous females with XLAS are at risk for ESRD. Potential living related donors must be evaluated carefully to avoid nephrectomy in an affected individual. Kashtan  discusses in detail the evaluation of potential donors.
- The optimal time for determination of genetic risk and discussion of the availability of prenatal testing is before pregnancy.
- X-linked or autosomal recessive inheritance. It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected, are heterozygous, or are at risk of being heterozygous.
- Autosomal dominant inheritance. It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected or at risk.
DNA banking is the storage of DNA (typically extracted from white blood cells) for possible future use. Because it is likely that testing methodology and our understanding of genes, allelic variants, and diseases will improve in the future, consideration should be given to banking DNA of affected individuals.
Prenatal Testing and Preimplantation Genetic Diagnosis
Once the COL4A3, COL4A4, or COL4A5 pathogenic variant(s) have been identified in an affected family member, prenatal testing for a pregnancy at increased risk for Alport syndrome and thin basement membrane nephropathy and preimplantation genetic diagnosis are possible options.
Differences in perspective may exist among medical professionals and in families regarding the use of prenatal testing, particularly if the testing is being considered for the purpose of pregnancy termination rather than early diagnosis. Although most centers consider decisions about prenatal testing to be the choice of the parents, discussion of these issues is appropriate.
GeneReviews staff has selected the following disease-specific and/or umbrella support organizations and/or registries for the benefit of individuals with this disorder and their families. GeneReviews is not responsible for the information provided by other organizations. For information on selection criteria, click here.
- Alport Syndrome Foundation1608 East Briarwood TerracePhoenix AZ 85048-9414Phone: 480-460-0621Fax: 480-460-0621Email: email@example.com
- My46 Trait Profile
- National Library of Medicine Genetics Home Reference
- NCBI Genes and Disease
- Kidney Foundation of Canada310-5160 Decarie Blvd.Montreal Ontario H3X 2H9CanadaPhone: 800-361-7494 (toll-free); 514-369-4806Fax: 514-369-2472Email: firstname.lastname@example.org
- National Association of the Deaf (NAD)8630 Fenton StreetSuite 820Silver Spring MD 20910Phone: 301-587-1788; 301-587-1789 (TTY)Fax: 301-587-1791Email: email@example.com
- National Kidney Foundation (NKF)30 East 33rd StreetNew York NY 10016Phone: 800-622-9010 (toll-free); 212-889-2210Email: firstname.lastname@example.org
- Alport Syndrome Treatments and Outcomes Registry (ASTOR)University of Minnesota, Department of Pediatrics516 Delaware Street Southeast13-148 PWBMinneapolis MN 55455Phone: 800-688-5252 #67632 (toll-free); 612-626-7632Fax: 612-626-1165Email: email@example.com
Information in the Molecular Genetics and OMIM tables may differ from that elsewhere in the GeneReview: tables may contain more recent information. —ED.
Molecular Genetic Pathogenesis
Basement membranes, the sheet-like structures that support epithelial and endothelial cells, display heterogeneity in protein composition, ultrastructural features, and function. Basement membranes are composed of several major and minor glycoprotein constituents. Type IV collagen is present ubiquitously in basement membranes, where it is the major collagenous component. Type IV collagen molecules secreted by endothelial and epithelial cells self-associate into polygonal networks, which interact with laminin networks, as well as with nidogen, proteoglycans, and other glycoproteins, to form basement membranes.
It is now clear that the tissue pathology and clinical features of Alport syndrome result from abnormalities of basement membrane expression of the collagen α3, α4, α5, and possibly α6(IV) chains. These chains are usually absent from or under-expressed in the basement membranes of individuals with Alport syndrome, such that the networks that they form are absent or, if present, defective in structure and function.
In the normal developing kidney, collagen α1(IV) and collagen α2(IV) chains predominate in the primordial glomerular basement membrane (GBM) of immature glomeruli. The formation of capillary loops within the maturing glomeruli is associated with the appearance of collagen α3, α4, and α5(IV) chains in the GBM. As glomerular maturation progresses, the α3, α4, and α5(IV) chains become the predominant type IV collagen chains in GBM. This process has been referred to as "isotype switching." Although an isotype switch does not occur in most males with Alport syndrome, glomerular development otherwise proceeds normally and the GBM of young animals and children with Alport syndrome exhibits a normal trilaminar appearance by electron microscopy. These glomeruli exhibit normal capacities for filtration and for selective permeability, as demonstrated by the normal glomerular filtration rates and absence of overt proteinuria that are characteristic of early Alport syndrome in both humans and animals. Therefore, it appears that proteinuria and renal insufficiency, as well as sensorineural deafness, come about as the result of processes initiated by the absence of the collagen α3-α4-α5(IV) network, rather than arising directly from the absence of this network.
The most straightforward demonstration of the consequences arising directly from the absence of the collagen α3-α4-α5(IV) network from basement membranes may be anterior lenticonus, in which the anterior lens capsule lacks the strength to maintain the normal conformation of the lens. Microhematuria, the first and invariable renal manifestation of Alport syndrome, probably reflects GBM thinning and a tendency to develop focal ruptures caused by the absent or defective expression of the collagen α3-α4- α5(IV) network. Episodic gross hematuria precipitated by infections, which is not uncommon during the first two decades of life, may reflect increased susceptibility of the Alport GBM to proteolysis.
The processes that bring about GBM thickening, proteinuria, and renal insufficiency in males with XLAS and in both males and females with ARAS remain undefined, although there are some clues to what may be occurring. Unlike other glomerulopathies, Alport syndrome is characterized by the accumulation of the collagen α1(IV) and α2(IV) chains, along with types V and VI collagen, in the GBM. These proteins appear to spread from their normal subendothelial location, occupying the full width of the GBM. As Alport glomeruli undergo sclerosis, the collagen α1(IV) and α2(IV) chains disappear from the GBM, but type V and type VI collagen persist and, in fact, continue to accumulate. It is possible that the altered expression of the collagen α1(IV) and α2(IV) chains, type V collagen and type VI collagen represents a compensatory response to the loss of the collagen α3(IV), α4(IV), and α5(IV) chains from GBM, or it may simply reflect altered gene expression resulting from changes in signaling from the extracellular matrix to the nucleus. In transgenic mice with ARAS caused by partial deletion of COL4A3, renal mRNA levels for the collagen α1(IV) and α2(IV) chains progressively increase, suggesting activation of these genes. Whatever the underlying mechanism, the unrestrained deposition of certain collagens in GBM may contribute to glomerulosclerosis in Alport syndrome.
Benign allelic variants. Several benign variants in COL4A3 have been described.
Pathogenic allelic variants. Relatively few COL4A3 pathogenic variants have been reported. However, pathogenic variants in this gene appear to exhibit the same variety as seen in COL4A5, with a predilection for glycine substitutions in the collagenous domains of the collagen α3(IV) chain.
Normal gene product. The gene products of COL4A3, COL4A4, and COL4A5 are, respectively, the α3, α4, and α5 chains of type IV collagen [α3(IV), α4(IV), and α5(IV)]. The six type IV collagen α chains share basic structural features and show extensive sequence homology. The major structural features of α(IV) chains are: a collagenous domain of approximately 1400 residues containing the repetitive triplet sequence glycine (Gly)-X-Y, in which X and Y represent a variety of other amino acids; a carboxy-terminal non-collagenous (NC1) domain of approximately 230 residues; and a non-collagenous aminoterminal sequence of 15-20 residues. Approximately 20 interruptions of the collagenous triplet sequence are present in the collagenous domain. The NC1 domains each contain 12 completely conserved cysteine residues, which participate in intrachain and interchain disulfide bonds.
Type IV collagen chains form heterotrimers through associations between their COO- NC1 domains, associated with folding of the collagenous domains into triple helices.
Type IV collagen heterotrimers form networks through several types of intermolecular interaction. These include end-to-end linkages between the COO- NC1 domains of two heterotrimers, covalent interactions between four heterotrimers at their NH- ends, and lateral associations between heterotrimers via binding of the COO- domains to sites along the collagenous region of another heterotrimer. Disulfide bonds involving conserved cysteine residues are critical to the interactions between NC1 domains. These various linkages between type IV collagen molecules produce a nonfibrillar polygonal assembly that serves as scaffolding for the deposition of other matrix glycoproteins and for cell attachment.
Abnormal gene product. The abnormalities of type IV collagen expression observed in individuals with XLAS and ARAS indicate that a pathogenic variant affecting one of the chains involved in the putative collagen 3- 4- 5(IV) network can prevent basement membrane expression not only of that chain but of the other two chains as well. Similarly, a pathogenic variant involving the collagen 5(IV) chain can interfere with basement membrane expression of collagen 6(IV). The mechanisms that produce these effects remain under investigation. It is likely that at least some pathogenic variants interfere in various ways with the formation of trimeric type IV collagen molecules, leading to degradation of normal chains that have been prevented from forming trimers or that have formed abnormal trimers. This kind of process accounts for abnormal type I collagen deposition in bone in osteogenesis imperfecta. Most of the available data suggest that COL4A5 pathogenic variants do not suppress transcription of COL4A3, COL4A4, and COL4A6.
Benign allelic variants. Several benign variants in COL4A4 have been described.
Pathogenic allelic variants. Relatively few COL4A4 pathogenic variants have been reported. However, pathogenic variants in this gene appear to exhibit the same variety as COL4A5, with a predilection for glycine substitutions in the collagenous domains of the collagen α4(IV) chain.
Normal gene product. See COL4A3.
Abnormal gene product. See COL4A3.
Gene structure. COL4A5 consists of 51 exons. For a detailed summary of gene and protein information, see Table A, Gene.
Benign allelic variants. A variety of benign variants in COL4A5 have been described.
Pathogenic allelic variants. Of the several hundred reported COL4A5 pathgoenic variants, an estimated 20% are large rearrangements, predominantly deletions [Jais et al 2000]. Missense variants account for approximately 35%-40%, approximately 15% are splice-site variants, and 25%-30% are nonsense variants or small frameshifting deletions or insertions that result in premature stop codons.
The great majority of missense COL4A5 variants are guanine substitutions in the first or second position of glycine codons that result in the replacement of a glycine residue in the collagenous domain of the collagen α5(IV) chain by another amino acid. Such pathogenic variants are thought to interfere with the normal folding of the mutant collagen α5(IV) chain into triple helices with other type IV collagen α chains. Glycine lacks a side chain, making it p.Cys1564Ser (c.4692G>A) the least bulky of amino acids and small enough to allow three glycine residues to fit into the interior of a tightly wound triple helix. The presence of a bulkier amino acid in a glycine position presumably creates a kink or an unfolding in the triple helix. Glycine substitutions in the collagen α1(I) chain account for the majority of pathogenic variants causing osteogenesis imperfecta and are common in other genetic disorders of collagen. Abnormally folded collagen triple helices exhibit increased susceptibility to proteolytic degradation. The position of the substituted glycine, or the substituting amino acid itself, may influence the effect of the pathogenic variant on triple helical folding and ultimately the impact of the pathogenic variant on the severity of the clinical phenotype.
Normal gene product. See COL4A3.
Abnormal gene product. Rare missense variants in COL4A5 involve critical residues in the carboxy-terminal NC1 domain of the collagen α5(IV) chain — for example, one of the twelve conserved cysteine moieties. The loss of one of these cysteines would eliminate a disulfide bond, which could interfere with the formation of triple helices, or with the construction of networks involving collagen α5(IV) chains.
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The author's work is supported by grants from the National Institutes of Health.
- 25 November 2015 (me) Comprehensive update posted live
- 28 February 2013 (me) Comprehensive update posted live
- 15 July 2010 (me) Comprehensive update posted live
- 23 January 2008 (me) Comprehensive update posted live
- 8 January 2007 (cd) Revision: deletion/duplication analysis for COL4A5 clinically available
- 26 September 2005 (me) Comprehensive update posted live
- 29 December 2003 (ck) Revision: sequence analysis for COL4A5, COL4A3, COL4A4 clinically available; prenatal diagnosis available
- 28 August 2003 (me) Comprehensive update posted live
- 28 August 2001 (me) Review posted live
- March 2001 (ck) Original submission
University of Minnesota
Initial Posting: August 28, 2001; Last Update: November 25, 2015.
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Kashtan CE. Alport Syndrome and Thin Basement Membrane Nephropathy. 2001 Aug 28 [Updated 2015 Nov 25]. In: Pagon RA, Adam MP, Ardinger HH, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2017.