Diagnostic Molecular Pathology Approach to the disease

1. Sept. 29, 2014
DIVYA NARAYANAN
POLYCYSTIC KIDNEY
DISEASE

2. OUTLINE
• History
• Introduction
• Pathophysiology
• Autosomal Dominant Polycystic Kidney disease
• Autosomal Recessive Polycystic Kidney disease
• Case Study

3. HISTORY
• Illness and death of Polish King Stefan Bathory (1533-1591) - Possibly the
first known case of PKD.
• Autopsy report described kidneys as ‘large like those of bull, with uneven
and bumpy surface’ (surgeon Jan Zigulitz & Buccella).
• Lejars in 1888, published in his thesis the term ‘Polycystic Kidney
Disease’. He described that PKD is a defined clinical entity with
characteristic symptoms and susceptibility to be diagnosed clinically.
• Osler in 1902, indicated two cases with clinical symptoms proving the
presence of Polycystic Kidney Disease.
Embalmed Body of King Stefan Bathory
Prof. Franciszek
Walter at Krakow
Medical School in
1933 concluded that
the death of King
Bathory is most likely
due to PKD and
uraemia.

4. INTRODUCTION

5. INTRODUCTION
• It is characterized by an abnormal proliferation of renal tubular
epithelial cells, which manifests as cysts that increase gradually in
size and number, leading to massive kidney enlargement and
progressive decline of renal function.
• Three types of PKD:
• Autosomal Dominant Polycystic Kidney Disease (ADPKD)
• Autosomal Recessive Polycystic Kidney Disease (ARPKD)
• Glomerulocystic Kidney Disease (GCKD)

6. PATHOPHYSIOLOGY

7. Autosomal Dominant Polycystic Kidney Disease
(ADPKD)
Incidence – 1:400- 1:1000 individuals
Genetics – PKD1(chr 16p13.2;polycystin1;Type I) and PKD2(chr 4q21-
q23;polycystin2;Type II) gene mutations. PKD3 (unidentified but predicted
to be present)
Somatic second hit hypothesis (Dr. Alfred Knudson)

8. Autosomal Dominant Polycystic Kidney Disease
(ADPKD)
Molecular Mechanism

9. Disease characteristics
• Present in any age: Generally in 40-50 yrs ; occasionally in
fetal/neo-natal period
• Cyst formation in Kidney and Liver.
• End stage renal failure (ESRD) in >50% of the cases above age 60.
• Arterial hypertension (>50% cases)
• Vascular aneurysms
• Cardiac valve defects
• Colonic diverticula
• Affects fertility in males but not in females.
Autosomal Dominant Polycystic Kidney Disease
(ADPKD)

10. Diagnostic Investigations
• Urinalysis
• Sonography
• Renal ultrasound and IVP (Intravenous Pyelogram)
• CT scan/ MRI
• Renal function tests
• Molecular Testing: Direct mutation analysis
Treatment
• Narcotic analgesics for pain
• Antibiotics for infection
• Laparoscopic cyst decortication
• Therapeutic intervention
• Renal dialysis
• Renal transplantation
Autosomal Dominant Polycystic Kidney Disease
(ADPKD)

11. Incidence – 1:20,000
Genetics – PKHD1 (chr6p21.1-p12; fibrocystin )
Disease characteristics
• Manifested in infancy and childhood with high mortality rate due to
renal failure.
• 30-50% affected neonates die shortly after birth; 67% children who
survive newborn period die at 15yrs of age
• Principal manifestations:
• Fusiform dilatation of renal collecting ducts and distal tubuli
• Dysgenesis of the hepatic portal triad
• Hypertension, Flank mass, Hepatomegaly and renal insufficiency
• Potter Phenotype (Short and snubbed nose, Deep eye creases,
Micrognathia, Low-set flattened ears)
• Inverse relative degrees of kidney and liver involvement
• Caroli disease
Autosomal Recessive Polycystic Kidney Disease
(ARPKD)

12. Autosomal Recessive Polycystic Kidney Disease
(ARPKD)
Potter Phenotype
Flank mass

13. Autosomal Recessive Polycystic Kidney Disease
(ARPKD)
Diagnostic Investigations
• Radiography
• Ultrasonography
• CT scan
• Ultrasonography and magnetic resonance cholangiography
• MRI (RARE-MR-urography)
• Histopathology
• Molecular Diagnosis
• Linkage analysis
• Direct DNA analysis
• 33 different mutations in 57 alleles
• frequent truncating mutations: 9689delA (9 alleles) and
589insA (8 alleles).

14. Case study
42 years
old
Female
Diagnosed hypertension at
age 32 & ADPKD at age 36.
Hypertension controlled;
abdominal & flank
discomfort treated
Ultrasonography showed
renal, liver and ovarian
cysts
Mother underwent
unilateral nephrectomy in
childhood.
3 pack an yr tobacco use
ceased at 26
BP: 124/84 mmHg; Heart
rate: 70 beats/min; 2/6
heart murmur; Serum
creatinine: 0.74mg/dL
MRI result: innumerable
cysts in liver & kidney; Right
& left kidneys: 19 & 22.3 cm
resp.; Total: Kidney vol. –
1925 mL, cyst vol. – 1289
mL; cyst fraction: 67%; Liver
vol. – 1431 mL, cyst vol. –
174 ml; cyst fraction: 12.2%
MRI of abdomen

15. Case Study
Touchdown/Hot-
start PCR
Amplification
•Long-range PCR fragments of PKD1(exon 1-33)
•PKD1 (exons 34-46) and PKD2(exon 1-15); Splice junctions, 5’ (PKD1) &
3’ untranslated regions
•GeneAmp High Fidelity PCR System
•PCR fragments: 250-550 bp
Heteroduplex
analysis &
SURVEYOR®
nuclease digestion
•SURVEYOR™ nuclease cleaves at the 3’ side of any
mismatch site (upto 12bp length)
Transgenomic
WAVE® Nucleic Acid
High Sensitivity
Fragment Analysis
System
Sequenced on ABI
3100 Genetic
Analyzer
LABORATORY TESTS

16. Case Study
Result: Heterozygous nonsense mutation

17. References
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Nephrology, Sixth Edition
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