Primary hyperoxaluria in Italy: the past 30 years and the near future of a (not so) rare disease

Abstract

Background Primary hyperoxalurias (PHs) are rare autosomal recessive diseases of the glyoxylate metabolism; PH1 is caused by mutations in the AGXT gene, PH2 in GRHPR and PH3 in HOGA1. Methods Here we report the first large multi-center cohort of Italian PH patients collected over 30 years (1992–2020 median follow-up time 8.5 years). Complete genotype was available for 94/95 PH1 patients and for all PH2 (n = 3) and PH3 (n = 5) patients. Symptoms at onset were mainly nephrolithiasis (46.3%) and nephrocalcinosis (33.7%). Median age at onset of symptoms and diagnosis were 4.0 years and 9.9 years, respectively. Results Fifty-four patients (56.8%) were diagnosed after chronic kidney disease. Sixty-three patients (66.3%) developed end stage kidney disease (median age 14.0 years). Twenty-one patients had a kidney-only transplant and, among them, seven had a second kidney transplant combined with liver transplant. A combined kidney–liver transplant was carried out in 29 patients and a sequential kidney–liver transplant was performed in two. In five cases a preemptive liver transplant was performed. Those receiving a liver-only transplant tended to have lower kidney function at last follow-up. Conclusion Our study of PHs in Italy underlines a considerable diagnostic delay, which has only slightly decreased in recent years. Therefore, we suggest a more extensive use of both metabolic screening among patients with recurrent kidney stones and genotyping, including unambiguous assignment of minor/major allele status in order to promptly begin appropriate treatment. This will be fundamental in order to have access to the new therapies, which are mainly focused on substrate reduction for the oxalate-producing enzymes using RNA-interference. Graphical abstract

Recurrence of rare disease after kidney transplant

“…Consequently, it is recommended for more widespread use of both metabolic and genotyping screening, containing the definite assignment of minor/ major allele status among patients with recurrent kidney stones. Thanks to the advances made in medicine, new therapies are accessible which essentially focused on substrate reduction of the oxalate-producing enzymes by using RNA-interference (15). Lumasiran is a new exciting treatment for PH1 that consist of interference RNA which destroys glycolate oxidase mRNAs and consequently decreases the level of glyoxylate and produces oxalate as a main toxic agent in PH1.…”

A clinical screening algorithm for primary hyperoxaluria type 1 in adults on dialysis

“…For this study, only patients with an established genetic diagnosis of PH1 who underwent HD during adulthood were included. This database represents the Italian section of the OxalEurope Registry, and its characteristics have been previously described [ 6 ].…”