Clinical spectrum of primary hyperoxaluria type 1: Experience of a tertiary center

Abstract

Background and aim: Primary hyperoxalurias are rare inborn errors of metabolism resulting in increased endogenous production of oxalate that leads to excessive urinary oxalate excretion. Diagnosis of primary hyperoxaluria type 1 (PH1) is a challenging issue and depends on diverse diagnostic tools including biochemical analysis of urine, stone analysis, renal biopsy, genetic studies and in some cases liver biopsy for enzyme assay. We characterized the clinical presentation as well as renal and extrarenal phenotypes in PH1 patients.

Methods: This descriptive cohort study included patients with presumable PH1 presenting with nephrolithiasis and/or nephrocalcinosis (NC). Precise clinical characterization of renal phenotype as well as systemic involvement is reported. AGXT mutational analysis was performed to confirm the diagnosis of PH1.

Results: The study cohort included 26 patients with presumable PH1 with male to female ratio of 1.4:1. The median age at time of diagnosis was 6 years, nevertheless the median age at initial symptoms was 3 years. Thirteen patients (50%) were diagnosed before the age of 5 years. Two patients had no symptoms and were diagnosed while screening siblings of index patients. Seventeen patients (65.4%) had reached end-stage renal disease (ESRD): 6/17 (35.3%) during infancy, 4/17 (23.5%) in early childhood and 7/17 (41.29%) in late childhood. Two patients (7.7%) had clinically manifest extra renal (retina, heart, bone, soft tissue) involvement. Mutational analysis of AGXT gene confirmed the diagnosis of PH1 in 15 out of 19 patients (79%) where analysis had been performed. Fifty percent of patients with maintained renal functions had projected 10 years renal survival.

Conclusion: PH1 is a heterogeneous disease with wide spectrum of clinical, imaging and functional presentation. More than two-thirds of patients presented prior to the age of 5 years; half of them with the stormy course of infantile PH1. ESRD was the commonest presenting manifestation in two-thirds of our cohort.

Keywords: End-stage renal disease; Nephrocalcinosis; Nephrolithiasis; Oxalosis; Post-transplantation recurrence; Primary hyperoxaluria type 1.

Fig. 1

Clinical presenting manifestations in study patients (n = 26).

Fig. 2

Correlation between age of onset and ESRD age (r = 0.52; P value 0.031).

Fig. 3

A. Renal USS of patient E-2 showing medullary nephrocalcinosis. B. Coronal reformatted CT scan images of the urinary tract of patient E-11 demonstrating bilateral medullary nephrocalcinosis with multiple pelvic renal stones. C. Renal USS of patient E-18 showing chalky-white hyperechogenic kidney due to severe cortical and medullary nephrocalcinosis. D. Post-contrast chest CT images of patient E-3 demonstrating focal mass lesion surrounding the sternum due to soft tissue deposition of CaOx. Moreover, there is distended costochondral junction due to CaOx deposits.