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2017 ; 32
(5
): 733-741
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Renal thrombotic microangiopathy in patients with cblC defect: review of an
under-recognized entity
#MMPMID27289364
Beck BB
; van Spronsen F
; Diepstra A
; Berger RM
; Kömhoff M
Pediatr Nephrol
2017[May]; 32
(5
): 733-741
PMID27289364
show ga
Methylmalonic aciduria and homocystinuria, cobalamin C (cblC) type, is the most
common genetic type of functional cobalamin (vitamin B(12)) deficiency. This
metabolic disease is characterized by marked heterogeneity of neurocognitive
disease (microcephaly, seizures, developmental delay, ataxia, hypotonia) and
variable extracentral nervous system involvement (failure to thrive,
cardiovascular, renal, ocular) manifesting predominantly early in life, sometimes
during gestation. To enhance awareness and understanding of renal disease
associated with cblC defect, we studied biochemical, genetic, clinical, and
histopathological data from 36 patients. Consistent clinical chemistry features
of renal disease were intravascular hemolysis, hematuria, and proteinuria in all
patients, with nephrotic-range proteinuria observed in three. Renal function
ranged from normal to renal failure, with eight patients requiring (intermittent)
dialysis. Two thirds were diagnosed with atypical (diarrhea-negative) hemolytic
uremic syndrome (HUS). Renal histopathology analyses of biopsy samples from 16
patients revealed glomerular lesions typical of thrombotic microangiopathy (TMA).
Treatment with hydroxycobalamin improved renal function in the majority,
including three in whom dialysis could be withdrawn. Neurological sequelae were
observed in 44 % and cardiopulmonary involvement in 39 % of patients, with half
of the latter group demonstrating pulmonary hypertension. Mortality reached 100 %
in untreated patients and 79 and 56 % in those with cardiopulmonary or
neurological involvement, respectively. In all patients presenting with unclear
intravascular hemolysis, hematuria, and proteinuria, cblC defect should be ruled
out by determination of blood/plasma homocysteine levels and/or genetic testing,
irrespective of actual renal function and neurological status, to ensure timely
diagnosis and treatment.