Renal transplantation in familial dysautonomia: report of two cases and review of the literature.

BACKGROUND AND OBJECTIVES: Chronic kidney disease (CKD) is an increasingly recognized complication of familial dysautonomia (FD), a neurodevelopmental disorder with protean systemic manifestations that are the result of sensory and autonomic dysfunction. Progressive renal dysfunction occurs due to chronic volume depletion and cardiovascular lability with supine hypertension and orthostatic hypotension. By age 25, nearly one-half of all patients with FD will have reached stage 3 CKD. Furthermore, dialysis for ESRD in FD patients is associated with multiple complications and poor outcomes. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS: We report two patients with FD who developed ESRD at ages 27 and 16, respectively, and underwent renal transplantation. Transplant was performed after 3 months on intermittent hemodialysis (HD) in the first case and after 1 month on twice-weekly continuous veno-venous hemodialysis (CVVHD) in the second case. RESULTS: Both patients tolerated surgery well and have maintained good graft function at 20 and 24 months posttransplantation, respectively. Symptomatic and functional improvements have included lower supine BP and increased sensitivity to antihypertensive agents. CONCLUSIONS: As general supportive care improves the lifespan of FD patients, issues related to the management of ESRD will become more important. Renal transplantation provides a viable alternative to dialysis for FD patients with ESRD.

Hypothesis: Dent disease is an underrecognized cause of focal glomerulosclerosis.

BACKGROUND AND OBJECTIVES: Dent disease is a hereditary form of progressive renal failure characterized by hypercalciuria and proximal tubular dysfunction. The clinical presentation is often insidious with the majority of patients remaining asymptomatic throughout childhood. Despite the seemingly mild, early course, more than 20% of 32 asymptomatic patients in one study had biopsy evidence of focal glomerulosclerosis. Furthermore, end-stage renal disease often occurs in men in early to middle adulthood. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This article describes two male patients who presented with asymptomatic proteinuria and were found to have focal glomerulosclerosis. Despite the absence of nephrocalcinosis on renal ultrasound, the diagnosis of Dent disease was considered because of unexplained proteinuria. Subsequent history revealed renal calculi in each maternal family. RESULTS: The clinical diagnosis of Dent disease was established by intermittent hypercalciuria and low molecular weight proteinuria and confirmed through mutational analysis. CONCLUSIONS: It is hypothesized that a diagnosis of Dent disease may be unrecognized in patients with unexplained proteinuria and idiopathic focal glomerulosclerosis.