Test ID: GRHMS
GRHPR Gene, Full Gene Analysis

Confirming a diagnosis of primary hyperoxaluria type 2 (PH2)

Carrier testing for individuals with a family history of PH2 in the absence of known mutations in the family

• Molecular Genetics-Congenital Inherited Diseases Patient Information Sheet
• Informed Consent for Genetic Testing

Polymerase Chain Reaction (PCR) followed by DNA Sequence Analysis and Gene Dosage Analysis by Multiplex Ligation-Dependent Probe Amplification (MLPA)

(PCR is utilized pursuant to a license agreement with Roche Molecular Systems, Inc.)

Specimen must arrive within 96 hours of draw.

Specimen Type: Whole blood

Container/Tube:

Preferred: Lavender top (EDTA) or yellow top (ACD)

Acceptable: Any anticoagulant

Specimen Volume: 3 mL

Collection Instructions:        

1. Invert several times to mix blood.

2. Send specimen in original tube.

Forms:

1. Molecular Genetics-Congenital Inherited Diseases Patient Information Sheet (Supply T521) in Special Instructions

2. New York Clients-Informed consent is required. Please document on the request form or electronic order that a copy is on file. An Informed Consent for Genetic Testing (Supply T576) is available in Special Instructions.

No specimen should be rejected. If specimen not received at appropriate temperature or in wrong anticoagulant, include note to laboratory. If questions, contact laboratory.

Primary hyperoxaluria type 2 (PH2) is a hereditary disorder of glyoxylate metabolism caused by deficiency of the hepatic enzyme glyoxylate reductase/hydroxypyruvate reductase (GRHPR). Absence of GRHPR activity results in excess oxalate and usually L-glycerate excreted in the urine leading to nephrolithiasis (kidney stones) and sometimes renal failure.

Onset of PH2 is typically in childhood or adolescence with symptoms related to kidney stones. In some cases, kidney failure may be the initial presenting feature. Nephrocalcinosis, as seen by renal ultrasound, is observed less frequently in individuals with PH2 than primary hyperoxaluria type 1 (PH1). End-stage renal disease (ESRD) is also less common and of later onset than PH1; however, once ESRD develops, oxalate deposition in other organs such as bone, retina, and myocardium can occur.

While, the exact prevalence and incidence of PH2 are not known, it is thought that PH2 is less common than PH1, which has an estimated prevalence rate of 1 to 3 per million population and an incidence of 0.1 per million/year.

Biochemical testing is indicated in patients with possible primary hyperoxaluria. Measurement of urinary oxalate in a timed, 24-hour urine collection is strongly preferred, with correction to adult body surface area in pediatric patients (HYOX/86213 Hyperoxaluria Panel, Urine; OXU/8669 Oxalate, Urine). In very young children (incapable of performing a timed collection), random urine oxalate to creatinine ratios may be used for determination of oxalate excretion. In patients with reduced kidney function, POXA/81408 Oxalate, Plasma is also recommended. Urinary excretion of oxalate of >1.0 mmol/1.73 m(2)/24 hours is strongly suggestive of, but not diagnostic for, primary hyperoxaluria, as there are other forms of inherited (PH1 and non-PH1/PH2) hyperoxaluria and secondary hyperoxaluria that may result in similarly elevated urine oxalate excretion rates. An elevated urine glycerate in the presence of hyperoxaluria is suggestive of PH2. Caution is warranted in interpretation of urine oxalate excretion in patients with reduced kidney function as urine oxalate concentrations may be lower due to reduced glomerular filtration rate. Historically, the diagnosis of PH2 was confirmed by GRHPR enzyme analysis performed on liver biopsy; however, this has been replaced by molecular testing, which forms the basis of confirmatory or carrier testing in most cases.

PH2 is inherited as an autosomal recessive disorder caused by mutations in the GRHPR gene, which encodes the enzyme GRHPR. Two common GRHPR mutations have been identified: c.103delG and c.403_404+2delAAGT. These mutations account for about one third of the mutant alleles described in the Northern European Caucasian population and about 15% in the Asian population. Direct sequencing of the GRHPR gene will identify these 2 mutations as well as other less common or novel mutations associated with PH2.

An interpretive report will be provided.

All detected alterations will be evaluated according to American College of Medical Genetics and Genomics (ACMG) recommendations.(1) Variants will be classified based on known, predicted, or possible pathogenicity, and reported with interpretive comments detailing their potential or known significance.

A small percentage of individuals who are carriers or have a diagnosis of primary hyperoxaluria type 2 (PH2) may have a mutation that is not identified by this method (eg, promoter mutations). The absence of a mutation, therefore, does not eliminate the possibility of positive carrier status or the diagnosis of PH2. For carrier testing, it is important to first document the presence of a PH2 gene mutation in an affected family member.

In some cases, DNA alterations of undetermined significance may be identified.

In addition to disease-related probes, this test utilizes probes localized to other chromosomal regions as internal controls. In certain circumstances, these control probes may detect other diseases or conditions for which this test was not specifically intended. Results of the control probes are not normally reported. However, in cases where clinically relevant information is identified, the ordering physician will be informed of the result and provided with recommendations for any appropriate follow-up testing.

Rare polymorphisms exist that could lead to false-negative or false-positive results. If results obtained do not match the clinical findings, additional testing should be considered.

A previous bone marrow transplant from an allogenic donor will interfere with testing. Call Mayo Medical Laboratories for instructions for testing patients who have received a bone marrow transplant.

Test results should be interpreted in the context of clinical findings, family history, and other laboratory data. Errors in our interpretation of results may occur if information given is inaccurate or incomplete.

1. Richards CS, Bale S, Bellissimo DB, et al: ACMG recommendations for standards of interpretation and reporting of sequence variations: revisions 2007. Genet Med 2008:10(4):294-300

2. Primary Hyperoxaluria Type 2-GeneReviews-NCBI Bookshelf. Available from URL: http://www.ncbi.nlm.nih.gov/books/NBK2692/, accessed 8-7-2012

3. Rumsby G, Williams E, Coulter-Mackie M: Evaluation of mutation screening as a first line test for the diagnosis of the primary hyperoxalurias. Kidney Int 2004;66(3):959-963

4. Cregeen DP, Williams EL, Hulton S, Rumsby G: Molecular analysis of the glyoxylate reductase (GRHPR) gene and description of mutations underlying primary hyperoxaluria type 2. Hum Mutat 2003;22(6):497

5. Laboratory and molecular diagnosis of primary hyperoxaluria and oxalosis. Mayo Medical Laboratories' Communique, April 2007

Bidirectional sequencing is performed to test for the presence of a mutation in all coding regions and intron/exon boundaries of the GRHPR gene. Additionally, gene dosage analysis (multiplex ligation-dependent probe amplification) is used to test for the presence of large deletions and duplications in this gene.(Unpublished Mayo method)

Monday, 10am

81479-Unlisted molecular pathology procedure