Renin–angiotensin system in kidney development: renal tubular dysgenesis

Autosomal recessive renal tubular dysgenesis (RTD) is a severe disorder of renal tubular development characterized by early onset and persistent fetal anuria leading to oligohydramnios and the Potter sequence. At birth, blood pressure is dramatically low and perinatal death occurs in most cases. Skull ossification defects are frequently associated with RTD. The disease is genetically heterogeneous and linked to mutations in the genes encoding any of the components of the renin–angiotensin system (RAS). An intense stimulation of renin production is noted in the kidneys of patients with mutations in the genes encoding angiotensinogen, angiotensin-converting enzyme, or AT1 receptor, whereas absence or increased renin production is associated with REN defects depending on the type of mutation. The severity of the disease underlines the importance of a functional RAS in the maintenance of blood pressure and renal blood flow during fetal life. The absence or poor development of proximal tubules, as well as renal vascular changes, may be attributable to renal hypoperfusion rather than to a morphogenic property of the RAS. The less severe phenotype in mice devoid of RAS may be linked to differences between mice and humans in the time of nephrogenesis and maturation of the RAS. The identification of the disease on the basis of precise clinical and histological analyses and the characterization of the genetic defects allow genetic counseling and early prenatal diagnosis.