mTOR-Activating Mutations in RRAGD Are Causative for Kidney Tubulopathy and Cardiomyopathy
Authors: Schlingmann Karl P. , Jouret François , Shen Kuang , Nigam Anukrati , Arjona Francisco J. , Dafinger Claudia , Houillier Pascal , Jones Deborah P. , Kleinerüschkamp Felix , Oh Jun , Godefroid Nathalie , Eltan Mehmet , Güran Tülay , Burtey Stéphane , Parotte Marie-Christine , König Jens , Braun Alina , Bos Caro , Ibars Serra Maria , Rehmann Holger , Zwartkruis Fried J.T. , Renkema Kirsten Y. , Klingel Karin , Schulze-Bahr Eric , Schermer Bernhard , Bergmann Carsten , Altmüller Janine , Thiele Holger , Beck Bodo B. , Dahan Karin , Sabatini David , Liebau Max C. , Vargas-Poussou Rosa , Knoers Nine V.A.M. , Konrad Martin , de Baaij Jeroen H.F. 
Published: October 2021

Significance Statement
Although advances in genetic techniques have resulted in the identification of rare hereditary disorders of renal magnesium and salt handling, some patients with tubulopathy lack a genetic diagnosis. In a cohort of patients with profound hypomagnesemia, renal salt wasting, nephrocalcinosis, and dilated cardiomyopathy, the authors performed whole-exome and -genome sequencing and identified heterozygous variants in RRAGD, which encodes a small Rag guanosine triphosphatase (GTPase). Subsequent functional analyses in vitro showed that the identified variants induce a constitutive activation of mechanistic target of rapamycin (mTOR) signaling in vitro. These findings not only establish a novel monogenic disorder of the kidney tubule, but demonstrate the essential role of mTOR signaling for distal tubular electrolyte handling and cardiac function.

Background
Over the last decade, advances in genetic techniques have resulted in the identification of rare hereditary disorders of renal magnesium and salt handling. Nevertheless, approximately 20% of all patients with tubulopathy lack a genetic diagnosis.

Methods
We performed whole-exome and -genome sequencing of a patient cohort with a novel, inherited, salt-losing tubulopathy; hypomagnesemia; and dilated cardiomyopathy. We also conducted subsequent in vitro functional analyses of identified variants of RRAGD, a gene that encodes a small Rag guanosine triphosphatase (GTPase).

Results
In eight children from unrelated families with a tubulopathy characterized by hypomagnesemia, hypokalemia, salt wasting, and nephrocalcinosis, we identified heterozygous missense variants in RRAGD that mostly occurred de novo. Six of these patients also had dilated cardiomyopathy and three underwent heart transplantation. We identified a heterozygous variant in RRAGD that segregated with the phenotype in eight members of a large family with similar kidney manifestations. The GTPase RagD, encoded by RRAGD, plays a role in mediating amino acid signaling to the mechanistic target of rapamycin complex 1 (mTORC1). RagD expression along the mammalian nephron included the thick ascending limb and the distal convoluted tubule. The identified RRAGD variants were shown to induce a constitutive activation of mTOR signaling in vitro.

Conclusions
Our findings establish a novel disease, which we call autosomal dominant kidney hypomagnesemia (ADKH-RRAGD), that combines an electrolyte-losing tubulopathy and dilated cardiomyopathy. The condition is caused by variants in the RRAGD gene, which encodes Rag GTPase D; these variants lead to an activation of mTOR signaling, suggesting a critical role of Rag GTPase D for renal electrolyte handling and cardiac function.