BACKGROUND: Fabry disease (FD) is a rare disorder caused by variants in the GLA gene encoding α-galactosidase A (GALA), leading to end-stage kidney disease (ESKD), among other health issues. The 2002 Czech nationwide FD screening in ESKD found undiagnosed cases in dialysis patients by examining GALA activity in dried blood spots (DBS). METHODS: The second nationwide FD screening (2016-2018; 21-month study) in ESKD patients on maintenance dialysis therapy (MDT) included 112 Czech dialysis units to assess country-wide FD diagnostic guidelines' efficacy in reducing its underdiagnosis. This involved GALA activity and/or lyso-Gb3 levels with GLA sequencing in positive males, the latter applied first in all females, followed by lyso-Gb3 examination in variant-positive cases. Screening-positive cases were referred to the FD center for follow-up and in vitro studies. RESULTS: The 6352 screened cases represent 93.9% of all MDT patients within the study duration. Eight GLA variants were identified in 39 patients, of which seven were in 35 ESKD cases classified as likely benign (LB), with normal lyso-Gb3 levels in all subjects. Four patients (three males with reduced GALA activity and one sequencing-positive female) bear a "hot variant of uncertain significance" (VUS) c.1181T>C(p.Leu394Pro), significantly enriched compared to the general population, suggesting its association with FD. CONCLUSIONS: This is one of the largest FD screening schemes in a European ESKD cohort. Subsequent in vitro studies proved that the hot VUS is linked to alternative FD pathogenesis, thereby substantiating the utility of combining biomarkers and sequencing/bioinformatics in FD screening. The broad application of FD diagnostic guidelines has reduced its underdiagnosis in ESKD.

2nd Department of Medicine Cardiology and Angiology 1st Faculty of Medicine Charles University Prague and General University Hospital Prague Czech Republic

Department of Biology and Medical Genetics 2nd School of Medicine Charles University and Motol University Hospital Prague Czech Republic

Department of Internal Medicine 3rd Faculty of Medicine Charles University Prague and University Hospital Královské Vinohrady Prague Czech Republic

Department of Internal Medicine Hospital České Budějovice Czech Republic

Department of Nephrology 1st Faculty of Medicine Charles University Prague and Faculty General Hospital Prague Czechia

Department of Nephrology Faculty of Medicine Charles University and University Hospital Hradec Králové Czech Republic

Department of Nephrology Institute of Clinical and Experimental Medicine Prague Czech Republic

Dialysis Unit B Braun Avitum Ohradní Prague Czech Republic

Dialysis Unit B Braun Avitum Teplice Teplice Czech Republic

Dialysis Unit Hedica Boskovice Czech Republic

Dialysis Unit Liberec Regional Hospital Liberec Czech Republic

Fresenius Medical Care DS Prague Czech Republic

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