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We present a stratification of the genetic basis of primary ciliary dyskinesia (PCD), based on screening >230 individuals for gene mutations using various approaches including whole exome sequencing. PCD is a genetically heterogeneous recessive ciliopathy, characterized by chronic lung disease and laterality and fertility defects arising from cilia and sperm dysmotility. Most PCD is caused by loss of the ciliary outer dynein arm motors (ODA) essential for motility, arising from mutations in ODA subunits or ODA docking and targeting proteins. Gene panel resequencing of candidate ciliopathy genes in affected children from a consanguineous Bedouin-Arabic family has recently revealed a homozygous protein truncating variant in CCDC151 (c.925G>T; p.Glu308*). Parallel exome sequencing combined with autozygosity mapping in a consanguineous UK-Pakistani-origin family highlighted a large autozygous region on chr 19p13 harbouring a homozygous CCDC151 protein-truncating variant (c.1256C>T; pSer419*). Sanger sequencing of CCDC151 in 150 more PCD cases identified another individual carrying c.925G>T. Transmission electron microscopy of respiratory cilia from individuals carrying CCDC151 mutations showed loss of ODA. Consistent with laterality defects in these individuals, we find Ccdc151 expressed in vertebrate left-right organizers. Both homozygous zebrafish and mouse Ccdc151-deficient mutants display situs defects associated with complex heart defects. Immunofluorescence analysis in patients shows that CCDC151 mutations abolish assembly of CCDC151 into respiratory cilia, and furthermore cause a failure in assembly of the ODA component DNAH5 and ODA docking proteins CCDC114 and ARMC4. We conclude that CCDC151 mutations appear to cause PCD by disruption of the axonemal ODA docking complex machinery.

Primary ciliary dyskinesia (PCD) is a genetically heterogeneous inherited disorder characterised by recurrent respiratory tract infections, bronchiectasis and subfertility which arises from cilia/sperm dysmotility associated with axonemal ultrastructural abnormalities. Laterality is randomized with ~50% of patients having situs inversus. Up to 15% of PCD cases show perturbation of the 9+2 microtubule structure and loss of the inner dynein arms, and these have tended to be referred to as ‘radial spoke defect’ cases. The radial spokes are essential for axoneme motility, mediating signal transduction between the central microtubular pair and dynein arm motors. Two genes causing this specific ultrastructural defect are known: CCDC39 (Merveille et. al., Nat Genet. 2011 43:72-8) and CCDC40 (Becker-Heck et. al. Nat Genet. 2011 43:79-84). We sequenced these genes in 22 PCD families with an ultrastructural defect involving microtubule disorganisation, either with or without accompanying loss of the inner dynein arms. We found recesively inherited CCDC39 mutations in 8/22 families and CCDC40 mutations in 7/22 families in the cohort, jointly accounting for a remarkable 68% (15/22) of families. The majority of CCDC39 and CCDC40 mutations were nonsense or frameshift resulting in early protein truncation, predicted to cause major disruption to the axoneme. Furthermore, there was a preponderance of homozygous mutations accounting for disease, even in families from outbred populations. Our results highlight the key role of the CCDC39 and CCDC40 genes in PCD with radial spoke defect, and suggest that disease is associated with complete protein loss (null alleles). These two genes represent prime targets for genetic testing in this disease phenotype. Work is in progress to identify the disease genes in the remaining patients within this subgroup, by next generation whole exome sequencing.

Objectives PCD is an autosomal recessive condition that affects the structure and function of motile cilia in the respiratory tract, middle ear and reproductive organs. The estimated prevalence is 1:15,000, but as high as 1:2265 in the British Asian population. Mutations in the CCDC103 gene have recently been identified as PCD disease-causing in Pakistani individuals. It is found to be an essential gene for dynein arm assembly and ciliary motility.