A disease trait that is inherited in an autosomal dominant manner can occur in either sex and can be transmitted by either parent. It manifests itself in the heterozygote (designated Aa), who receives a mutant gene (designated a) from one parent and a normal (“wild-type”) gene (designated A) from the other. In such a case the pedigree (i.e., a pictorial representation of family history) is vertical—that is, the disease passes from one generation to the next. The figure illustrates the pedigree for a family with achondroplasia, an autosomal dominant disorder characterized by short-limbed dwarfism that results from a specific mutation in the fibroblast growth factor receptor 3 (FGFR3) gene. In pedigrees of this sort, circles refer to females and squares to males; two symbols directly joined at the midpoint represent a mating, and those suspended from a common overhead line represent siblings, with descending birth order from left to right. Solid symbols represent affected individuals, and open symbols represent unaffected individuals. The Roman numerals denote generations, whereas the Arabic numerals identify individuals within each generation. Each person listed in a pedigree may therefore be specified uniquely by a combination of one Roman and one Arabic numeral, such as II-1.

An individual who carries one copy of a dominant mutation (Aa) will produce two kinds of germ cells—eggs or sperm—typically in equal proportions; one half will bear the mutant gene (A), and the other will bear the normal gene (a). As a result, an affected heterozygote has a 50 percent chance of passing on the disease gene to each of his or her children. If an individual were to carry two copies of the dominant mutant gene (inherited from both parents), he or she would be homozygous (AA). The homozygote for a dominantly inherited abnormal gene may be equally affected with the heterozygote. Alternatively, he or she may be much more seriously affected; indeed, the homozygous condition may be lethal, sometimes even in utero or shortly after birth. Such is the case with achondroplasia, so that a couple with one affected partner and one unaffected partner will typically see half of their children affected, whereas a couple with both partners affected will see two-thirds of their surviving children affected and one-third unaffected, because 1 out of 4 conceptions will produce a homozygous fetus who will die before or shortly after birth.

Although autosomal dominant traits are typically evident in multiple generations of a family, they can also arise from new mutations, so that two unaffected parents, neither of whom carries the mutant gene in their somatic cells, can conceive an affected child. Indeed, for some disorders the new mutation rate is quite high; almost 7 out of 8 children with achondroplasia are born to two unaffected parents. Examples of autosomal dominant inheritance are common among human traits and diseases. More than 2,000 of these traits have been clearly identified; a sampling is given in the table.

In many genetic diseases, including those that are autosomal dominant, specific mutations associated with the same disease present in different families may be uniform, such that every affected individual carries exactly the same molecular defect (allelic homogeneity), or they may be heterogeneous, such that tens or even hundreds of different mutations, all affecting the same gene, may be seen in the affected population (allelic heterogeneity). In some cases even mutations in different genes can lead to the same clinical disorder (genetic heterogeneity). Achondroplasia is characterized by allelic homogeneity, such that essentially all affected individuals carry exactly the same mutation.

With regard to the physical manifestations (i.e., the phenotype) of some genetic disorders, a mutant gene may cause many different symptoms and may affect many different organ systems (pleiotropy). For example, along with the short-limbed dwarfism characteristic of achondroplasia, some individuals with this disorder also exhibit a long, narrow trunk, a large head with frontal bossing, and hyperextensibility of most joints, especially the knees. Similarly, for some genetic disorders, clinical severity may vary dramatically, even among affected members in the same family. These variations of phenotypic expression are called variable expressivity, and they are undoubtedly due to the modifying effects of other genes or environmental factors. Although for some disorders, such as achondroplasia, essentially all individuals carrying the mutant gene exhibit the disease phenotype, for other disorders some individuals who carry the mutant gene may express no apparent phenotypic abnormalities at all. Such unaffected individuals are called “nonpenetrant,” although they can pass on the mutant gene to their offspring, who could be affected.

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Autosomal recessive inheritance

Nearly 2,000 traits have been related to single genes that are recessive; that is, their effects are masked by normal (“wild-type”) dominant alleles and manifest themselves only in individuals homozygous for the mutant gene. A partial list of recessively inherited diseases is given in the table. For example, sickle cell anemia, a severe hemoglobin disorder, results only when a mutant gene (a) is inherited from both parents. Each of the latter is a carrier, a heterozygote with one normal gene and one mutant gene (Aa) who is phenotypically unaffected. The chance of such a couple producing a child with sickle cell anemia is one out of four for each pregnancy. For couples consisting of one carrier (Aa) and one affected individual (aa), the chance of their having an affected child is one out of two for each pregnancy.

Many autosomal recessive traits reflect mutations in key metabolic enzymes and result in a wide variety of disorders classified as inborn errors of metabolism. One of the best-known examples of this class of disorders is phenylketonuria (PKU), which results from mutations in the gene encoding the enzyme phenylalanine hydroxylase (PAH). PAH normally catalyzes the conversion of phenylalanine, an amino acid prevalent in dietary proteins and in the artificial sweetener aspartame, to another amino acid called tyrosine. In persons with PKU, dietary phenylalanine either accumulates in the body or some of it is converted to phenylpyruvic acid, a substance that normally is produced only in small quantities. Individuals with PKU tend to excrete large quantities of this acid, along with phenylalanine, in their urine. When infants accumulate high concentrations of phenylpyruvic acid and unconverted phenylalanine in their blood and other tissues, the consequence is intellectual disability. Fortunately, with early detection, strict dietary restriction of phenylalanine, and supplementation of tyrosine, intellectual disability can be prevented.

Since the recessive genes that cause inborn errors of metabolism are individually rare in the gene pool, it is not often that both parents are carriers; hence, the diseases are relatively uncommon. If the parents are related (consanguineous), however, they will be more likely to have inherited the same mutant gene from a common ancestor. For this reason, consanguinity is often more common in the parents of those with rare, recessive inherited diseases. The pedigree of a family in which PKU has occurred is shown in the figure. This pedigree demonstrates that the affected individuals for recessive diseases are usually siblings in one generation—the pedigree tends to be “horizontal,” rather than “vertical” as in dominant inheritance.