Acrodysostosis type 1: mechanisms explaining PRKAR1A mutation mediated dysregulation of cAMP-PKA signalling

Acrodysostosis type 1 (ACRDYS1) is a rare multisystem developmental disorder affecting skeletal growth, endocrine function, neurodevelopment, metabolism, and tooth formation. It is caused by heterozygous mutations in PRKAR1A, which encodes the type Iα regulatory subunit (RIα) of protein kinase A (PKA), a central mediator of cyclic AMP (cAMP)-dependent signalling. Although ACRDYS1 belongs to the broader family of Gsα-cAMP-PKA-related disorders, its underlying mechanism is distinct. Disease-associated PRKAR1A mutations cluster within regions of RIα that bind cAMP and undergo conformational rearrangements required for PKA activation. These variants impair cAMP binding and disrupt the structural transitions needed to disinhibit catalytic subunits. Importantly, mutant RIα is expressed at near-normal levels and assembles efficiently into PKA holoenzymes, but these complexes respond weakly and sluggishly to physiological cAMP signals. Drawing on structural, biochemical, cellular, and in vivo studies, we define a dual pathogenic mechanism underlying ACRDYS1. First, defective cAMP-driven conformational changes reduce the sensitivity and amplitude of type I PKA activation, producing a hypomorphic signalling state despite intact upstream receptor coupling and cAMP production. Second, activation-resistant RIα holoenzymes impose a dominant-negative constraint by retaining catalytic subunits, further limiting the pool available for productive signalling in heterozygous cells. We relate this core defect in signal responsiveness to tissue-specific vulnerability. Impaired RIα-dependent decoding of cAMP signals disrupts the Ihh-PTHrP feedback loop in the growth plate, blunts hormone-responsive transcriptional programmes in endocrine epithelia, and alters spatially restricted PKA signalling domains in neurons and metabolically active tissues. Despite the diversity of affected organs, the unifying defect is an inability to generate appropriately timed and scaled PKA responses. This framework establishes ACRDYS1 as a disorder of signal decoding rather than signal generation, clarifies its mechanistic distinction from PRKAR1A-related Carney Complex, and highlights therapeutic strategies aimed at restoring local cAMP-PKA signalling dynamics rather than globally amplifying pathway activity.