The NM_000203.5:c.820G>T (p.Glu274Ter) variant in IDUA is a nonsense variant predicted to cause a premature stop codon in biologically-relevant exon 7 out of 14, leading to nonsense mediated decay in a gene in which loss-of function is an established disease mechanism (PVS1). At least 1 patient with this variant had documented IDUA deficiency within the affected range and bone marrow transplant resulted in a significant reduction in urine GAGs (PP4; PMID: 8401515). This individual was compound heterozygous for the variant and another variant in IDUA that has been classified as pathogenic by the ClinGen LD VCEP, c.208C>T (p.Gln70Ter), and confirmed in trans by parental testing (PM3; PMID: 8401515). The highest population minor allele frequency in gnomAD v4.1.0. is 0.000 (0/74926 alleles) in the African/African American population, which is lower than the ClinGen Lysosomal Diseases VCEP’s threshold for PM2_Supporting (<0.00025), meeting this criterion (PM2_Supporting). There is a ClinVar entry for this variant (Variation ID: 553227). In summary, this variant meets the criteria to be classified as pathogenic for MPS I based on the IDUA-specific ACMG/AMP criteria applied, as specified by the ClinGen Lysosomal Diseases Variant Curation Expert panel (Specifications Version 1.1.0): PVS1, PP4, PM3, PM2_Supporting. (Classification approved by the ClinGen Lysosomal Diseases Variant Curation Expert Panel on December 15, 2025)