Background The transport of transfer RNAs (tRNAs) from the nucleus to the cytoplasm is a crucial step in the regulation of gene expression and protein synthesis. This process is mediated by specialized export molecules, among which XPOT (Exportin-t, XPO3) plays a central role by recognizing and transporting mature tRNAs through the nuclear pore complex. XPOT is not essential in RNA trafficking in the simple organisms, however the potential impact of XPOT deficiency in human health remains unresolved. Methods We identified eight patients from five unrelated families with rare biallelic germline variants in XPOT resulting in putative loss-of-function. Functional analyses were carried out in patient-derived fibroblasts, lymphoblastoid cells and zebrafish models. Ex vivo immunohistochemical stainings for Xpot were performed in the mouse cochlea. xpot knockout zebrafish models were generated to assess the morphology and hearing ability. Results All patients presented with a uniform clinical phenotype that included increased susceptibility to infection, bronchiectasis, severe sensorineural hearing loss, developmental delay, and growth retardation. We demonstrated a complete absence of XPOT protein expression in three patient-derived cell lines. XPOT deficiency leads to disruptions in protein synthesis of the cytokine TNFα pathway upon cellular stimulation. Additional XPO1 inhibition in XPOT deficient cells had little effect on cellular functions, suggesting alternative tRNA nuclear transporter pathways. Increased XPOT immunoreactivity was observed in type I spiral ganglion neurons and hair cells of the mouse cochlea, with enrichment in stereocilia. xpot knockout zebrafish model showed dysmorphic features, and reduced hearing, recapitulating key patient phenotypes. Conclusions Our findings establish a direct connection between impaired XPOT-dependent tRNA export and human pathology. It illustrates that perturbations in nuclear export pathways lead to disease. It also raises the possibility that other nuclear transport receptors may play similarly underappreciated roles in human health and disease. The identification of XPOT as a disease-associated gene opens up new research directions and potential targets for therapeutic intervention. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement German Research Foundation (DFG) Heisenberg program (STR1027/5-2 to N.S. and VO2138/8-1 grant 543719215 to B.V.), and the DFG Collaborative Research Center 1690 (Project A01 to N.S. and A03 to B.V.). This work was done with the support of the Center for Rare Hearing Disorders at the Center of Rare Diseases Goettingen (ZSEG). Zebrafish work is supported by the Oklahoma Medical Research Foundation, Oklahoma City, USA. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the Ethics Committee (AZ\_8657\_BO\_K\_2019) at Hannover Medical School. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors

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