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Bose N, Chaudhuri K, Muorah M, Sinha R. Joining the dots: Answers. Pediatr Nephrol 2022; 37:1525-1528. [PMID: 35084566 DOI: 10.1007/s00467-021-05415-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 11/20/2021] [Accepted: 11/22/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Mordi Muorah
- Birmingham Women's And Children's NHS Foundation Trust, Birmingham, UK
| | - Rajiv Sinha
- Institute of Child Health, Kolkata, India. .,Paediatric Nephrology, Institute of Child Health, Kolkata, India.
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2
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Gómez-Conde S, García-Castaño A, Aguirre M, Herrero M, Gondra L, García-Pérez N, García-Ledesma P, Martín-Penagos L, Dall'Anese C, Ariceta G, Castaño L, Madariaga L. Molecular aspects and long-term outcome of patients with primary distal renal tubular acidosis. Pediatr Nephrol 2021; 36:3133-3142. [PMID: 33881640 DOI: 10.1007/s00467-021-05066-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Primary distal renal tubular acidosis (dRTA) is a rare genetic disorder caused by impaired distal mechanisms of urinary acidification. Most cases are secondary to pathogenic variants in ATP6V0A4, ATP6V1B1, and SLC4A1 genes, which encode transporters regulating acid-base balance in the collecting duct. METHODS Retrospective study of molecular and clinical data from diagnosis and long-term follow-up (10, 20, and 40±10 years) of 16 patients with primary dRTA diagnosed in childhood. RESULTS Molecular analyses revealed nine patients had ATP6V0A4 pathogenic variants, five in ATP6V1B1, and two in SLC4A1. A novel intragenic deletion and a common ATP6V0A4 gene variant (c.1691 + 2dupT) in ATP6V0A4 occurred in two-thirds of these patients, suggesting a founder effect. Median age at diagnosis was 3.25 months (IQR 1, 13.5), which was higher in the SLC4A1 group. Median SDS height at diagnosis was -1.02 (IQR -1.79, 0.14). Delayed clinical diagnosis was significantly related to growth failure (P = 0.01). Median SDS height at 20 years follow-up was -1.23 (IQR -1.71, -0.48), and did not significantly improve from diagnosis (P = 0.76). Kidney function declined over time: at last follow-up, 43% had moderate to severe chronic kidney disease (CKD). Adequate metabolic control was not related to CKD development. Incidence of sensorineural hearing loss (SNHL) was high in ATP6V1B1 patients, though not universal. Patients harboring ATP6V0A4 variants also developed SNHL at a high rate (80%) over time. CONCLUSIONS Patients with dRTA can develop moderate to severe CKD over time with a high frequency despite adequate metabolic control. Early diagnosis ameliorates long-term height prognosis.
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Affiliation(s)
| | - Alejandro García-Castaño
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain
| | - Mireia Aguirre
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Pediatric Nephrology Department, Cruces University Hospital, Barakaldo, Spain
| | - María Herrero
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Pediatric Nephrology Department, Cruces University Hospital, Barakaldo, Spain
| | - Leire Gondra
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Pediatric Nephrology Department, Cruces University Hospital, Barakaldo, Spain.,Pediatric Department, University of the Basque Country UPV/EHU, Leioa, Spain
| | - Nélida García-Pérez
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Pediatric Department, University of the Basque Country UPV/EHU, Leioa, Spain.,Pediatric Nephrology Department, Basurto University Hospital, Bilbao, Spain
| | | | - Luis Martín-Penagos
- Nephrology Department, Marqués de Valdecilla University Hospital, Santander, Spain
| | | | - Gema Ariceta
- Pediatric Nephrology Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Castaño
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain.,Pediatric Department, University of the Basque Country UPV/EHU, Leioa, Spain
| | - Leire Madariaga
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain. .,CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain. .,Pediatric Nephrology Department, Cruces University Hospital, Barakaldo, Spain. .,Pediatric Department, University of the Basque Country UPV/EHU, Leioa, Spain.
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3
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Trepiccione F, Walsh SB, Ariceta G, Boyer O, Emma F, Camilla R, Ferraro PM, Haffner D, Konrad M, Levtchenko E, Lopez-Garcia SC, Santos F, Stabouli S, Szczepanska M, Tasic V, Topaloglu R, Vargas-Poussou R, Wlodkowski T, Bockenhauer D. Distal Renal Tubular Acidosis: ERKNet/ESPN Clinical Practice Points. Nephrol Dial Transplant 2021; 36:1585-1596. [PMID: 33914889 DOI: 10.1093/ndt/gfab171] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Indexed: 12/15/2022] Open
Abstract
Distal renal tubular acidosis (dRTA) is characterised by an impaired ability of the distal tubule to excrete acid, leading to metabolic acidosis. Associated complications include bone disease, growth failure, urolithiasis and hypokalaemia. Due to its rarity, there is a limited evidence to guide diagnosis and management, however, available data strongly suggest that metabolic control of the acidosis by alkali supplementation can halt or revert almost all complications. Despite this, cohort studies show that adequate metabolic control is present in only about half of patients, highlighting problems with treatment provision or adherence. With these clinical practice points the authors, part of the working groups tubulopathies in the European Rare Kidney Disease Reference network (ERKnet) and inherited kidney diseases of the European Society for Paediatric Nephrology (ESPN) aim to provide guidance for the management of patients with dRTA to facilitate adequate treatment and establish an initial best practice standard against which treatment of patients can be audited.
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Affiliation(s)
- Francesco Trepiccione
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Steven B Walsh
- Department of Renal Medicine, University College London, UK
| | - Gema Ariceta
- Division of Pediatric Nephrology. Hospital Universitario Vall d' Hebron. Universitat Autonoma de Barcelona. Barcelona, Spain
| | - Olivia Boyer
- Pediatric Nephrology, Necker Hospital, APHP, MARHEA, Imagine Institute, Paris University, Paris, France
| | - Francesco Emma
- Division of Nephrology, Bambino Gesu Children's Hospital - IRCCS, Rome, Italy
| | - Roberta Camilla
- Nephrology, Dialysis, Transplantation, Regina Margherita University Hospital, Turin, Italy
| | - Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, U.O.C. Nefrologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Martin Konrad
- Department of General Pediatrics, University Children's Hospital, Muenster, Germany
| | - Elena Levtchenko
- Division of Pediatric Nephrology, University Hospitals Leuven; Department of Development & Regeneration, Katholieke Universiteit Leuven, Belgium
| | - Sergio Camilo Lopez-Garcia
- Department of Renal Medicine, University College London, UK.,Renal Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Fernando Santos
- Department of Pediatrics, Hospital Universitario Central de Asturias and Área de Pediatría, Dpto. de Medicina, Universidad de Oviedo, Oviedo, Spain
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University, Thessaloniki, Greece
| | | | - Velibor Tasic
- University Children's Hospital, Medical School, Skopje, Macedonia
| | - Rezan Topaloglu
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Rosa Vargas-Poussou
- Department of Genetics, Centre de Références MARHEA, Hôpital Européen Georges Pompidou Assistance Publique Hôpitaux de Paris, Paris France
| | - Tanja Wlodkowski
- Department of Paediatric Nephrology, University Children's Hospital, Heidelberg, Germany
| | - Detlef Bockenhauer
- Department of General Pediatrics, University Children's Hospital, Muenster, Germany.,Division of Pediatric Nephrology, University Hospitals Leuven; Department of Development & Regeneration, Katholieke Universiteit Leuven, Belgium
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4
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Liu J, Shen Q, Li G, Zhai Y, Fang X, Xu H. Clinical and genetic analysis of distal renal tubular acidosis in three Chinese children. Ren Fail 2018; 40:520-526. [PMID: 30230413 PMCID: PMC6147104 DOI: 10.1080/0886022x.2018.1487858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: Primary distal renal tubular acidosis (dRTA) is a rare genetic disease characterized by distal tubular dysfunction leading to metabolic acidosis and alkaline urine. Growth retardation is a major concern in these children. The disease is caused by defects in at least three genes (SLC4A1, ATP6V0A4, and ATP6V1B1) involved in urinary distal acidification. Several series of dRTA patients from different ethnic backgrounds have been genetically studied, but genetic studies regarding Chinese population is rare. Our aim was to investigate the clinical features and genetic basis of primary dRTA in Chinese children. Methods: Three unrelated patients with dRTA participated in our study. Next-generation sequencing was performed, and the findings were validated using the Sanger sequencing method. Results: All patients exhibited hyperchloraemic metabolic acidosis, abnormally high urine pH, hypokalemia, and nephrocalcinosis. Growth retardation was observed in all patients. During the follow-up (range 1–4 years), alkali replacement therapy corrected the systemic metabolic acidosis, and two patients demonstrated normal growth. rhGH therapy was administered to patient-3 at the age of 6 years, and his growth rate was significantly improved (growth velocity 9.6 cm/yr). In total, 5 mutations were identified in our cohort of three patients, and four mutations were novel. Conclusions: We report the clinical and molecular characteristics of dRTA patients from China. The four novel mutations detected in our study extend the spectrum of gene mutations associated with primary dRTA. Furthermore, our study confirms the effect of early treatment in improving growth for dRTA patient and provides insight into the effects of rhGH on dRTA patients who were diagnosed late and exhibiting a persistent growth delay despite appropriate therapy.
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Affiliation(s)
- Jiaojiao Liu
- a Department of Nephrology , Children's Hospital of Fudan University , Shanghai , China
| | - Qian Shen
- a Department of Nephrology , Children's Hospital of Fudan University , Shanghai , China
| | - Guomin Li
- a Department of Nephrology , Children's Hospital of Fudan University , Shanghai , China
| | - Yihui Zhai
- a Department of Nephrology , Children's Hospital of Fudan University , Shanghai , China
| | - Xiaoyan Fang
- a Department of Nephrology , Children's Hospital of Fudan University , Shanghai , China
| | - Hong Xu
- a Department of Nephrology , Children's Hospital of Fudan University , Shanghai , China
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5
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Trepiccione F, Prosperi F, de la Motte LR, Hübner CA, Chambrey R, Eladari D, Capasso G. New Findings on the Pathogenesis of Distal Renal Tubular Acidosis. KIDNEY DISEASES 2017; 3:98-105. [PMID: 29344504 DOI: 10.1159/000478781] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/07/2017] [Indexed: 12/23/2022]
Abstract
Background Distal renal tubular acidosis (dRTA) is characterized by an impairment of the urinary acidification process in the distal nephron. Complete or incomplete metabolic acidosis coupled with inappropriately alkaline urine are the hallmarks of this condition. Genetic forms of dRTA are caused by loss of function mutations of either SLC4A1, encoding the AE1 anion exchanger, or ATP6V1B1 and ATP6V0A4, encoding for the B1 and a4 subunits of the vH+ATPase, respectively. These genes are crucial for the function of A-type intercalated cells (A-IC) of the distal nephron. Summary Alterations of acid-base homeostasis are variably associated with hypokalemia, hypercalciuria, nephrocalcinosis or nephrolithiasis, and a salt-losing phenotype. Here we report the diagnostic test and the underlying physiopathological mechanisms. The molecular mechanisms identified so far can explain the defect in acid secretion, but do not explain all clinical features. We review the latest experimental findings on the pathogenesis of dRTA, reporting mechanisms that are instrumental for the clinician and potentially inspiring a novel therapeutic strategy. Key Message Primary dRTA is usually intended as a single-cell disease because the A-IC are mainly affected. However, novel evidence shows that different cell types of the nephron may contribute to the signs and symptoms, moving the focus from a single-cell towards a renal disease.
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Affiliation(s)
- Francesco Trepiccione
- Department of Cardiothoracic and Respiratory Science, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Federica Prosperi
- Department of Cardiothoracic and Respiratory Science, University of Campania "Luigi Vanvitelli," Naples, Italy.,Biogem S.c.a.r.l., Research Institute Gaetano Salvatore, Ariano Irpino, Italy
| | - Luigi Regenburgh de la Motte
- Department of Cardiothoracic and Respiratory Science, University of Campania "Luigi Vanvitelli," Naples, Italy.,Biogem S.c.a.r.l., Research Institute Gaetano Salvatore, Ariano Irpino, Italy
| | - Christian A Hübner
- Institute of Human Genetics, Jena University Hospital, Friedrich Schiller University, Jena, Germany
| | - Regine Chambrey
- Inserm U1188, Diabète athérothrombose Thérapies Réunion Océan Indien (DéTROI), Université de La Réunion, France
| | - Dominique Eladari
- Service d'Explorations Fonctionnelles Rénales, Hôpital Felix Guyon, CHU de la Réunion, Saint-Denis, Ile de la Réunion, France
| | - Giovambattista Capasso
- Department of Cardiothoracic and Respiratory Science, University of Campania "Luigi Vanvitelli," Naples, Italy.,Biogem S.c.a.r.l., Research Institute Gaetano Salvatore, Ariano Irpino, Italy
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6
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Marano M, Bottaro G, Goffredo B, Stoppa F, Pisani M, Marinaro AM, Deodato F, Dionisi-Vici C, Clementi E, Falvella FS. Deferasirox-induced serious adverse reaction in a pediatric patient: pharmacokinetic and pharmacogenetic analysis. Eur J Clin Pharmacol 2015; 72:247-8. [PMID: 26403473 DOI: 10.1007/s00228-015-1956-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 09/18/2015] [Indexed: 10/23/2022]
Affiliation(s)
- M Marano
- DEA Intensive Care Unit, IRCCS "Bambino Gesù" Children Hospital, Piazza S. Onofrio 4, Rome, 00165, Italy.
| | - G Bottaro
- Department of Pediatrics "Tor Vergata University", Rome, Italy
| | - B Goffredo
- Laboratory of Analytical Biochemistry, IRCCS "Bambino Gesù" Children Hospital, Rome, Italy
| | - F Stoppa
- DEA Intensive Care Unit, IRCCS "Bambino Gesù" Children Hospital, Piazza S. Onofrio 4, Rome, 00165, Italy
| | - M Pisani
- DEA, IRCCS "Bambino Gesù" Children Hospital, Rome, Italy
| | - A M Marinaro
- Department of Pediatrics, Section of Pediatrics Haematology and Oncology, University of Sassari, Sassari, Italy
| | - F Deodato
- Department of Pediatric Medicine, Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - C Dionisi-Vici
- Department of Pediatric Medicine, Division of Metabolism, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - E Clementi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy.,Department of Biomedical and Clinical Sciences L. Sacco, Unit of Clinical Pharmacology, CNR Institute of Neuroscience, "Luigi Sacco" University Hospital, University of Milano, Milan, Italy
| | - F S Falvella
- Department of Biomedical and Clinical Sciences, Unit of Clinical Pharmacology, "Luigi Sacco" University Hospital, University of Milano, Milan, Italy
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7
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Lee JH, Park JH, Ha TS, Han HS. Refractory rickets caused by mild distal renal tubular acidosis. Ann Pediatr Endocrinol Metab 2013; 18:152-5. [PMID: 24904870 PMCID: PMC4027071 DOI: 10.6065/apem.2013.18.3.152] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 09/24/2013] [Accepted: 09/25/2013] [Indexed: 12/04/2022] Open
Abstract
Type I (distal) renal tubular acidosis (RTA) is a disorder associated with the failure to excrete hydrogen ions from the distal renal tubule. It is characterized by hyperchloremic metabolic acidosis, an abnormal increase in urine pH, reduced urinary excretion of ammonium and bicarbonate ions, and mild deterioration in renal function. Hypercalciuria is common in distal RTA because of bone resorption, which increases as a buffer against metabolic acidosis. This can result in intractable rickets. We describe a case of distal RTA with nephrocalcinosis during follow-up of rickets in a patient who presented with clinical manifestations of short stature, failure to thrive, recurrent vomiting, dehydration, and irritability.
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Affiliation(s)
- Ji-Ho Lee
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joo Hyun Park
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Tae-Sun Ha
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Heon-Seok Han
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
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8
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Dell'Orto VG, Bianchetti MG, Brazzola P. Hyperchloraemic metabolic acidosis induced by the iron chelator deferasirox: a case report and review of the literature. J Clin Pharm Ther 2013; 38:526-7. [DOI: 10.1111/jcpt.12095] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Accepted: 07/29/2013] [Indexed: 11/28/2022]
Affiliation(s)
- V. G. Dell'Orto
- Integrated Department of Pediatrics; Ente Ospedaliero Cantonale Ticinese; University of Berne; Berne Switzerland
| | - M. G. Bianchetti
- Integrated Department of Pediatrics; Ente Ospedaliero Cantonale Ticinese; University of Berne; Berne Switzerland
| | - P. Brazzola
- Integrated Department of Pediatrics; Ente Ospedaliero Cantonale Ticinese; University of Berne; Berne Switzerland
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9
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Al-Haggar M. Fanconi-Bickel syndrome as an example of marked allelic heterogeneity. World J Nephrol 2012; 1:63-8. [PMID: 24175243 PMCID: PMC3782201 DOI: 10.5527/wjn.v1.i3.63] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Revised: 05/25/2012] [Accepted: 06/01/2012] [Indexed: 02/06/2023] Open
Abstract
Renal tubular acidosis (RTA) encompasses many renal tubular disorders characterized by hyperchloremic metabolic acidosis with a normal anion gap. Untreated patients usually complain of growth failure, osteoporosis, rickets, nephrolithiasis and eventually renal insufficiency. Fanconi-Bickel syndrome (FBS) is an example of proximal RTA due to a single gene disorder; it is caused by defects in the facilitative glucose transporter 2 gene that codes for the glucose transporter protein 2 expressed in hepatocytes, pancreatic β-cells, enterocytes and renal tubular cells. It is a rare inherited disorder of carbohydrate metabolism manifested by huge hepatomegaly [hence it is classified as glycogen storage disease (GSD) type XI; GSD XI], severe hypophosphatemic rickets and failure to thrive due to proximal renal tubular dysfunction leading to glucosuria, phosphaturia, generalized aminoaciduria, bicarbonate wasting and hypophosphatemia. The disorder has been reported from all parts of Europe, Turkey, Israel, Arabian countries, Japan and North America. Many mutant alleles have been described, its exact frequency is unknown and there is no single mutation found more frequently than the others. The presence of consanguinity in affected families suggests an autosomal recessive pattern of inheritance. New cases of FBS have been recently reported in the Middle and Far East in collaboration with specialized centers. Two novel mutations have been discovered in two unrelated Egyptian families. The first was two bases deletion, guanine and adenine, (c.253_254delGA) causing a frameshift mutation (p. Glu85fs) and the second is mutation in exon6 in splicing acceptor site with intron5 (c.776-1G>C or IVS5-1G>A). Moreover, a new different mutation was described in a 3 year old Indian boy.
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Affiliation(s)
- Mohammad Al-Haggar
- Mohammad Al-Haggar, Pediatrics and Genetics, Mansoura University Children's Hospital, 35516 Mansoura, Egypt
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10
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Kraut JA, Madias NE. Consequences and therapy of the metabolic acidosis of chronic kidney disease. Pediatr Nephrol 2011; 26:19-28. [PMID: 20526632 PMCID: PMC2991191 DOI: 10.1007/s00467-010-1564-4] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2010] [Revised: 04/22/2010] [Accepted: 05/04/2010] [Indexed: 01/18/2023]
Abstract
Metabolic acidosis is common in patients with chronic kidney disease (CKD), particularly once the glomerular filtration rate (GFR) falls below 25 ml/min/1.73 m(2). It is usually mild to moderate in magnitude with the serum bicarbonate concentration ([HCO(3)(-)]) ranging from 12 to 23 mEq/l. Even so, it can have substantial adverse effects, including development or exacerbation of bone disease, growth retardation in children, increased muscle degradation with muscle wasting, reduced albumin synthesis with a predisposition to hypoalbuminemia, resistance to the effects of insulin with impaired glucose tolerance, acceleration of the progression of CKD, stimulation of inflammation, and augmentation of β(2)-microglobulin production. Also, its presence is associated with increased mortality. The administration of base to patients prior to or after initiation of dialysis leads to improvement in many of these adverse effects. The present recommendation by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI) is to raise serum [HCO(3)(-)] to ≥ 22 mEq/l, whereas Caring for Australians with Renal Impairment (CARI) recommends raising serum [HCO(3)(-)] to >22 mEq/l. Base administration can potentially contribute to volume overload and exacerbation of hypertension as well as to metastatic calcium precipitation in tissues. However, sodium retention is less when given as sodium bicarbonate and sodium chloride intake is concomitantly restricted. Results from various studies suggest that enhanced metastatic calcification is unlikely with the pH values achieved during conservative base administration, but the clinician should be careful not to raise serum [HCO(3)(-)] to values outside the normal range.
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Affiliation(s)
- Jeffrey A. Kraut
- Medical and Research Services, VHAGLA Healthcare System, UCLA Membrane Biology Laboratory, Los Angeles, CA USA ,Division of Nephrology, VHAGLA Healthcare System, Los Angeles, USA ,David Geffen School of Medicine, Los Angeles, CA USA
| | - Nicolaos E. Madias
- Division of Nephrology, Department of Medicine, St. Elizabeth’s Medical Center, 736 Cambridge St., Boston, MA 02135 USA ,Department of Medicine, Tufts University School of Medicine, Boston, MA USA
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11
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von Vigier RO, Ortisi MT, La Manna A, Bianchetti MG, Bettinelli A. Hypokalemic rhabdomyolysis in congenital tubular disorders: a case series and a systematic review. Pediatr Nephrol 2010; 25:861-6. [PMID: 20033223 DOI: 10.1007/s00467-009-1388-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 09/24/2009] [Accepted: 10/28/2009] [Indexed: 12/30/2022]
Abstract
Hypokalemia is a recognized cause of rhabdomyolysis but very few reports document its association with inborn renal tubular disorders. We report our experience with hypokalemic rhabdomyolysis in 5 pediatric patients affected by inborn renal tubular disorders and the results of a careful review of the literature disclosing 9 further cases for a total of 14 patients (8 male and 6 female subjects, aged between 1.6 and 46, median 16 years). The inborn renal tubular disorders underlying rhabdomyolysis were classic distal renal tubular acidosis (n = 7), Gitelman syndrome (n = 5), classic Bartter syndrome (n = 1), and antenatal Bartter syndrome (n = 1). In 8 patients rhabdomyolysis followed an acute intestinal disease, an upper respiratory illness or the discontinuation of regular medication. Five patients experienced two or more episodes of rhabdomyolysis. In 10 patients the underlying renal tubular disorder was recognized concurrently with the episode of rhabdomyolysis or some weeks later. In conclusion some congenital renal tubular disorders predispose to hypokalemic rhabdomyolysis. Prevention of discontinuation of regular medication and electrolyte repair in the context of acute intercurrent illnesses might avoid the development of hypokalemic rhabdomyolysis.
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Affiliation(s)
- Rodo O von Vigier
- Pediatric Nephrology, University Children's Hospital Bern and University of Bern, Bern, Switzerland
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12
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13
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Scales CD, Chandrashekar AS, Robinson MR, Cantor DA, Sullivan J, Haleblian GE, Leitao VA, Sur RL, Borawski KM, Koeberl D, Kishnani PS, Preminger GM. Stone forming risk factors in patients with type Ia glycogen storage disease. J Urol 2010; 183:1022-5. [PMID: 20092831 DOI: 10.1016/j.juro.2009.11.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Indexed: 10/19/2022]
Abstract
PURPOSE Patients with type Ia glycogen storage disease have an increased recurrent nephrolithiasis rate. We identified stone forming risk factors in patients with type Ia glycogen storage disease vs those in stone formers without the disease. MATERIALS AND METHODS Patients with type Ia glycogen storage disease were prospectively enrolled from our metabolic clinic. Patient 24-hour urine parameters were compared to those in age and gender matched stone forming controls. RESULTS We collected 24-hour urine samples from 13 patients with type Ia glycogen storage disease. Average +/- SD age was 27.0 +/- 13.0 years and 6 patients (46%) were male. Compared to age and gender matched hypocitraturic, stone forming controls patients had profound hypocitraturia (urinary citrate 70 vs 344 mg daily, p = 0.009). When comparing creatinine adjusted urinary values, patients had profound hypocitraturia (0.119 vs 0.291 mg/mg creatinine, p = 0.005) and higher oxalate (0.026 vs 0.021 mg/mg creatinine, p = 0.038) vs other stone formers. CONCLUSIONS Patients with type Ia glycogen storage disease have profound hypocitraturia, as evidenced by 24-hour urine collections, even compared to other stone formers. This may be related to a recurrent nephrolithiasis rate greater than in the overall population. These findings may be used to support different treatment modalities, timing and/or doses to prevent urinary lithiasis in patients with type Ia glycogen storage disease.
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Affiliation(s)
- Charles D Scales
- Division of Medical Genetics, Duke University Medical Center, Durham, North Carolina 27710, USA
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14
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Stöhr W, Patzer L, Paulides M, Kremers A, Beck JD, Langer T, Rossi R. Growth impairment after ifosfamide-induced nephrotoxicity in children. Pediatr Blood Cancer 2007; 48:571-6. [PMID: 16755549 DOI: 10.1002/pbc.20920] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The goal of this study was to analyze long-term consequences of ifosfamide-induced nephrotoxicity on growth and renal function in children treated for cancer. PROCEDURE In a retrospective study, departments for pediatric oncology and nephrology in Germany, Austria, and Switzerland were asked to report patients with serious long-term nephrotoxicity after ifosfamide-treatment. Data at first appearance of renal dysfunction and at the last renal examination were collected using a standardized questionnaire. RESULTS Fifty-nine patients with tubulopathy (35 severe, 24 moderate) following ifosfamide therapy were eligible for analysis of long-term outcome (median follow-up 4 years, range 1.1 to 12.9). Median height standard deviation score was significantly reduced at renal diagnosis, and at last renal examination (-1.7 and -2.1 respectively, P < 0.01 at each point in time). Patients with tubulopathy also had stunted growth in comparison with a control group of cancer patients without renal disease (mean difference at last examination: 7.3 cm (95% confidence interval: 2.5 to 12.1 cm). In patients with severe tubulopathy, glomerular filtration rate deteriorated significantly over time. End-stage renal disease was reported in one patient only, not solely caused by ifosfamide. CONCLUSION Depending on the extent of tubular dysfunction, patients with ifosfamide-induced nephrotoxicity experienced significant growth impairment and a slow decline in glomerular filtration rate.
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Affiliation(s)
- Wolfgang Stöhr
- Department of Pediatric Oncology, LESS Centre, University Hospital for Children and Adolescents, Erlangen, Germany
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15
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Abstract
Metabolic bone disease in children includes many hereditary and acquired conditions of diverse etiology that lead to disturbed metabolism of the bone tissue. Some of these processes primarily affect bone; others are secondary to nutritional deficiencies, a variety of chronic disorders, and/or treatment with some drugs. Some of these disorders are rare, but some present public health concerns (for instance, rickets) that have been well known for many years but still persist. The most important clinical consequences of bone metabolic diseases in the pediatric population include reduced linear growth, bone deformations, and non-traumatic fractures leading to bone pain, deterioration of motor development and disability. In this article, we analyze primary and secondary osteoporosis, rickets, osteomalacia (nutritional and hereditary vitamin D-dependent, hypophosphatemic and that due to renal tubular abnormalities), renal osteodystrophy, sclerosing bony disorders, and some genetic bone diseases (hypophosphatasia, fibrous dysplasia, skeletal dysplasia, juvenile Paget disease, familial expansile osteolysis, and osteoporosis pseudoglioma syndrome). Early identification and treatment of potential risk factors is essential for skeletal health in adulthood. In most conditions it is necessary to ensure an appropriate diet, with calcium and vitamin D, and an adequate amount of physical activity as a means of prevention. In secondary bone diseases, treatment of the primary disorder is crucial. Most genetic disorders await prospective gene therapies, while bone marrow transplantation has been attempted in other disorders. At present, affected patients are treated symptomatically, frequently by interdisciplinary teams. The role of exercise and pharmacologic therapy with calcium, vitamin D, phosphate, bisphosphonates, calcitonin, sex hormones, growth hormone, and thiazides is discussed. The perspectives on future therapy with insulin-like growth factor-1, new analogs of vitamin D, strontium, osteoprotegerin, and calcimimetics are presented.
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16
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Ariceta G, Vallo A, Rodriguez-Soriano J. Acidosis increases magnesiuria in children with distal renal tubular acidosis. Pediatr Nephrol 2004; 19:1367-70. [PMID: 15503178 DOI: 10.1007/s00467-004-1609-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In experimental animals, metabolic acidosis increases renal magnesium (Mg) excretion, whereas metabolic alkalosis reduces it. The objective of this study was to examine renal magnesium handling (U(Mg)) in children with primary distal renal tubular acidosis (DRTA). We measured U(Mg) in 11 children (3 females, 8 males, aged 6.9+/-4.9 years) with primary DRTA. They were studied either during spontaneous acidosis post treatment removal (3 patients) or after ammonium chloride (100 mmol/m2) induced acidosis (8 patients), and then following oral sodium bicarbonate load (4 g/1.73 m2). During acidosis (plasma pH 7.28+/-0.09, bicarbonate 13.2+/-4.3 mEq/l), U(Mg) was elevated (U(Mg/Cr) 0.18+/-0.06 mg/mg, normal values 0.1+/-0.06, P=0.003) although plasma Mg (P(Mg)) was in the normal range (1.93+/-0.31 mg/dl, controls 1.77+/-0.19, P=NS). After acute correction of metabolic acidosis (plasma pH 7.44+/-0.05, bicarbonate 25.6+/-1.6 mEq/l, P<0.001; urine pH 7.52+/-0.28, bicarbonate 86.9+/-39.1 mEq/l), U(Mg) decreased significantly (P=0.003), returning to control values after about 2 h (U(Mg/Cr) 0.09+/-0.06 mg/mg). Bicarbonate load resulted not only in reduction in U(Mg) but also in a decrease in urinary calcium excretion (U(Ca/Cr)) from 0.46+/-0.17 mg/mg to 0.14+/-0.12 mg/mg (P<0.001). We conclude that in children with primary DRTA, urinary Mg excretion is markedly increased and that this defect, like the hypercalciuric defect, is correctable by sodium bicarbonate administration.
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Affiliation(s)
- Gema Ariceta
- Division of Pediatric Nephrology, Department of Pediatrics, Hospital Clinico Universitario de Santiago de Compostela, Spain.
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17
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Igarashi T, Sekine T, Inatomi J, Seki G. Unraveling the molecular pathogenesis of isolated proximal renal tubular acidosis. J Am Soc Nephrol 2002; 13:2171-7. [PMID: 12138151 DOI: 10.1097/01.asn.0000025281.70901.30] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Proximal renal tubular acidosis (pRTA) results from an impairment of bicarbonate (HCO(3)(-)) reabsorption in the renal proximal tubules and is characterized by a decreased renal HCO(3)(-) threshold. Proximal RTA most commonly occurs in association with multiple defects of proximal tubular transport (renal Fanconi syndrome). Although much more rare, pRTA may occur without other functional defects in proximal tubules (isolated pRTA). The presenting clinical symptom of isolated pRTA is usually growth retardation in infancy or early childhood. Three categories of isolated pRTA have been identified: (1) autosomal dominant pRTA; (2) autosomal recessive pRTA with ocular abnormalities; and (3) sporadic isolated pRTA. Autosomal dominant and autosomal recessive pRTA are usually permanent; life-long alkali therapy is needed. In contrast, sporadic isolated pRTA is transient; alkali therapy can be discontinued after several years without reappearance of symptoms. Recent genetic studies have begun to elucidate the molecular pathogenesis of inherited isolated pRTA. Studies in knockout mice have identified a candidate gene for autosomal dominant pRTA, SLC9A3, a gene encoding one of the five plasma membrane Na(+)/H(+) exchangers (NHE3). Patients with autosomal recessive pRTA and ocular abnormalities have recently been found to have mutations in the kidney type Na(+)/HCO(3)(-) cotransporter gene (SLC4A4). Identification of these gene mutations provides new insights into the molecular pathogenesis of pRTA.
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Affiliation(s)
- Takashi Igarashi
- Department of Pediatrics and Department of Internal Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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18
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Eckart P. [When to think of a renal tubule disease?]. Arch Pediatr 2002; 9 Suppl 2:167s-169s. [PMID: 12108256 DOI: 10.1016/s0929-693x(01)00884-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- P Eckart
- Service de pédiatrie, CHRU Clémenceau, boulevard Clémenceau, 14033 Caen, France.
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19
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Abstract
Although the definition of renal tubular acidosis (RTA) is simple, understanding the physiologic basis underlying the various types of this clinical entity is much more difficult. The pathophysiology of this disorder is reviewed using the normal acid-base functions of the involved segments of the nephron as a guide to understanding. Clinical and laboratory features of the subtypes of RTA are addressed, and diagnosis and treatment discussed. New developments in the knowledge and understanding of the associated growth disturbances, mineral metabolism, and molecular biology of RTA are also reviewed to provide the most current view of this relatively common pediatric entity.
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Affiliation(s)
- K S Roth
- Department of Pediatrics, Virginia Commonwealth University, MCV Campus, Richmond 23298-0239, USA
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20
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Tanaka H, Nakahata T, Ito R, Onodera N, Waga S. An infant case of bilateral small kidneys with both proximal and distal tubular dysfunction. ACTA PAEDIATRICA JAPONICA : OVERSEAS EDITION 1998; 40:367-9. [PMID: 9745783 DOI: 10.1111/j.1442-200x.1998.tb01950.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A male infant with bilateral small kidneys associated with both proximal and distal tubular dysfunction, who showed chronic renal failure soon after birth, is reported. He was also noted to have both proximal and distal type of renal tubular acidosis. The small kidneys were thought to be due to renal hypodysplasia associated with bilateral severe vesicoureteral reflux, by radiological findings. An alkalization therapy with chemoprophylaxis seemed to be of benefit in slowing the progression of renal failure in this case.
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Affiliation(s)
- H Tanaka
- Division of Pediatrics, Iwate Prefectural Kitakami Hospital, Kitakame, Japan
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21
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Karet FE, Gainza FJ, Györy AZ, Unwin RJ, Wrong O, Tanner MJ, Nayir A, Alpay H, Santos F, Hulton SA, Bakkaloglu A, Ozen S, Cunningham MJ, di Pietro A, Walker WG, Lifton RP. Mutations in the chloride-bicarbonate exchanger gene AE1 cause autosomal dominant but not autosomal recessive distal renal tubular acidosis. Proc Natl Acad Sci U S A 1998; 95:6337-42. [PMID: 9600966 PMCID: PMC27686 DOI: 10.1073/pnas.95.11.6337] [Citation(s) in RCA: 209] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Primary distal renal tubular acidosis (dRTA) is characterized by reduced ability to acidify urine, variable hyperchloremic hypokalemic metabolic acidosis, nephrocalcinosis, and nephrolithiasis. Kindreds showing either autosomal dominant or recessive transmission are described. Mutations in the chloride-bicarbonate exchanger AE1 have recently been reported in four autosomal dominant dRTA kindreds, three of these altering codon Arg589. We have screened 26 kindreds with primary dRTA for mutations in AE1. Inheritance was autosomal recessive in seventeen kindreds, autosomal dominant in one, and uncertain due to unknown parental phenotype or sporadic disease in eight kindreds. No mutations in AE1 were detected in any of the autosomal recessive kindreds, and analysis of linkage showed no evidence of linkage of recessive dRTA to AE1. In contrast, heterozygous mutations in AE1 were identified in the one known dominant dRTA kindred, in one sporadic case, and one kindred with two affected brothers. In the dominant kindred, the mutation Arg-589/Ser cosegregated with dRTA in the extended pedigree. An Arg-589/His mutation in the sporadic case proved to be a de novo mutation. In the third kindred, affected brothers both have an intragenic 13-bp duplication resulting in deletion of the last 11 amino acids of AE1. These mutations were not detected in 80 alleles from unrelated normal individuals. These findings underscore the key role of Arg-589 and the C terminus in normal AE1 function, and indicate that while mutations in AE1 cause autosomal dominant dRTA, defects in this gene are not responsible for recessive disease.
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Affiliation(s)
- F E Karet
- Howard Hughes Medical Institute, Departments of Medicine and Genetics, Boyer Center for Molecular Medicine, Yale University School of Medicine, New Haven, CT 06510, USA
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22
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Abstract
The case is reported of an infant with hyperammonaemia secondary to severe distal renal tubular acidosis. A clinical association between increased concentrations of ammonia in serum and renal tubular acidosis has not previously been described. In response to acidosis the infant's kidneys presumably increased ammonia synthesis but did not excrete ammonia, resulting in hyperammonaemia. The patient showed poor feeding, frequent vomiting, and failure to thrive, but did not have an inborn error of metabolism. This case report should alert doctors to consider renal tubular acidosis in the differential diagnosis of severely ill infants with metabolic acidosis and hyperammonaemia.
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Affiliation(s)
- S G Miller
- Department of Pediatrics, University of Rochester School of Medicine, NY 14642, USA
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23
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Skinner R, Cole M, Pearson AD, Coulthard MG, Craft AW. Specificity of pH and osmolality of early morning urine sample in assessing distal renal tubular function in children: results in healthy children. BMJ (CLINICAL RESEARCH ED.) 1996; 312:1337-8. [PMID: 8646047 PMCID: PMC2350985 DOI: 10.1136/bmj.312.7042.1337] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- R Skinner
- Sir James Spence Institute of Child Health, University of Newcastle upon Tyne, Royal Victoria Infirmary
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24
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Navarro JF, Quereda C, Quereda C, Gallego N, Antela A, Mora C, Ortuno J. Nephrogenic diabetes insipidus and renal tubular acidosis secondary to foscarnet therapy. Am J Kidney Dis 1996; 27:431-4. [PMID: 8604715 DOI: 10.1016/s0272-6386(96)90369-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Foscarnet is used as therapy of cytomegalovirus (CMV) infection in immunosuppressed subjects. We present a patient with human immunodeficiency virus infection under treatment with foscarnet for CMV retinitis who complained of thirst and polyuria. Laboratory data showed hypernatremia with increased plasma osmolality and metabolic hyperchloremic acidosis. A water deprivation test demonstrated a nephrogenic diabetes insipidus. Other laboratory studies, including urine pH, anion gap, titratable acidity, and bicarbonate, showed a distal tubular acidification defect. All abnormalities were transient, with recovery a few days after foscarnet withdrawal. No cases of renal acidosis, and only one case of nephrogenic diabetes insipidus, has been previously reported as a complication of foscarnet treatment. Our patient developed both nephrogenic diabetes insipidus and renal tubular acidosis with a temporal pattern that demonstrated a link between foscarnet therapy and these abnormalities.
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Affiliation(s)
- J F Navarro
- Department of Nephrology, Hospital Ramon y Cajal, Madrid, Spain
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25
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Rodríguez-Soriano J, Vallo A. Pathophysiology of the renal acidification defect present in the syndrome of familial hypomagnesaemia-hypercalciuria. Pediatr Nephrol 1994; 8:431-5. [PMID: 7947033 DOI: 10.1007/bf00856522] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A distal acidification defect is frequently observed in the syndrome of familial hypomagnesaemia-hypercalciuria and hence this condition can be confused with primary distal renal tubular acidosis (RTA). This study demonstrates that in four unrelated patients with familial hypomagnesaemia-hypercalciuria the acidification defect is functionally different from that present in primary distal RTA. All patients exhibited hypomagnesaemia, hypermagnesuria, hypercalciuria, hyposthenuria, nephrocalcinosis and slight reduction of glomerular filtration rate (GFR). A moderate degree of metabolic acidosis was also present and basal data showed an inappropriately high urine pH (5.7-5.9) and a positive urine anion gap (Na + K-Cl = 11-28 mmol/l). Stimulation of distal acidification induced a fall in urine pH (4.7-5.6), but ammonium excretion remained low despite factoring by GFR (26-46 mumol/min per 1.73 m2, 35-54 mumol/100 ml GF). The urine to blood PCO2 gradient also remained low after sodium bicarbonate loading (1.3-17.7 mmHg). These results are best explained by both defective ammonia transfer to the deep nephron and impaired hydrogen ion secretion at the level of the medullary collecting duct, and probably are secondary effects of the medullary interstitial nephropathy.
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26
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Abstract
Distal renal tubular acidosis is frequently associated with hypercalciuria. To further investigate the cause-and-effect relationships between the two conditions, we examined 20 children (5 to 18 years of age) with idiopathic hypercalciuria for evidence of renal tubular acidosis. Serum electrolytes and urine citrate levels were normal in all subjects. After a single dose of furosemide, 1 of the 20 subjects did not show a decrease in urine pH < 5.5, which suggests an acidification defect in the cortical collecting duct. Three other patients failed to show an increase in urine-minus-blood partial pressure of carbon dioxide > 20 mmHg after urine alkalinization with orally administered acetazolamide, a finding compatible with a rate-dependent distal renal tubular acidosis. These four subjects underwent acute acid loading with arginine hydrochloride. In all four subjects urine pH decreased < 5.5 but urinary ammonium excretion failed to increase normally; this supports the diagnosis of a defect in distal acidification. Four of six patients with nephrolithiasis had evidence of distal renal tubular acidosis, in contrast to none of the 14 patients without stones (p = 0.003). We conclude that distal acidification abilities seem to be intact in children with hypercalciuria in the absence of nephrolithiasis. We speculate that calcium precipitation may lead to tubular damage, including distal renal tubular acidosis.
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Affiliation(s)
- M Bonilla-Felix
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
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27
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Igarashi T, Ishii T, Watanabe K, Hayakawa H, Horio K, Sone Y, Ohga K. Persistent isolated proximal renal tubular acidosis--a systemic disease with a distinct clinical entity. Pediatr Nephrol 1994; 8:70-1. [PMID: 8142230 DOI: 10.1007/bf00868266] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
We describe a 16-year-old female with persistent isolated proximal renal tubular acidosis, cerebral calcification, mental retardation, band keratopathy, cataracts, glaucoma and short stature. Severe metabolic acidosis and hypokalaemia were linked to an abnormally low renal threshold for bicarbonate reabsorption (8 mmol/l). Maximal rates of urinary excretion of titratable acid and ammonium were normal; erythrocyte carbonic anhydrase II was normal. This rare case represents a systemic disease with a distinct clinical entity which may be transmitted by autosomal recessive inheritance.
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Affiliation(s)
- T Igarashi
- Department of Paediatrics, Faculty of Medicine, University of Tokyo, Japan
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28
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Restaino I, Kaplan BS, Stanley C, Baker L. Nephrolithiasis, hypocitraturia, and a distal renal tubular acidification defect in type 1 glycogen storage disease. J Pediatr 1993; 122:392-6. [PMID: 8441093 DOI: 10.1016/s0022-3476(05)83422-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Renal stones containing calcium can occur in patients with type 1 glycogen storage disease. We studied 11 patients with glycogen storage disease. Five patients had renal calculi, nephrocalcinosis, or both, and five had hypercalciuria. Serum levels of calcium, phosphorus, parathyroid hormone, and urate were normal. Serum levels of 1,25-dihydroxyvitamin D were elevated in each patient. None of the patients had a metabolic acidosis, but all nine who were tested had evidence of impaired acid excretion. In response to an acid load, eight of the nine patients had subnormal titratable acid excretion, and nine had subnormal ammonia excretion; six of nine patients were unable to secrete hydrogen ions in response to bicarbonate administration. These data indicate that patients with type 1 glycogen storage disease have an incomplete form of distal renal tubular acidosis. This may be the cause of hypercalciuria and nephrocalcinosis in these patients.
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Affiliation(s)
- I Restaino
- Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine 19104
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29
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Rossi R, Helmchen U, Schellong G. Tubular function and histological findings in ifosfamide-induced renal Fanconi syndrome--a report of two cases. Eur J Pediatr 1992; 151:384-7. [PMID: 1396897 DOI: 10.1007/bf02113264] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Two patients developed renal Fanconi syndrome (RFS) after intensive long-term chemotherapy for metastatic Ewing sarcoma and disseminated neuroblastoma. Whereas RFS was diagnosed in patient 1 before he developed osteomalacia, patient 2 experienced severe rickets and growth retardation. Renal function studies revealed slight glomerular impairment and severe tubular defects leading to increased excretion of glucose, amino acids, inorganic phosphate and low molecular weight proteins, indicating proximal tubular damage. Patient 2 additionally showed distal tubular dysfunction with acidosis and diminished concentrating capacity. Renal biopsy in patient 1 revealed marked proximal tubular defects without interstitial lymphocytic infiltration. In both patients renal damage could most likely be ascribed to previous ifosfamide (IFOS) therapy. Our patients showed no improvement in renal function after cessation of IFOS treatment, indicating a poor prognosis of once established RFS after IFOS therapy. Measurement of tubular reabsorption capacities provides exact information on the extent of tubular toxicity induced by IFOS and may be used to monitor IFOS treated patients.
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Affiliation(s)
- R Rossi
- Department of Haematology and Oncology, University Children's Hospital Münster, Federal Republic of Germany
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30
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Sly WS, Sato S, Zhu XL. Evaluation of carbonic anhydrase isozymes in disorders involving osteopetrosis and/or renal tubular acidosis. Clin Biochem 1991; 24:311-8. [PMID: 1959222 DOI: 10.1016/0009-9120(91)80005-n] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Carbonic anhydrase II (CA II) deficiency in man is an autosomal recessive disorder manifest by osteopetrosis, renal tubular acidosis, and cerebral calcification. Other features include growth failure and mental retardation. Complications of the osteopetrosis include frequent bone fractures, cranial nerve compression symptoms, and dental malocclusion. The anemia and leukopenia seen in the recessive, lethal infantile form of osteopetrosis are not seen in CA II deficient patients. The renal tubular acidosis usually includes both proximal and distal components. Symptoms of metabolic acidosis respond to therapy, but no specific treatment is available for the osteopetrosis or cerebral calcification. We review here the role of carbonic anhydrases in bone resorption and renal acidification, and discuss clinical features and laboratory findings which distinguish CA II deficiency from other disorders producing osteopetrosis, renal tubular acidosis, or brain calcification. Methods to evaluate patients with pure proximal renal tubular acidosis for deficiency of CA IV are also discussed.
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Affiliation(s)
- W S Sly
- Edward A. Doisy Department of Biochemistry and Molecular Biology, St. Louis University School of Medicine, MO 63104
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31
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Abstract
Distal renal tubular acidosis (dRTA) is not a single disease. The experimental forms of the syndrome are unsatisfactory as models of the naturally occurring disease, not least because they are seldom complicated by nephrocalcinosis, which is present in the majority of patients with spontaneous disease and contributes to the renal tubular defects found in the syndrome. Impairment of minimal urine pH, reduced urine carbon dioxide tension (PCO2) during passage of alkaline urine, and reduced urinary ammonium (NH4+) excretion, have all been advocated as essential criteria for the diagnosis of dRTA. Minimal urine pH, measured during metabolic acidosis, sulphate infusion, or after oral frusemide, is the yardstick against which other criteria should be assessed. A reduced urinary PCO2 is commonly found in dRTA but is not specific for the syndrome and may be accounted for by tubular defects other than those involving reduced distal hydrogen ion secretion. NH4+ excretion is reduced in most patients with renal acidosis whatever the nature of the underlying renal disease; this function is closely related to nephron mass, and is not specifically impaired in renal tubular disease.
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Affiliation(s)
- O Wrong
- Department of Medicine, University College and Middlesex School of Medicine, London, UK
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32
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Skinner R, Pearson AD, Coulthard MG, Skillen AW, Hodson AW, Goldfinch ME, Gibb I, Craft AW. Assessment of chemotherapy-associated nephrotoxicity in children with cancer. Cancer Chemother Pharmacol 1991; 28:81-92. [PMID: 2060086 DOI: 10.1007/bf00689694] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Assessment of the toxicity caused by chemotherapy in children with cancer has become more important as the number of long-term survivors has continued to increase. It is vital to monitor both acute life-threatening adverse effects and long-term toxicity that may impair the child's development and cause permanent morbidity. Renal damage may follow treatment with cytotoxic drugs, especially cisplatin or ifosfamide, and lead to glomerular, proximal tubular or distal tubular impairment or to any combination of these. Greater understanding of nephrotoxicity and of its prevention may enable the use of more intensive schedules or of higher doses of potentially nephrotoxic chemotherapy. However, the evaluation of cytotoxic drug-induced nephrotoxicity has frequently depended mainly on measurement of the plasma creatinine concentration, which may remain normal despite substantial glomerular impairment or severe tubular dysfunction. Detailed assessment of nephrotoxicity depends on an understanding of normal renal physiology and requires evaluation of all aspects of function. A comprehensive but simple investigatory protocol that enables assessment of the nature and severity of nephrotoxicity in children is described, which can be performed without admission to hospital. Glomerular function is assessed by measurement of the glomerular filtration rate from the plasma clearance of [51Cr]-ethylenediaminetetraacetic acid ([51Cr]-EDTA). Proximal nephron function is evaluated in three ways: by measurement of the concentration of calcium, magnesium, phosphate, glucose and urate in blood and urine along with calculations of their fractional excretion and of the renal threshold for phosphate; by determination of the excretion in urine of low-molecular-weight proteins (e.g. retinol-binding protein); and by investigation of urinary bicarbonate excretion in patients who are acidotic. Distal nephron function is initially investigated by examination of the concentration (osmolality) and acidification (pH) of an early morning sample of urine. Finally, a group of general investigations is performed, including quantitation of urinary excretion of renal tubular enzymes (e.g. N-acetylglucosaminidase) and measurement of blood pressure.
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Affiliation(s)
- R Skinner
- Department of Child Health, Medical School, University of Newcastle upon Tyne, U.K
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