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Morse J, Wang D, Mei S, Whitham D, Hladun C, Darie CC, Sintim HO, Wang M, Leung K. Chloride Homeostasis Regulates cGAS-STING Signaling. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.08.588475. [PMID: 38645072 PMCID: PMC11030317 DOI: 10.1101/2024.04.08.588475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
The cGAS-STING signaling pathway has emerged as a key mediator of inflammation. However, the roles of chloride homeostasis on this pathway are unclear. Here, we uncovered a correlation between chloride homeostasis and cGAS-STING signaling. We found that dysregulation of chloride homeostasis attenuates cGAS-STING signaling in a lysosome-independent manner. Treating immune cells with chloride channel inhibitors attenuated 2'3'-cGAMP production by cGAS and also suppressed STING polymerization, leading to reduced cytokine production. We also demonstrate that non-selective chloride channel blockers can suppress the NPC1 deficiency-induced, hyper-activated STING signaling in skin fibroblasts derived from Niemann Pick disease type C (NPC) patients. Our findings reveal that chloride homeostasis majorly affects cGAS-STING pathway and suggest a provocative strategy to dampen STING-mediated inflammation via targeting chloride channels.
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Affiliation(s)
- Jared Morse
- Department of Chemistry & Biomolecular Science, Clarkson University, NY, 13676, United States
| | - Danna Wang
- Department of Chemistry & Biomolecular Science, Clarkson University, NY, 13676, United States
| | - Serena Mei
- Department of Chemistry & Biomolecular Science, Clarkson University, NY, 13676, United States
| | - Danielle Whitham
- Department of Chemistry & Biomolecular Science, Clarkson University, NY, 13676, United States
| | - Colby Hladun
- Department of Chemistry & Biomolecular Science, Clarkson University, NY, 13676, United States
| | - Costel C. Darie
- Department of Chemistry & Biomolecular Science, Clarkson University, NY, 13676, United States
| | - Herman O. Sintim
- Department of Chemistry, Purdue University, West Lafayette, Indiana 47907, United States
| | - Modi Wang
- Department of Chemistry & Biomolecular Science, Clarkson University, NY, 13676, United States
| | - KaHo Leung
- Department of Chemistry & Biomolecular Science, Clarkson University, NY, 13676, United States
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Pathophysiologic approach in genetic hypokalemia: An update. ANNALES D'ENDOCRINOLOGIE 2023; 84:298-307. [PMID: 36639120 DOI: 10.1016/j.ando.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 11/30/2022] [Indexed: 01/12/2023]
Abstract
The pathophysiology of genetic hypokalemia is close to that of non-genetic hypokalemia. New molecular pathways physiologically involved in renal and extrarenal potassium homeostasis have been highlighted. A physiological approach to diagnosis is illustrated here, with 6 cases. Mechanisms generating and sustaining of hypokalemia are discussed. After excluding acute shift of extracellular potassium to the intracellular compartment, related to hypokalemic periodic paralysis, inappropriate kaliuresis (>40mmol/24h) concomitant to hypokalemia indicates renal potassium wasting. Clinical analysis distinguishes hypertension-associated hypokalemia, due to hypermineralocorticism or related disorders. Genetic hypertensive hypokalemia is rare. It includes familial hyperaldosteronism, Liddle syndrome, apparent mineralocorticoid excess,11beta hydroxylase deficiency and Geller syndrome. In case of normo- or hypo-tensive hypokalemia, two etiologies are to be considered: chloride depletion or salt-wasting tubulopathy. Diarrhea chlorea is a rare disease responsible for intestinal chloride depletion. Due to the severity of hypokalemic metabolic alkalosis, this disease can be misdiagnosed as pseudo-Bartter syndrome. Gitelman syndrome is the most frequent cause of genetic hypokalemia. It typically associates renal sodium and potassium wasting, hypomagnesemia, conserved chloride excretion (>40mmol/24h), and low-range calcium excretion (urinary Ca/creatinine ratio<0.20mmol/mmol). Systematic analysis of hydroelectrolytic disorder and dynamic hormonal investigation optimizes indications for and orientation of genotyping of hereditary salt-losing tubulopathy.
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The genetics of monogenic intestinal epithelial disorders. Hum Genet 2022; 142:613-654. [PMID: 36422736 PMCID: PMC10182130 DOI: 10.1007/s00439-022-02501-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/23/2022] [Indexed: 11/27/2022]
Abstract
Monogenic intestinal epithelial disorders, also known as congenital diarrheas and enteropathies (CoDEs), are a group of rare diseases that result from mutations in genes that primarily affect intestinal epithelial cell function. Patients with CoDE disorders generally present with infantile-onset diarrhea and poor growth, and often require intensive fluid and nutritional management. CoDE disorders can be classified into several categories that relate to broad areas of epithelial function, structure, and development. The advent of accessible and low-cost genetic sequencing has accelerated discovery in the field with over 45 different genes now associated with CoDE disorders. Despite this increasing knowledge in the causal genetics of disease, the underlying cellular pathophysiology remains incompletely understood for many disorders. Consequently, clinical management options for CoDE disorders are currently limited and there is an urgent need for new and disorder-specific therapies. In this review, we provide a general overview of CoDE disorders, including a historical perspective of the field and relationship to other monogenic disorders of the intestine. We describe the genetics, clinical presentation, and known pathophysiology for specific disorders. Lastly, we describe the major challenges relating to CoDE disorders, briefly outline key areas that need further study, and provide a perspective on the future genetic and therapeutic landscape.
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Hussein MH, Alsohaibani F, Alrubaysh A, Alhamed M, Alabdaljabar MS, Ullah A. Favorable Effects of Octreotide in Congenital Chloride Diarrhea Associated with Chronic Kidney Disease. Kidney Int Rep 2022; 7:2112-2115. [PMID: 36090494 PMCID: PMC9458996 DOI: 10.1016/j.ekir.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/06/2022] [Indexed: 11/12/2022] Open
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Whittamore JM, Hatch M. Oxalate Flux Across the Intestine: Contributions from Membrane Transporters. Compr Physiol 2021; 12:2835-2875. [PMID: 34964122 DOI: 10.1002/cphy.c210013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Epithelial oxalate transport is fundamental to the role occupied by the gastrointestinal (GI) tract in oxalate homeostasis. The absorption of dietary oxalate, together with its secretion into the intestine, and degradation by the gut microbiota, can all influence the excretion of this nonfunctional terminal metabolite in the urine. Knowledge of the transport mechanisms is relevant to understanding the pathophysiology of hyperoxaluria, a risk factor in kidney stone formation, for which the intestine also offers a potential means of treatment. The following discussion presents an expansive review of intestinal oxalate transport. We begin with an overview of the fate of oxalate, focusing on the sources, rates, and locations of absorption and secretion along the GI tract. We then consider the mechanisms and pathways of transport across the epithelial barrier, discussing the transcellular, and paracellular components. There is an emphasis on the membrane-bound anion transporters, in particular, those belonging to the large multifunctional Slc26 gene family, many of which are expressed throughout the GI tract, and we summarize what is currently known about their participation in oxalate transport. In the final section, we examine the physiological stimuli proposed to be involved in regulating some of these pathways, encompassing intestinal adaptations in response to chronic kidney disease, metabolic acid-base disorders, obesity, and following gastric bypass surgery. There is also an update on research into the probiotic, Oxalobacter formigenes, and the basis of its unique interaction with the gut epithelium. © 2021 American Physiological Society. Compr Physiol 11:1-41, 2021.
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Affiliation(s)
- Jonathan M Whittamore
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Marguerite Hatch
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, Florida, USA
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Di Meglio L, Castaldo G, Mosca C, Paonessa A, Gelzo M, Esposito MV, Berni Canani R. Congenital chloride diarrhea clinical features and management: a systematic review. Pediatr Res 2021; 90:23-29. [PMID: 33173177 DOI: 10.1038/s41390-020-01251-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/06/2020] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Congenital chloride diarrhea (CLD) is a rare autosomal recessive disorder characterized by watery diarrhea with a high level of fecal Cl-, metabolic alkalosis, and electrolyte alterations. Several intestinal and extraintestinal complications and even death can occur. An optimal knowledge of the clinical features and best therapeutic strategies is mandatory for an effective management. METHODS Articles published between 1 January 1965 and 31 December 2019, reported in PUBMED and EMBASE, were evaluated for a systematic review analyzing four categories: anamnestic features, clinical features, management, and follow-up strategies. RESULTS Fifty-seven papers reporting information on 193 CLD patients were included. The most common anamnestic features were positive family anamnesis for chronic diarrhea (44.4%), consanguinity (75%), polyhydramnios (98.3%), preterm delivery (78.6%), and failure to pass meconium (60.7%). Mean age at diarrhea onset was 6.63 days. Median diagnostic delay was 60 days. Prenatal diagnosis, based on molecular analysis, was described in 40/172 (23.3%). All patients received NaCl/KCl-substitutive therapy. An improvement of diarrhea during adulthood was reported in 91.3% of cases. Failure to thrive (21.6%) and chronic kidney disease (17.7%) were the most common complications. CONCLUSIONS This analysis of a large population suggests the necessity of better strategies for the management of CLD. A close follow-up and a multidisciplinary approach is mandatory to manage this condition characterized by heterogeneous and multisystemic complications. IMPACT In this systematic review, we describe data regarding anamnestic features, clinical features, management, and follow-up of CLD patients obtained from the largest population of patients ever described to date. The results of our investigation could provide useful insights for the diagnostic approach and the management of this condition.
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Affiliation(s)
- Lavinia Di Meglio
- Department of Translational Medical Science, University Federico II, Naples, Italy.,Diagnostica Ecografica e Prenatale di A.Di Meglio, Naples, Italy
| | - Giuseppe Castaldo
- CEINGE Advanced Biotechnologies Research Center, University Federico II, Naples, Italy
| | - Caterina Mosca
- Department of Translational Medical Science, University Federico II, Naples, Italy
| | - Andrea Paonessa
- Department of Translational Medical Science, University Federico II, Naples, Italy
| | - Monica Gelzo
- CEINGE Advanced Biotechnologies Research Center, University Federico II, Naples, Italy.,Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | | | - Roberto Berni Canani
- Department of Translational Medical Science, University Federico II, Naples, Italy. .,CEINGE Advanced Biotechnologies Research Center, University Federico II, Naples, Italy.
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Di Meglio L, Grimaldi G, Esposito F, Gelzo M, Esposito MV, Castaldo G, Canani RB. Step-Up Approach for Sodium Butyrate Treatment in Children With Congenital Chloride Diarrhea. Front Pediatr 2021; 9:810765. [PMID: 35127600 PMCID: PMC8811473 DOI: 10.3389/fped.2021.810765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Oral salt substitutive therapy is pivotal for the survival of patients with congenital chloride diarrhea (CLD), however this therapy is unable to influence the symptoms severity. Butyrate has been proposed to limit diarrhea severity in CLD. Unfortunately, the optimal dose schedule is still largely undefined. In addition, butyrate seems not to be well-tolerated by all patients, with some subjects reporting diarrhea worsening. We investigated the efficacy of a step-up therapeutic approach with sodium butyrate in patients who experienced a diarrhea worsening or an absent improvement after the direct administration of 100 mg/kg/day of sodium butyrate. METHODS The efficacy of a step-up therapeutic approach starting from 50 mg/Kg/day with a subsequent 25 mg/kg/day weekly increase up to 100 mg/kg/day of oral sodium butyrate was investigated in previously three unresponsive CLD children. RESULTS The step-up therapeutic approach resulted effective in limiting diarrhea severity in all our three previously unresponsive CLD patients. CONCLUSIONS Our results suggest the efficacy of the step-up therapeutic approach in CLD children.
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Affiliation(s)
- Lavinia Di Meglio
- Department of Translational Medical Science, University Federico II, Naples, Italy.,Diagnostica Ecografica e Prenatale Aniello Di Meglio, Naples, Italy
| | - Giusi Grimaldi
- Department of Translational Medical Science, University Federico II, Naples, Italy
| | - Francesco Esposito
- Department of Translational Medical Science, University Federico II, Naples, Italy
| | - Monica Gelzo
- Genetic Engineering and Advanced Biotechnology Center (CEINGE) Advanced Biotechnologies Research Center, University Federico II, Naples, Italy
| | - Maria Valeria Esposito
- Genetic Engineering and Advanced Biotechnology Center (CEINGE) Advanced Biotechnologies Research Center, University Federico II, Naples, Italy
| | - Giuseppe Castaldo
- Genetic Engineering and Advanced Biotechnology Center (CEINGE) Advanced Biotechnologies Research Center, University Federico II, Naples, Italy
| | - Roberto Berni Canani
- Department of Translational Medical Science, University Federico II, Naples, Italy.,Genetic Engineering and Advanced Biotechnology Center (CEINGE) Advanced Biotechnologies Research Center, University Federico II, Naples, Italy.,Task Force for Microbiome Studies, University Federico II, Naples, Italy
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8
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AP1S1 missense mutations cause a congenital enteropathy via an epithelial barrier defect. Hum Genet 2020; 139:1247-1259. [PMID: 32306098 PMCID: PMC7497319 DOI: 10.1007/s00439-020-02168-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/10/2020] [Indexed: 12/16/2022]
Abstract
Congenital diarrheal disorders (CDD) comprise > 50 monogenic entities featuring chronic diarrhea of early-onset, including defects in nutrient and electrolyte absorption, enterocyte polarization, enteroendocrine cell differentiation, and epithelial integrity. Diarrhea is also a predominant symptom in many immunodeficiencies, congenital disorders of glycosylation, and in some defects of the vesicular sorting and transporting machinery. We set out to identify the etiology of an intractable diarrhea in 2 consanguineous families by whole-exome sequencing, and identified two novel AP1S1 mutations, c.269T>C (p.Leu90Pro) and c.346G>A (p.Glu116Lys). AP1S1 encodes the small subunit of the adaptor protein 1 complex (AP-1), which plays roles in clathrin coat-assembly and trafficking between trans-Golgi network, endosomes and the plasma membrane. An AP1S1 knock-out (KO) of a CaCo2 intestinal cell line was generated to characterize intestinal AP1S1 deficiency as well as identified mutations by stable expression in KO background. Morphology and prototype transporter protein distribution were comparable between parental and KO cells. We observed altered localization of tight-junction proteins ZO-1 and claudin 3, decreased transepithelial electrical resistance and an increased dextran permeability of the CaCo2-AP1S1-KO monolayer. In addition, lumen formation in 3D cultures of these cells was abnormal. Re-expression of wild-type AP1S1 in CaCo2-AP1S1-KO cells reverted these abnormalities, while expression of AP1S1 containing either missense mutation did not. Our data indicate that loss of AP1S1 function causes an intestinal epithelial barrier defect, and that AP1S1 mutations can cause a non-syndromic form of congenital diarrhea, whereas 2 reported truncating AP1S1 mutations caused MEDNIK syndrome, characterized by mental retardation, enteropathy, deafness, neuropathy, ichthyosis, and keratodermia.
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Valavi E, Javaherizadeh H, Hakimzadeh M, Amoori P. Improvement Of Congenital Chloride Diarrhea With Corticosteroids: An Incidental Finding. PEDIATRIC HEALTH MEDICINE AND THERAPEUTICS 2019; 10:153-156. [PMID: 31827341 PMCID: PMC6901380 DOI: 10.2147/phmt.s220725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/08/2019] [Indexed: 11/23/2022]
Abstract
Congenital chloride diarrhea of infancy is a life threatening disease. We discuss two boys with congenital chloride diarrhea over a long time period before and after kidney transplantation. In the first case, prenatal sonography revealed polyhydramnios and generalized bowel loop distention. The genetic study confirmed congenital chloride diarrhea of infancy. Multiple episodes of severe dehydration, hyponatremia and acute tubular necrosis were seen during the follow up period. He underwent a year of hemodialysis before kidney transplantation. Three periods of improvement concerning diarrhea occurred with the use of corticosteroids, taken for other reasons. These improvements were seen after prednisolone administration for mastoiditis and following prednisolone administration for kidney transplantation. The second case was a 3.5 year old boy who is the cousin of the first case. He was referred to hospital with chronic watery diarrhea, metabolic alkalosis, hypokalemia, hyponatremia and failure to thrive in the first year of life. He was also treated with prednisolone and showed significant improvement.
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Affiliation(s)
- Ehsan Valavi
- Department of Pediatric Nephrology, Abuzar Children's Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Hazhir Javaherizadeh
- Alimentary Tract Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mehran Hakimzadeh
- Department of Pediatric Gastroenterology, Abuzar Children's Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Parisa Amoori
- Department of Pediatric Nephrology, Abuzar Children's Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Abstract
Congenital chloride diarrhoea is one of the rare causes of diarrhoea during infancy and it is infrequently reported throughout the world. It is an autosomal recessive condition which is more prevalent in Poland, Finland, Saudi Arabia and Kuwait while rarely reported in Pakistan. Our patient was 7.5-month-old baby boy who presented with diarrhoea since neonatal period. He had consanguineous parents. On examination, baby had distended abdomen, hypotonia and hyporeflexia. Investigations revealed hypochloremic hypokalemic metabolic alkalosis. Urinary electrolytes were normal. Stool electrolytes revealed increased stool chloride excretion that confirmed our diagnosis of congenital chloride diarrhoea. Patient was treated with intravenous fluids and electrolyte replacement, followed by oral potassium and sodium replacement. He was also started on butyrate, cholestyramine and proton-pump inhibitors. He started gaining weight during his hospital admission and is being followed up in clinic.
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Affiliation(s)
- Aisha Sajid
- Department of Pediatrics, Madina Teaching Hospital, The University of Faisalabad, Faisalabad, Pakistan
| | - Sohaib Riaz
- Department of Pediatrics, Madina Teaching Hospital, The University of Faisalabad, Faisalabad, Pakistan
| | - Aqsa Riaz
- Department of Pediatrics, Madina Teaching Hospital, The University of Faisalabad, Faisalabad, Pakistan
| | - Bisma Safdar
- Department of Pediatrics, Madina Teaching Hospital, The University of Faisalabad, Faisalabad, Pakistan
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Konishi KI, Mizuochi T, Yanagi T, Watanabe Y, Ohkubo K, Ohga S, Maruyama H, Takeuchi I, Sekine Y, Masuda K, Kikuchi N, Yotsumoto Y, Ohtsuka Y, Tanaka H, Kudo T, Noguchi A, Fuwa K, Mushiake S, Ida S, Fujishiro J, Yamashita Y, Taguchi T, Yamamoto K. Clinical Features, Molecular Genetics, and Long-Term Outcome in Congenital Chloride Diarrhea: A Nationwide Study in Japan. J Pediatr 2019; 214:151-157.e6. [PMID: 31477378 DOI: 10.1016/j.jpeds.2019.07.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/26/2019] [Accepted: 07/12/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To clarify clinical and genetic features of Japanese children with congenital chloride diarrhea (CCD). STUDY DESIGN This was a multi-institutional, retrospective survey of 616 pediatric centers in Japan with identified patients with CCD between 2014 and 2018. Mutations involving SLC26A3 were detected by Sanger sequencing. RESULTS Thirteen patients met all entry criteria including mutations in SLC26A3, and 14 patients satisfied clinical diagnostic criteria. Homozygous or compound heterozygous mutations in SLC26A3, including 6 novel mutations, were identified in 13 of these 14 patients (93%). The most common (detected in 7 of 13) was c.2063-1g>t. Median age at diagnosis was 1 day. Nine of the patients meeting all criteria were diagnosed as neonates (69%). Median follow-up duration was 10 years. When studied, 8 patients had <5 stools daily (62%), and all had fewer than in infancy. Only 1 patient had nephrocalcinosis, and 3 (23%) had mild chronic kidney disease. Neurodevelopment was generally good; only 1 patient required special education. Five patients (38%) received long-term sodium, potassium, and chloride supplementation. CONCLUSIONS Early fetal ultrasound diagnosis and prompt long-term sodium, potassium, and chloride supplementation were common management features. Genetic analysis of SLC26A3 provided definitive diagnosis of CCD. In contrast with previously reported localities, c.2063-1g>t might be a founder mutation in East Asia.
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Affiliation(s)
- Ken-Ichiro Konishi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan; Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuki Mizuochi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan.
| | - Tadahiro Yanagi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Yoriko Watanabe
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Kazuhiro Ohkubo
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hidehiko Maruyama
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Ichiro Takeuchi
- Division of Gastroenterology, National Center for Child Health and Development, Tokyo, Japan
| | - Yuji Sekine
- Department of Emergency and General Medicine, Shizuoka Children's Hospital, Shizuoka, Japan
| | - Kei Masuda
- Department of Pediatrics, Doai Memorial Hospital, Tokyo, Japan
| | - Nobuyuki Kikuchi
- Department of Pediatrics, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Yuka Yotsumoto
- Department of Pediatrics, Takatsuki General Hospital, Takatsuki, Japan
| | | | - Hidenori Tanaka
- Department of Pediatrics, Komaki City Hospital, Komaki, Japan
| | - Takahiro Kudo
- Department of Pediatrics, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Atsuko Noguchi
- Department of Pediatrics, Akita University Graduate School of Medicine, Akita, Japan
| | - Kazumasa Fuwa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Sotaro Mushiake
- Department of Pediatrics, Nara Hospital Kinki University, Ikoma, Japan
| | - Shinobu Ida
- Department of Pediatric Gastroenterology, Nutrition and Endocrinology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Jun Fujishiro
- Department of Pediatric Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yushiro Yamashita
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Tomoaki Taguchi
- Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Yamamoto
- Department of Medical Biochemistry, Kurume University School of Medicine, Kurume, Japan
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Kamal NM, Khan HY, El-Shabrawi MH, Sherief LM. Congenital chloride losing diarrhea: A single center experience in a highly consanguineous population. Medicine (Baltimore) 2019; 98:e15928. [PMID: 31145360 PMCID: PMC6709049 DOI: 10.1097/md.0000000000015928] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Congenital chloride losing diarrhea (CCLD) is a rare type of chronic watery diarrhea due to mutations in SLC26A3 gene leading to defective chloride-bicarbonate exchanges with the resultant loss of chloride and retention of bicarbonate.We aim to define pediatric Saudi CCLD patients' characteristics to achieve prompt diagnosis, management, follow up with good quality of life, and prevention of complications in these patients.We carried retrospective data review of demographic, clinical, laboratory, radiographic, and outcome of all pediatric patients fulfilling the criteria of CCLD over 10 years from 2004 to 2014 from a single center in Taif region, Saudi Arabia.Forty-nine patients fulfilled the criteria of CCLD from 21 families with more than one affected patient in the same family in 90% of them and positive consanguinity in 91% of the cohort. Most patients were born preterm with intrauterine growth restriction and usually neonatal intensive care unit (NICU) admissions with prematurity and its complications. Thirteen patients were discharged without diagnosis of CCLD and 3 were misdiagnosed as intestinal obstruction with unnecessary surgical intervention. Many complications do existed with renal complications being the most common with three patients received renal transplantation.Prematurity with abdominal distension and stool like urine were the commonest presentation of CCLD in Saudi children. Positive consanguinity and more than one affected sibling are present in most of our cohort.High index of suspicion by clinicians is a cornerstone for early diagnosis with subsequent favorable outcome.A multicenter national incidence study of CCLD in KSA and its genetic attributes is recommended. Premarital screening should be implemented specially for consanguineous marriage.
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Affiliation(s)
- Naglaa M. Kamal
- Pediatrics and Pediatric Hepatology, Faculty of Medicine, Cairo University, Egypt
- Pediatric Hepatology and Gastroenterology, Alhada Armed Forces Hospital, Taif, KSA
| | | | | | - Laila M. Sherief
- Pediatrics and Pediatric Hematology, Faculty of Medicine, Zagazig University, Egypt
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Dávid É, Török D, Farkas K, Nagy N, Horváth E, Kiss Z, Oroszlán G, Balogh M, Széll M. Genetic investigation confirmed the clinical phenotype of congenital chloride diarrhea in a Hungarian patient: a case report. BMC Pediatr 2019; 19:16. [PMID: 30635044 PMCID: PMC6330408 DOI: 10.1186/s12887-019-1390-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/02/2019] [Indexed: 01/22/2023] Open
Abstract
Background Congenital chloride diarrhea (CCD, OMIM 214700) is a rare autosomal recessively inherited condition characterized by watery diarrhea, hypochloremia and metabolic alkalosis. Mutations of the solute carrier family 26, member 3 (SLC26A3, OMIM 126650) gene are responsible for the disease. The gene encodes a transmembrane protein, which is essential for intestinal chloride absorption. Case presentation Here we report a Hungarian boy, presenting the clinical phenotype of CCD. The patient born at 32 weeks of gestation and underwent surgery for abdominal distension and intestinal obstruction related to malrotation. After recovery, electrolyte replacement therapy was necessary due to several periods of diarrhea. After exclusion of other possible causes, increased chloride concentration in the feces supported the diagnosis of CCD. The diagnosis was confirmed by molecular genetic testing. Direct sequencing revealed compound-heterozygosity for a frameshift mutation c.1295delT (p.Leu432Argfs*11) and the known Polish founder mutation c.2024_2026dupTCA (p.Ile675_Arg676insLeu). Conclusions Here we present the clinical symptoms of the first patient in Hungary diagnosed with CCD. Based on the clinical symptoms, stool analysis and genetic testing, the diagnosis of CCD was established. Our study provides expansion for the mutation spectrum of the SLC26A3 gene and the genetic background of CCD.
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Affiliation(s)
- Éva Dávid
- Department of Pediatrics, Markusovszky Teaching Hospital, Szombathely, Hungary
| | - Dóra Török
- Department of Medical Genetics, University of Szeged, Szeged, Hungary.
| | - Katalin Farkas
- Department of Medical Genetics, University of Szeged, Szeged, Hungary
| | - Nikoletta Nagy
- Department of Medical Genetics, University of Szeged, Szeged, Hungary
| | - Emese Horváth
- Department of Medical Genetics, University of Szeged, Szeged, Hungary
| | - Zsuzsanna Kiss
- Genetic Counseling Outpatient Clinic, Markusovszky Teaching Hospital, Szombathely, Hungary
| | - György Oroszlán
- Department of Pediatrics, Markusovszky Teaching Hospital, Szombathely, Hungary
| | - Márta Balogh
- Department of Pediatrics, Markusovszky Teaching Hospital, Szombathely, Hungary
| | - Márta Széll
- Department of Medical Genetics, University of Szeged, Szeged, Hungary.,MTA-SZTE Dermatological Research Group, University of Szeged, Szeged, Hungary
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Girod M, Allerton F, Gommeren K, Tutunaru A, de Marchin J, Van Soens I, Ramery E, Peeters D. Evaluation of the effect of oral omeprazole on canine cerebrospinal fluid production: A pilot study. Vet J 2016; 209:119-24. [DOI: 10.1016/j.tvjl.2015.10.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Revised: 10/18/2015] [Accepted: 10/19/2015] [Indexed: 10/22/2022]
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15
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Jo HC, Yoon JS, Jang JY, Sohn YB, Lee JH, Cheong HI, Park MS. Oral Proton Pump Inhibitor for Treatment of Congenital Chloride Diarrhea. NEONATAL MEDICINE 2016. [DOI: 10.5385/nm.2016.23.1.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Hee Cheol Jo
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Jong Seo Yoon
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Joo Young Jang
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Young Bae Sohn
- Department of Medical Genetics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Jang Hoon Lee
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Moon Sung Park
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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16
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Ali OM, Shealy C, Saklayen M. Acute pre-renal failure: acquired chloride diarrhea after bowel resection. Clin Kidney J 2015; 5:356-8. [PMID: 25874098 PMCID: PMC4393485 DOI: 10.1093/ckj/sfs082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Accepted: 06/18/2012] [Indexed: 12/23/2022] Open
Abstract
A 58-year old male with a history of small bowel resection and ileostomy presented with severe dehydration and high ostomy output. Laboratory investigation indicated hypochloremia, hypokalemia, hyponatremia, metabolic alkalosis, chloride-rich diarrhea, acute renal failure, and low urinary chloride excretion. Due to striking similarities to congenital chloridorrhea (CCD) reported in neonates, we empirically diagnosed acquired chloridorrhea (ACD, chloride diarrhea). This is a rare disorder resulting in profuse chloride-rich diarrhea and classic metabolic derangements affecting adults with chronic intestinal inflammation, often in association with bowel surgery. In this report, we review the relevant literature and discuss the genetic defects likely contributing to both the congenital and acquired forms of chloridorrhea.
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Affiliation(s)
- Omair M Ali
- V.A. Medical Center and Wright State University Boonshoft School of Medicine , Dayton, OH , USA
| | - Charlotte Shealy
- V.A. Medical Center and Wright State University Boonshoft School of Medicine , Dayton, OH , USA
| | - Mohammad Saklayen
- V.A. Medical Center and Wright State University Boonshoft School of Medicine , Dayton, OH , USA
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Abou Ziki MD, Verjee MA. Rare mutation in the SLC26A3 transporter causes life-long diarrhoea with metabolic alkalosis. BMJ Case Rep 2015; 2015:bcr-2014-206849. [PMID: 25568271 DOI: 10.1136/bcr-2014-206849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
SLC26A3, a chloride/bicarbonate transporter mainly expressed in the intestines, plays a pivotal role in chloride absorption. We present a 23-year-old woman with a history of congenital chloride diarrhoea (CCD) and renal transplant who was admitted for rehydration and treatment of acute kidney injury after she presented with an acute diarrhoeal episode. Laboratory investigations confirmed metabolic alkalosis and severe hypochloraemia, consistent with her underlying CCD. This contrasts with most other forms of diarrhoea, which are normally associated with metabolic acidosis. Genetic testing was offered and revealed a homozygous non-sense mutation in SLC26A3 (Gly-187-Stop). This loss-of-function mutation results in bicarbonate retention in the blood and chloride loss into the intestinal lumen. Symptomatic management with daily NaCl and KCl oral syrups was supplemented with omeprazole therapy. The loss of her own kidneys is most likely due to crystal-induced nephropathy secondary to chronic volume contraction and chloride depletion. This case summarises the pathophysiology and management of CCD.
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Affiliation(s)
- Maen D Abou Ziki
- Yale Waterbury Internal Medicine Residency Program, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mohamud A Verjee
- Department of Medical Education, Weill Cornell Medical College in Qatar, Doha, Qatar
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Fuwa K, Hosono S, Nagano N, Munakata S, Fukamachi R, Okada T, Takahashi S, Takahashi S, Sato N, Nakayama T. Japanese neonate with congenital chloride diarrhea caused by SLC26A3 mutation. Pediatr Int 2015; 57:e11-3. [PMID: 25711268 DOI: 10.1111/ped.12501] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 07/13/2014] [Accepted: 08/07/2014] [Indexed: 01/26/2023]
Abstract
Congenital chloride diarrhea (CCD) beginning in utero is a rare autosomal recessive inherited disorder characterized by impairment of Cl(-) /HCO3 (-) exchange in an otherwise normal distal ileum and colon. Life-long secretory diarrhea is caused by mutations in solute carrier family 26, member 3, (SLC26A3), which disrupt epithelial Cl(-) /HCO3 (-) transport in the ileum and colon. Although 55 mutations in SLC26A3 have been identified throughout the world, few Japanese cases have been confirmed on genetic analysis. We report the successful treatment of a Japanese neonate with CCD caused by SLC26A3 mutation.
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Affiliation(s)
- Kazumasa Fuwa
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
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19
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Canani RB, Terrin G, Elce A, Pezzella V, Heinz-Erian P, Pedrolli A, Centenari C, Amato F, Tomaiuolo R, Calignano A, Troncone R, Castaldo G. Genotype-dependency of butyrate efficacy in children with congenital chloride diarrhea. Orphanet J Rare Dis 2013; 8:194. [PMID: 24350656 PMCID: PMC3878237 DOI: 10.1186/1750-1172-8-194] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Accepted: 12/10/2013] [Indexed: 12/23/2022] Open
Abstract
Background Congenital chloride diarrhea (CLD) is an autosomal recessive disorder characterized by life-long, severe diarrhea with intestinal Cl- malabsorption. It results from a reduced activity of the down regulated in adenoma exchanger (DRA), due to mutations in the solute carrier family 26, member 3 (SLC26A3) gene. Currently available therapies are not able to limit the severity of diarrhea in CLD. Conflicting results have been reported on the therapeutic efficacy of oral butyrate. Methods We investigated the effect of oral butyrate (100 mg/kg/day) in seven CLD children with different SLC26A3 genotypes. Nasal epithelial cells were obtained to assess the effect of butyrate on the expression of the two main Cl- transporters: DRA and putative anion transporter-1 (PAT-1). Results A variable clinical response to butyrate was observed regarding the stool pattern and fecal ion loss. The best response was observed in subjects with missense and deletion mutations. Variable response to butyrate was also observed on SLC26A3 (DRA) and SLC26A6 (PAT1) gene expression in nasal epithelial cells of CLD patients. Conclusions We demonstrate a genotype-dependency for butyrate therapeutic efficacy in CLD. The effect of butyrate is related in part on a different modulation of the expression of the two main apical membrane Cl- exchangers of epithelial cells, members of the SLC26 anion family. Trial registration Australian New Zealand Clinical trial Registry ACTRN12613000450718.
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Affiliation(s)
- Roberto Berni Canani
- Department of Translational Medical Science - Pediatric Section, and European Laboratory for the Investigation of Food Induced Diseases, University of Naples, "Federico II" Via S, Pansini, 5 80131 Naples, Italy.
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20
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Mandal U, De D, Ali KM, Biswas A, Ghosh D. Effect of different solvent extracts of Benincasa hispida T. on experimental hypochlorhydria in rat. J Adv Pharm Technol Res 2012; 3:41-6. [PMID: 22470892 PMCID: PMC3312726 DOI: 10.4103/2231-4040.93563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hypochlorhydria is a common problem in any age of people like other gastric disorders. It has so many etiologies such as sympathetic dominance, antiseretory drug use, excess sugar and refined foods, etc. In the present study, our objective was to search out the effective solvent extract of fruit of Benincasa hispida T. for the management of hypochlorhydria in model male albino rats. Hypochlorhydria was induced in rat as per standard method by oral administration of ranitidine. Different solvent extracts (Hydro-methanol, ethyl acetate, and aqueous) of ripe fruit of B. hispida were prepared following the standard protocol. Various parameters in this concern like free acidity, total acidity, pH, pepsin concentration, chloride and vitamin C levels in gastric juice were measured by standard biochemical and titrimetric methods. It was found that pre-administration followed by co-administration of aqueous extract of B. hispida (ABH) resulted significant correction of ranitidine-induced hypochlorhydria in rat. This aqueous extract-treated group showed increased levels of vitamin C, pepsin, and chloride concentration in gastric juice as well as the antioxidant status significantly (P<0.05) in respect to other extract-treated groups. From the results, it can be concluded that the ABH has most effective anti-hypochlorhydric and antioxidative efficacy than other solvent extracts of said plant fruit.
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Affiliation(s)
- Upanandan Mandal
- Andrology, Endocrinology and Molecular Medicine Laboratory, Department of Bio-Medical Laboratory Science and Management (UGC Innovative Programme Funded Department), Vidyasagar University, Midnapore, India
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Sakallı H, Bucak Hİ. Type IV neonatal Bartter syndrome complicated with congenital chloride diarrhea. AMERICAN JOURNAL OF CASE REPORTS 2012; 13:230-3. [PMID: 23569535 PMCID: PMC3616172 DOI: 10.12659/ajcr.883446] [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] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 07/20/2012] [Indexed: 01/24/2023]
Abstract
BACKGROUND Pseudo-Bartter syndrome encompasses a heterogenous group of disorders similar to Bartter syndrome. Sometimes a few status may be nested, as in our case presented here. CASE REPORT An 8-month-old boy was referred to our hospital with of intractable diarrhea, polyuria, persistent hypokalemia, abdominal distension and failure to thrive. He was born in the 34 6/7 gestational week (GW) to consanguineous parents. In the 30(th) GW polyhydramnios was verified by ultrasonography. The laboratory results showed hypokalemic-hypochloremic metabolic alkalosis, hyponatremia, and increased urinary loss of chloride, potassium and calcium. An audiogram test revealed complete sensorineural deafness. Ultrasonography revealed medullary nephrocalcinosis in both kidneys. Elevated plasma renin activity and aldosterone were found and a provisional diagnosis of type-IV neonatal Bartter syndrome was made. Treatment with indomethacin, spironolactone and additional intake of NaCl/KCl was initiated. Despite these therapies, the child's diarrhea persisted but serum potassium concentration normalized, and hypercalciuria and urine output reduced. After determining the high fecal chloride concentration, there was an immediate decompensation of the disease on indomethacin withdrawal, thus a diagnosis of type IV neonatal Bartter syndrome complicated with congenital chloride diarrhea was considered. Indomethacin, spironolactone and supplementary therapies with NaCl/KCl were continued, which resulted in the normalization of serum electrolytes as well as his physical development, but high contents of chloride in urine and faeces and nephrocalcinosis remains unchanged during 1-year follow-up. CONCLUSIONS Because of the clinical and laboratory simulations between the various diseases that lead to hypokalemic-hypochloremic metabolic alkalosis, patients must be evaluated carefully.
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Affiliation(s)
- Hale Sakallı
- Department of Pediatric Nephrology, Numune Teaching and Research Hospital, Adana, Turkey
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22
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Pieroni KP, Bass D. Proton pump inhibitor treatment for congenital chloride diarrhea. Dig Dis Sci 2011; 56:673-6. [PMID: 21127979 DOI: 10.1007/s10620-010-1491-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Accepted: 11/09/2010] [Indexed: 12/09/2022]
Affiliation(s)
- Kevin P Pieroni
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Lucile Packard Children's Hospital at Stanford, Stanford University Medical Center, 750 Welch Road Suite 116, Palo Alto, CA 94304-0126, USA
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23
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Wedenoja S, Höglund P, Holmberg C. Review article: the clinical management of congenital chloride diarrhoea. Aliment Pharmacol Ther 2010; 31:477-85. [PMID: 19912155 DOI: 10.1111/j.1365-2036.2009.04197.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Congenital chloride diarrhoea in a newborn is a medical emergency, requiring early diagnostics and treatment to prevent severe dehydration and infant mortality. While most of the 250 cases reported arise from Finland, Poland and Arab countries, single cases with this autosomal recessive disorder appear worldwide. Such congenital chloride diarrhoea rarity makes diagnosis difficult. Life-long salt substitution with NaCl and KCl stabilizes fluid, electrolyte and acid-base balance diagnosis. When properly treated, the long-term outcome is favourable. AIM To summarize data on congenital chloride diarrhoea diagnosis, pathophysiology and treatment, and to provide guidelines for both acute and long-term management of congenital chloride diarrhoea. METHODS Data are based on MEDLINE search for 'chloride diarrhoea', in addition to clinical experience in the treatment of the largest known series of patients. RESULTS Treatment of congenital chloride diarrhoea involves (i) life-long salt substitution; (ii) management of acute dehydration and hypokalaemia during gastroenteritis or other infections; and (iii) recognition and treatment of other manifestations of the disease, such as intestinal inflammation, renal impairment and male subfertility. CONCLUSIONS This review summarizes data on congenital chloride diarrhoea and provides guidelines for treatment. After being a mostly paediatric problem, adult patients constitute a rare challenge for gastroenterologists worldwide.
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Affiliation(s)
- S Wedenoja
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
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24
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Abstract
Disruption of normal gastrointestinal function as a result of infection, hereditary or acquired diseases, or complications of surgical procedures uncovers its important role in acid-base homeostasis. Metabolic acidosis or alkalosis may occur, depending on the nature and volume of the unregulated losses that occur. Investigation into the specific pathophysiology of gastrointestinal disorders has provided important new insights into the normal physiology of ion transport along the gut and has also provided new avenues for treatment. This review provides a brief overview of normal ion transport along the gut and then discusses the pathophysiology and treatment of the metabolic acid-base disorders that occur when normal gut function is disrupted.
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Affiliation(s)
- F John Gennari
- Department of Medicine, University of Vermont College of Medicine, Burlington, Vermont, USA.
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25
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Iijima S, Ohzeki T. A case of congenital chloride diarrhea: information obtained through long-term follow-up with reduced electrolyte substitution. Clin J Gastroenterol 2008; 1:28-31. [PMID: 26193357 DOI: 10.1007/s12328-008-0005-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2007] [Accepted: 02/05/2008] [Indexed: 11/28/2022]
Abstract
Congenital chloride diarrhea (CCD) is an inherited disorder of intestinal electrolyte transport that results in a large wastage of electrolytes and water. The patient, who is now 24 years old, was diagnosed at the age of 16 months with CCD based on hypochloremic alkalosis, hyponatremia, and hypokalemia with increased plasma renin and aldosterone levels, and high fecal Cl(-). Serum Na(+) and plasma aldosterone levels were normalized by replacement therapy with NaCl [8 mmol/(kg day)] and KCl [3 mmol/(kg day)]. On follow-up, watery diarrhea persisted, and she was frequently noted to have hypokalemia despite normal serum Na(+) and Cl(-) and plasma aldosterone levels with only reduced dosages of KCl [1-1.5 mmol/(kg day)] substitution due to only sporadic ambulatory care and unsatisfactory compliance with medication, and a normal diet. However, she had acceptable growth, normal renal function, and had an uneventful pregnancy and delivery of a healthy child. In adolescence and adulthood, hypokalemia may be the main problem requiring treatment, and substitution therapy with adequate doses of KCl alone may be sufficient, although a combination of NaCl and KCl is generally recommended even after childhood.
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Affiliation(s)
- Shigeo Iijima
- Department of Pediatrics, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
| | - Takehiko Ohzeki
- Department of Pediatrics, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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Abstract
Although significant contributions to the understanding of metabolic alkalosis have been made recently, much of our knowledge rests on data from clearance studies performed in humans and animals many years ago. This article reviews the contributions of these studies, as well as more recent work relating to the control of renal acid-base transport by mineralocorticoid hormones, angiotensin, endothelin, nitric oxide, and potassium balance. Finally, clinical aspects of metabolic alkalosis are considered.
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Affiliation(s)
- Melvin E Laski
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX 79413, USA.
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Hihnala S, Höglund P, Lammi L, Kokkonen J, Ormälä T, Holmberg C. Long-term clinical outcome in patients with congenital chloride diarrhea. J Pediatr Gastroenterol Nutr 2006; 42:369-75. [PMID: 16641574 DOI: 10.1097/01.mpg.0000214161.37574.9a] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Congenital chloride diarrhea (CLD) is a rare, autosomal recessive disorder of intestinal Cl/HCO3 exchange caused by mutations in the SLC26A3 gene and characterized by persistent Cl rich diarrhea from birth. Treatment is symptomatic and replacement therapy with NaCl and KCl has been shown to be effective in children, but the long-term prognosis remains unclear. We studied the largest known cohort of patients to evaluate the long-term outcome of CLD and to search for extraintestinal manifestations. METHODS This is a cross-sectional clinical evaluation and retrospective analysis of medical history of 36 Finnish patients with CLD, born in the 1960s (n = 8), 1970s (n = 7) and 1980s (n = 21). RESULTS Early diagnosis and aggressive salt replacement therapy were associated with normal growth and development, in addition to significantly reduced mortality rates among the groups of patients born in the different decades, respectively (P = 0.001). No deaths due to CLD were observed after 1972. Enuresis, slight soiling and hospitalizations for gastroenteritis were common, especially in childhood, but 92% of the patients found their health excellent or good. Complications documented were end-stage renal disease (n = 1) and hyperuricemia (n = 4), novel findings possibly associated with CLD being male subfertility (n = 3), spermatoceles (n = 3), intestinal inflammation (n = 2), inguinal hernias (n = 4) and increased concentrations of sweat Cl in 12% of the patients. CONCLUSIONS When early diagnosed and adequately treated, the long-term prognosis of CLD is favorable. A putative role of a primary anion exchange defect of SLC26A3 in male subfertility and the decline of renal function due to chronic dehydration deserve further characterization.
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Affiliation(s)
- Satu Hihnala
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland.
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28
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Canani RB, Terrin G, Cirillo P, Castaldo G, Salvatore F, Cardillo G, Coruzzo A, Troncone R. Butyrate as an effective treatment of congenital chloride diarrhea. Gastroenterology 2004; 127:630-4. [PMID: 15300594 DOI: 10.1053/j.gastro.2004.03.071] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Many therapeutic attempts have demonstrated to be ineffective in reducing the severity of congenital chloride diarrhea and its long-term complications. The short-chain fatty acid butyrate stimulates intestinal water and ion absorption through a variety of mechanisms, including the activation of a parallel Cl-/butyrate and Na+/H+ exchanger. In this case report, we report the therapeutic efficacy of butyrate on an 11-year-old patient affected by congenital chloride diarrhea. METHODS The efficacy of increasing doses of oral butyrate (from 50 to 100 mg/kg/day) was investigated through the daily evaluation of stool volume, bowel movements, fecal incontinence, serum, and stool electrolytes concentrations. The modifications in transepithelial intestinal ion transport elicited by butyrate were examined by rectal dialysis study. RESULTS A butyrate dose of 100 mg/kg/day induced a normalization of stool pattern and of serum and fecal electrolytes concentration. The rectal dialysis study demonstrated a proabsorptive effect induced by butyrate on Na+, Cl-, and K+ intestinal transport. Butyrate therapy was well tolerated during the entire 12-month observation period, and the stool pattern and fecal and serum ion concentrations remained stable within the normal ranges. No clinical adverse events or episodes of dehydration requiring hospital care were observed. CONCLUSIONS Butyrate could be effective in treating congenital chloride diarrhea. It is easily administered, useful in preventing severe dehydration episodes, and may be a promising therapeutic approach for a long-term treatment in this rare and severe condition.
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29
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Pecache N, Patole S, Hagan R, Hill D, Charles A, Papadimitriou JM. Neonatal congenital microvillus atrophy. Postgrad Med J 2004; 80:80-3. [PMID: 14970294 PMCID: PMC1742937 DOI: 10.1136/pmj.2003.007930] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Congenital microvillous atrophy (CMVA) is the leading cause of neonatal secretory diarrhoea with onset either in the first 72 hours of life (early onset) or at 6-8 weeks after birth (late onset). To date over 30 cases have been reported worldwide. The prognosis for this life threatening condition continues to be poor. Therapeutic agents like somatostatin and epidermal growth factor are either ineffective or of marginal benefit. Overall five year survival after small bowel transplantation is currently approximately 50%. The following brief review is aimed towards helping neonatologists/perinatologists in the early diagnosis, and management of CMVA and in counselling the parents appropriately.
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MESH Headings
- Atrophy/etiology
- Atrophy/pathology
- Atrophy/therapy
- Dehydration/etiology
- Dehydration/therapy
- Diarrhea, Infantile/congenital
- Diarrhea, Infantile/pathology
- Diarrhea, Infantile/therapy
- Humans
- Infant
- Infant, Newborn
- Infant, Newborn, Diseases/etiology
- Infant, Newborn, Diseases/pathology
- Infant, Newborn, Diseases/therapy
- Intestinal Mucosa/ultrastructure
- Microvilli/ultrastructure
- Prognosis
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Affiliation(s)
- N Pecache
- Princess Margaret and King Edward Memorial Hospitals, Neonatal Clinical Care Unit, Subiaco, Western Australia
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Abstract
The authors encountered a patient who had profound hypochloremic metabolic alkalosis after developing profuse diarrhea related to rejection of her small bowel transplant. Her ileostomy fluid showed massive electrolyte losses and was exceptionally high in chloride content. She improved with volume substitution and a proton pump inhibitor, although she subsequently required repeat small bowel transplant. The authors speculate that an impaired "downregulated in adenoma" gene (DRA) that enclodes an apical Cl(-)/HO(-)(HCO(3)) exchanger may have contributed to an acquired chloridorrhea in this patient.
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Affiliation(s)
- Manfred Marx
- Center for Dialysis and Nephrology, Südharz Hospital, Nordhausen, Germany
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31
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A not-so-basic case of metabolic alkalosis: an analysis featuring Leendert Paul and emphasizing Occam’s razor. Transplant Rev (Orlando) 2004. [DOI: 10.1016/j.trre.2004.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Chernova MN, Jiang L, Shmukler BE, Schweinfest CW, Blanco P, Freedman SD, Stewart AK, Alper SL. Acute regulation of the SLC26A3 congenital chloride diarrhoea anion exchanger (DRA) expressed in Xenopus oocytes. J Physiol 2003; 549:3-19. [PMID: 12651923 PMCID: PMC2342915 DOI: 10.1113/jphysiol.2003.039818] [Citation(s) in RCA: 136] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Mutations in the human SLC26A3 gene, also known as down-regulated in adenoma (hDRA), cause autosomal recessive congenital chloride-losing diarrhoea (CLD). hDRA expressed in Xenopus oocytes mediated bidirectional Cl--Cl- and Cl--HCO3- exchange. In contrast, transport of oxalate was low, and transport of sulfate and of butyrate was undetectable. Two CLD missense disease mutants of hDRA were nonfunctional in oocytes. Truncation of up to 44 C-terminal amino acids from the putatively cytoplasmic C-terminal hydrophilic domain left transport function unimpaired, but deletion of the adjacent STAS (sulfate transporter anti-sigma factor antagonist) domain abolished function. hDRA-mediated Cl- transport was insensitive to changing extracellular pH, but was inhibited by intracellular acidification and activated by NH4+ at acidifying concentrations. These regulatory responses did not require the presence of either hDRA's N-terminal cytoplasmic tail or its 44 C-terminal amino acids, but they did require more proximate residues of the C-terminal cytoplasmic domain. Although only weakly sensitive to inhibition by stilbenes, hDRA was inhibited with two orders of magnitude greater potency by the anti-inflammatory drugs niflumate and tenidap. cAMP-insensitive Cl--HCO3- exchange mediated by hDRA gained modest cAMP sensitivity when co-expressed with cystic fibrosis transmembrane conductance regulator (CFTR). Despite the absence of hDRA transcripts in human cell lines derived from CFTR patients, DRA mRNA was present at wild-type levels in proximal colon and nearly so in the distal ileum of CFTR(-/-) mice. Thus, pharmacological modulation of DRA might be a useful adjunct treatment of cystic fibrosis.
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Affiliation(s)
- Marina N Chernova
- Molecular Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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Bieringer M, Kettritz R. A wretching business: 'how to get the most out of the numbers'. Nephrol Dial Transplant 2003; 18:836-9. [PMID: 12637660 DOI: 10.1093/ndt/gfg148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Markus Bieringer
- HELIOS-Klinikum-Berlin, Franz Volhard Clinic, Medical Faculty of the Charité, Humboldt University of Berlin, Germany
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Levy J, Chung W, Garzon M, Gallagher MP, Oberfield SE, Lieber E, Anyane-Yeboa K. Congenital myopathy, recurrent secretory diarrhea, bullous eruption of skin, microcephaly, and deafness: a new genetic syndrome? Am J Med Genet A 2003; 116A:20-5. [PMID: 12476446 DOI: 10.1002/ajmg.a.10072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
We describe three siblings with congenital myopathy, bullous eruption of the skin, secretory diarrhea, apparent zinc deficiency, failure to thrive, deafness, and microcephaly. The parents are not consanguineous and there are no other affected relatives. This new syndrome, which follows an apparent autosomal recessive pattern, appears to be distinct from known syndromes of secretory diarrhea, myopathy, deafness, microcephaly, and zinc deficiency.
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Affiliation(s)
- J Levy
- Department of Pediatrics, Columbia University, New York, New York, USA
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Böhmer CJ, Taminiau JA, Klinkenberg-Knol EC, Meuwissen SG. The prevalence of constipation in institutionalized people with intellectual disability. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2001; 45:212-218. [PMID: 11422645 DOI: 10.1046/j.1365-2788.2001.00300.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Constipation is a common problem in people with intellectual disability (ID). Laxatives are frequently prescribed with disappointing results. The prevalence of constipation was investigated in a random population of 215 people with ID (IQ < 50) and constipation was correlated with clinical symptoms. All subjects were scored for bowel habits. Constipation was defined as having a bowel movement less than three times a week or the necessity of using laxatives more than three times a week. Further possible accompanying factors were evaluated. The control subjects were defined as individuals who did not use laxatives. Subjects with constipation were defined as patients and were compared to subjects without constipation (controls). One hundred and forty-nine out of 215 cases (69.3%) showed constipation. Constipation was significantly correlated with non-ambulancy, cerebral palsy, the use of anticonvulsive medication or benzodiazepines, H2-receptor antagonists or proton pump inhibitors, food refusal, and an IQ < 35. Fifty-eight per cent of the patients used bisacodyl or magnesium oxide, 39% lactulose, 13% sodiumlaurylsulphoacetate/sodium citrate/sorbitol and only 10% were given sodium phosphate enemas. Faecal soiling was found in 15% of subjects, while manual evacuation of faeces was performed in nearly 7% of cases. Constipation was randomly demonstrated in almost 70% of the population with ID. Subjects with the above-mentioned accompanying factors are especially at risk for constipation. Contrary to the general population, constipation in people with ID is associated with little use of phosphate enemas, microlax, a low incidence of faecal soiling and manual evacuation of faeces, suggesting an aetiology without distal faecal impaction. The regimen and effect of therapy has to be studied to define adequate treatment schedules.
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Affiliation(s)
- C J Böhmer
- Academic Hospital Vrije Universiteit, Department of Gastroenterology, 1007 MB Amsterdam, the Netherlands.
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Höglund P, Holmberg C, Sherman P, Kere J. Distinct outcomes of chloride diarrhoea in two siblings with identical genetic background of the disease: implications for early diagnosis and treatment. Gut 2001; 48:724-7. [PMID: 11302976 PMCID: PMC1728262 DOI: 10.1136/gut.48.5.724] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Congenital chloride diarrhoea (CLD, OMIM 214700) is a serious inherited defect of intestinal electrolyte absorption transmitted in an autosomal recessive fashion. The major clinical manifestation is diarrhoea with high chloride content which can be balanced by substitution. The molecular pathology involves an epithelial Cl(-)/HCO(3)(-) exchanger protein, encoded by the solute carrier family 26, member 3 gene (SLC26A3), previously known as CLD or DRA (downregulated in adenomas). To date, almost 30 different mutations in the SLC26A3 gene have been identified throughout the world. No clear genotype-phenotype correlation has been established. PATIENTS/METHODS Two siblings presenting with CLD were studied for disease history, supplementation, or other treatments, and for mutations in the SLC26A3 gene. RESULTS Mutation analysis revealed a homozygous I544N mutation in both patients. However, despite the uniform genetic background of CLD in this family, the clinical picture and outcome of the disease were remarkably different between siblings. The older sibling had a late diagnosis and chronic course of the disease whereas the younger one, who was diagnosed soon after birth and immediately received supplementation therapy, grows and develops normally. CONCLUSION Time of diagnosis, substitution therapy, compliance, and compensatory mechanisms are more important modulators of the clinical picture of CLD than the type of mutation in the SLC26A3 gene.
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Affiliation(s)
- P Höglund
- Department of Medical Genetics, Haartman Institute, University of Helsinki, Finland.
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Affiliation(s)
- John H Galla
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Abstract
Diarrhea, defined as loose stools, occurs when the intestine does not complete absorption of electrolytes and water from luminal contents. This can happen when a nonabsorbable, osmotically active substance is ingested ("osmotic diarrhea") or when electrolyte absorption is impaired ("secretory diarrhea"). Most cases of acute and chronic diarrhea are due to the latter mechanism. Secretory diarrhea can result from bacterial toxins, reduced absorptive surface area caused by disease or resection, luminal secretagogues (such as bile acids or laxatives), circulating secretagogues (such as various hormones, drugs, and poisons), and medical problems that compromise regulation of intestinal function. Evaluation of patients with secretory diarrhea must be tailored to find the likely causes of this problem. Specific and nonspecific treatment can be valuable.
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Affiliation(s)
- L R Schiller
- Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA
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Israel DM, Hassall E. Omerprazole and other proton pump inhibitors: pharmacology, efficacy, and safety, with special reference to use in children. J Pediatr Gastroenterol Nutr 1998; 27:568-79. [PMID: 9822325 DOI: 10.1097/00005176-199811000-00014] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- D M Israel
- British Columbia Children's Hospital, Vancouver, Canada
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