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Gaggar P, Raju DSB, Tej MR, Pragna P. Late-Onset Bartter's Syndrome Type II with End-Stage Renal Disease Due to a Novel Mutation in KCNJ1 Gene in an Indian Adult Male - A Case Report. Indian J Nephrol 2023; 33:57-60. [PMID: 37197039 PMCID: PMC10185019 DOI: 10.4103/ijn.ijn_383_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/06/2021] [Indexed: 11/04/2022] Open
Abstract
Mutations in ROMK1 potassium channel gene (KCNJ1) causes antenatal/neonatal Bartter's syndrome type II, which presents with renal salt wasting, hypokalemic metabolic alkalosis, secondary hyperaldosteronism, hypercalciuria, and nephrocalcinosis. We herein describe a case of late-onset Bartter's syndrome type II with progressive renal failure requiring renal replacement therapy secondary to a novel homozygous missense mutation in Exon 2 of KCNJ1 gene (c.500G>A). With this case, we aim to highlight the need for a high index of suspicion and the role of genetic evaluation to diagnose clinically unclassified cases of nephrocalcinosis with renal electrolyte abnormalities more so in late and atypical presentations.
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Affiliation(s)
- Payal Gaggar
- Department of Nephrology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - D Sree Bhushan Raju
- Department of Nephrology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - M Ravi Tej
- Department of Nephrology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - P Pragna
- Department of Nephrology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
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2
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Clinical and Genetic Characterization of Patients with Bartter and Gitelman Syndrome. Int J Mol Sci 2022; 23:ijms23105641. [PMID: 35628451 PMCID: PMC9144947 DOI: 10.3390/ijms23105641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 02/04/2023] Open
Abstract
Bartter (BS) and Gitelman (GS) syndrome are autosomal recessive inherited tubulopathies, whose clinical diagnosis can be challenging, due to rarity and phenotypic overlap. Genotype-phenotype correlations have important implications in defining kidney and global outcomes. The aim of our study was to assess the diagnostic rate of whole-exome sequencing (WES) coupled with a bioinformatic analysis of copy number variations in a population of 63 patients with BS and GS from a single institution, and to explore genotype-phenotype correlations. We obtained a diagnostic yield of 86% (54/63 patients), allowing disease reclassification in about 14% of patients. Although some clinical and laboratory features were more commonly reported in patients with BS or GS, a significant overlap does exist, and age at onset, preterm birth, gestational age and nephro-calcinosis are frequently misleading. Finally, chronic kidney disease (CKD) occurs in about 30% of patients with BS or GS, suggesting that the long-term prognosis can be unfavorable. In our cohort the features associated with CKD were lower gestational age at birth and a molecular diagnosis of BS, especially BS type 1. The results of our study demonstrate that WES is useful in dealing with the phenotypic heterogeneity of these disorders, improving differential diagnosis and genotype-phenotype correlation.
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3
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Wieërs MLAJ, Mulder J, Rotmans JI, Hoorn EJ. Potassium and the kidney: a reciprocal relationship with clinical relevance. Pediatr Nephrol 2022; 37:2245-2254. [PMID: 35195759 PMCID: PMC9395506 DOI: 10.1007/s00467-022-05494-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/02/2022] [Accepted: 02/02/2022] [Indexed: 10/26/2022]
Abstract
By controlling urinary potassium excretion, the kidneys play a key role in maintaining whole-body potassium homeostasis. Conversely, low urinary potassium excretion (as a proxy for insufficient dietary intake) is increasingly recognized as a risk factor for the progression of kidney disease. Thus, there is a reciprocal relationship between potassium and the kidney: the kidney regulates potassium balance but potassium also affects kidney function. This review explores this relationship by discussing new insights into kidney potassium handling derived from recently characterized tubulopathies and studies on sexual dimorphism. These insights reveal a central but non-exclusive role for the distal convoluted tubule in sensing potassium and subsequently modifying the activity of the sodium-chloride cotransporter. This is another example of reciprocity: activation of the sodium-chloride cotransporter not only reduces distal sodium delivery and therefore potassium secretion but also increases salt sensitivity. This mechanism helps explain the well-known relationship between dietary potassium and blood pressure. Remarkably, in children, blood pressure is related to dietary potassium but not sodium intake. To explore how potassium deficiency can cause kidney injury, we review the mechanisms of hypokalemic nephropathy and discuss if these mechanisms may explain the association between low dietary potassium intake and adverse kidney outcomes. We discuss if potassium should be repleted in patients with kidney disease and what role dietary potassium plays in the risk of hyperkalemia. Supported by data and physiology, we reach the conclusion that we should view potassium not only as a potentially dangerous cation but also as a companion in the battle against kidney disease.
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Affiliation(s)
- Michiel L. A. J. Wieërs
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Room Ns403, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Jaap Mulder
- grid.5645.2000000040459992XDepartment of Pediatrics, Division of Pediatric Nephrology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands ,grid.10419.3d0000000089452978Department of Pediatrics, Division of Pediatric Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Joris I. Rotmans
- grid.10419.3d0000000089452978Department of Internal Medicine, Division of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ewout J. Hoorn
- grid.5645.2000000040459992XDepartment of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Room Ns403, PO Box 2040, 3000 CA Rotterdam, The Netherlands
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4
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Jdiaa SS, Walsh SB, Bockenhauer D, Fakhredine SW, Koubar SH. The hypokalemia mystery: distinguishing Gitelman and Bartter syndromes from 'pseudo-Bartter syndrome'. Nephrol Dial Transplant 2021; 37:29-30. [PMID: 32494811 DOI: 10.1093/ndt/gfaa100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sara S Jdiaa
- Division of Nephrology and Hypertension, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Stephen B Walsh
- Division of Nephrology and Hypertension, University College London, London, UK
| | - Detlef Bockenhauer
- Division of Nephrology and Hypertension, University College London, London, UK
| | - Sara W Fakhredine
- Division of Nephrology and Hypertension, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Sahar H Koubar
- Division of Nephrology and Hypertension, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
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5
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Iio K, Mori T, Bessho S, Imai Y, Hatanaka M, Omori H, Kouhara H, Chiga M, Sohara E, Uchida S, Kaimori JY. Gitelman syndrome with a novel frameshift variant in SLC12A3 gene accompanied by chronic kidney disease and type 2 diabetes mellitus. CEN Case Rep 2021; 11:191-195. [PMID: 34617250 DOI: 10.1007/s13730-021-00652-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/28/2021] [Indexed: 11/28/2022] Open
Abstract
Gitelman syndrome is an autosomal recessive genetic disease caused by pathogenic variants in SLC12A3 resulting in the loss of function of the Na-Cl co-transporter (NCC) in the distal tubules. Hypokalemia and diuretic effects can cause secondary type 2 diabetes and renal function decline. Here, we present the case of a 49-year-old male patient with chronic persistent treatment-resistant hypokalemia for the past 13 years who had been receiving treatment for type 2 diabetes mellitus for 6 years. He was referred to our department due to the presence of urinary protein, impaired renal function, high renin activity, and hyperaldosteronism. Laboratory test results showed hypokalemia, hypomagnesemia, hypocalciuria, and metabolic alkalosis. Using next-generation and Sanger sequencing, we identified a novel stop-gain variant (NM_000339.3:c.137del [p.His47fs]) and a missense variant (NM_000339.3:c.2927C > T [p.Ser976Phe]) in the SLC12A3 gene. This novel pathogenic variant was located at the intracellular N-terminus of the NCC. Based on these findings, the patient was diagnosed with Gitelman syndrome. The use of next-generation sequencing facilitated the exclusion of diseases with similar clinical symptoms.
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Affiliation(s)
- Kenichiro Iio
- Department of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi, Kawachinagano, Osaka, 586-8521, Japan.
| | - Takayasu Mori
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Saki Bessho
- Department of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi, Kawachinagano, Osaka, 586-8521, Japan
| | - Yosuke Imai
- Department of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi, Kawachinagano, Osaka, 586-8521, Japan
| | - Masaki Hatanaka
- Department of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi, Kawachinagano, Osaka, 586-8521, Japan
| | - Hiroki Omori
- Department of Nephrology, National Hospital Organization Osaka Minami Medical Center, 2-1 Kidohigashimachi, Kawachinagano, Osaka, 586-8521, Japan
| | - Haruhiko Kouhara
- Department of Endocrinology and Metabolism, Osaka Minami Medical Center, 2-1 Kidohigashimachi, Kawachinagano, Osaka, 586-8521, Japan
| | - Motoko Chiga
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Eisei Sohara
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Shinichi Uchida
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Jun-Ya Kaimori
- Department of Inter-Organ Communication Research in Kidney Disease, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, 565-0871, Japan
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6
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Kamejima S, Yamamoto I, Tajiri A, Tanno Y, Ohkido I, Yokoo T. Long-term Clinical Course after Living Kidney Donation by a Patient with Gitelman Syndrome Harboring a Compound Heterozygous Mutation of the SLC12A3 Gene. Intern Med 2021; 60:1567-1572. [PMID: 33328404 PMCID: PMC8188029 DOI: 10.2169/internalmedicine.5977-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The eligibility for kidney donation and long-term post-donation renal prognosis of patients with Gitelman syndrome (GS) are unknown. We herein report a 44-year-old woman with GS who donated her kidney for transplant. A gene sequence analysis revealed compound heterozygous mutations of T180K and L858H in the SLC12A3 gene. Since transplantation, the renal function and serum potassium and magnesium levels of the donor and recipient have remained stable for seven years with careful monitoring and supplementation. Patients with asymptomatic GS who have no complications can be considered eligible to donate their kidney for transplant with proper monitoring after transplantation.
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Affiliation(s)
- Sahoko Kamejima
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Akiko Tajiri
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Yudo Tanno
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
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7
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Review and Analysis of Two Gitelman Syndrome Pedigrees Complicated with Proteinuria or Hashimoto's Thyroiditis Caused by Compound Heterozygous SLC12A3 Mutations. BIOMED RESEARCH INTERNATIONAL 2021; 2021:9973161. [PMID: 34046503 PMCID: PMC8128541 DOI: 10.1155/2021/9973161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/25/2021] [Accepted: 05/03/2021] [Indexed: 02/07/2023]
Abstract
Gitelman syndrome (GS) is an autosomal recessive inherited salt-losing renal tubular disease, which is caused by a pathogenic mutation of SLC12A3 encoding thiazide-sensitive Na-Cl cotransporter, which leads to disturbance of sodium and chlorine reabsorption in renal distal convoluted tubules, resulting in phenotypes such as hypovolemia, renin angiotensin aldosterone system (RAAS) activation, hypokalemia, and metabolic alkalosis. In this study, two GS families with proteinuria or Hashimoto's thyroiditis were analyzed for genetic-phenotypic association. Sanger sequencing revealed that two probands carried SLC12A3 compound heterozygous mutations, and proband A carried two pathogenic mutations: missense mutation Arg83Gln, splicing mutation, or frameshift mutation NC_000016.10:g.56872655_56872667 (gcggacatttttg>accgaaaatttt) in exon 8. Proband B carries two missense mutations: novel Asp839Val and Arg904Gln. Both probands manifested hypokalemia, hypomagnesemia, hypocalcinuria, metabolic alkalosis, and RAAS activation; in addition, the proband A exhibited decreased urinary chloride, phosphorus, and increased magnesium ions excretion, complicated with Hashimoto's Thyroiditis, while the proband B exhibited enhanced urine sodium excretion and proteinuria. The older sister of proband B with GS also had Hashimoto's thyroiditis. Electron microscopy revealed swelling and vacuolar degeneration of glomerular epithelial cells, diffuse proliferation of mesangial cells and matrix, accompanied by a small amount of low-density electron-dense deposition, and segmental fusion of epithelial cell foot processes in proband B. Light microscopy showed mild mesangial hyperplasia in the focal segment of the glomerulus, hyperplasia, and hypertrophy of juxtaglomerular apparatus cells, mild renal tubulointerstitial lesions, and one glomerular sclerosis. So, long-term hypokalemia of GS can cause kidney damage and may also be susceptible to thyroid disease.
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8
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Konrad M, Nijenhuis T, Ariceta G, Bertholet-Thomas A, Calo LA, Capasso G, Emma F, Schlingmann KP, Singh M, Trepiccione F, Walsh SB, Whitton K, Vargas-Poussou R, Bockenhauer D. Diagnosis and management of Bartter syndrome: executive summary of the consensus and recommendations from the European Rare Kidney Disease Reference Network Working Group for Tubular Disorders. Kidney Int 2021; 99:324-335. [PMID: 33509356 DOI: 10.1016/j.kint.2020.10.035] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/30/2020] [Accepted: 10/29/2020] [Indexed: 12/13/2022]
Abstract
Bartter syndrome is a rare inherited salt-losing renal tubular disorder characterized by secondary hyperaldosteronism with hypokalemic and hypochloremic metabolic alkalosis and low to normal blood pressure. The primary pathogenic mechanism is defective salt reabsorption predominantly in the thick ascending limb of the loop of Henle. There is significant variability in the clinical expression of the disease, which is genetically heterogenous with 5 different genes described to date. Despite considerable phenotypic overlap, correlations of specific clinical characteristics with the underlying molecular defects have been demonstrated, generating gene-specific phenotypes. As with many other rare disease conditions, there is a paucity of clinical studies that could guide diagnosis and therapeutic interventions. In this expert consensus document, the authors have summarized the currently available knowledge and propose clinical indicators to assess and improve quality of care.
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Affiliation(s)
- Martin Konrad
- Department of General Pediatrics, University Hospital Münster, Münster, Germany.
| | - Tom Nijenhuis
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Lorenzo A Calo
- Department of Medicine (DIMED), Nephrology, Dialysis, Transplantation, University of Padova, Padua, Italy
| | - Giovambattista Capasso
- Division of Nephrology, Department of Translational Medical Sciences, School of Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Emma
- Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Karl P Schlingmann
- Department of General Pediatrics, University Hospital Münster, Münster, Germany
| | - Mandeep Singh
- Fetal Medicine Centre, Southend University Hospital NHS Foundation Trust, Essex, UK
| | - Francesco Trepiccione
- Division of Nephrology, Department of Translational Medical Sciences, School of Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Stephen B Walsh
- Department of Renal Medicine, University College London, London, United Kingdom
| | | | - Rosa Vargas-Poussou
- Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Centre d'Investigation Clinique, Paris, France; Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
| | - Detlef Bockenhauer
- Department of Renal Medicine, University College London, London, United Kingdom; Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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9
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Syndromes de Bartter–Gitelman. Nephrol Ther 2020; 16:233-243. [DOI: 10.1016/j.nephro.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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10
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Hoorn EJ, Gritter M, Cuevas CA, Fenton RA. Regulation of the Renal NaCl Cotransporter and Its Role in Potassium Homeostasis. Physiol Rev 2020; 100:321-356. [DOI: 10.1152/physrev.00044.2018] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Daily dietary potassium (K+) intake may be as large as the extracellular K+ pool. To avoid acute hyperkalemia, rapid removal of K+ from the extracellular space is essential. This is achieved by translocating K+ into cells and increasing urinary K+ excretion. Emerging data now indicate that the renal thiazide-sensitive NaCl cotransporter (NCC) is critically involved in this homeostatic kaliuretic response. This suggests that the early distal convoluted tubule (DCT) is a K+ sensor that can modify sodium (Na+) delivery to downstream segments to promote or limit K+ secretion. K+ sensing is mediated by the basolateral K+ channels Kir4.1/5.1, a capacity that the DCT likely shares with other nephron segments. Thus, next to K+-induced aldosterone secretion, K+ sensing by renal epithelial cells represents a second feedback mechanism to control K+ balance. NCC’s role in K+ homeostasis has both physiological and pathophysiological implications. During hypovolemia, NCC activation by the renin-angiotensin system stimulates Na+ reabsorption while preventing K+ secretion. Conversely, NCC inactivation by high dietary K+ intake maximizes kaliuresis and limits Na+ retention, despite high aldosterone levels. NCC activation by a low-K+ diet contributes to salt-sensitive hypertension. K+-induced natriuresis through NCC offers a novel explanation for the antihypertensive effects of a high-K+ diet. A possible role for K+ in chronic kidney disease is also emerging, as epidemiological data reveal associations between higher urinary K+ excretion and improved renal outcomes. This comprehensive review will embed these novel insights on NCC regulation into existing concepts of K+ homeostasis in health and disease.
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Affiliation(s)
- Ewout J. Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Martin Gritter
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Catherina A. Cuevas
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Robert A. Fenton
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands; and Department of Biomedicine, Aarhus University, Aarhus, Denmark
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11
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Blanchard A, Vallet M, Dubourg L, Hureaux M, Allard J, Haymann JP, de la Faille R, Arnoux A, Dinut A, Bergerot D, Becker PH, Courand PY, Baron S, Houillier P, Tack I, Devuyst O, Jeunemaitre X, Azizi M, Vargas-Poussou R. Resistance to Insulin in Patients with Gitelman Syndrome and a Subtle Intermediate Phenotype in Heterozygous Carriers: A Cross-Sectional Study. J Am Soc Nephrol 2019; 30:1534-1545. [PMID: 31285285 DOI: 10.1681/asn.2019010031] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 05/24/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Gitelman syndrome is a salt-losing tubulopathy caused by mutations in the SLC12A3 gene, which encodes the thiazide-sensitive sodium-chloride cotransporter. Previous studies suggested an intermediate phenotype for heterozygous carriers. METHODS To evaluate the phenotype of heterozygous carriers of pathogenic SLC12A3 mutations, we performed a cross-sectional study of patients with Gitelman syndrome, heterozygous carriers, and healthy noncarriers. Participants measured their BP at home for three consecutive days before hospital admission for blood and urine sampling and an oral glucose tolerance test. RESULTS We enrolled 242 participants, aged 18-75 years, including 81 heterozygous carriers, 82 healthy noncarriers, and 79 patients with Gitelman syndrome. The three groups had similar age, sex ratio, and body mass index. Compared with healthy noncarriers, heterozygous carriers showed significantly higher serum calcium concentration (P=0.01) and a trend for higher plasma aldosterone (P=0.06), but measures of home BP, plasma and urine electrolytes, renin, parathyroid hormone, vitamin D, and response to oral glucose tolerance testing were similar. Patients with Gitelman syndrome had lower systolic BP and higher heart rate than noncarriers and heterozygote carriers; they also had significantly higher fasting serum glucose concentration, higher levels of markers of insulin resistance, and a three-fold higher sensitivity to overweight. According to oral glucose tolerance testing, approximately 14% of patients with Gitelman syndrome were prediabetic, compared with 5% of heterozygous carriers and 4% of healthy noncarriers. CONCLUSIONS Heterozygous carriers had a weak intermediate phenotype, between that of healthy noncarriers and patients with Gitelman syndrome. Moreover, the latter are at risk for development of type 2 diabetes, indicating the heightened importance of body weight control in these patients.
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Affiliation(s)
- Anne Blanchard
- Clinical Investigations Center.,Faculty of Medicine, Paris Descartes Université, Sorbonne Paris Cité, Paris, France.,Clinical Investigations Center-1418, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Marion Vallet
- Department of Physiological Functional Investigations, Université Paul Sabatier, CHU de Toulouse, Toulouse, France
| | - Laurence Dubourg
- Department of Physiological Functional Investigations, Hospital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Marguerite Hureaux
- Faculty of Medicine, Paris Descartes Université, Sorbonne Paris Cité, Paris, France.,Department of Genetics
| | - Julien Allard
- Department of Nephrology, Hôpital Dupuytren, Centre Hospitalier Universitaire de Limoges, Limoges, France.,Clinical Investigations Center-1435, Institut National de la Santé et de la Recherche Médicale, Limoges, France
| | - Jean-Philippe Haymann
- Department of Physiological Functional Investigations, Hôpital Tenon, Assistance Publique Hôpitaux des Hôpitaux de Paris, Paris, France.,Faculty of Medicine, Université Pierre et Marie Curie, Paris, France.,Unité Mixte de Recherche_S 1155, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Renaud de la Faille
- Department of Nephrology, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Armelle Arnoux
- Clinical Investigations Center-1418, Institut National de la Santé et de la Recherche Médicale, Paris, France.,Clinical Research Unit, and
| | - Aurelie Dinut
- Clinical Investigations Center-1418, Institut National de la Santé et de la Recherche Médicale, Paris, France.,Clinical Research Unit, and
| | - Damien Bergerot
- Clinical Investigations Center.,Faculty of Medicine, Paris Descartes Université, Sorbonne Paris Cité, Paris, France.,Clinical Investigations Center-1418, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Pierre-Hadrien Becker
- Department of Biochemistry, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Pierre-Yves Courand
- Clinical Investigations Center.,Department of Cardiology, Croix-Rousse and Lyon-Sud Hospital, Hospices Civils de Lyon, Lyon, France
| | - Stéphanie Baron
- Faculty of Medicine, Paris Descartes Université, Sorbonne Paris Cité, Paris, France.,Department of Physiological Functional Investigations, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Pascal Houillier
- Faculty of Medicine, Paris Descartes Université, Sorbonne Paris Cité, Paris, France.,Department of Physiological Functional Investigations, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Ivan Tack
- Department of Physiological Functional Investigations, Université Paul Sabatier, CHU de Toulouse, Toulouse, France
| | - Olivier Devuyst
- Institute of Physiology, University of Zurich, Zurich, Switzerland.,Division of Nephrology, Catholic University of Louvain Medical School, Brussels, Belgium; and
| | - Xavier Jeunemaitre
- Faculty of Medicine, Paris Descartes Université, Sorbonne Paris Cité, Paris, France.,Department of Genetics.,Unité Mixte de Recherche_970, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Michel Azizi
- Clinical Investigations Center.,Faculty of Medicine, Paris Descartes Université, Sorbonne Paris Cité, Paris, France.,Clinical Investigations Center-1418, Institut National de la Santé et de la Recherche Médicale, Paris, France
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12
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Zhong F, Ying H, Jia W, Zhou X, Zhang H, Guan Q, Xu J, Fang L, Zhao J, Xu C. Characteristics and Follow-Up of 13 pedigrees with Gitelman syndrome. J Endocrinol Invest 2019; 42:653-665. [PMID: 30413979 PMCID: PMC6531408 DOI: 10.1007/s40618-018-0966-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/05/2018] [Indexed: 01/01/2023]
Abstract
CONTEXT Gitelman syndrome (GS) is clinically heterogeneous. The genotype and phenotype correlation has not been well established. Though the long-term prognosis is considered to be favorable, hypokalemia is difficult to cure. OBJECTIVE To analyze the clinical and genetic characteristics and treatment of all members of 13 GS pedigrees. METHODS Thirteen pedigrees (86 members, 17 GS patients) were enrolled. Symptoms and management, laboratory findings, and genotype-phenotype associations among all the members were analyzed. RESULTS The average ages at onset and diagnosis were 27.6 ± 10.2 years and 37.9 ± 11.6 years, respectively. Males were an average of 10 years younger and exhibited more profound hypokalemia than females. Eighteen mutations were detected. Two novel mutations (p.W939X, p.G212S) were predicted to be pathogenic by bioinformatic analysis. GS patients exhibited the lowest blood pressure, serum K+, Mg2+, and 24-h urinary Ca2+ levels. Although blood pressure, serum K+ and Mg2+ levels were normal in heterozygous carriers, 24-h urinary Na+ excretion was significantly increased. During follow-up, only 41.2% of patients reached a normal serum K+ level. Over 80% of patients achieved a normal Mg2+ level. Patients were taking 2-3 medications at higher doses than usual prescription to stabilize their K+ levels. Six patients were taking spironolactone simultaneously, but no significant elevation in the serum K+ level was observed. CONCLUSION The phenotypic variability of GS and therapeutic strategies deserve further research to improve GS diagnosis and prognosis. Even heterozygous carriers exhibited increased 24-h Na+ urine excretion, which may make them more susceptible to diuretic-induced hypokalemia.
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Affiliation(s)
- F Zhong
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong University, 324, Jing 5 Road, Jinan, 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, 250021, Shandong, China
| | - H Ying
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong University, 324, Jing 5 Road, Jinan, 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, 250021, Shandong, China
| | - W Jia
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong University, 324, Jing 5 Road, Jinan, 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, 250021, Shandong, China
| | - X Zhou
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong University, 324, Jing 5 Road, Jinan, 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, 250021, Shandong, China
| | - H Zhang
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong University, 324, Jing 5 Road, Jinan, 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, 250021, Shandong, China
| | - Q Guan
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong University, 324, Jing 5 Road, Jinan, 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, 250021, Shandong, China
| | - J Xu
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong University, 324, Jing 5 Road, Jinan, 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, 250021, Shandong, China
| | - L Fang
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong University, 324, Jing 5 Road, Jinan, 250021, Shandong, China
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, 250021, Shandong, China
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, 250021, Shandong, China
| | - J Zhao
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong University, 324, Jing 5 Road, Jinan, 250021, Shandong, China.
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, 250021, Shandong, China.
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, 250021, Shandong, China.
| | - C Xu
- Department of Endocrinology and Metabolism, Shandong Provincial Hospital Affiliated to Shandong University, 324, Jing 5 Road, Jinan, 250021, Shandong, China.
- Institute of Endocrinology, Shandong Academy of Clinical Medicine, Jinan, 250021, Shandong, China.
- Shandong Clinical Medical Center of Endocrinology and Metabolism, Jinan, 250021, Shandong, China.
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13
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Thomson MN, Schneider W, Mutig K, Ellison DH, Kettritz R, Bachmann S. Patients with hypokalemia develop WNK bodies in the distal convoluted tubule of the kidney. Am J Physiol Renal Physiol 2018; 316:F292-F300. [PMID: 30484345 DOI: 10.1152/ajprenal.00464.2018] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Hypokalemia contributes to the progression of chronic kidney disease, although a definitive pathophysiological theory to explain this remains to be established. K+ deficiency results in profound alterations in renal epithelial transport. These include an increase in salt reabsorption via the Na+-Cl- cotransporter (NCC) of the distal convoluted tubule (DCT), which minimizes electroneutral K+ loss in downstream nephron segments. In experimental conditions of dietary K+ depletion, punctate structures in the DCT containing crucial NCC-regulating kinases have been discovered in the murine DCT and termed "WNK bodies," referring to their component, with no K (lysine) kinases (WNKs). We hypothesized that in humans, WNK bodies occur in hypokalemia as well. Renal needle biopsies of patients with chronic hypokalemic nephropathy and appropriate controls were examined by histological stains and immunofluorescence. Segment- and organelle-specific marker proteins were used to characterize the intrarenal and subcellular distribution of established WNK body constituents, namely, WNKs and Ste20-related proline-alanine-rich kinase (SPAK). In both patients with hypokalemia, WNKs and SPAK concentrated in non-membrane-bound cytoplasmic regions in the DCT, consistent with prior descriptions of WNK bodies. The putative WNK bodies were located in the perinuclear region close to, but not within, the endoplasmic reticulum. They were closely adjacent to microtubules but not clustered in aggresomes. Notably, we provide the first report of WNK bodies, which are functionally challenging structures associated with K+ deficiency, in human patients.
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Affiliation(s)
- Martin N Thomson
- Department of Anatomy, Charité-Universitätsmedizin Berlin, Berlin , Germany
| | - Wolfgang Schneider
- Department of Pathology, Charité-Universitätsmedizin Berlin, Berlin , Germany
| | - Kerim Mutig
- Department of Anatomy, Charité-Universitätsmedizin Berlin, Berlin , Germany
| | - David H Ellison
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health & Science University , Portland, Oregon
| | - Ralph Kettritz
- Nephrology and Medical Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Berlin , Germany.,Experimental and Clinical Research Center, Charité-Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine , Berlin , Germany
| | - Sebastian Bachmann
- Department of Anatomy, Charité-Universitätsmedizin Berlin, Berlin , Germany
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14
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Abstract
Bartter syndrome is an inherited renal tubular disorder caused by a defective salt reabsorption in the thick ascending limb of loop of Henle, resulting in salt wasting, hypokalemia, and metabolic alkalosis. Mutations of several genes encoding the transporters and channels involved in salt reabsorption in the thick ascending limb cause different types of Bartter syndrome. A poor phenotype-genotype relationship due to the interaction with other cotransporters and different degrees of compensation through alternative pathways is currently reported. However, phenotypic identification still remains the first step to guide the suspicion of Bartter syndrome. Given the rarity of the syndrome, and the lack of genetic characterization in most cases, limited clinical evidence for treatment is available and the therapy is based mainly on the comprehension of renal physiology and relies on the physician's personal experiences. A better understanding of the mutated channels and transporters could possibly generate targets for specific treatment in the future, also encompassing drugs aiming to correct deficiencies in folding or plasma membrane expression of the mutated proteins.
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Affiliation(s)
- Tamara da Silva Cunha
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina, São Paulo, Brazil,
| | - Ita Pfeferman Heilberg
- Nephrology Division, Universidade Federal de São Paulo (UNIFESP), Escola Paulista de Medicina, São Paulo, Brazil,
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15
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Lü Q, Dong Y, Wan H, Zhang Y, Tang L, Zhang F, Yan Z, Tong N. Consideration of the diagnosis of hypertension accompanied with hypokalaemia: monism or dualism? J Int Med Res 2018; 46:2944-2953. [PMID: 29808706 PMCID: PMC6124265 DOI: 10.1177/0300060518768154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 03/07/2018] [Indexed: 02/05/2023] Open
Abstract
This case report describes a 53-year-old male patient with persistent hypertension and hypokalaemia. Laboratory tests showed that the patient had hypokalaemia, hypocalcaemia and reduced urine calcium/creatinine. Levels of aldosterone and renin activity were increased significantly. Serum levels of adrenocorticotropic hormone, plasma total cortisol level, 24-h urinary-free cortisol, catecholamines, thyroid stimulating hormone and free tetraiodothyronine were normal. A novel single heterozygous mutation (c.836T> G [E6]) was found after full sequencing of the solute carrier family 12 member 3 ( SLC12A3) gene exons. The patient was diagnosed as having primary hypertension with Gitelman syndrome (GS). These findings triggered the careful consideration of whether a monistic or dualist approach to the diagnosis of this patient was the most appropriate. Monism may not always be the most appropriate approach for the diagnosis of coexistent hypertension and hypokalaemia. Consideration should be given to the possibility of the independent existence of distinct diseases (i.e. dualism) when secondary hypertension cannot be confirmed by conventional examinations and when a genetic diagnosis is crucial. As a common cause of hypokalaemia with a high level of clinical phenotypic variation, GS does not conform to the usual diagnostic criteria. It should also be noted that single heterozygous SLC12A3 gene mutations can cause disease symptoms and other genetic mutations might be involved in the pathogenesis of GS.
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Affiliation(s)
- Qingguo Lü
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yajie Dong
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Heng Wan
- Department of Internal Medicine, Xi'an Road Community Health Service Centre, Chengdu, Sichuan Province, China
| | - Yuwei Zhang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Lizhi Tang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Fang Zhang
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Zhe Yan
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Nanwei Tong
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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16
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Enerbäck S, Nilsson D, Edwards N, Heglind M, Alkanderi S, Ashton E, Deeb A, Kokash FEB, Bakhsh ARA, Van't Hoff W, Walsh SB, D'Arco F, Daryadel A, Bourgeois S, Wagner CA, Kleta R, Bockenhauer D, Sayer JA. Acidosis and Deafness in Patients with Recessive Mutations in FOXI1. J Am Soc Nephrol 2017; 29:1041-1048. [PMID: 29242249 DOI: 10.1681/asn.2017080840] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 11/15/2017] [Indexed: 11/03/2022] Open
Abstract
Maintenance of the composition of inner ear fluid and regulation of electrolytes and acid-base homeostasis in the collecting duct system of the kidney require an overlapping set of membrane transport proteins regulated by the forkhead transcription factor FOXI1. In two unrelated consanguineous families, we identified three patients with novel homozygous missense mutations in FOXI1 (p.L146F and p.R213P) predicted to affect the highly conserved DNA binding domain. Patients presented with early-onset sensorineural deafness and distal renal tubular acidosis. In cultured cells, the mutations reduced the DNA binding affinity of FOXI1, which hence, failed to adequately activate genes crucial for normal inner ear function and acid-base regulation in the kidney. A substantial proportion of patients with a clinical diagnosis of inherited distal renal tubular acidosis has no identified causative mutations in currently known disease genes. Our data suggest that recessive mutations in FOXI1 can explain the disease in a subset of these patients.
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Affiliation(s)
- Sven Enerbäck
- Department of Medical Biochemistry and Cell Biology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden;
| | - Daniel Nilsson
- Department of Medical Biochemistry and Cell Biology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Noel Edwards
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Mikael Heglind
- Department of Medical Biochemistry and Cell Biology, Institute of Biomedicine, University of Gothenburg, Gothenburg, Sweden
| | - Sumaya Alkanderi
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Emma Ashton
- North East Thames Regional Genetic Service Laboratories, London, United Kingdom
| | - Asma Deeb
- Pediatric Services, Mafraq Hospital, Abu Dhabi, United Arab Emirates
| | - Feras E B Kokash
- College of Medicine, Gulf Medical University, Ajman, United Arab Emirates
| | - Abdul R A Bakhsh
- College of Medicine, Gulf Medical University, Ajman, United Arab Emirates
| | - William Van't Hoff
- Great Ormond Street Hospital for Children, National Health Service Foundation Trust, London, United Kingdom
| | - Stephen B Walsh
- University College London Centre for Nephrology, London, United Kingdom
| | - Felice D'Arco
- College of Medicine, Gulf Medical University, Ajman, United Arab Emirates
| | - Arezoo Daryadel
- Institute of Physiology, University of Zürich, Zurich, Switzerland; and.,National Center for Competence in Research, National Center in Competence in Research Kidney.CH, Zurich, Switzerland
| | - Soline Bourgeois
- Institute of Physiology, University of Zürich, Zurich, Switzerland; and.,National Center for Competence in Research, National Center in Competence in Research Kidney.CH, Zurich, Switzerland
| | - Carsten A Wagner
- Institute of Physiology, University of Zürich, Zurich, Switzerland; and.,National Center for Competence in Research, National Center in Competence in Research Kidney.CH, Zurich, Switzerland
| | - Robert Kleta
- Great Ormond Street Hospital for Children, National Health Service Foundation Trust, London, United Kingdom.,University College London Centre for Nephrology, London, United Kingdom
| | - Detlef Bockenhauer
- Great Ormond Street Hospital for Children, National Health Service Foundation Trust, London, United Kingdom.,University College London Centre for Nephrology, London, United Kingdom
| | - John A Sayer
- Institute of Genetic Medicine, Newcastle University, Newcastle Upon Tyne, United Kingdom
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17
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Walsh PR, Tse Y, Ashton E, Iancu D, Jenkins L, Bienias M, Kleta R, Van't Hoff W, Bockenhauer D. Clinical and diagnostic features of Bartter and Gitelman syndromes. Clin Kidney J 2017; 11:302-309. [PMID: 29942493 PMCID: PMC6007694 DOI: 10.1093/ckj/sfx118] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/12/2017] [Indexed: 12/31/2022] Open
Abstract
Background Bartter and Gitelman syndromes are autosomal recessive disorders of renal tubular salt handling. Due to their rarity, limited long-term data are available to inform prognosis and management. Methods Long-term longitudinal data were analysed for 45 children with pathogenic variants in SLC12A1 (n = 8), KCNJ1 (n = 8), CLCNKB (n = 17), BSND (n = 2) and SLC12A3 (n = 10) seen at a single centre between 1984 and 2014. Median follow-up was 8.9 [interquartile range (IQR) 0.7–18.1] years. Results Polyhydramnios and prematurity were seen in children with SLC12A1 and KCNJ1 mutations. Patients with CLCNKB mutations had the lowest serum potassium and serum magnesium and the highest serum bicarbonate levels. Fractional excretion of chloride was >0.5% in all patients prior to supplementation. Nephrocalcinosis at presentation was present in the majority of patients with SLC12A1 and KCNJ1 mutations, while it was only present in one patient with CLCNKB and not in SLC12A3 or BSND mutations. Growth was impaired, but within the normal range (median height standard deviation score −1.2 at the last follow-up). Impaired estimated glomerular filtration rate (eGFR <90 mL/min/1.73 m2) at the last follow-up was seen predominantly with SLC12A1 [71 mL/min/1.73 m2 (IQR 46–74)] and KCNJ1 [62 mL/min/1.73 m2 (IQR 48–72)] mutations. Pathological albuminuria was detected in 31/45 children. Conclusions Patients with Bartter and Gitelman syndromes had a satisfactory prognosis during childhood. However, decreased eGFR and pathologic proteinuria was evident in a large number of these patients, highlighting the need to monitor glomerular as well as tubular function. Electrolyte abnormalities were most severe in CLCNKB mutations both at presentation and during follow-up. Fractional excretion of chloride prior to supplementation is a useful screening investigation in children with hypokalaemic alkalosis to establish renal salt wasting.
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Affiliation(s)
- Patrick R Walsh
- Department of Nephrology, Great North Children's Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Yincent Tse
- Department of Nephrology, Great North Children's Hospital NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Emma Ashton
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Daniela Iancu
- Division of Medicine, UCL Centre for Nephrology, London, UK
| | - Lucy Jenkins
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marc Bienias
- Department of Paediatrics, Medical Faculty Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Robert Kleta
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Division of Medicine, UCL Centre for Nephrology, London, UK
| | - William Van't Hoff
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Detlef Bockenhauer
- Department of Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Division of Medicine, UCL Centre for Nephrology, London, UK
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18
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Blanchard A, Bockenhauer D, Bolignano D, Calò LA, Cosyns E, Devuyst O, Ellison DH, Karet Frankl FE, Knoers NVAM, Konrad M, Lin SH, Vargas-Poussou R. Gitelman syndrome: consensus and guidance from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2017; 91:24-33. [PMID: 28003083 DOI: 10.1016/j.kint.2016.09.046] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/14/2016] [Accepted: 09/28/2016] [Indexed: 12/18/2022]
Abstract
Gitelman syndrome (GS) is a rare, salt-losing tubulopathy characterized by hypokalemic metabolic alkalosis with hypomagnesemia and hypocalciuria. The disease is recessively inherited, caused by inactivating mutations in the SLC12A3 gene that encodes the thiazide-sensitive sodium-chloride cotransporter (NCC). GS is usually detected during adolescence or adulthood, either fortuitously or in association with mild or nonspecific symptoms or both. The disease is characterized by high phenotypic variability and a significant reduction in the quality of life, and it may be associated with severe manifestations. GS is usually managed by a liberal salt intake together with oral magnesium and potassium supplements. A general problem in rare diseases is the lack of high quality evidence to inform diagnosis, prognosis, and management. We report here on the current state of knowledge related to the diagnostic evaluation, follow-up, management, and treatment of GS; identify knowledge gaps; and propose a research agenda to substantiate a number of issues related to GS. This expert consensus statement aims to establish an initial framework to enable clinical auditing and thus improve quality control of care.
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Affiliation(s)
- Anne Blanchard
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France; Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Centre d'Investigation Clinique, Paris, France; Centre d'Investigation Clinique 1418, Institut National de la Santé et de la Recherche Médicale, Paris, France; UMR 970, Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Detlef Bockenhauer
- Centre for Nephrology, University College London, London, UK; Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, UK
| | - Davide Bolignano
- Institute of Clinical Physiology, National Research Council, Reggio, Calabria, Italy
| | - Lorenzo A Calò
- Department of Medicine, Nephrology, University of Padova, Padova, Italy
| | | | - Olivier Devuyst
- Institute of Physiology, University of Zurich, Zurich, Switzerland.
| | - David H Ellison
- Division of Nephrology and Hypertension, Oregon Health and Science University, Veterans Affairs Portland Health Care System, Portland, Oregon, USA
| | - Fiona E Karet Frankl
- Department of Medical Genetics, University of Cambridge and Cambridge University Hospitals National Health Service Trust, Cambridge, UK; Division of Renal Medicine, University of Cambridge and Cambridge University Hospitals National Health Service Trust, Cambridge, UK
| | - Nine V A M Knoers
- Department of Genetics, Center for Molecular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Martin Konrad
- Department of General Pediatrics, University Children's Hospital, Münster, Germany
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Medical Science, National Defense Medical Center, Taipei, Taiwan
| | - Rosa Vargas-Poussou
- Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Centre d'Investigation Clinique, Paris, France; Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
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19
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Gollasch B, Anistan YM, Canaan-Kühl S, Gollasch M. Late-onset Bartter syndrome type II. Clin Kidney J 2017; 10:594-599. [PMID: 28979772 PMCID: PMC5622898 DOI: 10.1093/ckj/sfx033] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 03/27/2017] [Indexed: 02/07/2023] Open
Abstract
Mutations in the ROMK1 potassium channel gene (KCNJ1) cause antenatal/neonatal Bartter syndrome type II (aBS II), a renal disorder that begins in utero, accounting for the polyhydramnios and premature delivery that is typical in affected infants, who develop massive renal salt wasting, hypokalaemic metabolic alkalosis, secondary hyperreninaemic hyperaldosteronism, hypercalciuria and nephrocalcinosis. This BS type is believed to represent a disorder of the infancy, but not in adulthood. We herein describe a female patient with a remarkably late-onset and mild clinical manifestation of BS II with compound heterozygous KCNJ1 missense mutations, consisting of a novel c.197T > A (p.I66N) and a previously reported c.875G > A (p.R292Q) KCNJ1 mutation. We implemented and evaluated the performance of two different bioinformatics-based approaches of targeted massively parallel sequencing [next generation sequencing (NGS)] in defining the molecular diagnosis. Our results demonstrate that aBS II may be suspected in patients with a late-onset phenotype. Our experimental approach of NGS-based mutation screening combined with Sanger sequencing proved to be a reliable molecular approach for defining the clinical diagnosis in our patient, and results in important differential diagnostic and therapeutic implications for patients with BS. Our results could have a significant impact on the diagnosis and methodological approaches of genetic testing in other patients with clinical unclassified phenotypes of nephrocalcinosis and congenital renal electrolyte abnormalities.
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Affiliation(s)
- Benjamin Gollasch
- Franz Volhard Clinical Research Center at the Experimental and Clinical Research Center (ECRC), a joint cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine (MDC) in the Helmholtz Association of National Research Centers, Berlin, Germany
| | - Yoland-Marie Anistan
- Experimental and Clinical Research Center (ECRC), a joint cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine (MDC) in the Helmholtz Association of National Research Centers, Berlin, Germany
| | - Sima Canaan-Kühl
- Medical Clinic for Nephrology and Internal Intensive Care, Campus Virchow, Charité University Medicine, Berlin, Germany
| | - Maik Gollasch
- Experimental and Clinical Research Center (ECRC), a joint cooperation between the Charité Medical Faculty and the Max Delbrück Center for Molecular Medicine (MDC) in the Helmholtz Association of National Research Centers, Berlin, Germany.,Medical Clinic for Nephrology and Internal Intensive Care, Campus Virchow, Charité University Medicine, Berlin, Germany
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20
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van der Merwe PDT, Rensburg MA, Haylett WL, Bardien S, Davids MR. Gitelman syndrome in a South African family presenting with hypokalaemia and unusual food cravings. BMC Nephrol 2017; 18:38. [PMID: 28125972 PMCID: PMC5270235 DOI: 10.1186/s12882-017-0455-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 01/19/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Gitelman syndrome (GS) is an autosomal recessive renal tubular disorder characterised by renal salt wasting with hypokalaemia, metabolic alkalosis, hypomagnesaemia and hypocalciuria. It is caused by mutations in SLC12A3 encoding the sodium-chloride cotransporter on the apical membrane of the distal convoluted tubule. We report a South African family with five affected individuals presenting with hypokalaemia and unusual food cravings. METHODS The affected individuals and two unaffected first degree relatives were enrolled into the study. Phenotypes were evaluated through history, physical examination and biochemical analysis of blood and urine. Mutation screening was performed by sequencing of SLC12A3, and determining the allele frequencies of the sequence variants found in this family in 117 ethnically matched controls. RESULTS The index patient, her sister, father and two aunts had a history of severe salt cravings, fatigue and tetanic episodes, leading to consumption of large quantities of salt and vinegar. All affected individuals demonstrated hypokalaemia with renal potassium wasting. Genetic analysis revealed that the pseudo-dominant pattern of inheritance was due to compound heterozygosity with two novel mutations: a S546G substitution in exon 13, and insertion of AGCCCC at c.1930 in exon 16. These variants were present in the five affected individuals, but only one variant each in the unaffected family members. Neither variant was found in any of the controls. CONCLUSIONS The diagnosis of GS was established in five members of a South African family through clinical assessment, biochemical analysis and mutation screening of the SLC12A3 gene, which identified two novel putative pathogenic mutations.
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Affiliation(s)
- Pieter Du Toit van der Merwe
- Division of Nephrology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Megan A Rensburg
- Division of Chemical Pathology, Stellenbosch University and National Health Laboratory Service, Cape Town, South Africa
| | - William L Haylett
- Division of Molecular Biology and Human Genetics, Stellenbosch University, Cape Town, South Africa
| | - Soraya Bardien
- Division of Molecular Biology and Human Genetics, Stellenbosch University, Cape Town, South Africa
| | - M Razeen Davids
- Division of Nephrology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.
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Kersten S, Arjona FJ. Ion transport in the zebrafish kidney from a human disease angle: possibilities, considerations, and future perspectives. Am J Physiol Renal Physiol 2017; 312:F172-F189. [DOI: 10.1152/ajprenal.00425.2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 11/11/2016] [Accepted: 11/14/2016] [Indexed: 12/31/2022] Open
Abstract
Unique experimental advantages, such as its embryonic/larval transparency, high-throughput nature, and ease of genetic modification, underpin the rapid emergence of the zebrafish ( Danio rerio) as a preeminent model in biomedical research. Particularly in the field of nephrology, the zebrafish provides a promising model for studying the physiological implications of human solute transport processes along consecutive nephron segments. However, although the zebrafish might be considered a valuable model for numerous renal ion transport diseases and functional studies of many channels and transporters, not all human renal electrolyte transport mechanisms and human diseases can be modeled in the zebrafish. With this review, we explore the ontogeny of zebrafish renal ion transport, its nephron structure and function, and thereby demonstrate the clinical translational value of this model. By critical assessment of genomic and amino acid conservation of human proteins involved in renal ion handling (channels, transporters, and claudins), kidney and nephron segment conservation, and renal electrolyte transport physiology in the zebrafish, we provide researchers and nephrologists with an indication of the possibilities and considerations of the zebrafish as a model for human renal ion transport. Combined with advanced techniques envisioned for the future, implementation of the zebrafish might expand beyond unraveling pathophysiological mechanisms that underlie distinct genetic or environmentally, i.e., pharmacological and lifestyle, induced renal transport deficits. Specifically, the ease of drug administration and the exploitation of improved genetic approaches might argue for the adoption of the zebrafish as a model for preclinical personalized medicine for distinct renal diseases and renal electrolyte transport proteins.
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Affiliation(s)
- Simone Kersten
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; and
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Charlestown, Massachusetts
| | - Francisco J. Arjona
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands; and
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23
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Lee EY, Yoon H, Yi JH, Jung WY, Han SW, Kim HJ. Does hypokalemia contribute to acute kidney injury in chronic laxative abuse? Kidney Res Clin Pract 2015; 34:109-12. [PMID: 26484031 PMCID: PMC4570648 DOI: 10.1016/j.krcp.2014.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 09/29/2014] [Accepted: 10/17/2014] [Indexed: 11/26/2022] Open
Abstract
Prolonged hypokalemia from chronic laxative abuse is recognized as the cause of chronic tubulointerstitial disease, known as “hypokalemic nephropathy,” but it is not clear whether it contributes to acute kidney injury (AKI). A 42-year-old woman with a history of chronic kidney disease as a result of chronic laxative abuse from a purging type of anorexia nervosa (AN-P), developed an anuric AKI requiring hemodialysis and a mild AKI 2 months later. Both episodes of AKI involved severe to moderate hypokalemia (1.2 and 2.7 mmol/L, respectively), volume depletion, and mild rhabdomyolysis. The histologic findings of the first AKI revealed the remnants of acute tubular necrosis with advanced chronic tubulointerstitial nephritis and ischemic glomerular injury. Along with these observations, the intertwined relationship among precipitants of recurrent AKI in AN-P is discussed, and then we postulate a contributory role of hypokalemia involved in the pathophysiology of the renal ischemia-induced AKI.
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Affiliation(s)
- Eun-Young Lee
- Renal Division, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Hyaejin Yoon
- Renal Division, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Joo-Hark Yi
- Renal Division, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Woon-Yong Jung
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Woong Han
- Renal Division, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Ho-Jung Kim
- Renal Division, Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
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24
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Khosravi M, Walsh SB. The long-term complications of the inherited tubulopathies: an adult perspective. Pediatr Nephrol 2015; 30:385-95. [PMID: 24566812 DOI: 10.1007/s00467-014-2779-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/23/2014] [Accepted: 01/27/2014] [Indexed: 11/25/2022]
Abstract
The inherited tubulopathies are lifelong disorders and their clinical features and complications may present quite different challenges in adulthood from those in childhood. In this review we outline the pathophysiology and documented complications (including the late and unusual) of the monogenic tubulopathies from the perspective of the adult nephrologist.
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Affiliation(s)
- Maryam Khosravi
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
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25
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Lee JH, Lee J, Han JS. Gitelman's syndrome with vomiting manifested by severe metabolic alkalosis and progressive renal insufficiency. TOHOKU J EXP MED 2013; 231:165-9. [PMID: 24162365 DOI: 10.1620/tjem.231.165] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Gitelman's syndrome is an autosomal recessive salt-losing tubulopathy showing hypokalemic hypomagnesemic hypocalciuria with metabolic alkalosis and hyperreninemic hyperaldosteronism. This syndrome is caused by mutations in the SLC12A3 gene that encodes sodium-chloride cotransporter expressed at the apical membrane of renal distal convoluted tubule. Symptoms and renal outcomes of Gitelman's syndrome are, in general, mild and benign, and renal insufficiency from Gitelman's syndrome associated with long-standing hypokalemia and volume depletion is extremely rare. Herein, we report a 27-year-old male patient with Gitelman's syndrome who manifested renal failure, hypokalemia, severe metabolic alkalosis and altered mentality. About one year ago, the patient had been transferred to Seoul National University Hospital, because of unsolved hypokalemia, and was diagnosed as Gitelman's syndrome by clinical features and genetic analysis of the SLC12A3 gene. The patient carries a missense mutation at one allele of SLC12A3 gene (c.781C>T, p.Arg261Cys). His mother is also heterozygous for the same mutation and she had a history of hypokalemia. On this admission, the patient had recurrent bouts of vomiting induced by psychiatric eating disorder and showed severe volume depletion with hypotension, azotemia and metabolic alkalosis. Intense hydration therapy and emergency hemodialysis transiently improved his fluid-electrolyte imbalance and renal function. However, renal dysfunction progressively deteriorated despite the medical treatment. Our findings suggest that even in Gitelman's syndrome, constant monitoring for volume status and other comorbid conditions should be employed to prevent progressive renal injury.
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Affiliation(s)
- Jong-Ho Lee
- Department of Internal Medicine, Konkuk University School of Medicine
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Tavira B, Gómez J, Ortega F, Tranche S, Díaz-Corte C, Alvarez F, Ortiz A, Santos F, Sánchez-Niño MD, Coto E. A CLCNKA polymorphism (rs10927887; p.Arg83Gly) previously linked to heart failure is associated with the estimated glomerular filtration rate in the RENASTUR cohort. Gene 2013; 527:670-2. [PMID: 23850580 DOI: 10.1016/j.gene.2013.06.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 06/03/2013] [Accepted: 06/14/2013] [Indexed: 12/18/2022]
Abstract
A total of 569 individuals aged 55-85 and Caucasian were genotyped for SNP rs10927887 in the Ka renal chloride channel gene (CLCNKA). The following variables were significantly associated with an estimated glomerular filtration rate of (eGFR) <60 ml/min./1.73 m(2): age, type 2 diabetes, total cholesterol, LDL-cholesterol, and the CLCNKA GG genotype (p=0.03; OR=1.65, 95% CI=1.04-2.62). This novel finding could partly explain the reported greater risk of heart failure linked to the CLCNKA SNP, but requires confirmation on other populations.
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Affiliation(s)
- Beatriz Tavira
- Genética Molecular-Laboratorio Medicina, HUCA, Oviedo, Spain
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Cruz AJ, Castro A. Gitelman or Bartter type 3 syndrome? A case of distal convoluted tubulopathy caused by CLCNKB gene mutation. BMJ Case Rep 2013; 2013:bcr-2012-007929. [PMID: 23345488 DOI: 10.1136/bcr-2012-007929] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
A 32-year-old woman with no significant medical history was sent to our consultation due to hypokalaemia (<3.0 mmol/l). Her main complaints were longstanding polyuria and nocturia. Physical examination was normal. Basic investigations showed normal renal function, low serum potassium (2.7 mmol/l) and magnesium (0.79 mmol/l), metabolic alkalosis (pH 7.54; bicarbonate 32.5 mmol/l), elevated urinary potassium (185 mmol/24 h) and normal urinary calcium (246 mg/24 h). Thiazide test revealed blunted response. Chronic vomiting and the abuse of diuretics were excluded. Genetic tests for SLC12A3 gene mutation described in Gitelman syndrome (GS) came negative. CLCNKB gene mutation analysis present in both GS and Bartter (BS) type 3 syndromes was positive. The patient is now being treated with potassium and magnesium oral supplements, ramipril and spironolactone with stable near-normal potassium and magnesium levels. This article presents the case of a patient with hypokalaemia caused by CLCNKB gene mutation hard to categorise as GS or BS type 3.
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Affiliation(s)
- António José Cruz
- Serviço de Medicina Interna, Centro Hospitalar de Entre o Douro e Vouga-Hospital de São Sebastião, Santa Maria da Feira, Portugal.
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