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Shi X, Guo T, Wen Y, Ye W, Ye W, Zheng K, Qin Y, Li X, Zhang F, Chen L. Rare renal proximal tubular dysfunctions in primary biliary cholangitis. Ren Fail 2024; 46:2302409. [PMID: 38275162 PMCID: PMC10823888 DOI: 10.1080/0886022x.2024.2302409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 01/02/2024] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Renal involvement of primary biliary cholangitis (PBC) usually presents as distal renal tubular acidosis. Proximal tubular (PT) dysfunctions in PBC were rarely reported with unclear clinicopathological characteristics and renal prognosis. METHODS We identified 11 cases of PBC with PT dysfunctions (PBC-PT). Their medical document, kidney pathology, and follow-up data were retrospectively reviewed and analyzed. RESULTS The 11 PBC-PT patients were mainly middle-aged (57.8 ± 5.2 years) females (81.8%). Most of them were asymptomatic PBC (7, 63.6%) with a high prevalence of elevated serum immunoglobulin M (IgM, 81.8%) and G (IgG, 54.5%) levels. In the kidney, they had a mean estimated glomerular filtration rate (eGFR) level of 46.54 ± 23.03 ml/min/1.73m2, and 81.8% of them had eGFR below 60 ml/min/1.73m2. They showed different degrees of PT dysfunctions, including hyperuricosuria, hypouricemia, normoglycemic glycosuria, generalized aminoaciduria, hyperphosphaturia, and hypophosphatemia. Their kidney pathology showed tubulointerstitial nephritis with lymphoplasmacytic infiltrates, brush border defects, and proximal tubulitis. After glucocorticoids treatment, the PT dysfunctions manifesting as hypophosphatemia, hypouricemia, and renal glycosuria all recovered, and the eGFR levels were improved from 43.24 ± 19.60 ml/min/1.73m2 to 55.02 ± 21.14 ml/min/1.73m2 (p = 0.028), accompanied by significant improvements of serum IgM levels (from 5.97 ± 4.55 g/L to 2.09 ± 1.48 g/L, p = 0.019). CONCLUSIONS The PT dysfunctions were rare in PBC patients, and glucocorticoids treatment could benefit the improvements of eGFR and tubular functions.
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Affiliation(s)
- Xiaoxiao Shi
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Tianchen Guo
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yubing Wen
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Wei Ye
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Wenling Ye
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ke Zheng
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yan Qin
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xuemei Li
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Limeng Chen
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Kunchur MG, Mauch TJ, Parkanzky M, Rahilly LJ. A review of renal tubular acidosis. J Vet Emerg Crit Care (San Antonio) 2024. [PMID: 39023331 DOI: 10.1111/vec.13407] [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: 01/08/2021] [Revised: 10/14/2022] [Accepted: 11/11/2022] [Indexed: 07/20/2024]
Abstract
OBJECTIVE To review the current scientific literature on renal tubular acidosis (RTA) in people and small animals, focusing on diseases in veterinary medicine that result in secondary RTA. DATA SOURCES Scientific reviews and original research publications on people and small animals focusing on RTA. SUMMARY RTA is characterized by defective renal acid-base regulation that results in normal anion gap hyperchloremic metabolic acidosis. Renal acid-base regulation includes the reabsorption and regeneration of bicarbonate in the renal proximal tubule and collecting ducts and the process of ammoniagenesis. RTA occurs as a primary genetic disorder or secondary to disease conditions. Based on pathophysiology, RTA is classified as distal or type 1 RTA, proximal or type 2 RTA, type 3 RTA or carbonic anhydrase II mutation, and type 4 or hyperkalemic RTA. Fanconi syndrome comprises proximal RTA with additional defects in proximal tubular function. Extensive research elucidating the genetic basis of RTA in people exists. RTA is a genetic disorder in the Basenji breed of dogs, where the mutation is known. Secondary RTA in human and veterinary medicine is the sequela of diseases that include immune-mediated, toxic, and infectious causes. Diagnosis and characterization of RTA include the measurement of urine pH and the evaluation of renal handling of substances that should affect acid or bicarbonate excretion. CONCLUSIONS Commonality exists between human and veterinary medicine among the types of RTA. Many genetic defects causing primary RTA are identified in people, but those in companion animals other than in the Basenji are unknown. Critically ill veterinary patients are often admitted to the ICU for diseases associated with secondary RTA, or they may develop RTA while hospitalized. Recognition and treatment of RTA may reverse tubular dysfunction and promote recovery by correcting metabolic acidosis.
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Affiliation(s)
| | - Teri Jo Mauch
- University of Nebraska Medical Center and Children's Hospital, Omaha, Nebraska, USA
- University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | | | - Louisa J Rahilly
- Cape Cod Veterinary Specialists, Buzzards Bay, Massachusetts, USA
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Medina E, Ariceta G, Batlle D. Primary Distal Renal Tubular Acidosis: Toward an Optimal Correction of Metabolic Acidosis. Clin J Am Soc Nephrol 2024:01277230-990000000-00420. [PMID: 38967973 DOI: 10.2215/cjn.0000000000000535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 06/28/2024] [Indexed: 07/07/2024]
Abstract
The term classic, type 1 renal tubular acidosis or primary distal renal tubular acidosis is used to designate patients with impaired ability to excrete acid normally in the urine as a result of tubular transport defects involving type A intercalated cells in the collecting duct. The clinical phenotype is largely characterized by the complications of chronic metabolic acidosis (MA): stunted growth, bone abnormalities, and nephrocalcinosis and nephrolithiasis that develop as the consequence of hypercalciuria and hypocitraturia. All these manifestations are preventable with early and sustained correction of MA with alkali therapy. The optimal target for plasma bicarbonate should be as close as possible to the range considered normal by current standards (between 23 and 28 mEq/L.). Most of the benefits of alkali therapy are tangible early in the course of the disease in childhood, but life-long treatment is required to prevent the vast array of complications attributable to chronic MA.
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Affiliation(s)
- Elba Medina
- Division of Nephrology, General Hospital of México, Eduardo Liceaga, México City, México and Master's and PhD Program in Dental and Health Medical Sciences, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Gema Ariceta
- Pediatric Nephrology, University Hospital Vall d'Hebron, and Autonomous University of Barcelona, Barcelona, Spain
| | - Daniel Batlle
- Division of Nephrology/Hypertension, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Marino CL, Foster JD. Pseudohypoaldosteronism and acquired renal aldosterone resistance with hyperkalemic type IV renal tubular acidosis in 2 cats. J Vet Intern Med 2024; 38:2344-2347. [PMID: 38695414 PMCID: PMC11256122 DOI: 10.1111/jvim.17098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 04/18/2024] [Indexed: 07/19/2024] Open
Abstract
This report describes the diagnosis and treatment of aldosterone resistance (AR) and acquired hyperkalemic type IV renal tubular acidosis (RTA) in 2 cats comparable to acquired pseudohypoaldosteronism in people. One cat developed AR from chronic kidney disease after an acute kidney injury and was treated with furosemide per os, which resolved the hyperkalemic RTA. The second cat developed transient AR secondary to a bacterial urinary tract infection associated with urethral catheterization, and treatment with antibiotics resolved the hyperkalemic RTA.
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Leventoğlu E. Distal renal tubular acidosis as a rare complication of vesicoureteral reflux in children: a case report and literature review. CEN Case Rep 2024:10.1007/s13730-024-00873-3. [PMID: 38637460 DOI: 10.1007/s13730-024-00873-3] [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: 10/11/2023] [Accepted: 03/29/2024] [Indexed: 04/20/2024] Open
Abstract
Distal renal tubular acidosis (dRTA) is a clinical picture of hyperchloremic hypokalemic metabolic acidosis with a normal anion gap. It can be caused by a variety of conditions including obstructive uropathy such as vesicoureteral reflux (VUR). We report a rare case of dRTA secondary to VUR in a 4-year-old girl with a history of meningomyelocele, neurogenic bladder and recurrent urinary tract infections. She was admitted to the hospital with complaints of polydipsia, polyuria, and inability to gain weight for the last 1 year. She was on prophylactic antibiotic treatment with clean intermittent catheterization and anticholinergic drug. She had a history of subureteral injection of various agents and botulin toxin injection into the bladder. Her voiding cystourethrogram revealed grade 5 VUR in the left kidney, tortuosity in the left ureter, and the bladder had a dome-like appearance and was trabeculated. When all laboratory values of the patient since birth were examined, it was observed that urine pH was high despite hypokalemic hyperchloremic metabolic acidosis for the last year; these abnormalities became more severe in the last few months. In conclusion, the development of hypokalemia and nephrolithiasis/nephrocalcinosis along with metabolic acidosis in a patient diagnosed with VUR should be considered as an indicator of impaired tubular functions. Also, the possibility of an underlying VUR in the presence of recurrent urinary tract infection in a patient diagnosed with dRTA should not be ignored.
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Affiliation(s)
- Emre Leventoğlu
- Department of Pediatric Nephrology, Konya City Hospital, Konya, Turkey.
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Fogleman BM, McKinnon E, Nebeker S, Arukala KS. Severe Electrolyte Abnormalities and Distal Renal Tubular Acidosis in the Setting of Apremilast Use for Psoriatic Arthritis: A Case Report. Cureus 2024; 16:e53514. [PMID: 38440019 PMCID: PMC10910423 DOI: 10.7759/cureus.53514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2024] [Indexed: 03/06/2024] Open
Abstract
Renal tubular acidosis (RTA) involves dysfunction of the renal tubular system, which leads to electrolyte abnormalities and acid-base dysregulation. The case we present here discusses a patient with a past medical history of psoriatic arthritis who presented to the emergency department with progressive generalized weakness and anorexia in the preceding four weeks. She was found to have profound hypokalemia (1.2 mmol/L), hyperchloremic metabolic acidosis, and multiple other electrolyte abnormalities. Following an extensive workup, her principle problem was deemed to be distal (type 1) RTA. She was treated with sodium bicarbonate, spironolactone, and aggressive rehydration, which eventually led to the stabilization of her electrolytes alongside clinical improvement over the course of an eight-day hospitalization. The workup did not reveal a clear etiology for the RTA. One month prior to hospitalization, she was started on apremilast, a new medication for her psoriatic arthritis. Given the limited availability of alternative explanations and the temporality of clinical manifestations, our findings raise suspicion that apremilast might be associated with her clinical presentation.
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Affiliation(s)
- Brody M Fogleman
- Internal Medicine, Edward Via College of Osteopathic Medicine, Spartanburg, USA
| | - Emilie McKinnon
- Internal Medicine, Grand Strand Medical Center, Myrtle Beach, USA
| | - Schuyler Nebeker
- Internal Medicine, Grand Strand Medical Center, Myrtle Beach, USA
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Kang MJ, Ioannou S, Lougheide Q, Dittmar M, Hsu Y, Pastor-Soler NM. The study of intercalated cells using ex vivo techniques: primary cell culture, cell lines, kidney slices, and organoids. Am J Physiol Cell Physiol 2024; 326:C229-C251. [PMID: 37899748 DOI: 10.1152/ajpcell.00479.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 10/23/2023] [Accepted: 10/24/2023] [Indexed: 10/31/2023]
Abstract
This review summarizes methods to study kidney intercalated cell (IC) function ex vivo. While important for acid-base homeostasis, IC dysfunction is often not recognized clinically until it becomes severe. The advantage of using ex vivo techniques is that they allow for the differential evaluation of IC function in controlled environments. Although in vitro kidney tubular perfusion is a classical ex vivo technique to study IC, here we concentrate on primary cell cultures, immortalized cell lines, and ex vivo kidney slices. Ex vivo techniques are useful in evaluating IC signaling pathways that allow rapid responses to extracellular changes in pH, CO2, and bicarbonate (HCO3-). However, these methods for IC work can also be challenging, as cell lines that recapitulate IC do not proliferate easily in culture. Moreover, a "pure" IC population in culture does not necessarily replicate its collecting duct (CD) environment, where ICs are surrounded by the more abundant principal cells (PCs). It is reassuring that many findings obtained in ex vivo IC systems signaling have been largely confirmed in vivo. Some of these newly identified signaling pathways reveal that ICs are important for regulating NaCl reabsorption, thus suggesting new frontiers to target antihypertensive treatments. Moreover, recent single-cell characterization studies of kidney epithelial cells revealed a dual developmental origin of IC, as well as the presence of novel CD cell types with certain IC characteristics. These exciting findings present new opportunities for the study of IC ex vivo and will likely rediscover the importance of available tools in this field.NEW & NOTEWORTHY The study of kidney intercalated cells has been limited by current cell culture and kidney tissue isolation techniques. This review is to be used as a reference to select ex vivo techniques to study intercalated cells. We focused on the use of cell lines and kidney slices as potential useful models to study membrane transport proteins. We also review how novel collecting duct organoids may help better elucidate the role of these intriguing cells.
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Affiliation(s)
- Min Ju Kang
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Silvia Ioannou
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Quinn Lougheide
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Michael Dittmar
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Young Hsu
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California, United States
| | - Nuria M Pastor-Soler
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine of USC, Los Angeles, California, United States
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Alsabri M, Street H, Sircy A, Labib B. Misdiagnosed metabolic bone abnormality: a case report. J Med Case Rep 2023; 17:436. [PMID: 37858137 PMCID: PMC10588102 DOI: 10.1186/s13256-023-04164-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 09/05/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Metabolic bone disease causes significant morbidity and mortality, especially when misdiagnosed. With genetic testing, multiple disease pathologies can be analyzed. CASE PRESENTATION A 5-year and 9-month-old otherwise healthy Yemeni girl presented to her Yemen physician for evaluation of inward bending of her right knee and short stature. After extensive medical testing, she was given a diagnosis of hypophosphatemic rickets and growth hormone deficiency and started on treatment. Despite appropriate treatment, however, her condition continued to progress, prompting her family to pursue additional workup including genetic testing outside of Yemen. Genetic testing ultimately revealed a variation of unknown significance associated with amelogenesis imperfecta. CONCLUSIONS Hypophosphatemic rickets secondary to renal tubular acidosis was the working diagnosis. However, the patient's condition did not improve. Further genetic testing revealed a variation of unknown significance associated with amelogenesis imperfecta. We aim to present this case, provide an overview of the causes, and diagnostic metabolic bone health evaluation.
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Affiliation(s)
- Mohammed Alsabri
- Pediatrics, 1 Brookdale University Hospital and Medical Center, 1Brookdale Plaza, Brooklyn, NY, 11212, USA.
- Emergency Medicine Department, Al Thawra Modern General Hospital (TMGH), Sana'a City, Yemen.
- College of Osteopathic Medicine, NYIT, Glen Head, NY, USA.
| | - Hannah Street
- NYU Langone Medical Center, 550 1st Avenue, New York, NY, 10016, USA
| | - Aaron Sircy
- CMEF Aultman Hospital, 2600 6th st. SW, Canton, OH, 44710, USA
| | - Bahaaeldin Labib
- Rutgers-Robert Wood Johnson University Hospital, 200 Somerset Street, New Brunswick, NJ, 08901, USA
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Clemente-Suárez VJ, Martín-Rodríguez A, Redondo-Flórez L, Villanueva-Tobaldo CV, Yáñez-Sepúlveda R, Tornero-Aguilera JF. Epithelial Transport in Disease: An Overview of Pathophysiology and Treatment. Cells 2023; 12:2455. [PMID: 37887299 PMCID: PMC10605148 DOI: 10.3390/cells12202455] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 10/28/2023] Open
Abstract
Epithelial transport is a multifaceted process crucial for maintaining normal physiological functions in the human body. This comprehensive review delves into the pathophysiological mechanisms underlying epithelial transport and its significance in disease pathogenesis. Beginning with an introduction to epithelial transport, it covers various forms, including ion, water, and nutrient transfer, followed by an exploration of the processes governing ion transport and hormonal regulation. The review then addresses genetic disorders, like cystic fibrosis and Bartter syndrome, that affect epithelial transport. Furthermore, it investigates the involvement of epithelial transport in the pathophysiology of conditions such as diarrhea, hypertension, and edema. Finally, the review analyzes the impact of renal disease on epithelial transport and highlights the potential for future research to uncover novel therapeutic interventions for conditions like cystic fibrosis, hypertension, and renal failure.
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Affiliation(s)
- Vicente Javier Clemente-Suárez
- Faculty of Sports Sciences, Universidad Europea de Madrid, Tajo Street, s/n, 28670 Madrid, Spain;
- Group de Investigación en Cultura, Educación y Sociedad, Universidad de la Costa, Barranquilla 080002, Colombia
| | | | - Laura Redondo-Flórez
- Department of Health Sciences, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, C/Tajo s/n, Villaviciosa de Odón, 28670 Madrid, Spain; (L.R.-F.); (C.V.V.-T.)
| | - Carlota Valeria Villanueva-Tobaldo
- Department of Health Sciences, Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, C/Tajo s/n, Villaviciosa de Odón, 28670 Madrid, Spain; (L.R.-F.); (C.V.V.-T.)
| | - Rodrigo Yáñez-Sepúlveda
- Faculty of Education and Social Sciences, Universidad Andres Bello, Viña del Mar 2520000, Chile;
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Yao Y, Audil HY, Aakre CA. 91-Year-Old Woman With Hyperkalemia. Mayo Clin Proc 2023; 98:1552-1556. [PMID: 37793729 DOI: 10.1016/j.mayocp.2023.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 10/06/2023]
Affiliation(s)
- Yuan Yao
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Hadiyah Y Audil
- Fellow in Hematology and Medical Oncology, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Christopher A Aakre
- Advisor to residents and Fellow and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN.
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Guo W, Ji P, Xie Y. Genetic Diagnosis and Treatment of Inherited Renal Tubular Acidosis. KIDNEY DISEASES (BASEL, SWITZERLAND) 2023; 9:371-383. [PMID: 37901710 PMCID: PMC10601937 DOI: 10.1159/000531556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 06/12/2023] [Indexed: 10/31/2023]
Abstract
Background Renal tubular acidosis (RTA) is caused by various disruptions to the secretion of H+ by distal renal tubules and/or dysfunctional reabsorption of HCO3- by proximal renal tubules, which causes renal acidification dysfunction, ultimately leading to a clinical syndrome characterized by hyperchloremic metabolic acidosis with a normal anion gap. With the development of molecular genetics and gene sequencing technology, inherited RTA has also attracted attention, and an increasing number of RTA-related pathogenic genes have been discovered and reported. Summary This paper focuses on the latest progress in the research of inherited RTA and systematically reviews the pathogenic genes, protein functions, clinical manifestations, internal relationship between genotypes and clinical phenotypes, diagnostic clues, differential diagnosis, and treatment strategies associated with inherited RTA. This paper aims to deepen the understanding of inherited RTA and reduce the missed diagnosis and misdiagnosis of RTA. Key Messages This review systematically summarizes the pathogenic genes, pathophysiological mechanisms, differential diagnosis, and treatment of different types of inherited RTA, which has good clinical value for guiding the diagnosis and treatment of inherited RTA.
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Affiliation(s)
- Wenkai Guo
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
- School of Medicine, Nankai University, Tianjin, China
| | - Pengcheng Ji
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
| | - Yuansheng Xie
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing, China
- School of Medicine, Nankai University, Tianjin, China
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Seong EY, Kim DW, Kim HJ, Rhee H, Song SH. Incomplete distal renal tubular acidosis uncovered during pregnancy: A case report. World J Clin Cases 2023; 11:5988-5993. [PMID: 37727491 PMCID: PMC10506016 DOI: 10.12998/wjcc.v11.i25.5988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/12/2023] [Accepted: 08/08/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Renal tubular acidosis (RTA) is a renal cause of non-anion-gap metabolic acidosis characterized by low urinary ammonia excretion. This condition has a low prevalence, and various congenital and acquired etiologies. To date, only a few cases of idiopathic RTA uncovered during pregnancy have been reported. CASE SUMMARY A previously healthy 32-year-old Korean woman at 30 wk of gestation was admitted to Pusan National University Hospital with preterm labor. At admission, the patient presented with hypokalemia, non-anion-gap metabolic acidosis, and nephrocalcinosis. Distal RTA was diagnosed based on laboratory blood and urine findings and imaging examinations. Various tests, including next-generation gene sequencing panels for nephropathy, were performed to determine the etiology of the disease, which indicated that it was idiopathic. The patient received sodium bicarbonate and potassium chloride supplementation. After 3 wk, she delivered a baby who was subsequently diagnosed with corpus callosum agenesis and colpocephaly. During regular follow-ups for 6 mo postpartum, her hypokalemia and metabolic acidosis were gradually resolved, and medications eventually discontinued. CONCLUSION Herein we describe a case of idiopathic distal RTA discovered during pregnancy. Hypokalemia and metabolic acidosis resolved spontaneously after delivery.
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Affiliation(s)
- Eun Young Seong
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan-si 50612, Gyeongsangnam-do, South Korea
| | - Da Woon Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan 49241, South Korea
| | - Hyo Jin Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan-si 50612, Gyeongsangnam-do, South Korea
| | - Harin Rhee
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan-si 50612, Gyeongsangnam-do, South Korea
| | - Sang Heon Song
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, South Korea
- Department of Internal Medicine, School of Medicine, Pusan National University, Yangsan-si 50612, Gyeongsangnam-do, South Korea
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Hamada S, Takata T, Yamada K, Yamamoto M, Mae Y, Iyama T, Sugihara T, Takata M, Isomoto H. Renal tubular acidosis without interstitial nephritis in Sjögren's syndrome: a case report and review of the literature. BMC Nephrol 2023; 24:237. [PMID: 37582721 PMCID: PMC10426178 DOI: 10.1186/s12882-023-03290-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/03/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Renal tubular acidosis is the principal clinical feature associated with tubulointerstitial nephritis in patients with primary Sjögren's syndrome. Renal tubular dysfunction due to interstitial nephritis has been considered the underlying pathophysiology connecting renal tubular acidosis and primary Sjögren's syndrome. However, the detailed mechanisms underlying the pathophysiology of renal tubular acidosis in primary Sjögren's syndrome is not fully understood. CASE PRESENTATION A 30-year-old woman was admitted with complaints of weakness in the extremities. The patient was hospitalized thirteen years earlier for similar issues and was diagnosed with hypokalemic paralysis due to distal renal tubular acidosis with primary Sjögren's syndrome. This diagnosis was based on a positive Schirmer's test. Besides, anti-Sjögren's syndrome-related antigen A was also detected. Laboratory tests indicated distal RTA; however, a renal biopsy showed no obvious interstitial nephritis. Laboratory tests conducted during the second admission indicated distal renal tubular acidosis. Therefore, a renal biopsy was performed again, which revealed interstitial nephritis. Histological analysis of acid-base transporters revealed the absence of vacuolar type H+-ATPases in the collecting duct. The vacuolar type H+-ATPase was also absent in the past renal biopsy, suggesting that the alteration in acid-base transporters is independent of interstitial nephritis. CONCLUSIONS This case study demonstrates that vacuolar-type H+-ATPases are associated with distal renal tubular acidosis, and distal renal tubular acidosis precedes interstitial nephritis in patients with primary Sjögren's syndrome.
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Affiliation(s)
- Shintaro Hamada
- Division of Gastroenterology and Nephrology, Tottori University Faculty of Medicine, Yonago, Tottori, 683-8504, Japan
| | - Tomoaki Takata
- Division of Gastroenterology and Nephrology, Tottori University Faculty of Medicine, Yonago, Tottori, 683-8504, Japan.
| | - Kentaro Yamada
- Division of Gastroenterology and Nephrology, Tottori University Faculty of Medicine, Yonago, Tottori, 683-8504, Japan
| | - Marie Yamamoto
- Division of Gastroenterology and Nephrology, Tottori University Faculty of Medicine, Yonago, Tottori, 683-8504, Japan
| | - Yukari Mae
- Division of Gastroenterology and Nephrology, Tottori University Faculty of Medicine, Yonago, Tottori, 683-8504, Japan
| | - Takuji Iyama
- Division of Gastroenterology and Nephrology, Tottori University Faculty of Medicine, Yonago, Tottori, 683-8504, Japan
| | - Takaaki Sugihara
- Division of Gastroenterology and Nephrology, Tottori University Faculty of Medicine, Yonago, Tottori, 683-8504, Japan
| | - Miki Takata
- Department of Respiratory Medicine and Rheumatology Graduate School of Medicine, Tottori University Hospital, Yonago, Tottori, 683-8504, Japan
| | - Hajime Isomoto
- Division of Gastroenterology and Nephrology, Tottori University Faculty of Medicine, Yonago, Tottori, 683-8504, Japan
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Deesker LJ, Oosterveld MJS, van Mill MJ, Roelofs JJTH, van Heerde M. Weight loss and metabolic acidosis in a neonate: Answers. Pediatr Nephrol 2023; 38:2581-2584. [PMID: 36598597 DOI: 10.1007/s00467-022-05847-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023]
Affiliation(s)
- Lisa J Deesker
- Pediatric Nephrology, Emma Children's Hospital Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Michiel J S Oosterveld
- Pediatric Nephrology, Emma Children's Hospital Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Marije J van Mill
- Department of Pediatric Gastroenterology, Wilhelmina Children's Hospital, Utrecht Medical Center, University of Utrecht, Utrecht, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc van Heerde
- Pediatric Intensive Care, Emma Children's Hospital Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
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15
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Bhadada S, Malhotra B, Shetty A, Mukherjee S. Metabolic bone disease heralding the diagnosis of Wilson's disease. BMJ Case Rep 2023; 16:e252290. [PMID: 37491126 PMCID: PMC10373720 DOI: 10.1136/bcr-2022-252290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
We report a short-statured, young man in his 20s presenting with bilateral cataract, recurrent kidney stones, history of refractory rickets and bone deformity. He had been consuming calcium and vitamin D supplements and had been operated for cataract and renal stone disease, prior to reporting in our clinic without any significant laboratory or clinical improvement. The patient was diagnosed as having Fanconi's syndrome attributable to Wilson's disease. This patient highlights that in case of resistant rickets, a high index of suspicion must be invoked for Wilson's disease. Timely recognition of this entity results in prompt ministrations and prevention of disability.
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Affiliation(s)
- Sanjay Bhadada
- Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhanu Malhotra
- Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anirudh Shetty
- Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Soham Mukherjee
- Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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16
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Akagi R, Ishii A, Kaneko K, Kondo N, Yokoi H, Matsubara T, Minamiguchi S, Kanno Y, Yanagita M. A report of three cases of patients with tubulointerstitial nephritis with IgM-positive plasma cells, treatment, and serum-IgM as a sensitive marker for relapse. BMC Nephrol 2023; 24:201. [PMID: 37403069 PMCID: PMC10318630 DOI: 10.1186/s12882-023-03253-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Tubulointerstitial nephritis with IgM-positive plasma cells (IgMPC-TIN) is a newer disease about which there are many unclear points. Glucocorticoid therapy is effective in many cases of IgMPC-TIN; however, relapse during glucocorticoid tapering has been reported. Relapse and its treatment are poorly defined. CASE PRESENTATION Case 1 was a 61-year-old man with renal dysfunction and proteinuria. Tubulointerstitial nephritis and IgM-positive plasma cells were observed in a renal biopsy. He was diagnosed with IgMPC-TIN accompanied by Fanconi syndrome and distal renal tubular acidosis (d-RTA). Prednisolone (PSL; 30 mg daily, 0.45 mg/kg/day) treatment was highly effective, and PSL was gradually tapered and discontinued after 1 year. However, 1 month after PSL discontinuation, therapeutic markers were elevated. Therefore, PSL (10 mg daily, 0.15 mg/kg/day) was administered, and the markers indicated improvement. Case 2 was a 43-year-old woman referred for renal dysfunction and proteinuria. Laboratory data revealed that she had primary biliary cholangitis (PBC), d-RTA, and Fanconi syndrome. A renal biopsy showed accumulation of IgM-positive plasma cells in the tubulointerstitium without any glomerular changes. A diagnosis of IgMPC-TIN was made and the patient was started on PSL (35 mg daily, 0.6 mg/kg/day). Therapeutic markers decreased immediately and PSL was discontinued after 1 year. Three months later, the proteinuria and Fanconi syndrome worsened. PSL treatment was restarted (20 mg daily, 0.35 mg/kg/day) and markers indicated improvement. Case 3 was a 45-year-old woman with renal dysfunction and proteinuria. Tubulointerstitial nephritis and IgM-positive plasma cells were observed in a renal biopsy. The patient had PBC, Sjögren syndrome, d-RTA, and Fanconi syndrome, and the diagnosis of IgMPC-TIN was made. The patient was started on PSL (30 mg daily, 0.4 mg/kg/day) and disease markers decreased immediately. However, when PSL was tapered to 15 mg daily (0.2 mg/kg/day), the patient's serum IgM levels increased; therefore, we maintained the PSL at 15 mg daily (0.2 mg/kg/day). CONCLUSION We report three cases of relapsed IgMPC-TIN associated with reduction or discontinuation of glucocorticoid therapy. In these cases, elevation of serum IgM preceded that of other markers such as urinary β2-microglobulin, proteinuria, and glycosuria. We recommend monitoring serum IgM levels while tapering glucocorticoids; a maintenance dose of glucocorticoid should be considered if relapse is suspected or anticipated.
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Affiliation(s)
- Ryota Akagi
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Akira Ishii
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Keiichi Kaneko
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Naoya Kondo
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
- Department of Nephrology, Kyoto Katsura Hospital, 17 Yamadahirao-Cho, Nishikyo-Ku, Kyoto, 615-8257 Japan
| | - Hideki Yokoi
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Takeshi Matsubara
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Yoshihiko Kanno
- Department of Nephrology, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023 Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
- Institute for the Advanced Study of Human Biology (ASHBi), Kyoto University, Yoshida Konoe-Cho, Sakyo-Ku, Kyoto, 606-8501 Japan
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17
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Guerra Hernández NE, Gómez Tenorio C, Méndez Silva LP, Moraleda Mesa T, Escobar LI, Salvador C, Vargas Poussou R, García Nieto VM. Autosomal dominant distal renal tubular acidosis in two pediatric patients with mutations in the SLC4A1 gene. Can the maximum urinary pCO 2 test be normal? Nefrologia 2023; 43:484-490. [PMID: 37775346 DOI: 10.1016/j.nefroe.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/06/2021] [Indexed: 10/01/2023] Open
Abstract
Primary distal renal tubular acidosis (dRTA) is a rare tubulopathy characterised by the presence of hyperchloremic metabolic acidosis. It is caused by the existence of a defect in the function of the H+ -ATPase located on the luminal side of the α-intercalated cells or the Cl - HCO3- (AE1) anion exchanger located on the basolateral side. Patients do not acidify the urine after acid overload (NH4Cl) or after stimulating H+ secretion by obtaining a high intratubular concentration of an anion such as chlorine (pH is measured) or HCO3- (urinary pCO2 is measured). We present a family with autosomal dominant dRTA produced by a heterozygous mutation in the SLC4A1 gene in which the two paediatric members showed a test of normal maximum urinary pCO2. Our hypothesis is that since the H + -ATPase is intact, at least initially, the stimulation induced by intratubular electronegativity to secrete H + could be effective, which would allow the maximum urinary pCO2 to be paradoxically normal, which could explain the onset, moderate presentation of symptoms and late diagnosis in patients with this mutation. This is the first documented case of a dominant dRTA in Mexico.
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Affiliation(s)
- Norma E Guerra Hernández
- Servicio de Nefrología Pediátrica, Hospital General del Centro Médico Nacional «La Raza», Instituto Mexicano del Seguro Social, Ciudad de México, Mexico.
| | - Circe Gómez Tenorio
- Servicio de Nefrología Pediátrica, Hospital General del Centro Médico Nacional «La Raza», Instituto Mexicano del Seguro Social, Ciudad de México, Mexico; Servicio de Nefrología Pediátrica, Hospital Hospital de Ginecología No. 48, Instituto Mexicano del Seguro Social, León, Guanajuato, Mexico
| | - Laura Paloma Méndez Silva
- Servicio de Nefrología Pediátrica, Hospital Hospital de Ginecología No. 48, Instituto Mexicano del Seguro Social, León, Guanajuato, Mexico
| | - Teresa Moraleda Mesa
- Servicio de Nefrología Pediátrica, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Tenerife, Spain
| | - Laura I Escobar
- Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
| | - Carolina Salvador
- Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
| | | | - Víctor M García Nieto
- Servicio de Nefrología Pediátrica, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Tenerife, Spain
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18
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Ting YH, Wang YF, Lin YC, Chen HT, Lin KH, Tarng DC, Tseng WC. The Case | Chronic hypokalemia and painful diffuse bone lesions. Kidney Int 2023; 104:207-208. [PMID: 37349055 DOI: 10.1016/j.kint.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/07/2023] [Accepted: 03/17/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Yu-Hsin Ting
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Feng Wang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Chun Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiu-Ting Chen
- Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ko-Han Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Department of Nuclear Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Der-Cherng Tarng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department and Institute of Physiology, National Yang Ming Chiao Tung University, Taipei, Taiwan; Center for Intelligent Drug Systems and Smart Bio-devices, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.
| | - Wei-Cheng Tseng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Center for Intelligent Drug Systems and Smart Bio-devices, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.
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19
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Bertholet-Thomas A, Manso-Silván MA, Navas-Serrano V, Guittet C, Joukoff S, Bacchetta J, Boyer O, Rodriguez Portillo M, Granier LA. Bone mineral density and growth changes in patients with distal renal tubular acidosis after two-years treatment with a new alkalizing drug (ADV7103). Nefrologia 2023; 43:458-466. [PMID: 36529656 DOI: 10.1016/j.nefroe.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 02/27/2022] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES ADV7103 is a new prolonged-release treatment for distal renal tubular acidosis (dRTA), containing potassium citrate and potassium bicarbonate. Since acidosis may affect bone mineral contents, the effects of ADV7103 on bone mineral density (BMD) and growth in patients with dRTA over 24 months were evaluated. PATIENTS AND METHODS Thirty patients (24 paediatric patients and 6 adults) were included in an open-label extension study after a phase II/III trial. BMD, measured by densitometry, was assessed at baseline and at 24 months. Growth was evaluated throughout the study. Plasma bicarbonate, parathyroid hormone, 25-hydroxy vitamin D, 1,25-dihydroxy vitamin D, bone alkaline phosphatase, calciuria and citraturia, were also determined. Safety and treatment compliance were evaluated as well. RESULTS After 24 months of treatment with ADV7103, mean spine BMD z-score values significantly increased as compared with baseline (p=0.024). In adults, spine and whole-body densitometry z-scores showed a significant correlation with plasma bicarbonate levels (rS=0.82 and rS=0.97, respectively, p<0.005). There was an increase>0.5 units in z-scores for height and weight in 18% and 36% of the paediatric patients, respectively. With treatment, plasma bicarbonate concentration and calciuria at the different visits were normal in 69-86% and 93-96% patients, respectively. Only nine treatment-related gastrointestinal AEs of mild/moderate severity, were reported in five patients. CONCLUSIONS Two years of ADV7103 treatment improved growth and increased spine BMD. These results suggest that control of acidosis by ADV7103 treatment improves bone parameters.
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Affiliation(s)
- Aurélia Bertholet-Thomas
- Centre de Référence des Maladies Rénales Rares - Néphrogones - Hôpital Femme Mère Enfant, Hospices Civils de Lyon - Filière ORKiD, Bron, France
| | | | | | | | | | - Justine Bacchetta
- Centre de Référence des Maladies Rénales Rares - Néphrogones - Hôpital Femme Mère Enfant, Hospices Civils de Lyon - Filière ORKiD, Bron, France
| | - Olivia Boyer
- Service de Néphrologie Pédiatrique, Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Institut Imagine, Hôpital Necker-Enfants Malades, Université de Paris, France
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20
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Ghimire A, Li D, Amin L. Ibuprofen-Induced Renal Tubular Acidosis: Case Report on a Not-So-Basic Clinical Conundrum. Can J Kidney Health Dis 2023; 10:20543581231183813. [PMID: 37426490 PMCID: PMC10327409 DOI: 10.1177/20543581231183813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/23/2023] [Indexed: 07/11/2023] Open
Abstract
Rationale Renal tubular acidosis (RTA) is a cause of non-anion gap metabolic acidosis (NAGMA) that is infrequently diagnosed and is due to various underlying etiologies that impair the kidney's ability to retain bicarbonate or excrete acid. Ibuprofen is an over-the-counter non-steroidal anti-inflammatory medication that is used by patients widely for a variety of reasons. Although it is well known that ibuprofen and other non-steroidal anti-inflammatory drugs may have nephrotoxic effects, the role of ibuprofen as a cause of RTA and hypokalemia is not well recognized. Presenting Concerns A 66-year-old man with chemotherapy-treated lymphoma in remission and ongoing heavy ibuprofen use for chronic pain presented to hospital with a 1-week history of increasing lethargy and otherwise unremarkable review of systems. Investigations showed acute kidney injury, hypokalemia, hyperchloremia, and NAGMA with elevated urinary pH and positive urine anion gap. Diagnoses The final diagnosis of distal RTA secondary to ibuprofen was made after ruling out gastrointestinal bicarbonate loss and additional secondary causes of RTA, including other medications, autoimmune conditions, and obstructive uropathy. Interventions The patient was admitted and treated with intravenous sodium bicarbonate for 24 hours with correction of hypokalemia via oral supplementation. His ibuprofen-containing medication was discontinued. Outcomes His acute kidney injury and electrolyte abnormalities resolved within 48 hours of initiating treatment with concurrent resolution of his lethargy. He was discharged home and advised to stop taking ibuprofen. Lessons Learned We report a case of patient with hypokalemia and NAGMA secondary to ibuprofen and highlight the importance of monitoring for this side effect in patients taking ibuprofen.
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Affiliation(s)
- Anukul Ghimire
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - David Li
- Department of Medicine, University of Alberta, Edmonton, Canada
| | - Leena Amin
- Department of Medicine, University of Alberta, Edmonton, Canada
- Grey Nuns Community Hospital, Edmonton, AB, Canada
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21
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Shaikh W, Suratkal L, Bhave A. Rare Case of Hemolytic Anemia and Distal Renal Tubular Acidosis in an adult due to Homozygous SLC4A1 Mutation. Indian J Nephrol 2023; 33:209-212. [PMID: 37448902 PMCID: PMC10337233 DOI: 10.4103/ijn.ijn_210_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 09/14/2021] [Indexed: 07/18/2023] Open
Abstract
In this case study, we report an adult patient presenting with generalized weakness, marked anemia, spherocytosis, and no features of thalassemia. The patient was treated for suspicion of autoimmune hemolytic anemia but was recalcitrant to treatment. Genetic analysis revealed the patient to be homozygous for SLC4A1 c.2573C>A (p.Ala858Asp). Distal renal tubular acidosis (dRTA) can be caused by mutations in SLC4A1, which encodes the Cl-/HCO3- exchanger of the renal type A intercalated cell, kidney AE1. SLC4A1 variants have been reported in dRTA patients from North America, Europe, and Southeast Asia. In some rare instances, SLC4A1 dRTA can present with hemolytic anemia resulting in marked anemia that is not responsive to standard interventions. This report identifies an autosomal recessive inheritance pattern for SLC4A1 variants in a patient presenting with dRTA and hemolytic anemia.
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Affiliation(s)
- Wasiyeeullah Shaikh
- Department of Nephrology, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
| | - Lohitaksha Suratkal
- Department of Nephrology, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
| | - Abhay Bhave
- Department of Hematology, Lilavati Hospital and Research Center, Mumbai, Maharashtra, India
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22
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Ay E, Gurses E, Aslan F, Gulhan B, Alniacik A, Duzova A, Bajin MD, Sennaroglu L, Genc GA, Ozaltin F, Topaloglu R. Hearing Loss Related to Gene Mutations in Distal Renal Tubular Acidosis. Audiol Neurootol 2023; 28:350-359. [PMID: 37121229 DOI: 10.1159/000529486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 01/30/2023] [Indexed: 05/02/2023] Open
Abstract
INTRODUCTION Distal renal tubular acidosis (dRTA) is a disease that may develop either primarily or secondarily, resulting from urinary acidification defects in distal tubules. Hearing loss may accompany primary forms of dRTA. This study aims to determine the characteristics of hearing loss due to different gene mutations in patients with dRTA. METHODS Behavioral and electrophysiological audiological evaluations were performed after otolaryngology examination in 21 patients with clinically diagnosed dRTA. Radiological imaging of the inner ear (n = 9) was conducted and results of genetic analyses using next-generation sequencing method (n = 16) were included. RESULTS Twenty-one patients with dRTA from 20 unrelated families, aged between 8 months and 33 years (median = 12, interquartile range = 20), participated. All patients with ATP6V1B1 mutations (n = 9) had different degrees of hearing loss. There was one patient with hearing loss in patients with ATP6V0A4 mutations (n = 6). One patient with the WDR72 mutation had normal hearing. Large vestibular aqueduct syndrome (LVAS) was detected in 6 (67%) of 9 patients whose radiological evaluation results were available. CONCLUSIONS LVAS is common in patients with dRTA and may influence the type and severity of hearing loss in these patients. The possibility of both congenital and late-onset and progressive hearing loss should be considered in dRTA patients. A regular audiological follow-up is essential for the early detection of a possible late-onset or progressive hearing loss in these patients.
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Affiliation(s)
- Ezgi Ay
- Department of Audiology, Baskent University Faculty of Health Sciences, Ankara, Turkey
| | - Emre Gurses
- Department of Audiology, Hacettepe University Faculty of Health Sciences, Ankara, Turkey
| | - Filiz Aslan
- Department of Audiology, Hacettepe University Faculty of Health Sciences, Ankara, Turkey
| | - Bora Gulhan
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Asuman Alniacik
- Department of Audiology, Baskent University Faculty of Health Sciences, Ankara, Turkey
| | - Ali Duzova
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Munir Demir Bajin
- Department of Ear Nose and Throat, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Levent Sennaroglu
- Department of Ear Nose and Throat, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Gulsum Aydan Genc
- Department of Audiology, Hacettepe University Faculty of Health Sciences, Ankara, Turkey
| | - Fatih Ozaltin
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
- Nephrogenetics Laboratory, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Rezan Topaloglu
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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23
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Long-term complications of primary distal renal tubular acidosis. Pediatr Nephrol 2023; 38:635-642. [PMID: 35543873 DOI: 10.1007/s00467-022-05546-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/12/2022] [Accepted: 03/14/2022] [Indexed: 01/19/2023]
Abstract
The clinical manifestations of primary distal renal tubular acidosis usually begin in childhood, but the disease is caused by a genetic defect that persists throughout life. This review focuses on the complications of distal tubular acidosis that occur or remain long-term such as nephrocalcinosis and urolithiasis, growth impairment, bone mineralization, severe hypokalemia, kidney cysts, and progressive kidney failure, as well as other persistent manifestations that occur independent of acidosis but are associated with some inherited forms of the disease. The pathogenic factors responsible for kidney failure are discussed in particular because it is a complication to which different publications have recently drawn attention and which affects a high percentage of adults with primary distal renal tubular acidosis. The need to maintain optimal metabolic control of the disease and scheduled clinical follow-up throughout life and the importance of organizing protocols for the transition of patients to adult nephrology services are emphasized.
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24
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Caretti R, Fiechter C, Babek N, Smith T, Sadiek H. A Case Report of Nearly Missed Renal Tubular Acidosis in the Setting of Sjögren's Syndrome. Cureus 2023; 15:e34899. [PMID: 36925975 PMCID: PMC10014039 DOI: 10.7759/cureus.34899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2023] [Indexed: 02/14/2023] Open
Abstract
The association of renal tubular acidosis (RTA) and Sjögren's syndrome (SS) has been well-documented in the literature previously but is often undiagnosed in clinical practice. In this case report, we present a case of a woman with distal RTA who presented with nausea, vomiting, and confusion. The case shows the diagnostic value of urine studies when evaluating a patient who has exaggerated and unexplained electrolyte losses and how this will change management. Recognizing the extra glandular manifestations of patients with SS is important for patient care to prevent delays in care and treatment.
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Affiliation(s)
- Rachael Caretti
- Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | | | - Natan Babek
- Medicine, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Travis Smith
- Clinical Curriculum Integration & Assessment, Lake Erie College of Osteopathic Medicine, Bradenton, USA
| | - Happy Sadiek
- Nephrology, Lake Erie College of Osteopathic Medicine, Bradenton, USA
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25
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Giovanni Raimondo P, Ilaria P, Andrea S, Pierangela C, Fabio P, Tommaso M, Marco Z, Enrico F. A novel SLC4A1 mutation in a child with hereditary spherocytosis and distal renal tubular acidosis. Pediatr Blood Cancer 2022; 69:e29729. [PMID: 35441494 DOI: 10.1002/pbc.29729] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/13/2022] [Accepted: 03/29/2022] [Indexed: 11/07/2022]
Affiliation(s)
| | - Possenti Ilaria
- Pediatric and Pediatric Emergency Unit, Children Hospital, Alessandria, Italy
| | - Secco Andrea
- Pediatric and Pediatric Emergency Unit, Children Hospital, Alessandria, Italy
| | | | - Paglialonga Fabio
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione Ca' Grande IRRCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Mina Tommaso
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Zecca Marco
- Pediatric Hematology/Oncology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Felici Enrico
- Pediatric and Pediatric Emergency Unit, Children Hospital, Alessandria, Italy
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26
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El-Reshaid K, Al-Terki A, Al-Bader S. Detailed Nephro-urological Management of a Case of Medullary Sponge Kidney with Distal Renal Tubular Acidosis and Obstructive Uropathy. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:828-832. [PMID: 38018723 DOI: 10.4103/1319-2442.390261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2023] Open
Abstract
Medullary sponge kidney (MSK) is a rare renal malformation characterized by precalyceal tubular ectasia of the renal collecting ducts that clinically manifests as recurrent renal stones, distal renal tubular acidosis (dRTA), osteoporosis, and nephrocalcinosis. In this case report, we present the case of a woman with a severe form of MSK associated with dRTA. She had extensive nephrocalcinosis and obstructive uropathy caused by a large upper ureteric stone in the left kidney. The stone was disintegrated by flexible ureteroscopic laser lithotripsy. Her initial biochemical derangements were identified and corrected with a Polycitra-K solution and hydrochlorothiazide, leading to reduced stone load and osteopenia 1 year later.
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Affiliation(s)
- Kamel El-Reshaid
- Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Abdullatif Al-Terki
- Department of Surgery, Urology Unit, Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
| | - Shaikha Al-Bader
- Department of Medicine, Nephrology Unit, Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
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27
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Lithiase urinaire de type IVa2 et pathologies associées : à propos de 3 cas. Nephrol Ther 2022; 18:570-574. [DOI: 10.1016/j.nephro.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 07/07/2022] [Accepted: 08/17/2022] [Indexed: 11/11/2022]
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28
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Muacevic A, Adler JR. Hypokalemic Periodic Paralysis Secondary to Medullary Sponge Kidney Complicated With Renal Tubular Acidosis. Cureus 2022; 14:e30160. [PMID: 36238424 PMCID: PMC9552125 DOI: 10.7759/cureus.30160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2022] [Indexed: 11/07/2022] Open
Abstract
Hypokalemic periodic paralysis has a high risk of life-threatening dysrhythmias. Hyperchloremic acidosis with hypokalemia is a dangerous condition. There are several causes of hypokalemia, in addition to common diseases, such as hyperthyroidism, hyperaldosteronism, and Cushing’s syndrome; the other rare diseases include renal tubular acidosis (RTA), Bartter’s syndrome, and Gitelman’s syndrome. We present an unusual case of hypokalemic periodic paralysis, which was caused by a medullary sponge kidney with distal RTA. The patient had no significant medical history and was not taking any conventional drugs. Investigations demonstrated a combination of hypokalemia, hyperchloremia, metabolic acidosis with a normal anion gap, relatively raised urinary pH, and decreased phosphate level. Results suggested a diagnosis of RTA with secondary hyperparathyroidism. After potassium citrate replacement and correction of acidosis, the patient’s condition was in remission. This case highlights the rare etiology of hypokalemia and the need to actively search for the pathogenesis of unexplained hypokalemia to avoid delaying the condition.
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Vincent-Johnson A, Scialla JJ. Importance of Metabolic Acidosis as a Health Risk in Chronic Kidney Disease. Adv Chronic Kidney Dis 2022; 29:329-336. [PMID: 36175070 DOI: 10.1053/j.ackd.2022.05.002] [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: 02/23/2022] [Revised: 05/09/2022] [Accepted: 05/25/2022] [Indexed: 01/25/2023]
Abstract
Human kidneys are well adapted to excrete the daily acid load from diet and metabolism in order to maintain homeostasis. In approximately 30% of patients with more advanced stages of CKD, these homeostatic processes are no longer adequate, resulting in metabolic acidosis. Potential deleterious effects of chronic metabolic acidosis in CKD, including muscle wasting, bone demineralization, hyperkalemia, and more rapid progression of CKD, have been well cataloged. Based primarily upon concerns related to nutrition and bone disease, early Kidney Disease Outcomes Quality Initiative guidelines recommended treating metabolic acidosis with alkali therapy targeting a serum bicarbonate ≥22 mEq/L. More recent guidelines have suggested similar targets based upon potential slowing of CKD progression. However, appropriately powered, long-term, randomized controlled trials to study efficacy and safety of alkali therapy for these outcomes are largely lacking. As a result, practice among physicians varies, underscoring the complexity of treatment of chronic metabolic acidosis in real-world CKD practice. Novel treatment approaches and rigorous phase 3 trials may resolve some of this controversy in the coming years. Metabolic acidosis is an important complication of CKD, and where it "falls" in the priority schema of CKD care will depend upon the generation of strong clinical evidence.
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Affiliation(s)
- Anita Vincent-Johnson
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA
| | - Julia J Scialla
- Department of Medicine, University of Virginia School of Medicine, Charlottesville, VA; Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA.
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30
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Cortellazzo Wiel L, Conversano E, Carlone G, Di Leo G, Gortani G, Zanchi C, Barbi E. Unarousable child with a short bowel. Arch Dis Child Educ Pract Ed 2022; 107:196-198. [PMID: 33122261 DOI: 10.1136/archdischild-2020-318826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 10/07/2020] [Indexed: 11/03/2022]
Abstract
Unarousable child with short bowelA 4-year-old boy was admitted with progressive lethargy of a few hours' duration and no other symptoms. His medical history was relevant for short bowel syndrome (SBS), following neonatal volvulus, with residual bowel length of 23 cm and intact ileocecal valve. He had similar self-limiting episodes in the past, after weaning parenteral nutrition, especially after eating large meals. The day before, he had consumed a large amount of apples.Arterial blood gas (ABG) analysis showed metabolic acidosis with normal lactacidaemia (pH 7.09, pCO2 19 mm Hg, pO2 101 mm Hg, HCO3 5.8 mmol/L, BE -24, anion gap 29.4, chloride 116 mmol/L, L-lactate level 4 mmol/L).On admission, the child could be awakened, but he was confused with slurred speech (Glasgow Coma Scale 14), with a body temperature of 37 C°, a heart rate of 125 beats/min and a respiratory rate of 38 breaths/min. The abdomen was distended, without guarding and with normal bowel sounds. Blood glucose levels were normal, as well as white blood cell count, liver and kidney function test and C reactive protein. An abdominal ultrasound ruled out an intussusception. An abdominal X-ray was performed too (see figure 1).
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Affiliation(s)
- Luisa Cortellazzo Wiel
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Ester Conversano
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Giorgia Carlone
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Grazia Di Leo
- Paediatrics, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
| | - Giulia Gortani
- Paediatrics, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
| | - Chiara Zanchi
- Paediatrics, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
| | - Egidio Barbi
- Paediatrics, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
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31
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Tu R, Yu J, Zhang X, Zhu Y, Zeng G. Renal tubular acidosis and nephrogenic diabetes insipidus caused by Sjögren's syndrome with hypokalemic periodic paralysis as the first symptom: A case report. Rev Neurol (Paris) 2022; 178:861-864. [PMID: 35568514 DOI: 10.1016/j.neurol.2022.02.458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/14/2022] [Accepted: 02/21/2022] [Indexed: 11/19/2022]
Affiliation(s)
- R Tu
- Affiliated Hospital of North Sichuan Medical College Nanchong, 637000 Sichuan, China
| | - J Yu
- Affiliated Hospital of North Sichuan Medical College Nanchong, 637000 Sichuan, China.
| | - X Zhang
- Affiliated Hospital of North Sichuan Medical College Nanchong, 637000 Sichuan, China
| | - Y Zhu
- Affiliated Hospital of North Sichuan Medical College Nanchong, 637000 Sichuan, China
| | - G Zeng
- Affiliated Hospital of North Sichuan Medical College Nanchong, 637000 Sichuan, China
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32
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Imenez Silva PH, Mohebbi N. Kidney metabolism and acid-base control: back to the basics. Pflugers Arch 2022; 474:919-934. [PMID: 35513635 PMCID: PMC9338915 DOI: 10.1007/s00424-022-02696-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 01/18/2023]
Abstract
Kidneys are central in the regulation of multiple physiological functions, such as removal of metabolic wastes and toxins, maintenance of electrolyte and fluid balance, and control of pH homeostasis. In addition, kidneys participate in systemic gluconeogenesis and in the production or activation of hormones. Acid-base conditions influence all these functions concomitantly. Healthy kidneys properly coordinate a series of physiological responses in the face of acute and chronic acid-base disorders. However, injured kidneys have a reduced capacity to adapt to such challenges. Chronic kidney disease patients are an example of individuals typically exposed to chronic and progressive metabolic acidosis. Their organisms undergo a series of alterations that brake large detrimental changes in the homeostasis of several parameters, but these alterations may also operate as further drivers of kidney damage. Acid-base disorders lead not only to changes in mechanisms involved in acid-base balance maintenance, but they also affect multiple other mechanisms tightly wired to it. In this review article, we explore the basic renal activities involved in the maintenance of acid-base balance and show how they are interconnected to cell energy metabolism and other important intracellular activities. These intertwined relationships have been investigated for more than a century, but a modern conceptual organization of these events is lacking. We propose that pH homeostasis indissociably interacts with central pathways that drive progression of chronic kidney disease, such as inflammation and metabolism, independent of etiology.
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Affiliation(s)
- Pedro Henrique Imenez Silva
- Institute of Physiology, University of Zurich, Winterthurerstrasse 190, CH-8057, Zurich, Switzerland.
- National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland.
| | - Nilufar Mohebbi
- National Center of Competence in Research NCCR Kidney.CH, Zurich, Switzerland
- Praxis Und Dialysezentrum Zurich, Zurich, Switzerland
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33
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Gheith OA, Dahab M, Nagib AM, Adel M, Elserwy N, Sobhy I, AbdelMonem M, Abo Atya H, Al-Otaibi T. Fludrocortisone Among Adult Renal Transplant Recipients With Persistent Hyperkalemia: Single-Center Experience. EXP CLIN TRANSPLANT 2022; 20:69-73. [PMID: 35384810 DOI: 10.6002/ect.mesot2021.o27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Calcineurin inhibitors are the cornerstone of immunosuppression following solid-organ transplant. However, hyperkalemia may occur by multiple mechanisms affecting potassium in the distal tubule. Hyperkalemia is commonly observed in renal transplant recipients, and it is dose-dependent. Here, we evaluated the impact of fludrocortisone in the management of calcineurin inhibitor-induced hyperkalemia after renal transplant. MATERIALS AND METHODS We evaluated newly transplanted patients who developed hyperkalemia or those with hyperkalemia who attended our outpatient renal transplant clinic (Hamed Al-Essa Organ Transplant Center, Kuwait). Clinical and laboratory parameters were collected before starting fludrocortisone (baseline values) and then at 1, 2, 4, and 8 weeks. Drug history was assessed, with any drugs that could induce hyperkalemia being discontinued (such as spironolactone); otherwise, essential drugs like prophylactic agents (sulfamethoxazole-trimethoprim) were maintained. Oral anti-hyperkalemic doses (bicarbonate, resonium calcium, fludrocortisone) were noted. RESULTS Our study included 29 patients; most were men (aged 45.8 ± 15 years). Body weight did not significantly change after introduction of fludrocortisone (79.53 ± 24.31, 79.82 ± 23.85, 80.62 ± 24.24, 77.03 ± 20.7, and 79.21 ± 27.93 kg at baseline and at postdose week 1, 2, 4, and 8, respectively). Systolic and diastolic blood pressure levels were also similar at baseline versus postdose. Steroid doses (prednisolone) were significantly reduced over 1 month (15.7 ± 12.4, 14.1 ± 10.19, 12.6 ± 8.7, 9.5 ± 5.2, and 9.5 ± 5.2 mg/ day). Serum potassium levels significantly improved (5.18 ± 0.58, 4.9 ± 0.49, 4.8 ± 0.54, 4.8 ± 0.65, and 4.4 ± 0.72 mmol/L). Serum creatinine levels significantly improved by postdose week 8 (129.28 ± 48.9, 130.92 ± 52.2, 127.66 ± 50.9, 121.42 ± 41.7, and 124.1 ± 51.27 μmol/L). Serum bicarbonate levels remained similar. CONCLUSIONS Fludrocortisone was a safe and effective option in management of calcineurin inhibitor-induced hyperkalemia among renal transplant recipients.
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Affiliation(s)
- Osama A Gheith
- From the Nephrology Department, Hamed Al-Essa Organ Transplant Center, Sabah Area, Kuwait.,From the Nephrology and Transplantation Unit, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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34
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Kaneko S, Usui J, Takahashi K, Oda T, Yamagata K. Increased intrarenal post-glomerular blood flow is a key condition for the development of calcineurin inhibitor-induced renal tubular acidosis in kidney transplant recipients. Clin Transplant 2022; 36:e14648. [PMID: 35293652 DOI: 10.1111/ctr.14648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hyperchloremic metabolic acidosis (HCMA) from renal tubular acidosis (RTA) is common in kidney transplant (KT) recipients. Calcineurin inhibitors (CNIs) are a potential cause of RTA, and whether HCMA is a determinant of poor graft prognosis is controversial. METHODS The subjects were living-donor KT recipients (LDKTRs, n = 47) and matched donors (n = 43). All cases of rejection, extrarenal causes, and respiratory disorders were excluded. HCMA was defined as having a [Na+] - [Cl-] value of ≤ 34 or starting alkalization. We determined the potential causes of HCMA in LDKTRs at 3 months (m) and 1 year (y) post-KT. We examined renal hemodynamic parameters in 26 LDKTRs at 1 y post-KT: namely, glomerular filtration rate (GFR), renal plasma flow (RPF), filtration fraction (FF; GFR/RPF) and pre-/post-glomerular vascular resistance (pre-/postVR). RESULTS The HCMA incidence in the 3-m post-KT LDKTR group was higher than that of the donors (51.0% vs. 6.9%, p<0.001, adjusted odds ratio: 6.7-15.7). Among adjusted factors, the most dominant HCMA contributor was low hemoglobin concentration (Hb ≤12 g/dL). Compared to non-HCMA cases, HCMA patients had low FF and low post-VR (p = 0.008, 0.003, respectively) suggesting increased intrarenal post-glomerular blood flow. The high pathological score of alternative arteriolar hyalinosis (aah) ≥2 was a significant HCMA risk. The tacrolimus trough level was not high in HCMA but was significantly high in HCMA in the low post-VR setting (p = 0.002). CONCLUSION Among LDKTRs, low hemoglobin level is an important contributor to the manifestation of HCMA in the induction period, and increased intrarenal post-glomerular blood flow is a key condition for the development of CNI-induced RTA. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Shuzo Kaneko
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.,Department of Nephrology, Itabashi Chuo Medical Center, Itabashi, Tokyo, Japan
| | - Joichi Usui
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Kazuhiro Takahashi
- Department of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Tatsuya Oda
- Department of Gastroenterological and Hepatobiliary Surgery and Organ Transplantation, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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35
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Bone mineral density and growth changes in patients with distal renal tubular acidosis after two-years treatment with a new alkalizing drug (ADV7103). Nefrologia 2022. [DOI: 10.1016/j.nefro.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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36
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Barton JC, Mäntylä Noble PJ, O'Connell EM. Acute kidney injury manifesting as renal tubular acidosis with proximal and distal renal tubular dysfunction in a dog with acute pancreatitis. J Vet Emerg Crit Care (San Antonio) 2022; 32:524-531. [PMID: 35129879 PMCID: PMC9545851 DOI: 10.1111/vec.13186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 11/28/2020] [Accepted: 12/02/2020] [Indexed: 11/28/2022]
Abstract
Objective To describe the clinical presentation and management of a critically ill dog with profound renal tubular acidosis (RTA) with proximal and distal renal tubular dysfunction. Case Summary A 3‐year‐old neutered female Border Terrier was presented with frequent regurgitation resulting from acute pancreatitis with severe ileus. Venous acid–base analysis and complete urinalysis confirmed the presence of normal anion gap metabolic acidosis with inappropriately alkaline urine (pH 8), consistent with distal RTA. Urinalysis, urine amino acids, and urinary fractional excretion of electrolytes revealed glycosuria (with normoglycemia), aminoaciduria, and increased fractional excretion of sodium, calcium, and phosphate consistent with generalized proximal renal tubulopathy or Fanconi syndrome. The dog responded well to supportive care and alkaline therapy and made a complete recovery. New or Unique Information Provided To the authors’ knowledge, this is the first description of RTA with proximal and distal renal tubular dysfunction in the veterinary literature. Furthermore, the authors hypothesize that the transient RTA was a manifestation of acute kidney injury secondary to acute pancreatitis, the first report of this in the literature.
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Affiliation(s)
- James C Barton
- Department of Small Animal Clinical Sciences, Institute of Veterinary Science, University of Liverpool, Neston, UK
| | - Peter-John Mäntylä Noble
- Department of Small Animal Clinical Sciences, Institute of Veterinary Science, University of Liverpool, Neston, UK
| | - Erin M O'Connell
- Department of Small Animal Clinical Sciences, Institute of Veterinary Science, University of Liverpool, Neston, UK
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Boro H, Khatiwada S, Alam S, Kubihal S, Dogra V, Mannar V, Khadgawat R. Renal Tubular Acidosis Manifesting as Severe Metabolic Bone Disease. TOUCHREVIEWS IN ENDOCRINOLOGY 2022; 17:59-67. [PMID: 35118447 DOI: 10.17925/ee.2021.17.1.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 02/05/2021] [Indexed: 11/24/2022]
Abstract
Renal tubular acidosis (RTA) is a condition characterized by normal anion gap metabolic acidosis. Type 1 and type 2 RTA are the most common, and are caused by defective secretion of hydrogen ions and impaired absorption of bicarbonate, respectively. Long-standing uncorrected acidosis can lead to metabolic bone disease (MBD). Rickets and osteomalacia remain the commonest manifestations of uncorrected RTA. In addition, there can be a myriad of other skeletal manifestations like fractures, pseudofractures, secondary osteoporosis and even sclerotic bone disease. The postulated mechanism for bone involvement includes acidosis-mediated exaggerated osteoclastic bone resorption. Other contributory factors include abnormal renal handling of phosphate leading to hypophosphataemia in proximal RTA, and impaired vitamin D metabolism and action. In distal RTA, hypercalciuria and secondary hyperparathyroidism may play a key role for bone involvement. Recognizing the disease in its early course is important to prevent permanent sequelae of skeletal involvement. Most of these patients may, in fact, undergo orthopaedic interventions without primary correction of acidosis. We describe five cases who presented with MBD in varied forms. While evaluating the aetiology of MBD, they were diagnosed with RTA. Subsequently, we attempted to analyse the causes of RTA. Although the common causes were ruled out, genetic aetiology could not be ascertained due to resource constraints. RTA remains an important differential diagnosis of MBD. More awareness is required to diagnose the disease early and to treat it adequately. Our case series is an attempt to provide the clinical, biochemical and skeletal spectrum of RTA. In addition, we have attempted to provide algorithms for the approach and evaluation of RTA along with their varied causes.
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Affiliation(s)
- Hiya Boro
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Saurav Khatiwada
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Sarah Alam
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Suraj Kubihal
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Vinay Dogra
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Velmurugan Mannar
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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Sromicki J, Kacl G, Föhl M, Hess B. Prospective long-term evaluation of incomplete distal renal tubular acidosis in idiopathic calcium nephrolithiasis diagnosed by low-dose NH 4CL loading - gender prevalences and impact of alkali treatment. J Nephrol 2022; 35:1619-1626. [PMID: 34973150 PMCID: PMC9300500 DOI: 10.1007/s40620-021-01207-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/09/2021] [Indexed: 11/23/2022]
Abstract
Purpose Prospective evaluation of the prevalence of incomplete distal renal tubular acidosis (idRTA) in idiopathic calcium stone formers (ICSF) diagnosed by half-dose ammonium chloride loading (NH4Cl, 0.05 g/kg body weight/day) and impact of alkali treatment of idRTA. Methods Evaluation of 386 consecutive idiopathic calcium stone formers (ICSF) (280 males, 106 females) for idRTA. If screening fasting urine pH was > 5.80, 1-day NH4Cl loading was performed without severe adverse effects. Normally, urine pH falls below 5.45. Results Sixty-four idiopathic calcium stone formers exhibited idRTA, one complete dRTA. Prevalence was higher in women (25.4%) than in men (13.6%). Thus, for more equilibrated comparisons, we formed pairs of 62 idiopathic calcium stone formers (ICSF) with and 62 without idRTA, matched for gender, age, BMI and serum creatinine. Idiopathic calcium stone formers with idRTA more often had hypercalciuria (p < 0.025) and urine citrate < 2 mmol/d (p < 0.05), formed calcium phosphate stones more frequently, exhibited higher numbers of stones/year (1.4 ± 1.5 vs. 0.9 ± 0.8, p = 0.034) and 2.5 times more intrarenal calcifications (4.6 ± 5.9 vs. 1.8 ± 3.6, p = 0.002). All idiopathic calcium stone formers with idRTA were recommended chronic alkali therapy. After 4–15 years of follow-up, stone events /years follow-up (stone passage or urologic intervention) were higher in patients non-adherent to alkali therapy (0.61 ± 0.92) than in patients adherent to treatment (0.11 ± 0.21, p = 0.006). Conclusion Incomplete distal renal tubular acidosis is 1.8-fold more prevalent among female idiopathic calcium stone formers, predicts more stone recurrences, predisposes to calcium phosphate stones and is associated with 2.5 times more intrarenal calcifications vs. non-idRTA patients. Chronic alkali treatment reduces clinical stone recurrences by 5.5 times. Graphical abstract ![]()
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Affiliation(s)
- Juri Sromicki
- Internal Medicine and Nephrology, Kidney Stone Center Zurich, Klinik Im Park and University of Zurich, Bellariastrasse 38, CH-8038, Zurich, Switzerland.,Department of Cardiac Surgery, University Hospital, Zurich, Switzerland
| | - Georg Kacl
- Internal Medicine and Nephrology, Kidney Stone Center Zurich, Klinik Im Park and University of Zurich, Bellariastrasse 38, CH-8038, Zurich, Switzerland.,Radiology, Klinik Im Park, Zurich, Switzerland
| | - Malin Föhl
- Internal Medicine and Nephrology, Kidney Stone Center Zurich, Klinik Im Park and University of Zurich, Bellariastrasse 38, CH-8038, Zurich, Switzerland
| | - Bernhard Hess
- Internal Medicine and Nephrology, Kidney Stone Center Zurich, Klinik Im Park and University of Zurich, Bellariastrasse 38, CH-8038, Zurich, Switzerland.
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39
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Baker LW, Trautman C. Refractory Hypokalemia: A Quiz. Am J Kidney Dis 2021; 79:A15-A17. [PMID: 34930530 DOI: 10.1053/j.ajkd.2021.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/18/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Lyle Wesley Baker
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida.
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40
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Baleguli V, Mahmood R, Herrera M, Raybon-Rojas E. Heparin-Induced Renal Tubular Acidosis Masquerading as Hyperkalemia in a SARS-CoV-2 (COVID-19) Patient: A Case Report. Cureus 2021; 13:e20312. [PMID: 35028212 PMCID: PMC8747980 DOI: 10.7759/cureus.20312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2021] [Indexed: 11/24/2022] Open
Abstract
Type 4 renal tubular acidosis (RTA) is a type of metabolic acidosis characterized by hyperchloremia and hyperkalemia resulting from the reduction in and/or resistance to aldosterone. RTA can be caused by multiple different medications including angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), potassium-sparing diuretics, and heparin. In this case, we discuss renal tubular acidosis caused by heparin use for the prevention of thromboembolic disease in COVID-19 infections.
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Guerra Hernández NE, Gómez Tenorio C, Méndez Silva LP, Moraleda Mesa T, Escobar LI, Salvador C, Vargas Poussou R, García Nieto VM. Acidosis tubular renal distal autosómica dominante en dos pacientes pediátricos con mutaciones en el gen SLC4A1. ¿La prueba de la pCO2 urinaria máxima puede ser normal? Nefrologia 2021. [DOI: 10.1016/j.nefro.2021.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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42
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Abstract
Nephrolithiasis is a worldwide problem with increasing prevalence, enormous costs, and significant morbidity. Calcium-containing kidney stones are by far the most common kidney stones encountered in clinical practice. Consequently, hypercalciuria is the greatest risk factor for kidney stone formation. Hypercalciuria can result from enhanced intestinal absorption, increased bone resorption, or altered renal tubular transport. Kidney stone formation is complex and driven by high concentrations of calcium-oxalate or calcium-phosphate in the urine. After discussing the mechanism mediating renal calcium salt precipitation, we review recent discoveries in renal tubular calcium transport from the proximal tubule, thick ascending limb, and distal convolution. Furthermore, we address how calcium is absorbed from the intestine and mobilized from bone. The effect of acidosis on bone calcium resorption and urinary calcium excretion is also considered. Although recent discoveries provide insight into these processes, much remains to be understood in order to provide improved therapies for hypercalciuria and prevent kidney stone formation. Expected final online publication date for the Annual Review of Physiology, Volume 84 is February 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- R T Alexander
- Departments of Physiology and Pediatrics, University of Alberta, Edmonton, Canada; .,Membrane Protein Disease Research Group, University of Alberta, Edmonton, Canada
| | - D G Fuster
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - H Dimke
- Department of Cardiovascular and Renal Research, Institute of Molecular Medicine, University of Southern Denmark, Odense, Denmark.,Department of Nephrology, Odense University Hospital, Odense, Denmark
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Vall-Palomar M, Madariaga L, Ariceta G. Familial hypomagnesemia with hypercalciuria and nephrocalcinosis. Pediatr Nephrol 2021; 36:3045-3055. [PMID: 33595712 DOI: 10.1007/s00467-021-04968-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 01/14/2021] [Accepted: 01/25/2021] [Indexed: 10/22/2022]
Abstract
Familial hypomagnesemia with hypercalciuria and nephrocalcinosis (FHHNC; OMIM 248250) is a rare autosomal recessive kidney disease caused by mutations in the CLDN16 or CLDN19 genes encoding the proteins claudin-16 and claudin-19, respectively. These are involved in paracellular magnesium and calcium transport in the thick ascending limb of Henle's loop and account for most of the magnesium reabsorption in the tubules. FHHNC is characterized by hypomagnesaemia, hypercalciuria, and nephrocalcinosis, and progresses to kidney failure, requiring dialysis and kidney transplantation mainly during the second to third decades of life. Patients carrying CLDN19 mutations frequently exhibit associated congenital ocular defects leading to variable visual impairment. Despite this severe clinical course, phenotype variability even among siblings has been described in this disease, suggesting unidentified epigenetic mechanisms or other genetic or environmental modifiers. Currently, there is no specific therapy for FHHNC. Supportive treatment with high fluid intake and dietary restrictions, as well as magnesium salts, thiazides, and citrate, are commonly used in an attempt to retard the progression of kidney failure. A kidney transplant remains the only curative option for kidney failure in these patients. In this review, we summarize the current knowledge about FHHNC and discuss the remaining open questions about this disorder.
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Affiliation(s)
- Mònica Vall-Palomar
- Fisiopatologia Renal, Centro de Investigaciones en Bioquímica y Biología Molecular (CIBBIM), Vall d'Hebron. Institut de Recerca (VHIR), Barcelona, Spain
| | - Leire Madariaga
- Biocruces Bizkaia Health Research Institute, Barakaldo, Bizkaia, Spain.,Pediatric Nephrology Department, Cruces University Hospital, UPV/EHU, Barakaldo, Spain
| | - Gema Ariceta
- Fisiopatologia Renal, Centro de Investigaciones en Bioquímica y Biología Molecular (CIBBIM), Vall d'Hebron. Institut de Recerca (VHIR), Barcelona, Spain. .,Pediatric Nephrology Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain. .,Servei Nefrología Pediátrica, Hospital Vall d' Hebron, Passeig de la Vall d'Hebron, 119-129, 08035, Barcelona, Spain.
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Gómez-Conde S, García-Castaño A, Aguirre M, Herrero M, Gondra L, García-Pérez N, García-Ledesma P, Martín-Penagos L, Dall'Anese C, Ariceta G, Castaño L, Madariaga L. Molecular aspects and long-term outcome of patients with primary distal renal tubular acidosis. Pediatr Nephrol 2021; 36:3133-3142. [PMID: 33881640 DOI: 10.1007/s00467-021-05066-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 03/17/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Primary distal renal tubular acidosis (dRTA) is a rare genetic disorder caused by impaired distal mechanisms of urinary acidification. Most cases are secondary to pathogenic variants in ATP6V0A4, ATP6V1B1, and SLC4A1 genes, which encode transporters regulating acid-base balance in the collecting duct. METHODS Retrospective study of molecular and clinical data from diagnosis and long-term follow-up (10, 20, and 40±10 years) of 16 patients with primary dRTA diagnosed in childhood. RESULTS Molecular analyses revealed nine patients had ATP6V0A4 pathogenic variants, five in ATP6V1B1, and two in SLC4A1. A novel intragenic deletion and a common ATP6V0A4 gene variant (c.1691 + 2dupT) in ATP6V0A4 occurred in two-thirds of these patients, suggesting a founder effect. Median age at diagnosis was 3.25 months (IQR 1, 13.5), which was higher in the SLC4A1 group. Median SDS height at diagnosis was -1.02 (IQR -1.79, 0.14). Delayed clinical diagnosis was significantly related to growth failure (P = 0.01). Median SDS height at 20 years follow-up was -1.23 (IQR -1.71, -0.48), and did not significantly improve from diagnosis (P = 0.76). Kidney function declined over time: at last follow-up, 43% had moderate to severe chronic kidney disease (CKD). Adequate metabolic control was not related to CKD development. Incidence of sensorineural hearing loss (SNHL) was high in ATP6V1B1 patients, though not universal. Patients harboring ATP6V0A4 variants also developed SNHL at a high rate (80%) over time. CONCLUSIONS Patients with dRTA can develop moderate to severe CKD over time with a high frequency despite adequate metabolic control. Early diagnosis ameliorates long-term height prognosis.
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Affiliation(s)
| | - Alejandro García-Castaño
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain
| | - Mireia Aguirre
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Pediatric Nephrology Department, Cruces University Hospital, Barakaldo, Spain
| | - María Herrero
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Pediatric Nephrology Department, Cruces University Hospital, Barakaldo, Spain
| | - Leire Gondra
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Pediatric Nephrology Department, Cruces University Hospital, Barakaldo, Spain.,Pediatric Department, University of the Basque Country UPV/EHU, Leioa, Spain
| | - Nélida García-Pérez
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,Pediatric Department, University of the Basque Country UPV/EHU, Leioa, Spain.,Pediatric Nephrology Department, Basurto University Hospital, Bilbao, Spain
| | | | - Luis Martín-Penagos
- Nephrology Department, Marqués de Valdecilla University Hospital, Santander, Spain
| | | | - Gema Ariceta
- Pediatric Nephrology Department, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Castaño
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.,CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain.,Pediatric Department, University of the Basque Country UPV/EHU, Leioa, Spain
| | - Leire Madariaga
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain. .,CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain. .,Pediatric Nephrology Department, Cruces University Hospital, Barakaldo, Spain. .,Pediatric Department, University of the Basque Country UPV/EHU, Leioa, Spain.
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45
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Horvat G, Tarana S, Vidović N, Cindro N, Speranza G, Tomišić V. Thermodynamic and MD studies of anion complexation by cyclopentaleucine in acetonitrile and dimethyl sulfoxide. J Mol Liq 2021. [DOI: 10.1016/j.molliq.2021.116848] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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46
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Subtyping Hyperchloremia among Hospitalized Patients by Machine Learning Consensus Clustering. MEDICINA-LITHUANIA 2021; 57:medicina57090903. [PMID: 34577826 PMCID: PMC8465989 DOI: 10.3390/medicina57090903] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 01/20/2023]
Abstract
Background and Objectives: Despite the association between hyperchloremia and adverse outcomes, mortality risks among patients with hyperchloremia have not consistently been observed among all studies with different patient populations with hyperchloremia. The objective of this study was to characterize hyperchloremic patients at hospital admission into clusters using an unsupervised machine learning approach and to evaluate the mortality risk among these distinct clusters. Materials and Methods: We performed consensus cluster analysis based on demographic information, principal diagnoses, comorbidities, and laboratory data among 11,394 hospitalized adult patients with admission serum chloride of >108 mEq/L. We calculated the standardized mean difference of each variable to identify each cluster's key features. We assessed the association of each hyperchloremia cluster with hospital and one-year mortality. Results: There were three distinct clusters of patients with admission hyperchloremia: 3237 (28%), 4059 (36%), and 4098 (36%) patients in clusters 1 through 3, respectively. Cluster 1 was characterized by higher serum chloride but lower serum sodium, bicarbonate, hemoglobin, and albumin. Cluster 2 was characterized by younger age, lower comorbidity score, lower serum chloride, and higher estimated glomerular filtration (eGFR), hemoglobin, and albumin. Cluster 3 was characterized by older age, higher comorbidity score, higher serum sodium, potassium, and lower eGFR. Compared with cluster 2, odds ratios for hospital mortality were 3.60 (95% CI 2.33-5.56) for cluster 1, and 4.83 (95% CI 3.21-7.28) for cluster 3, whereas hazard ratios for one-year mortality were 4.49 (95% CI 3.53-5.70) for cluster 1 and 6.96 (95% CI 5.56-8.72) for cluster 3. Conclusions: Our cluster analysis identified three clinically distinct phenotypes with differing mortality risks in hospitalized patients with admission hyperchloremia.
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Bockenhauer D, Kleta R. Tubulopathy meets Sherlock Holmes: biochemical fingerprinting of disorders of altered kidney tubular salt handling. Pediatr Nephrol 2021; 36:2553-2561. [PMID: 34143300 PMCID: PMC8260524 DOI: 10.1007/s00467-021-05098-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/27/2021] [Indexed: 11/19/2022]
Abstract
Evolution moves in mysterious ways. Excretion of waste products by glomerular filtration made perfect sense when life evolved in the ocean. Yet, the associated loss of water and solutes became a problem when life moved onto land: a serious design change was needed and this occurred in the form of ever more powerful tubules that attached to the glomerulus. By reabsorbing typically more than 99% of the glomerular filtrate, the tubules not only minimise urinary losses, but, crucially, also maintain homeostasis: tubular reabsorption and secretion are adjusted so as to maintain an overall balance, in which urine volume and composition matches intake and environmental stressors. A whole orchestra of highly specialised tubular transport proteins is involved in this process and dysfunction of one or more of these results in the so-called kidney tubulopathies, characterised by specific patterns of clinical and biochemical abnormalities. In turn, recognition of these patterns helps establish a specific diagnosis and pinpoints the defective transport pathway. In this review, we will discuss these clinical and biochemical "fingerprints" of tubular disorders of salt-handling and how sodium handling affects volume homeostasis but also handling of other solutes.
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Affiliation(s)
- Detlef Bockenhauer
- Department of Renal Medicine, University College London, NW3 2PF, London, UK. .,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Robert Kleta
- Department of Renal Medicine, University College London, NW3 2PF, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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48
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Tantisattamo E, Ho BT, Workeneh BT. Editorial: Metabolic Changes After Kidney Transplantation. Front Med (Lausanne) 2021; 8:709644. [PMID: 34307432 PMCID: PMC8297834 DOI: 10.3389/fmed.2021.709644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 05/31/2021] [Indexed: 01/21/2023] Open
Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California, Irvine School of Medicine, Orange, CA, United States.,Nephrology Section, Department of Medicine, Tibor Rubin Veterans Affairs Medical Center, Veterans Affairs Long Beach Healthcare System, Long Beach, CA, United States.,Multi-Organ Transplant Center, Section of Nephrology, Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, MI, United States
| | - Bing T Ho
- Comprehensive Transplant Center, Division of Nephrology and Hypertension, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Biruh T Workeneh
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
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D'Ambrosio V, Azzarà A, Sangiorgi E, Gurrieri F, Hess B, Gambaro G, Ferraro PM. Results of a Gene Panel Approach in a Cohort of Patients with Incomplete Distal Renal Tubular Acidosis and Nephrolithiasis. Kidney Blood Press Res 2021; 46:469-474. [PMID: 34107482 DOI: 10.1159/000516389] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 04/07/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Distal renal tubular acidosis (dRTA) is characterized by an impairment of urinary acidification resulting in metabolic acidosis, hypokalemia, and inappropriately elevated urine pH. If not treated, this chronic condition eventually leads to nephrocalcinosis, nephrolithiasis, impaired renal function, and bone demineralization. dRTA is a well-defined entity that can be diagnosed by genetic testing of 5 genes known to be disease-causative. Incomplete dRTA (idRTA) is defined as impaired urinary acidification that does not lead to overt metabolic acidosis and therefore can be diagnosed if patients fail to adequately acidify urine after an ammonium chloride (NH4Cl) challenge or furosemide and fludrocortisone test. It is still uncertain whether idRTA represents a distinct entity or is part of the dRTA spectrum and whether it is caused by mutations in the same genes of overt dRTA. METHODS In this cross-sectional study, we investigated a group of 22 stone formers whose clinical features were suspicious of idRTA. They underwent an NH4Cl challenge and were found to have impaired urinary acidification ability. These patients were then analyzed by genetic testing with sequencing of 5 genes: SLC4A1, ATP6V1B1, ATP6V0A4, FOXI1, and WDR72. RESULTS Two unrelated individuals were found to have two different variants in SLC4A1 that had never been described before. CONCLUSIONS Our results suggest the involvement of other genes or nongenetic tubular dysfunction in the pathogenesis of idRTA in stone formers. However, genetic testing may represent a cost-effective tool to recognize, treat, and prevent complications in these patients.
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Affiliation(s)
- Viola D'Ambrosio
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, U.O.C. Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessia Azzarà
- Istituto di Medicina Genomica, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eugenio Sangiorgi
- Università Cattolica del Sacro Cuore, Rome, Italy.,Istituto di Medicina Genomica, Fondazione Policlinico Universitario A. Gemelli IRCCS - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fiorella Gurrieri
- Unità di genetica Medica e Funzionale, Università Campus Bio-Medico, Rome, Italy
| | - Bernhard Hess
- Internal Medicine and Nephrology, Klinik Im Park, Zurich, and University of Zurich, Zurich, Switzerland
| | - Giovanni Gambaro
- Renal Unit, Division of Nephrology and Dialysis, Department of Medicine, University of Verona, Verona, Italy
| | - Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, U.O.C. Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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50
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Cystic fibrosis in the kidney: new lessons from impaired renal HCO3- excretion. Curr Opin Nephrol Hypertens 2021; 30:437-443. [PMID: 34027905 DOI: 10.1097/mnh.0000000000000725] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW A key role of cystic fibrosis transmembrane conductance regulator (CFTR) in the kidney has recently been uncovered. This needs to be integrated into the understanding of the developed phenotypes in cystic fibrosis (CF) patients. RECENT FINDINGS In the beta-intercalated cells of the collecting duct , CFTR functions in very similar terms as established in the exocrine pancreatic duct and both CFTR and SLC26A4 (pendrin) orchestrate regulated HCO3- secretion. Like in the pancreas, the hormone secretin is a key agonist to activate renal HCO3- secretion. In mice lacking CFTR or pendrin, acute and chronic base challenges trigger marked metabolic alkalosis because collecting duct base secretion is defective. Also in CF patients, the ability to acutely increase renal HCO3- excretion is markedly reduced. SUMMARY The now much enlarged understanding of CFTR in the kidney may permit the measurement of challenged urine HCO3- excretion as a new biomarker for CF. We suggest a new explanation for the electrolyte disorder in CF termed Pseudo-Bartter Syndrome. The hallmark electrolyte disturbance features of this can be well explained by a reduced function of collecting duct Cl-/HCO3- exchange. Eventually, we suggest the diagnostic term distal renal tubular alkalosis to cover those disturbances that causes metabolic alkalosis by a reduced collecting duct base secretion.
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