1
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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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2
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Verlander JW, Lee HW, Wall SM, Harris AN, Weiner ID. The proximal tubule through an NBCe1-dependent mechanism regulates collecting duct phenotypic and remodeling responses to acidosis. Am J Physiol Renal Physiol 2023; 324:F12-F29. [PMID: 36264886 PMCID: PMC9762982 DOI: 10.1152/ajprenal.00175.2022] [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: 06/27/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 02/04/2023] Open
Abstract
The renal response to acid-base disturbances involves phenotypic and remodeling changes in the collecting duct. This study examines whether the proximal tubule controls these responses. We examined mice with genetic deletion of proteins present only in the proximal tubule, either the A variant or both A and B variants of isoform 1 of the electrogenic Na+-bicarbonate cotransporter (NBCe1). Both knockout (KO) mice have spontaneous metabolic acidosis. We then determined the collecting duct phenotypic responses to this acidosis and the remodeling responses to exogenous acid loading. Despite the spontaneous acidosis in NBCe1-A KO mice, type A intercalated cells in the inner stripe of the outer medullary collecting duct (OMCDis) exhibited decreased height and reduced expression of H+-ATPase, anion exchanger 1, Rhesus B glycoprotein, and Rhesus C glycoprotein. Combined kidney-specific NBCe1-A/B deletion induced similar changes. Ultrastructural imaging showed decreased apical plasma membrane and increased vesicular H+-ATPase in OMCDis type A intercalated cell in NBCe1-A KO mice. Next, we examined the collecting duct remodeling response to acidosis. In wild-type mice, acid loading increased the proportion of type A intercalated cells in the connecting tubule (CNT) and OMCDis, and it decreased the proportion of non-A, non-B intercalated cells in the connecting tubule, and type B intercalated cells in the cortical collecting duct (CCD). These changes were absent in NBCe1-A KO mice. We conclude that the collecting duct phenotypic and remodeling responses depend on proximal tubule-dependent signaling mechanisms blocked by constitutive deletion of proximal tubule NBCe1 proteins.NEW & NOTEWORTHY This study shows that the proximal tubule regulates collecting duct phenotypic and remodeling responses to acidosis.
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Affiliation(s)
- Jill W Verlander
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida
| | - Hyun-Wook Lee
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida
| | - Susan M Wall
- Renal Division, Emory University, Atlanta, Georgia
| | - Autumn N Harris
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida
- Deparment of Small Animal Clinical Science, University of Florida College of Veterinary Medicine, Gainesville, Florida
| | - I David Weiner
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida
- Nephrology and Hypertension Section, Gainesville Veterans Administration Medical Center, Gainesville, Florida
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3
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Muacevic A, Adler JR, Kaur K, Noorani R. An Intraoperative Episode of Severe Type II Renal Tubular Acidosis in an 83-Year-Old Woman. Cureus 2022; 14:e31786. [PMID: 36569703 PMCID: PMC9777354 DOI: 10.7759/cureus.31786] [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: 11/22/2022] [Indexed: 11/24/2022] Open
Abstract
Type II renal tubular acidosis (RTA) is a rare defect in bicarbonate transport that can cause serious metabolic derangements. We report the case of a spontaneous, isolated intraoperative episode of severe type II RTA in an elderly woman who presented for radical neck dissection, mandible excision, and flap creation. Intraoperatively, she developed a stark metabolic acidosis with hypokalemia, progressively worsening base excess, and prolific urine output. Aggressive resuscitation with bicarbonate corrected all metabolic abnormalities. There was no identifiable trigger and the patient was successfully discharged with no further recurrences during hospitalization. The inability to identify the clinical presentation of RTA perioperatively can lead to poor outcomes.
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4
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Díaz-Anadón L, Cardo L, Santos F, Gil-Peña H. Evaluation of urinary acidification in children: Clinical utility. Front Pediatr 2022; 10:1051481. [PMID: 36389372 PMCID: PMC9660234 DOI: 10.3389/fped.2022.1051481] [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: 09/22/2022] [Accepted: 10/10/2022] [Indexed: 11/13/2022] Open
Abstract
The kidney plays a fundamental role in acid-base homeostasis by reabsorbing the filtered bicarbonate and by generating new bicarbonate, to replace that consumed in the buffering of non-volatile acids, a process that leads to the acidification of urine and the excretion of ammonium (NH4 +). Therefore, urine pH (UpH) and urinary NH4 + (UNH4 +) are valuable parameters to assess urinary acidification. The adaptation of automated plasma NH4 + quantification methods to measure UNH4 + has proven to be an accurate and feasible technique, with diverse potential indications in clinical practice. Recently, reference values for spot urine NH4 +/creatinine ratio in children have been published. UpH and UNH4 +, aside from their classical application in the study of metabolic acidosis, have shown to be useful in the identification of incomplete distal renal tubular acidosis (dRTA), an acidification disorder, without overt metabolic acidosis, extensively described in adults, and barely known in children, in whom it has been found to be associated to hypocitraturia, congenital kidney abnormalities and growth impairment. In addition, a low UNH4 + in chronic kidney disease (CKD) is a risk factor for glomerular filtration decay and mortality in adults, even in the absence of overt metabolic acidosis. We here emphasize on the need of measuring UpH and UNH4 + in pediatric population, establishing reference values, as well as exploring their application in metabolic acidosis, CKD and disorders associated with incomplete dRTA, including growth retardation of unknown cause.
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Affiliation(s)
- Lucas Díaz-Anadón
- Division of Pediatric Nephrology, Department of Pediatrics, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.,Department of Medicine, Faculty of Medicine, University of Oviedo, Oviedo, Asturias, Spain
| | - Leire Cardo
- Clinical Biochemistry Department, Laboratory of Medicine, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Fernando Santos
- Department of Medicine, Faculty of Medicine, University of Oviedo, Oviedo, Asturias, Spain
| | - Helena Gil-Peña
- Division of Pediatric Nephrology, Department of Pediatrics, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain.,Department of Medicine, Faculty of Medicine, University of Oviedo, Oviedo, Asturias, Spain.,Section of Pediatrics, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Asturias, Spain
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5
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Cavaliere GA, Murali N, Bontempo LJ, Dezman ZDW. 19-year-old Woman with Intermittent Weakness. Clin Pract Cases Emerg Med 2021; 5:276-282. [PMID: 34437031 PMCID: PMC8373190 DOI: 10.5811/cpcem.2021.4.52011] [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] [Received: 02/01/2021] [Accepted: 04/01/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction Systemic weakness is a common chief complaint of patients presenting to the emergency department (ED). A well thought out approach to the assessment and workup of these patients is key to diagnostic accuracy and definitive therapy. Case Presentation In this case, a 19-year-old female presented to the ED with generalized weakness and near syncope. She had global weakness in her extremities and multiple electrolyte abnormalities. Discussion This case takes the reader through the differential diagnosis and evaluation of a patient with weakness and profound electrolyte derangements. It includes a discussion of the diagnostic studies and calculations that ultimately led to the patient’s diagnosis.
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Affiliation(s)
- Garrett A Cavaliere
- University of Maryland Medical Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Neeraja Murali
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Laura J Bontempo
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Zachary D W Dezman
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland.,University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, Maryland
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6
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Kidney function in patients with primary distal renal tubular acidosis. Pediatr Nephrol 2021; 36:1931-1935. [PMID: 33834289 DOI: 10.1007/s00467-021-05068-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/26/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recent reports indicate that chronic reduction of glomerular filtration rate (GFR) is common in patients with distal renal tubular acidosis (DRTA). Factors responsible for decreased GFR need clarification. METHODS We reviewed records of 25 patients with genetically confirmed DRTA included in the RenalTube database. Patients < 18 years at diagnosis and having at least one annual follow-up were selected and classified in two groups according to GFR ≥ 90 (normal GFR) or < 90 mL/min/1.73 m2 (low GFR) after median follow-up of 8.8 years. RESULTS Eighteen and seven patients had normal and low GFR (X ± SEM, 121.16 ± 28.87 and 71.80 ± 10.60 mL/min/1.73 m2, respectively, p < 0.01). At diagnosis, these 2 subgroups did not differ in sex, age, underlying mutated gene, GFR, height SDS, or percentage of ultrasound nephrocalcinosis. Serum creatinine (SCr) was different but likely due to median ages of presentation being 0.6 and 4.0 in normal and low GFR patients, respectively. On the last recorded visit, no differences between both groups were found in serum bicarbonate, serum potassium, or alkali dosage. Height SDS of patients with normal GFR was - 0.15 ± 0.47 whereas it was - 1.06 ± 0.60 in the low GFR group (p = 0.27). Interestingly, 23% of the whole group had low birth weight (LBW; < 2500 g), equating to 20% and 29% in the normal and low GFR patients, respectively (p = 0.65). CONCLUSIONS Our findings confirm the risk of kidney function reduction in patients with DRTA of pediatric age onset, suggesting that low GFR is related with less favorable growth outcome and discloses the high frequency of LBW in primary DRTA, a hitherto unrecognized feature.
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7
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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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8
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Trepiccione F, Walsh SB, Ariceta G, Boyer O, Emma F, Camilla R, Ferraro PM, Haffner D, Konrad M, Levtchenko E, Lopez-Garcia SC, Santos F, Stabouli S, Szczepanska M, Tasic V, Topaloglu R, Vargas-Poussou R, Wlodkowski T, Bockenhauer D. Distal Renal Tubular Acidosis: ERKNet/ESPN Clinical Practice Points. Nephrol Dial Transplant 2021; 36:1585-1596. [PMID: 33914889 DOI: 10.1093/ndt/gfab171] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Indexed: 12/15/2022] Open
Abstract
Distal renal tubular acidosis (dRTA) is characterised by an impaired ability of the distal tubule to excrete acid, leading to metabolic acidosis. Associated complications include bone disease, growth failure, urolithiasis and hypokalaemia. Due to its rarity, there is a limited evidence to guide diagnosis and management, however, available data strongly suggest that metabolic control of the acidosis by alkali supplementation can halt or revert almost all complications. Despite this, cohort studies show that adequate metabolic control is present in only about half of patients, highlighting problems with treatment provision or adherence. With these clinical practice points the authors, part of the working groups tubulopathies in the European Rare Kidney Disease Reference network (ERKnet) and inherited kidney diseases of the European Society for Paediatric Nephrology (ESPN) aim to provide guidance for the management of patients with dRTA to facilitate adequate treatment and establish an initial best practice standard against which treatment of patients can be audited.
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Affiliation(s)
- Francesco Trepiccione
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
| | - Steven B Walsh
- Department of Renal Medicine, University College London, UK
| | - Gema Ariceta
- Division of Pediatric Nephrology. Hospital Universitario Vall d' Hebron. Universitat Autonoma de Barcelona. Barcelona, Spain
| | - Olivia Boyer
- Pediatric Nephrology, Necker Hospital, APHP, MARHEA, Imagine Institute, Paris University, Paris, France
| | - Francesco Emma
- Division of Nephrology, Bambino Gesu Children's Hospital - IRCCS, Rome, Italy
| | - Roberta Camilla
- Nephrology, Dialysis, Transplantation, Regina Margherita University Hospital, Turin, Italy
| | - Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, U.O.C. Nefrologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italy.,Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany
| | - Martin Konrad
- Department of General Pediatrics, University Children's Hospital, Muenster, Germany
| | - Elena Levtchenko
- Division of Pediatric Nephrology, University Hospitals Leuven; Department of Development & Regeneration, Katholieke Universiteit Leuven, Belgium
| | - Sergio Camilo Lopez-Garcia
- Department of Renal Medicine, University College London, UK.,Renal Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Fernando Santos
- Department of Pediatrics, Hospital Universitario Central de Asturias and Área de Pediatría, Dpto. de Medicina, Universidad de Oviedo, Oviedo, Spain
| | - Stella Stabouli
- 1st Department of Pediatrics, Aristotle University, Thessaloniki, Greece
| | | | - Velibor Tasic
- University Children's Hospital, Medical School, Skopje, Macedonia
| | - Rezan Topaloglu
- Department of Pediatric Nephrology, Hacettepe University Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Rosa Vargas-Poussou
- Department of Genetics, Centre de Références MARHEA, Hôpital Européen Georges Pompidou Assistance Publique Hôpitaux de Paris, Paris France
| | - Tanja Wlodkowski
- Department of Paediatric Nephrology, University Children's Hospital, Heidelberg, Germany
| | - Detlef Bockenhauer
- Department of General Pediatrics, University Children's Hospital, Muenster, Germany.,Division of Pediatric Nephrology, University Hospitals Leuven; Department of Development & Regeneration, Katholieke Universiteit Leuven, Belgium
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9
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Zhu H, Wan H, Duan S, Zhang C, Li Q, Liu S, Wu L, Zhang B, Xing C, Yuan Y. Value of monitoring urine ammonia at time of biopsy in patients with lupus nephritis. BMC Nephrol 2020; 21:442. [PMID: 33081708 PMCID: PMC7576709 DOI: 10.1186/s12882-020-02106-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Abstract
Objective Although lupus nephritis (LN) is mostly characterized by glomerular involvement, tubular injury is indispensable in its pathogenesis and progression. The purpose of this study is to examine associations between urinary acidification function and clinical and pathological features in LN. Methods A total of 103 patients with renal biopsy-proven LN were included, and clinical parameters and laboratory data were obtained from the medical records. Plasma samples, 24-h urine samples and the urinary acidification function, including urine pH, titratable acid, and ammonia, were collected within 3 days before the day of renal biopsy. The correlations between defects of acid excretion and clinical and pathological features were then assessed. Logistic regression analysis was used to assess factors associated with the presence of nephrotic range proteinuria. Results The urine ammonia level was inversely correlated with SLEDAI-2 K scores, rSLEDAI scores, serum creatinine levels and proteinuria, while it was positively correlated with eGFR. And urine titratable acid was only inversely correlated with rSLEDAI scores and proteinuria. Moreover, urine ammonia had significant negative correlations with AI scores, interstitial inflammatory cell infiltration, CI scores, glomerular sclerosis, fibrous crescents, tubular atrophy and interstitial fibrosis. And urine titratable acid was mainly inversely correlated with CI scores. Furthermore, univariate logistic analyses identified that both urine titratable acid and ammonia were correlated with the presence of nephrotic range proteinuria. After the adjustment for chronicity index and eGFR in a multivariate logistic analysis, only urine titratable acid was still identified as an independent risk factor for the occurrence of nephrotic range proteinuria. Conclusions Urine ammonia was associated with clinical and pathological features of chronicity and tubulointerstitial disease activity among patients with lupus nephritis. Furthermore, the strong association between urinary protein and titratable acid excretion at the time of kidney biopsy is significant even after adjusting for the chronicity index and eGFR at biopsy.
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Affiliation(s)
- Huanhuan Zhu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, P.R. China
| | - Huiting Wan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, P.R. China
| | - Suyan Duan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, P.R. China
| | - Chengning Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, P.R. China
| | - Qing Li
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, P.R. China
| | - Simeng Liu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, P.R. China
| | - Lin Wu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, P.R. China
| | - Bo Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, P.R. China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, P.R. China
| | - Yanggang Yuan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu Province, 210029, P.R. China.
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10
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Screening and function discussion of a hereditary renal tubular acidosis family pathogenic gene. Cell Death Dis 2020; 11:159. [PMID: 32123165 PMCID: PMC7052238 DOI: 10.1038/s41419-020-2354-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/11/2020] [Accepted: 02/11/2020] [Indexed: 12/18/2022]
Abstract
Hereditary distal renal tubular acidosis (dRTA) is a rare disease of H+ excretion defect of α-intercalated cells in renal collecting duct, caused by decreased V-ATPase function due to mutations in the ATP6V1B1 or ATP6V0A4 genes. In the present study, a genetic family with 5 members of the complete dRTA phenotype were found with distal tubule H+ secretion disorder, hypokalemia, osteoporosis, and kidney stones. A variant NM_020632.2:c.1631C > T (p.Ser544Leu) in exon 16 on an ATP6V0A4 gene associated with dRTA was detected by next generation sequencing target region capture technique and verified by Sanger sequencing, which suggested that except for one of the patients who did not receive the test, the other four patients all carried the p.S544L heterozygote. In transfected HEK293T cells, cells carrying p.S544L-mut showed early weaker ATPase activity and a slower Phi recovery rate after rapid acidification. By immunofluorescence localization, it was observed that the expression level of p.S544L-mut on the cell membrane increased and the distribution was uneven. Co-immunoprecipitation showed the a4 subunit of ATP6V0A4/p.S544L-mut could not bind to the B1 subunit, which might affect the correct assembly of V-ATPase. The present study of dRTA family suggests that the p.S544L variant may be inherited in a dominant manner.
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11
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Zhu H, Liu X, Zhang C, Li Q, An X, Liu S, Wu L, Zhang B, Yuan Y, Xing C. Association of urinary acidification function with the progression of diabetic kidney disease in patients with type 2 diabetes. J Diabetes Complications 2019; 33:107419. [PMID: 31473080 DOI: 10.1016/j.jdiacomp.2019.107419] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/10/2019] [Accepted: 08/16/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Although diabetic kidney disease (DKD) has been considered as a glomerulocentric disease in the past few decades, growing evidence demonstrated that tubular damage was indispensable in its pathogenesis and progression. This study was designed to investigate the association of urinary acidification dysfunction with the progression of DKD in type 2 diabetic patients. METHODS Here the urinary acidification functions were measured from 80 participants with renal biopsy-proven DKD. The different kinds of renal tubular transportation dysfunction were analyzed, including the dysfunction of bicarbonate reabsorption, titratable acid secretion, and ammonium secretion. In addition, patients were followed up for 17 (interquartile range, 11-32) months to evaluate the effect of urinary acidification dysfunction in the progression of DKD. RESULTS The most common urinary acidification dysfunction was the disorder of ammonium secretion, accounting for 53.75%. The more proteinuria excretion and the lower glomerular filtration rate (GFR) were observed in the urinary titratable acid disorder group than the normal group, and the same results were obtained for ammonium secretion disorder. Urine titratable acid was positively correlated with eGFR whereas it was inversely correlated with proteinuria, serum creatinine, and BUN. Moreover, 24 h urine protein, serum creatinine, BUN and cystatin C increased from DKD stage II to stage IV, whereas the eGFR and urine titratable acid decreased in the same way. Furthermore, Kaplan-Meier analysis and Cox regression showed that the disorder of titratable acid was an independent risk factor for DKD progression. CONCLUSIONS The dysfunction of urinary titratable acid is a potential biomarker for the severity of proteinuria, eGFR and glomerular lesions in patients with DKD. Moreover, the titratable acid disorder is an independent risk factor of the DKD progression.
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MESH Headings
- Acidosis, Renal Tubular/complications
- Acidosis, Renal Tubular/diagnosis
- Acidosis, Renal Tubular/epidemiology
- Acidosis, Renal Tubular/etiology
- Acids/analysis
- Acids/metabolism
- Adult
- Aged
- Biomarkers/metabolism
- Biomarkers/urine
- Comorbidity
- Diabetes Mellitus, Type 2/complications
- Diabetes Mellitus, Type 2/epidemiology
- Diabetes Mellitus, Type 2/pathology
- Diabetes Mellitus, Type 2/urine
- Diabetic Nephropathies/complications
- Diabetic Nephropathies/epidemiology
- Diabetic Nephropathies/pathology
- Diabetic Nephropathies/urine
- Disease Progression
- Female
- Glomerular Filtration Rate
- Humans
- Hydrogen-Ion Concentration
- Kidney/metabolism
- Kidney/physiopathology
- Kidney Failure, Chronic/diagnosis
- Kidney Failure, Chronic/epidemiology
- Kidney Failure, Chronic/physiopathology
- Kidney Failure, Chronic/urine
- Male
- Middle Aged
- Prognosis
- Proteinuria/epidemiology
- Proteinuria/etiology
- Proteinuria/urine
- Urine/chemistry
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Affiliation(s)
- Huanhuan Zhu
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Xi Liu
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Chengning Zhang
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Qing Li
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Xiaofei An
- Department of Endocrinology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Simeng Liu
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Lin Wu
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Bo Zhang
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Yanggang Yuan
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China.
| | - Changying Xing
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China.
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12
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Distal renal tubular acidosis: genetic causes and management. World J Pediatr 2019; 15:422-431. [PMID: 31079338 DOI: 10.1007/s12519-019-00260-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Distal renal tubular acidosis (dRTA) is a kidney tubulopathy that causes a state of normal anion gap metabolic acidosis due to impairment of urine acidification. This review aims to summarize the etiology, pathophysiology, clinical findings, diagnosis and therapeutic approach of dRTA, with emphasis on genetic causes of dRTA. DATA SOURCES Literature reviews and original research articles from databases, including PubMed and Google Scholar. Manual searching was performed to identify additional studies about dRTA. RESULTS dRTA is characterized as the dysfunction of the distal urinary acidification, leading to metabolic acidosis. In pediatric patients, the most frequent etiology of dRTA is the genetic alteration of genes responsible for the codification of distal tubule channels, whereas, in adult patients, dRTA is more commonly secondary to autoimmune diseases, use of medications and uropathies. Patients with dRTA exhibit failure to thrive and important laboratory alterations, which are used to define the diagnosis. The oral alkali and potassium supplementation can correct the biochemical defects, improve clinical manifestations and avoid nephrolithiasis and nephrocalcinosis. CONCLUSIONS dRTA is a multifactorial disease leading to several clinical manifestations. Clinical and laboratory alterations can be corrected by alkali replacement therapy.
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13
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Abstract
Renal tubular acidosis should be suspected in poorly thriving young children with hyperchloremic and hypokalemic normal anion gap metabolic acidosis, with/without syndromic features. Further workup is needed to determine the type of renal tubular acidosis and the presumed etiopathogenesis, which informs treatment choices and prognosis. The risk of nephrolithiasis and calcinosis is linked to the presence (proximal renal tubular acidosis, negligible stone risk) or absence (distal renal tubular acidosis, high stone risk) of urine citrate excretion. New formulations of slow-release alkali and potassium combination supplements are being tested that are expected to simplify treatment and lead to sustained acidosis correction.
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Affiliation(s)
- Robert Todd Alexander
- Department of Pediatrics and Physiology, Stollery Children's Hospital, 11405-87 Avenue, Edmonton, Alberta T6G 1C9, Canada
| | - Martin Bitzan
- Division of Nephrology, Department of Pediatrics, The Montreal Children's Hospital, McGill University Health Centre, Room B RC.6651, Montreal, Quebec H4A 3J1, Canada; Al Jalila Children's Hospital, Al Jadaf PO Box 7662, Dubai, UAE.
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14
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Abstract
The frontline nurse is confronted daily with patients that have some type of kidney dysfunction or disease. Some renal issues resolve themselves, some disorders can be reversed, and others are permanent. Major complications from kidney impairment discussed are fluid and electrolyte disequilibrium with common problems in volume overload, hyperkalemia, metabolic acidosis, hyperphosphatemia, and hormonal secretion. Each problem is presented with potential clinical manifestations and management.
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Affiliation(s)
- Deborah Ellison
- Austin Peay State University, School of Nursing, 601 College Street, Clarksville, TN 37043, USA.
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15
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Abstract
Distal renal tubular acidosis (DRTA) is defined as hyperchloremic, non-anion gap metabolic acidosis with impaired urinary acid excretion in the presence of a normal or moderately reduced glomerular filtration rate. Failure in urinary acid excretion results from reduced H+ secretion by intercalated cells in the distal nephron. This results in decreased excretion of NH4+ and other acids collectively referred as titratable acids while urine pH is typically above 5.5 in the face of systemic acidosis. The clinical phenotype in patients with DRTA is characterized by stunted growth with bone abnormalities in children as well as nephrocalcinosis and nephrolithiasis that develop as the consequence of hypercalciuria, hypocitraturia, and relatively alkaline urine. Hypokalemia is a striking finding that accounts for muscle weakness and requires continued treatment together with alkali-based therapies. This review will focus on the mechanisms responsible for impaired acid excretion and urinary potassium wastage, the clinical features, and diagnostic approaches of hypokalemic DRTA, both inherited and acquired.
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16
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Harris AN, Grimm PR, Lee HW, Delpire E, Fang L, Verlander JW, Welling PA, Weiner ID. Mechanism of Hyperkalemia-Induced Metabolic Acidosis. J Am Soc Nephrol 2018; 29:1411-1425. [PMID: 29483157 DOI: 10.1681/asn.2017111163] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/03/2018] [Indexed: 12/22/2022] Open
Abstract
Background Hyperkalemia in association with metabolic acidosis that are out of proportion to changes in glomerular filtration rate defines type 4 renal tubular acidosis (RTA), the most common RTA observed, but the molecular mechanisms underlying the associated metabolic acidosis are incompletely understood. We sought to determine whether hyperkalemia directly causes metabolic acidosis and, if so, the mechanisms through which this occurs.Methods We studied a genetic model of hyperkalemia that results from early distal convoluted tubule (DCT)-specific overexpression of constitutively active Ste20/SPS1-related proline-alanine-rich kinase (DCT-CA-SPAK).Results DCT-CA-SPAK mice developed hyperkalemia in association with metabolic acidosis and suppressed ammonia excretion; however, titratable acid excretion and urine pH were unchanged compared with those in wild-type mice. Abnormal ammonia excretion in DCT-CA-SPAK mice associated with decreased proximal tubule expression of the ammonia-generating enzymes phosphate-dependent glutaminase and phosphoenolpyruvate carboxykinase and overexpression of the ammonia-recycling enzyme glutamine synthetase. These mice also had decreased expression of the ammonia transporter family member Rhcg and decreased apical polarization of H+-ATPase in the inner stripe of the outer medullary collecting duct. Correcting the hyperkalemia by treatment with hydrochlorothiazide corrected the metabolic acidosis, increased ammonia excretion, and normalized ammoniagenic enzyme and Rhcg expression in DCT-CA-SPAK mice. In wild-type mice, induction of hyperkalemia by administration of the epithelial sodium channel blocker benzamil caused hyperkalemia and suppressed ammonia excretion.Conclusions Hyperkalemia decreases proximal tubule ammonia generation and collecting duct ammonia transport, leading to impaired ammonia excretion that causes metabolic acidosis.
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Affiliation(s)
- Autumn N Harris
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida
| | - P Richard Grimm
- Department of Physiology and Maryland Center for Kidney Discovery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Hyun-Wook Lee
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida
| | - Eric Delpire
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Lijuan Fang
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida
| | - Jill W Verlander
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida
| | - Paul A Welling
- Department of Physiology and Maryland Center for Kidney Discovery, University of Maryland School of Medicine, Baltimore, Maryland
| | - I David Weiner
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida College of Medicine, Gainesville, Florida; .,Nephrology and Hypertension Section, Gainesville Veterans Administration Medical Center, Gainesville, Florida
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17
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A Rare Case of Transient Proximal Renal Tubular Acidosis in Pregnancy. Case Rep Nephrol 2018; 2017:1342135. [PMID: 29333305 PMCID: PMC5733205 DOI: 10.1155/2017/1342135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 11/15/2017] [Indexed: 11/30/2022] Open
Abstract
Renal tubular acidosis (RTA) is a disorder that has improper function of renal acid-base regulation and is rarely encountered during pregnancy. Currently, there is no clear evidence on management and outcomes in patients with this condition. We report a case of a previously healthy 23-year-old female at 30 weeks of gestation who presented with proximal RTA and had spontaneous resolution of the condition shortly after delivery.
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18
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Yamamura T, Nozu K, Miyoshi Y, Nakanishi K, Fujimura J, Horinouchi T, Minamikawa S, Mori N, Fujimaru R, Nakanishi K, Ninchoji T, Kaito H, Mariko TI, Morioka I, Matsuo M, Iijima K. An in vitro splicing assay reveals the pathogenicity of a novel intronic variant in ATP6V0A4 for autosomal recessive distal renal tubular acidosis. BMC Nephrol 2017; 18:353. [PMID: 29202719 PMCID: PMC5716019 DOI: 10.1186/s12882-017-0774-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 11/23/2017] [Indexed: 02/07/2023] Open
Abstract
Background Autosomal recessive distal renal tubular acidosis (dRTA) is a rare hereditary disease caused by pathogenic variants in the ATP6V0A4 gene or ATP6V1B1 gene, and characterized by hyperchloremic metabolic acidosis with normal anion gap, hypokalemia, hypercalciuria, hypocitraturia and nephrocalcinosis. Although several intronic nucleotide variants in these genes have been detected, all of them fell in the apparent splice consensus sequence. In general, transcriptional analysis is necessary to determine the effect on function of the novel intronic variants located out of splicing consensus sequences. In recent years, functional splicing analysis using minigene construction was used to assess the pathogenicity of novel intoronic variant in various field. Methods We investigated a sporadic case of dRTA with a compound heterozygous mutation in the ATP6V0A4 gene, revealed by next generation sequencing. One variant was already reported as pathogenic; however, the other was a novel variant in intron 11 (c.1029 + 5G > A) falling outside of the apparent splicing consensus sequence. Expression of ATP6V0A4 was not detected in peripheral leukocytes by RT-PCR analysis. Therefore, an in vitro functional splicing study using minigene construction was conducted to analyze the splicing pattern of the novel variant. Results A minigene assay revealed that the novel intronic variant leads to a 104 bp insertion immediately following exon 11. In addition, this result was confirmed using RNA extracted from the patient’s cultured leukocytes. Conclusion These results proved the pathogenicity of a novel intronic variant in our patient. We concluded that the minigene assay is a useful, non-invasive method for functional splicing analysis of inherited kidney disease, even if standard transcriptional analysis could not detect abnormal mRNA. Electronic supplementary material The online version of this article (10.1186/s12882-017-0774-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan.
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
| | - Yuya Miyoshi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
| | - Keita Nakanishi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
| | - Junya Fujimura
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
| | - Shogo Minamikawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
| | - Nobuo Mori
- Nakano Children's Hospital, 4-13-17 Shinmori, Asahi, Osaka, 5350022, Japan
| | - Rika Fujimaru
- Department of Pediatrics, Osaka City General Hospital, 2-13-22 Miyakojimahondori, Miyakojima, Osaka, 5340021, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Nakagami, 9030125, Japan
| | - Takeshi Ninchoji
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
| | - Hiroshi Kaito
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
| | - Taniguchi-Ikeda Mariko
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
| | - Ichiro Morioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
| | - Masafumi Matsuo
- Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, 518 Arise, Ikawadani, Nishi, Kobe, 6512180, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Chuo, Kobe, Hyogo, 6500017, Japan
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19
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Parikh RP, Tiwari A, Washimkar S, Deshmukh P, Deshpande M. Calcium on Mitral Valve: Decipher Aetiopathogenesis. J Clin Diagn Res 2017; 11:OD03-OD04. [PMID: 28892961 DOI: 10.7860/jcdr/2017/26592.10171] [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: 01/05/2017] [Accepted: 05/03/2017] [Indexed: 11/24/2022]
Abstract
We hereby describe an unusual case of a 17-year-old female with severe mitral regurgitation secondary to heavily calcified immobile valve leaflets. Along with the mitral valve, corneas were also calcified, due to congenital systemic metabolic disorder, distal renal tubular acidosis. Histopathology proved that there was no intrinsic pathology of the mitral valve. Congenital distal renal tubular acidosis with normokalemia presenting with severe mitral and corneal calcification is not known. This case notes important clinical features and is thought to add to the existing knowledge regarding the disease. Patient succumbed to her illness during mitral valve surgery and genetic analysis was not done prior. This is the limitation of our reporting. In this modern era, specific clinical features are also important and of equal value to try and understand molecular and genetic basics of the diseases.
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Affiliation(s)
- Rohan P Parikh
- Senior Resident, Department of Cardiology, Govt. Medical College and Super Speciality Hospital, Nagpur, Maharashtra, India
| | - Ashlesh Tiwari
- Senior Resident, Department of Cardiology, Govt. Medical College and Super Speciality Hospital, Nagpur, Maharashtra, India
| | - Sunil Washimkar
- Assistant Professor, Department of Cardiology, Govt. Medical College and Super Speciality Hospital, Nagpur, Maharashtra, India
| | - Pradeep Deshmukh
- Associate Professor, Department of Cardiology, Govt. Medical College and Super Speciality Hospital, Nagpur, Maharashtra, India
| | - Mukund Deshpande
- Head and Professor, Department of Cardiology, Govt. Medical College and Super Speciality Hospital, Nagpur, Maharashtra, India
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