Sporadic distal renal tubular acidosis and periodic hypokalaemic paralysis in Kashmir

Long-term complications of primary distal renal tubular acidosis

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.

Clinical and Biochemical Characteristics of Patients with Renal Tubular Acidosis in Southern Part of West Bengal, India: A Retrospective Study

PURPOSE OF THE STUDY

Reversible proximal tubular dysfunction associated with distal renal tubular acidosis (dRTA) mimics type 3 RTA, a condition classically associated with features of both proximal RTA (pRTA) and dRTA. Proximal tubulopathy has been reported in children with primary dRTA, but the data in adults are lacking.

STUDY DESIGN

In this hospital record-based retrospective study, data from 66 consecutive cases of RTA, between January 2016 to December 2018, were retrieved and analyzed.

RESULTS

Mean age of the study population was 25.3 years (range: 3 months to 73 years). Six (9.1%) of them had pRTA, 58 (87.9%) had dRTA, 1 (1.5%) had type 3 RTA, and the remaining 1 (1.5%) had type 4 RTA. Ten patients (17.2%) with dRTA and 3 patients of pRTA (50%) had underlying secondary etiologies. Data on proximal tubular dysfunction were available for 30 patients with dRTA, of whom 1 had isolated dRTA, and the rest 29 patients had accompanying completely reversible proximal tubular dysfunction. Among the 10 cases of secondary dRTA, 6 were not evaluated for proximal tubular dysfunction. Of the remaining 4, 3 had reversible form of proximal tubular abnormality. Fifty-two patients with dRTA came from a population, indigenous to the "Rarh" region of India.

CONCLUSIONS

Proximal tubular dysfunction often accompanies dRTA; 75% of the children with primary dRTA, at least 29% of adults with primary dRTA, and at least 30% of adults with secondary dRTA manifest such completely reversible form of proximal tubulopathy. "Rarh' region of India probably is a hotspot for endemic dRTA.

Atypical clinical presentation of distal renal tubular acidosis: a case report registered in Amazonas, Brazil

We report an unusual case of a 24-year-old girl with a history of recurrent hypokalemic paralysis episodes and skin lesions on the lower limbs and buttocks, both of which had an acute evolution. In subsequent investigations, the patient also had nephrocalcinosis, nephrolithiasis, hyperchloremic metabolic acidosis and persistent alkaline urinary pH. The findings were consistent with distal renal tubular acidosis as the cause of hypokalemic paralysis. Clinical findings, immunological tests and the result of skin biopsy suggested primary Sjögren's syndrome as an underlying cause. The patient developed azotemia due to obstructive nephrolithiasis. All the features presented in this case are an unusual manifestation of distal renal tubular acidosis; so far, we are not aware of a similar report in the literature.

A child with distal (type 1) renal tubular acidosis presenting with progressive gross motor developmental regression and acute paralysis

Background

Distal (Type 1) renal tubular acidosis (dRTA) is characterized by inability to secrete hydrogen irons from the distal tubule. The aetiology of dRTA is diverse and can be either inherited or acquired. Common clinical presentations of dRTA in the paediatric age group include polyuria, nocturia, failure to thrive, constipation, abnormal breathing and nephrolithiasis. Though persistent hypokalemia is frequently seen in dRTA, hypokalemic muscular paralysis is uncommon and rarely described in children.

Case presentation

Three and a half years old girl was referred for evaluation of progressive loss of gross motor milestones over 6 months and acute episode of paralysis. Her other developmental domains were age appropriate. Notably, there was no history of polyuria, polydipsia, nocturia and abnormal breathing. Physical examination revealed proximal myopathy (waddling gait and positive Gower’s sign), diminished lower limb reflexes and muscle tone. Her serum potassium was low (2.1 meq/l) and she was subsequently investigated for hypokalemic paralysis. Diagnosis of distal renal tubular acidosis was made, based on hypokalemic hyperchloremic metabolic acidosis with normal anion gap, high urine pH, borderline hypercalciuria, medullary nephrocalcinosis and exclusion of other differential diagnosis. The child showed complete symptomatic recovery upon commencement of standard treatment for distal renal tubular acidosis.

Conclusions

This case report highlights the importance of considering hypokalemia and renal tubular acidosis in the differential diagnosis of acute flaccid paralysis and proximal myopathy. Early diagnosis will prevent costly investigations and enable rapid clinical recovery in the affected child.

Clinical and biochemical spectrum of hypokalemic paralysis in North: East India

Background:

Acute hypokalemic paralysis, characterized by acute flaccid paralysis is primarily a calcium channelopathy, but secondary causes like renal tubular acidosis (RTA), thyrotoxic periodic paralysis (TPP), primary hyperaldosteronism, Gitelman’s syndrome are also frequent.

Objective:

To study the etiology, varied presentations, and outcome after therapy of patients with hypokalemic paralysis.

Materials And Methods:

All patients who presented with acute flaccid paralysis with hypokalemia from October 2009 to September 2011 were included in the study. A detailed physical examination and laboratory tests including serum electrolytes, serum creatine phosphokinase (CPK), urine analysis, arterial blood gas analysis, thyroid hormones estimation, and electrocardiogram were carried out. Patients were further investigated for any secondary causes and treated with potassium supplementation.

Result:

The study included 56 patients aged 15-92 years (mean 36.76 ± 13.72), including 15 female patients. Twenty-four patients had hypokalemic paralysis due to secondary cause, which included 4 with distal RTA, 4 with Gitelman syndrome, 3 with TPP, 2 each with hypothyroidism, gastroenteritis, and Liddle’s syndrome, 1 primary hyperaldosteronism, 3 with alcoholism, and 1 with dengue fever. Two female patients were antinuclear antibody-positive. Eleven patient had atypical presentation (neck muscle weakness in 4, bladder involvement in 3, 1 each with finger drop and foot drop, tetany in 1, and calf hypertrophy in 1), and 2 patient had respiratory paralysis. Five patients had positive family history of similar illness. All patients improved dramatically with potassium supplementation.

Conclusion:

A high percentage (42.9%) of secondary cause for hypokalemic paralysis warrants that the underlying cause must be adequately addressed to prevent the persistence or recurrence of paralysis.

Type 1 renal tubular acidosis in a patient of Type 1 diabetes mellitus: Is it coincidence or coexistence?

A 26-year-old male patient suffering from Type 1 diabetes mellitus got admitted with abdominal pain and high blood sugars. On further evaluation, he was found to have normal anion gap metabolic acidosis without ketonuria and urinary pH was alkaline. The patient was diagnosed as Type 1 renal tubular acidosis (RTA) (distal RTA) and was managed by alkali replacement in addition to control of blood sugars. The association of Type 1 RTA with Type 1 diabetes mellitus has been rarely reported in the literature. The association needs a different attention as diagnosis and management of diabetic ketoacidosis in such cases will be tricky. The case presented here is the first of its kind from our part of the world and second as far as English literature is concerned.

Severe life-threatening hypokalemia in a cat with suspected distal renal tubular acidosis

OBJECTIVE

Description of the clinical presentation and management of a critically ill cat with profound hypokalemia associated with a suspicion of distal renal tubular acidosis (DRTA) and secondary hyperaldosteronism.

CASE SUMMARY

A cat was presented with severe generalized weakness and acute ventilatory failure associated with severe hypokalemia. The acid-base analysis and complete analytical profile of the urine confirmed the presence of a normal anion-gap metabolic acidosis with a urine pH of 7, a disorder consistent with DRTA. The high plasma renin activity, high aldosterone concentration, and low normal plasma aldosterone concentration/plasma renin activity ratio suggested secondary hyperaldosteronism. The management of the patient in the ICU was successful. No identifiable cause could be determined as a cause for the DRTA, so the disorder was assumed to be the primary problem.

NEW OR UNIQUE INFORMATION PROVIDED

DRTA is a rare disorder occasionally reported in the veterinary literature; it is especially rare in cats. Complete diagnostic evaluation was necessary to identify the reported disorders as the cause of the clinical presentation. To the author's knowledge, this is the first case reporting DRTA, and a simultaneously documented mineralocorticoid response, as a cause of a life-threatening hypokalemia.

A case report and review of hypokalemic paralysis secondary to renal tubular acidosis

A 5-year-old girl with distal renal tubular acidosis (RTA) and hypokalemic muscle paralysis is reported. RTA is a known cause of hypokalemia, but in spite of the presence of persistent hypokalemia muscular paralysis is uncommon, rarely described in children, and the onset of paralysis may initially be misinterpreted particularly if the patient is attended by a physician who is not a pediatric nephrologist. Therefore parents must be informed about this possibility. Still, as the clinical appearance of hypokalemic paralysis is quite similar to familial hypokalemic periodic paralysis, and because the emergent and prophylactic treatment of the two disorders are quite different, we discuss the diagnostic evaluation and the treatment for both of them.

An aetiological profile of short stature in the Indian subcontinent

OBJECTIVE

To determine the aetiological causes of short stature in a developing region of the world.

METHODOLOGY

A retrospective analysis was made of data from 193 subjects who were primarily evaluated for short stature in the Endocrinology Department, Institute of Medical Sciences, Kashmir, India. These subjects had a height of more than 3 standard deviations (SD) below the mean for their age and sex, and were seen over a decade (January 1987 to December 1996). A logical and comprehensive clinical and investigative protocol was followed to identify the aetiology of short stature.

RESULTS

Growth hormone deficiency was the commonest identifiable cause of short stature and accounted for 22.8% of cases. Thirty-six subjects (18.7%) had a normal variant short stature. Renal tubular acidosis was diagnosed in 10.4%, primary hypothyroidism, malnutrition and hypothalamic syndrome in 7.8% each, and growth hormone insensitivity syndrome in 4.1% cases.

CONCLUSIONS

We conclude that, in addition to growth hormone deficiency and normal variant short stature, distal renal tubular acidosis and growth hormone insensitivity syndrome are significant causes of short stature in India.

Renal tubular acidosis complicated with hypokalemic periodic paralysis

Three Chinese girls with hypokalemic periodic paralysis secondary to different types of renal tubular acidosis are presented. One girl has primary distal renal tubular acidosis complicated with nephrocalcinosis. Another has primary Sjögren syndrome with distal renal tubular acidosis, which occurs rarely with hypokalemic periodic paralysis in children. The third has an isolated proximal renal tubular acidosis complicated with multiple organ abnormalities, unilateral carotid artery stenosis, respiratory failure, and consciousness disturbance. The diagnostic evaluation and emergent and prophylactic treatment for these three types of renal tubular acidosis are discussed.

Hypokalaemic paralysis precipitated by working in hot weather

Twenty-two cases of hypokalaemic paralysis seen over the past 7 years, are presented here. They included five Chinese, five Bangladeshis, six Arabs, four Philippinos and two Indians. The number of cases related to the population of each nationality in our area showed that the Chinese had the biggest number of cases in relation to their population in our area, followed by Philippinos then Bangladeshis. All patients were men admitted in the hot season, dehydrated and not able to walk. It seems that dehydration was an important precipitating factor in our cases. Although family history was positive in one patient, apart from four thyrotoxic patients, the others were apparently healthy. Patients improved dramatically with i.v. potassium and rehydration. Four patients were readmitted with the same picture.