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Fujioka K, Nakasone R, Nishida K, Ashina M, Sato I, Nozu K. Neonatal Pseudohypoaldosteronism Type-1 in Japan. J Clin Med 2022; 11:jcm11175135. [PMID: 36079066 PMCID: PMC9456610 DOI: 10.3390/jcm11175135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/28/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Pseudohypoaldosteronism type 1 (PHA-1) is a disorder caused by renal tubular resistance to aldosterone and is characterized by problems with sodium regulation. PHA-1 is typically divided into primary PHA-1, which is caused by genetic mutation, and secondary PHA-1, which is associated with urinary tract abnormality. However, data on the clinical features of PHA-1 among newborn infants are limited. (2) Methods: We conducted a nationwide prospective surveillance study of neonatal PHA in Japan from 1 April 2019 to 31 March 2022 as part of a rare disease surveillance project of the Japan Society for Neonatal Health and Development. (3) Results: Fifteen cases (male:female = 7:8), including four primary, four secondary, and seven non-classified cases, were reported during the study period. The median gestational age and birthweight were 34 weeks (28–41) and 1852 g (516–4610), respectively. At the onset, the median serum Na and K levels were 132 mEq/L (117–137) and 6.3 mEq/L (4.7–8.3), respectively. The median plasma renin activity was 45 ng/mL/h (3.1–310, n = 9), active renin concentration was 1017 pg/mL (123–2909, n = 6), and serum aldosterone concentration was 5310 pg/mL (3250–43,700). (4) Conclusions: Neonatal PHA-1 was more common among preterm infants with no male predominance. It developed immediately after birth in cases without genetic or renal complications.
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Affiliation(s)
- Kazumichi Fujioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
- Correspondence: ; Tel.: +81-78-382-6090
| | - Ruka Nakasone
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Kosuke Nishida
- Department of Pediatrics, Kakogawa Central City Hospital, Kakogawa 675-8611, Japan
| | - Mariko Ashina
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Itsuko Sato
- Department of Clinical Laboratory, Kobe University Hospital, Kobe 650-0017, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
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Alvarado C, Balestracci A, Toledo I, Martin SM, Beaudoin L, Voyer LE. Transient early-childhood hyperkalaemia without salt wasting, pathophysiological approach of three cases. Nefrologia 2022; 42:203-208. [PMID: 36153917 DOI: 10.1016/j.nefroe.2022.04.004] [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: 07/31/2020] [Accepted: 12/16/2020] [Indexed: 06/16/2023] Open
Abstract
Two types of early childhood hyperkalemia had been recognized, according to the presence or absence of urinary salt wasting. This condition was attributed to a maturation disorder of aldosterone receptors and is characterized by sustained hyperkalemia, hyperchloremic metabolic acidosis (MA) due to reduced ammonium urinary excretion and bicarbonate loss, and normal creatinine with growth delay. We present 3 patients of the type without salt wasting, which we will call transient early-childhood hyperkalemia (TECHH) without salt wasting, and discuss its physiopathology according to new insights into sodium and potassium handling by the aldosterone in distal nephron. In 3 children from 30 to 120-day-old admitted with bronchiolitis and growth delay hyperkalemia was found in routine laboratory. Further studies revealed a normal creatinine with inappropriately normal or low fractional excretion (FE) of potassium, accompanied by inadequately normal serum aldosterone and plasma renin activity for their higher plasma potassium levels, but without urine salt wasting. They also presented hyperchloremic MA with FE of bicarbonate 0.58%-2.2%, positive urinary anion gap during MA and normal ability to acidify the urine. Based on these findings a diagnosis of TECHH without salt wasting was made and they were treated sodium bicarbonate and hydrochlorothiazide with favorable response. The condition was transient in all cases leading to treatment discontinuation. Given that TECCH without salt wasting is a tubular disorder of transient nature with mild symptoms; it must be keep in mind in the differential diagnosis of hyperkalemia in young children.
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Affiliation(s)
- Caupolicán Alvarado
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ismael Toledo
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Sandra Mariel Martin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Beaudoin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Luis Eugenio Voyer
- Department of Pediatrics, Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Alvarado C, Balestracci A, Toledo I, Martin SM, Beaudoin L, Voyer LE. Transient early-childhood hyperkalemia without salt wasting, physiopathological approach of three cases. Nefrologia 2021; 42:S0211-6995(21)00068-0. [PMID: 33902940 DOI: 10.1016/j.nefro.2020.12.018] [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: 07/31/2020] [Revised: 12/10/2020] [Accepted: 12/16/2020] [Indexed: 11/25/2022] Open
Abstract
Two types of early-childhood hyperkalemia had been recognized, according to the presence or absence of urinary salt wasting. This condition was attributed to a maturation disorder of aldosterone receptors and is characterized by sustained hyperkalemia, hyperchloremic metabolic acidosis due to reduced ammonium urinary excretion and bicarbonate loss, and normal creatinine with growth delay. We present three patients of the type without salt wasting, which we will call transient early-childhood hyperkalemia without salt wasting, and discuss its physiopathology according to new insights into sodium and potassium handling by the aldosterone in distal nephron. In three children from 30 to 120-day-old admitted with bronchiolitis and growth delay hyperkalemia was found in routine laboratory. Further studies revealed a normal creatinine with inappropriately normal or low fractional excretion of potassium, accompanied by inadequately normal serum aldosterone and plasma renin activity for their higher plasma potassium levels, but without urine salt wasting. They also presented hyperchloremic metabolic acidosis with fractional excretion of bicarbonate 0.58-2.2%, positive urinary anion gap during metabolic acidosis and normal ability to acidify the urine. Based on these findings a diagnosis of transient early-childhood hyperkalemia without salt wasting was made and they were treated sodium bicarbonate and hydrochlorothiazide with favorable response. The condition was transient in all cases leading to treatment discontinuation. Given that transient early-childhood hyperkalemia without salt wasting is a tubular disorder of transient nature with mild symptoms; it must be keep in mind in the differential diagnosis of hyperkalemia in young children.
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Affiliation(s)
- Caupolicán Alvarado
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Alejandro Balestracci
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Ismael Toledo
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Sandra Mariel Martin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Laura Beaudoin
- Nephrology Unit, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Luis Eugenio Voyer
- Department of Pediatrics, Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Adam WR. Hypothesis: a simple algorithm to distinguish between hypoaldosteronism and renal aldosterone resistance in patients with persistent hyperkalemia. Nephrology (Carlton) 2008; 13:459-64. [PMID: 18518934 DOI: 10.1111/j.1440-1797.2008.00962.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM Many patients with hyperkalemia have a readily identifiable cause, which leads to appropriate management. In others, particularly those with a reduced glomerular filtration rate, differentiating between (relative) hypoaldosteronism (HA) and renal aldosterone resistance (RAR) can be problematic. The aim of this study was to see if a plasma aldosterone to potassium algorithm could be defined which would help identify patients with hyperkalemia owing to suboptimal levels of aldosterone, thereby validating treatment with 9-alpha-fluhydrocortisone, instead of cation exchange resins, if more conservative treatment fails. METHODS A literature search for, and analysis of, studies providing details of plasma aldosterone and plasma potassium in normals (made hyperkalemic)and patients with a plasma potassium >5.3 mmol/L, and a contemporaneous plasma aldosterone. RESULTS One study was found in which normals were made significantly hyperkalemic (to 6.3 mmol/L). These subjects, while on a high sodium, low potassium (western) diet (n = 5), provided an arbitrary definition of a simple aldosterone to potassium algorithm for diagnosis (factored aldosterone (FAldo) = plasma aldosterone/(plasma K - 4.2)). The limit for FAldo is set at 280(pmol/L) or 10(ng/dL): results below the limit suggest HA; above the limit, RAR. This algorithm was then tested against, and, when plasma potassium was greater than 5.3, found to be consistent with, reported patients with confirmed HA (n = 33) and pseudohypoaldosteronism (n = 23). The ratios in reported patients with renal failure (n = 43) were consistent with either HA (n = 30) or RAR(n = 13). HYPOTHESIS In hyperkalemic patients a plasma aldosterone to potassium algorithm may help distinguish HA from RAR, thereby guiding therapy.
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Affiliation(s)
- William R Adam
- University of Melbourne, School of Rural Health, Shepparton, Victoria, Australia.
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Abstract
There has been a dramatic recent increase in the understanding of the renal epithelial transport systems with the identification, cloning and characterization of a large number of membrane transport proteins. The aim of this chapter is to integrate this body of knowledge with the understanding of the clinical disorders that accompany gain, loss or dysregulation of function of these transport systems. The specific focus is on the best-defined human clinical syndromes in which there are derangements in potassium (K(+)) homeostasis. The focus is on inherited syndromes, rather than on acquired syndromes due to tubular transport defects, and the therapeutic approaches address chronic derangements of K(+) homeostasis rather than acute interventions directed at life-threatening hyperkalaemia.
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Affiliation(s)
- David G Warnock
- Division of Nephrology, Departments of Medicine and Physiology, Nephrology Research and Training Center, University of Alabama at Birmingham, 647 THT, 1530 3rd Avenue South, Birmingham, AL 35294-0006, USA.
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7
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Abstract
The recent knowledge of the renal epithelial transport systems has exploded with the identification, cloning, and characterization of a large number of membrane transport proteins. The fundamental aspects of these transporters are beginning to emerge at the molecular level and are summarized in the accompanying contributions in this volume of the Annual Review of Physiology. The aim of my review is to integrate this body of knowledge with the understanding of the clinical disorders of human mineral homeostasis that accompany gain, loss, or dysregulation of function of these transport systems. The specific focus is on the best defined human clinical syndromes in which there are derangements in K(+) and Mg(2+) homeostasis.
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Affiliation(s)
- David G Warnock
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, 35294, USA.
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Komesaroff PA, Funder JW, Fuller PJ. Hormone-nuclear receptor interactions in health and disease. Mineralocorticoid resistance. BAILLIERE'S CLINICAL ENDOCRINOLOGY AND METABOLISM 1994; 8:333-55. [PMID: 8092976 DOI: 10.1016/s0950-351x(05)80256-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Mineralocorticoid resistance, or pseudohypoaldosteronism (PHA), is a rare cause of salt wasting in young children. It may be inherited as an autosomal dominant or recessive trait, it may occur sporadically or, rarely, it may develop secondary to other conditions. It is characterized by episodes of dehydration and hyponatraemia in the face of high aldosterone levels. In most cases, after a short period of salt supplementation no further ill effects are experienced. The condition is of great interest because it provides insights into both the mechanisms by which salt and water balance are controlled and the actions of aldosterone. This article reviews the normal physiology of aldosterone, with particular reference to its biosynthesis and its actions in specific target tissues. Current knowledge regarding the molecular mechanisms involved in aldosterone action is discussed in some detail. The clinical features of PHA are reviewed and diagnostic issues and clinical management considered. Finally, current views regarding the pathophysiology of the condition are presented. Here, considerable uncertainty remains. Whilst in many cases of PHA there is greatly reduced binding of aldosterone to its receptor, the underlying abnormality is yet to be identified; in particular, in spite of strong reasons for suspecting a defect or defects in the mineralocorticoid receptor, there is so far no direct evidence to support this hypothesis. The article concludes with a discussion of other possible explanations for the underlying abnormality in PHA.
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Affiliation(s)
- P A Komesaroff
- Baker Medical Research Institute, Prahran, Victoria, Australia
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Abstract
Hypokalemia and hyperkalemia are common problems that may be artifactual, iatrogenic, or due to altered body homeostatic mechanisms. ECG may help one to recognize hyperkalemia but not hypokalemia. Excessive K supplementation is a common iatrogenic cause of hyperkalemia whereas fluid therapy is a common cause of iatrogenic hypokalemia. The most common causes of spontaneous hyperkalemia are renal failure and hypoadrenocorticism whereas the most common causes of spontaneous hypokalemia are vomiting, diarrhea, and renal wasting. Symptomatic therapy is usually done until the underlying cause(s) is resolved.
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Affiliation(s)
- M D Willard
- Department of Small Animal Medicine and Surgery, Texas A & M University College of Veterinary Medicine, College Station
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Abstract
Potassium output from the body is regulated by renal excretion, which takes place predominantly in the late distal and cortical collecting tubules. The accepted model for potassium secretion implies the accumulation of potassium into the cell by the activity of basolateral Na-K-ATPase and its exit through voltage-dependent conductive channels. The factors regulating renal potassium secretion are potassium intake, distal urinary flow, systemic acid-base equilibrium, aldosterone, antidiuretic hormone and, probably, epinephrine. Renal handling of potassium is best studied by the response to the acute administration of furosemide. This loop diuretic not only increases sodium and chloride excretion but also enhances potassium and hydrogen ion excretion and stimulates the renin-aldosterone axis. The term "renal tubular hyperkalaemia" refers to a tubular dysfunction where the hyperkalaemia is disproportionate to any reduction in glomerular filtration rate (GFR) and not due primarily or solely to aldosterone deficiency or to drugs impairing either mineralocorticoid action or tubular transport. The syndromes of renal tubular hyperkalaemia mainly observed in childhood are "chloride shunt" syndrome, hyporeninaemic hypoaldosteronism and primary or secondary pseudohypoaldosteronism. Differential diagnosis between these conditions is easily made if attention is paid to the level of GFR, presence of sodium wasting, activity of the renin-aldosterone axis and renal response to acute administration of furosemide.
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