Fetal pseudohypoaldosteronism: another cause of hydramnios

Renin-aldosterone system evaluation over four decades in an extended family with autosomal dominant pseudohypoaldosteronism due to a deletion in the NR3C2 gene

Renal pseudohypoaldosteronism (PHA1) is a mild form of an aldosterone-resistance syndrome caused by mutations in the NR3C2 gene that codes for the mineralocorticoid receptor (MR). The disease is inherited as an autosomal dominant trait characterized by signs and symptoms of salt-losing in infancy. Disease manifestations could be severe in infancy but improve after the age of 1-3 years. Some affected members are asymptomatic and remain so life-long. In this study, we report the identification of a large deletion in the NR3C2 gene (c.1897+1_1898-1)_(c.*2955+?)del in renal PHA1 patients from an extended family spanning four generations. We prospectively evaluated the plasma renin activity and serum aldosterone profiles over four decades in symptomatic and asymptomatic affected family members. The benefits of early diagnosis on the clinical outcome were assessed as well. The long-term follow-up showed an age-dependent decrease in both plasma renin activity and serum aldosterone levels over the years. However, aldosterone levels remain high life-long. Thus, levels of aldosterone are a reliable marker to detect asymptomatic family members. The diagnosis of the proposita led to early diagnosis and therapy in other affected family members, significantly mitigating the clinical course. Despite the extremely elevated serum aldosterone levels during pregnancy, affected pregnant women did not experience any ill effects. However, this should be verified by observations in other adult patients.

Syndromes of impaired ion handling in the distal nephron: pseudohypoaldosteronism and familial hyperkalemic hypertension

The distal nephron, which is the site of the micro-regulation of water absorption and ion handling in the kidneys, is under the control of aldosterone. Impairment of the mineralocorticoid signal transduction pathway results in resistance to the action of aldosterone and of mineralocorticoids in general. Herein, we review two syndromes in which ion handling in the distal nephron is impaired: pseudohypoaldosteronism (PHA) and familial hyperkalemic hypertension (FHH). PHA is a rare inherited syndrome characterized by mineralocorticoid resistance, which leads to salt loss, hypotension, hyperkalemia and metabolic acidosis. There are two types of this syndrome: a renal (autosomal dominant) type due to mutations of the mineralocorticoid receptor (MR), and a systemic (autosomal recessive) type due to mutations of the epithelial sodium channel (ENaC). There is also a transient form of PHA, which may be due to urinary tract infections, obstructive uropathy or several medications. FHH is a rare autosomal dominant syndrome, characterized by salt retention, hypertension, hyperkalemia and metabolic acidosis. In FHH, mutations of WNK (with-no-lysine kinase) 4 and 1 alter the activity of several ion transportation systems in the distal nephron. The study of the pathophysiology of PHA and FHH greatly elucidated our understanding of the renin-angiotensin-aldosterone system function and ion handling in the distal nephron. The physiological role of the distal nephron and the pathophysiology of diseases in which the renal tubule is implicated may hence be better understood and, based on this understanding, new drugs can be developed.

Phenotype-genotype correlation in antenatal and neonatal variants of Bartter syndrome

BACKGROUND

Ante/neonatal Bartter syndrome (BS) is a hereditary salt-losing tubulopathy due to mutations in genes encoding proteins involved in NaCl reabsorption in the thick ascending limb of Henle's loop. Our aim was to study the frequency, clinical characteristics and outcome of each genetic subtype.

METHODS

Charts of 42 children with mutations in KCNJ1 (n = 19), SLC12A1 (n = 13) CLCNKB (n = 6) or BSND (n = 4) were retrospectively analysed. The median follow-up was 8.3 [0.4-18.0] years.

RESULTS

We describe 24 new mutations: 10 in KCNJ1, 11 in SLC12A1 and 3 in CLCNKB. The onset of polyhydramnios, birth term, height and weight were similar for all groups; three patients had no history of polyhydramnios or premature birth and had CLCNKB mutations according to a less severe renal sodium wasting. Contrasting with these data, patients with CLCNKB had the lowest potassium (P = 0.006 versus KCNJ1 and P = 0.034 versus SLC12A1) and chloride plasma concentrations (P = 0.039 versus KCNJ1 and P = 0.024 versus SLC12A1) and the highest bicarbonataemia (P = 0.026 versus KCNJ1 and P = 0.014 versus SLC12A1). Deafness at diagnosis was constant in patients with BSND mutations; transient neonatal hyperkalaemia was present in two-thirds of the children with KCNJ1 mutations. Nephrocalcinosis was constant in KCNJ1 and SLC12A1 but not in BSND and CLCNKB patients. In most cases, water/electrolyte supplementation + indomethacin led to catch-up growth. Three patients developed chronic renal failure: one with KCNJ1 mutations during the second decade of age and two with CLCNKB and BSND mutations and without nephrocalcinosis during the first year of life.

CONCLUSIONS

We confirmed in a large cohort of ante/ neonatal BS that deafness, transient hyperkalaemia and severe hypokalaemic hypochloraemic alkalosis orientate molecular investigations to BSND, KCNJ1 and CLCNKB genes, respectively. Chronic renal failure is a rare event, associated in this cohort with three genotypes and not always associated with nephrocalcinosis.

Molecular pathogenesis of renal pseudohypoaldosteronism type 1

Pseudohypoaldosteronism is a rare heterogeneous syndrome of mineralocorticoid resistance resulting in insufficient potassium and hydrogen secretion. Pseudohypoaldosteronism type 1 is characterized by mineralocorticoid resistance leading to neonatal salt loss, dehydration and failure to thrive. At least two different forms of pseudohypoaldosteronism type 1 can be distinguished, showing either a systemic or renal form of mineralocorticoid resistance. This review offers an overview on transepithelial sodium reabsorption and pseudohypoaldosteronism in general, and focuses on the underlying molecular pathology of the renal-restricted pseudohypoaldosteronism type 1 form caused by heterozygous mutations in the mineralocorticoid receptor-coding gene NR3C2. The investigation of several NR3C2 mutants in vitro has resulted in important progress in the understanding of the physiology of the mineralocorticoid receptor. However, there are still some families or individuals suffering from renal pseudohypoaldosteronism type 1 in whom no genetic defect was found in the NR3C2 or other genes such as SCNN1A, SCNN1B, SCNN1G, NEDD4 or SGK1 that are involved in the epithelial salt transport machinery. Further research in these cases may enable the identification of other pathologies leading to renal pseudohypoaldosteronism type 1 and permit deeper insights into the epithelial sodium reabsorption process.

Effect of early glucocorticoid treatment on MR and GR in late gestation ovine kidney

BACKGROUND

The ontogeny of the renal mineralocorticoid (MR) and glucocorticoid (GR) receptors in the ovine fetus, and the effects of early exposure to synthetic or natural glucocorticoids on the expression of these genes in late gestation were examined.

METHODS

A partial cDNA sequence for the ovine MR was cloned and used to generate primers and probes to measure MR mRNA expression by real-time polymerase chain reaction (PCR). GR mRNA was also measured. Kidneys were collected from ovine fetuses at various stages of gestation (days 60 to 140), twin ovine fetuses at 130 days, from ewes treated at days 26 to 28 with either saline, dexamethasone or cortisol, and adult sheep. Ligand binding was used to determine both GR and MR protein levels in all 130-day-old fetuses and adults.

RESULTS

No significant changes in the expression of either renal MR or GR were detected throughout gestation. Cytosolic protein levels were higher in the fetal kidneys than in the adult. There was a significant increase in both fetal MR and GR mRNA expression, but not protein levels in kidneys from ewes pretreated with dexamethasone.

CONCLUSIONS

MR and GR mRNA are expressed throughout development in ovine fetal kidneys. Dexamethasone treatment resulted in increased expression of MR and GR mRNA but not protein levels. The dissociation between fetal mRNA and protein levels, relative to adult kidneys, suggests that it may be confounding to draw conclusions based on mRNA levels alone.