Abnormal membrane sodium transport in Liddle's syndrome

Liddle's syndrome mechanisms, diagnosis and management

Liddle's syndrome is a genetic disorder characterized by hypertension with hypokalemic metabolic alkalosis, hyporeninemia and suppressed aldosterone secretion that often appears early in life. It results from inappropriately elevated sodium reabsorption in the distal nephron. Liddle's syndrome is caused by mutations to subunits of the Epithelial Sodium Channel (ENaC). Among other mechanisms, such mutations typically prevent ubiquitination of these subunits, slowing the rate at which they are internalized from the membrane, resulting in an elevation of channel activity. A minority of Liddle's syndrome mutations, though, result in a complementary effect that also elevates activity by increasing the probability that ENaC channels within the membrane are open. Potassium-sparing diuretics such as amiloride and triamterene reduce ENaC activity, and in combination with a reduced sodium diet can restore normotension and electrolyte imbalance in Liddle's syndrome patients and animal models. Liddle's syndrome can be diagnosed clinically by phenotype and confirmed through genetic testing. This review examines the clinical features of Liddle's syndrome, the differential diagnosis of Liddle's syndrome and differentiation from other genetic diseases with similar phenotype, and what is currently known about the population-level prevalence of Liddle's syndrome. This review gives special focus to the molecular mechanisms of Liddle's syndrome.

Hemolytic disease due to membrane ion channel disorders

PURPOSE OF REVIEW

To summarize recent findings in the study of the 'hereditary stomatocytoses and allied disorders', diseases in which the red cell membrane leaks Na and K, disturbing the osmotic homeostasis of the cell.

RECENT FINDINGS

Recent work has emphasized the diversity of these conditions, especially evident in the variations in temperature dependence of the cation leak. The association between the dehydrated, xerocytic form that maps to chromosome 16, with perinatal ascites is confirmed. Two cases that may represent a new hematoneurologic syndrome have been recognized.

SUMMARY

These leaky-membrane diseases fall into three main categories. The 'dehydrated' or xerocytic form maps to chromosome 16 and shows a minimal leak, and can show an excess of phosphatidylcholine in the membrane. Some of these xerocytic cases show a syndrome of self-limiting perinatal ascites of unknown cause. A second group shows very variable temperature dependence in the cation leak. The most severe 'overhydrated' form shows very leaky cells and the 32 kD stomatin protein is missing, although the gene is not mutated. This deficiency seems to be the result of a trafficking problem. The protein is associated with cholesterol and sphingomyelin-rich 'rafts' and may be some kind of partner protein for a membrane-bound proteolytic system.

Eukaryotic and prokaryotic stomatins: the proteolytic link

The 32kD membrane protein stomatin was first studied because it is deficient from the red cell membrane in two forms of the class of haemolytic anaemias known as "hereditary stomatocytosis." The hallmark of these conditions is a plasma membrane leak to the monovalent cations Na+ and K+: the protein is missing only in the most severely leaky of these conditions. No mutation has ever been found in the stomatin gene in these conditions. Stomatin-like proteins have been identified in all three domains of biology, yet their function remains enigmatic. Although the murine knock-out is without phenotype, we have identified a family showing a splicing defect in the stomatin mRNA, in which affected children showed a catastrophic multisystem disease not inconsistent with the now-known wide tissue distribution of stomatin. We report here a study of strongly homologous stomatin-like genes in prokaryotes, which reveals a close connection with a never-studied gene erroneously known as "nfed." This gene codes for a hydrophobic protein with a probable serine protease motif. It is possible that these stomatin-like genes and those which are known as"nfed" form an operon, suggesting that the two protein products are aimed at a common function. The corollary is that stomatin could be a partner protein for a membrane-bound proteolytic process, in both prokaryotes and in eukaryotes generally: this idea is consistent with experimental evidence.

The hereditary stomatocytoses and allied disorders: congenital disorders of erythrocyte membrane permeability to Na and K

The hereditary stomatocytoses and allied disorders are a set of dominantly inherited haemolytic anaemias in which the plasma membrane of the red cell 'leaks' sodium and potassium. There are about 10 different forms of these conditions, ranging from a moderately severe haemolytic anaemia to minor conditions in which the haematology is essentially normal, but where the patients present with pseudohyperkalaemia, due to leakage of K from the red cells on cooling to room temperature. Frequently misdiagnosed as atypical hereditary spherocytosis, these conditions can show marked thrombotic complications after splenectomy, which should be avoided. Laboratory studies of these conditions have drawn attention to a 32 kDa membrane protein, stomatin, which seems to act as a regulator of Na and K transport in human and animal tissues generally, but mutations in this gene do not cause these diseases. Genetic mapping in some kindreds, but not all, points to a mutation locus on chromosome 16.

Liddle's syndrome, an underrecognized entity: a report of four cases, including the first report in black individuals

Liddle's syndrome, a rare cause of hypokalemic hypertension, is characterized by a renal tubular sodium channel defect resulting in excessive sodium absorption and concomitant potassium wasting. In this disorder, although the clinical manifestations resemble primary aldosteronism, serum and urine aldosterone are suppressed. The syndrome is transmitted in an autosomal dominant pattern. It has been reported previously in white and oriental populations but not in the black individuals. We identified four patients (two of whom are black) in our nephrology clinic, with severe hypokalemic hypertension not correctly diagnosed for several years. All patients underwent an extensive work-up for secondary hypertension because of persistent severe hypertension (average blood pressure, 210/130 mm Hg) despite high-dose multi-drug therapy. Primary aldosteronism was excluded because of low serum aldosterone. Cushing's syndrome, pheochromocytoma, renal artery stenosis, and enzymatic deficiencies of cortisol synthesis (11 beta-hydroxylase, 17 alpha-hydroxylase, 5 beta-reductase, and 11 beta-hydroxysteroid dehydrogenase) were ruled out with extensive endocrine and radiologic studies. Once the diagnosis of Liddle's syndrome was suspected, all patients were treated with either triamterene or ameloride, with resolution of hypokalemia and correction of hypertension occurring within 5 to 7 days. Our findings suggest that Liddle's syndrome can occur in the black population. Although the actual incidence of this syndrome remains unknown, it may be significantly more common than we are led to believe since it is inherited in a Mendelian pattern. Whether there is a subset of low-renin, salt-sensitive black hypertensive patients who have the same or similar sodium channel defect remains to be elucidated.

Genetic hypertension. A direct link to salt

The basis of one type of inherited hypertension has been discovered-it is caused by mutations in the gene for the beta subunit of a renal sodium channel.

Liddle's syndrome: heritable human hypertension caused by mutations in the beta subunit of the epithelial sodium channel

Liddle's syndrome (pseudoaldosteronism) is an autosomal dominant form of human hypertension characterized by a constellation of findings suggesting constitutive activation of the amiloride-sensitive distal renal epithelial sodium channel. We demonstrate complete linkage of the gene encoding the beta subunit of the epithelial sodium channel to Liddle's syndrome in Liddle's original kindred. Analysis of this gene reveals a premature stop codon that truncates the cytoplasmic carboxyl terminus of the encoded protein in affected subjects. Analysis of subjects with Liddle's syndrome from four additional kindreds demonstrates either premature termination or frameshift mutations in this same carboxy-terminal domain in all four. These findings demonstrate that Liddle's syndrome is caused by mutations in the beta subunit of the epithelial sodium channel and have implications for the regulation of this epithelial ion channel as well as blood pressure homeostasis.

Liddle syndrome: clinical and cellular abnormalities

Clinical findings resemble those of primary hyperaldosteronism, except that aldosterone secretion is negligible. The fault appears to lie with continuously avid sodium channels in the distal nephron, resulting in excessive salt absorption, potassium wasting, and severe hypertension. Insights gained in this disorder may help clarify more common forms of low-renin hypertension.

Liddle's syndrome, an uncommon form of hyporeninemic hypoaldosteronism: functional and histopathological studies

Liddle's syndrome was diagnosed in a 72-year-old man who presented clinically with hypertension and muscle weakness. This disorder has been characterized by hyporeninemic hypoaldosteronism, hypertension, hypokalemia and enhanced erythrocyte sodium influx. Administration of spironolactone failed to correct the hypertension and electrolyte abnormality, which subsequently improved with triamterene therapy and a low salt diet. However, suppression of the renin-angiotensin-aldosterone system remained unchanged after this treatment. In addition, an atrophic juxtaglomerular apparatus and hypertensive lesions in the arterioles were confirmed by kidney biopsy after triamterene therapy. Therefore, a process of intrinsic hyperactive distal sodium reabsorption, probably affected by aldosterone-independent sodium transport into erythrocytes, appears to be important in the pathogenesis of this syndrome. Triamterene therapy, which usually is performed in patients with this disease, might not be the ultimate therapy in the future even if electrolyte abnormalities were to be improved temporarily.

Pseudohyperaldosteronism (Liddle's syndrome): a case report

A 22-year-old man was hospitalized because of hypertension, hypokalemic alkalosis and suppressed plasma renin activity. Although these findings were similar to hyperaldosteronism, plasma aldosterone concentration and urinary aldosterone excretion were lower than the normal range. Adrenocortical function also was normal except for aldosterone. Treatment with spironolactone, salt restriction and potassium supplementation improved the hypokalemia but not the hypertension. Blood pressure decreased markedly after administration of triamterene.

Fatal, low renin hypertension associated with a disturbance of cortisol metabolism

A 5 month old boy died after fever, persistently raised blood pressure, and hypokalaemia. A disorder of cortisol metabolism caused by 11 beta-hydroxysteroid dehydrogenase deficiency was detected retrospectively.

Prevalence and pattern of renal disease in eastern Libya

A prospective study was conducted to identify the pattern and aetiology of kidney disease in children living in eastern Libya. A total of 343 patients was studied, representing 3% of annual admissions to the children's hospital. The major renal diseases were post-streptococcal glomerulonephritis (in 116), acute renal failure (in 93), and idiopathic nephrotic syndrome (in 65). Less common diseases were tubular transport defect (in 3) and end-stage renal disease (in 3). The mortality rate (excluding neonates) was below 1%. The pattern of kidney disease referred to this hospital in Libya was different from that reported in other parts of Africa.

Erythrocyte lipid composition and sodium transport in human liver disease

In patients with liver disease there are usually increases in erythrocyte cholesterol and phosphatidylcholine concentrations. This increase in membrane lipid changes the shape of the erythrocyte and "spur" or "target" cells may be present. Sodium fluxes were measured in erythrocytes from 17 patients with a variety of liver diseases and from 17 normal subjects and the values related to the lipid content of the membrane. Ouabain-insensitive and ouabain-sensitive effluxes were lower in patients than in normal subjects and the reduction in ouabain-insensitive efflux was more marked. Sodium influx was also significantly lower in erythrocytes from patients than controls. Ouabain-sensitive and ouabain-insensitive effluxes and sodium influx did not correlate with the cholesterol content of erythrocytes from patients. Significant negative correlations were noted between ouabain-insensitive sodium efflux (r=--0.63, P less than 0.01), sodium influx (r=--0.61, P less than 0.01) and intracellular sodium concentration (r=--0.66, P less than 0.01) and the cholesterol : phospholipid molar ratio of the cell but there was no significant correlation between this ratio and the ouabain-sensitive sodium efflux (r=0.41, P less than 0.05). These results support the hypothesis that an altered lipid composition may affect the permeability of the erythrocyte membrane in patients with liver disease.

Ouabain binding and cation transport in human erythrocytes

In the present studies we have explored the relation between ouabain binding and the inhibition of potassium influx in intact human erythrocytes. The rate at which bound ouabain molecules dissociate from the erythrocyte membrane is not altered by complete replacement of choline with sodium or by partial replacement with potassium. These findings indicate that the effects of these cations on ouabain binding reflect alterations in the rate of association of ouabain molecules with the erythrocyte membrane. Variations in the cation composition of the incubation solution did not alter the relation between the fraction of the glycosidebinding sites occupied by ouabain or the fraction of ouabain-sensitive potassium influx which was inhibited. That is, irrespective of the affinity of the erythrocyte membrane for ouabain molecules and irrespective of the magnitude of glycoside-sensitive potassium influx, occupation of a given fraction of the glycoside-binding sites by ouabain results in the inhibition of an equal fraction of the ouabain-sensitive potassium transport sites.

Effects of digoxin-specific antibodies on accumulation and binding of digoxin by human erythrocytes

THE PRESENT STUDIES INDICATE THAT ACCUMULATION OF DIGOXIN BY INTACT HUMAN ERYTHROCYTES IS THE RESULT OF TWO PROCESSES: binding of digoxin to the erythrocyte membrane and uptake of digoxin across the membrane into the cell. In contrast, accumulation of ouabain by human erythrocytes is entirely attributable to binding of this glycoside to the plasma membrane. Digoxin binding to the erythrocyte membrane involves a single class of binding sites, is a saturable function of the extracellular digoxin concentration, reversible, temperature-sensitive, dependent on the cation composition of the incubation medium, inhibited by other cardioactive steroids, and correlates with the inhibition of erythrocyte potassium influx. Digoxin uptake across the membrane into the cell is also temperature-sensitive and reversible but is a linear function of the extracellular digoxin concentration, not altered by changes in the cation composition of the incubation medium, not inhibited by other cardioactive steroids, and does not correlate with inhibition of erythrocyte potassium influx. Digoxinspecific antibodies can both prevent and reverse effects of digoxin on potassium influx in human erythrocytes by virtue of the capacity of the antibodies to decrease the amount of digoxin that is bound to the erythrocyte membrane. These antibodies also reduce uptake of digoxin across the plasma membrane into the erythrocyte; however, this portion of cellular digoxin is not responsible for the observed inhibition of potassium influx. In the presence of digoxin-specific antibodies, the changes in digoxin binding to the erythrocyte membrane and in digoxin uptake across the membrane into the cell reflect the ability of the antibodies to form complexes with "free" digoxin molecules in the incubation medium and thereby decrease the effective concentration of digoxin.

The effects of sodium and potassium on ouabain binding by human erythrocytes

Ouabain binding by the human erythrocyte membrane is reversible, exhibits a high degree of chemical specificity, and can be detected at ouabain concentrations as low as 1 x 10(-10)M. The relation between ouabain binding and ouabain concentration can be described by a rectangular hyperbola permitting determination of the maximal binding (B(max)) and the ouabain concentration at which ouabain binding is half-maximal (K(B)). Reducing the external sodium concentration increased K(B), while reducing the external potassium concentration decreased K(B). Neither cation altered B(max) The reciprocal of K(B) was a linear function of the sodium concentration at sodium concentrations ranging from 0 to 150 mM. Conversely, the relation between the reciprocal of K(B) and the external potassium concentration was nonlinear, and raising the potassium concentration above 4 mM produced no further increase in K(B). These results are compatible with a model which postulates that the erythrocyte membrane contains a finite number of receptors each composed of a glycoside-binding site and a cation-binding site. When sodium occupies the cation-binding site, the affinity of the glycoside site for ouabain is increased; when potassium occupies the cation-binding site the affinity of the glycoside site for ouabain is decreased.

Hypertension with aldosterone excess

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