1
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Saffari F, Bahadoran E, Homaei A, Moghbelinejad S. Novel homozygous mutation in SCNN1A gene in an Iranian boy with PHA1B. J Pediatr Endocrinol Metab 2024; 37:745-749. [PMID: 38963175 DOI: 10.1515/jpem-2023-0505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/07/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVES Pseudohypoaldosteronism type 1 (PHA1) has two genetically distinct variants, including renal and systemic forms. Systemic PHA type I (PHA1B) has varying degrees of clinical presentation and results from mutations in genes encoding subunits of the epithelial sodium channel (ENaC) including the alpha, beta, and gamma subunits. To date, about 45 variants of PHA1B have been identified. CASE PRESENTATION We report a boy with PHA1B, who presented with vomiting, lethargy, and poor feeding due to salt wasting six days after birth. The patient had electrolyte imbalances. A novel SCNN1A (sodium channel epithelial subunit alpha) gene mutation, NM_001038.6:c.1497G>C, with an autosomal recessive pattern, was identified by whole exosome sequencing. This variant was inherited as a homozygote from both heterozygous parents. CONCLUSIONS PHA should be considered in neonates with hyponatremia and hyperkalemia. This case report presents a patient with a novel mutation in SCNN1A that has not been previously reported. Long-term follow-up of identified patients to understand the underlying phenotype--genotype link is necessary.
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Affiliation(s)
- Fatemeh Saffari
- Children Growth Research Center, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Ensiyeh Bahadoran
- School of Medicine, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Ali Homaei
- School of Medicine, Harvard University, Boston, USA
| | - Sahar Moghbelinejad
- Cellular and Molecular Research Centre, Research Institute for Prevention of Non-Communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran
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2
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Fincher S, Gibbons K, Johnson K, Trnka P, Mattke AC. Urinary Chloride Excretion Postcardiopulmonary Bypass in Pediatric Patients-A Pilot Study. J Pediatr Intensive Care 2024; 13:80-86. [PMID: 38571987 PMCID: PMC10987220 DOI: 10.1055/s-0041-1736549] [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: 06/06/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022] Open
Abstract
The aim of this study was to describe renal chloride metabolism following cardiopulmonary bypass (CPB) surgery in pediatric patients. A prospective observational trial in a tertiary pediatric intensive care unit (PICU) with 20 recruited patients younger than 2 years following CPB surgery was conducted. Urinary electrolytes, plasma urea, electrolytes, creatinine, and arterial blood gases were collected preoperatively, on admission to PICU and at standardized intervals thereafter. The urinary and plasma strong ion differences (SID) were calculated from these results at each time point. Fluid input and output and electrolyte and drug administration were also recorded. Median chloride administration was 67.7 mmol/kg over the first 24 hours. Urinary chloride (mmol/L; median interquartile range [IQR]) was 30 (19, 52) prior to surgery, 15 (15, 65) on admission, and remained below baseline until 24 hours. Plasma chloride (mmol/L; median [IQR]) was 105 (98, 107) prior to surgery and 101 (101, 106) on admission to PICU. It then increased from baseline, but remained within normal limits, for the remainder of the study. The urinary SID increased from 49.8 (19.1, 87.2) preoperatively to a maximum of 122.7 (92.5, 151.8) at 6 hours, and remained elevated until 48 hours. Plasma and urinary chloride concentrations were not associated with the development of acute kidney injury. Urinary chloride excretion is impaired after CPB. The urinary SID increase associated with the decrease in chloride excretion suggests impaired production and/or excretion of ammonium by the nephron following CPB, with gradual recovery postoperatively.
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Affiliation(s)
- Sophie Fincher
- Department of Pediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
- Pediatric Critical Care Research Group, Brisbane, Australia
| | - Kristen Gibbons
- Pediatric Critical Care Research Group, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Kerry Johnson
- Department of Pediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
- Pediatric Critical Care Research Group, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
| | - Peter Trnka
- School of Medicine, The University of Queensland, Brisbane, Australia
- Queensland Child and Adolescent Renal Service, Queensland Children's Hospital, Brisbane, Australia
| | - Adrian C. Mattke
- Department of Pediatric Intensive Care, Queensland Children's Hospital, Brisbane, Australia
- Pediatric Critical Care Research Group, Brisbane, Australia
- Child Health Research Centre, The University of Queensland, Brisbane, Australia
- School of Medicine, The University of Queensland, Brisbane, Australia
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3
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Affiliation(s)
- Jacob Adney
- Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine, Saint Louis, MO
| | - Seth Koehler
- Southeast Primary Care, SoutheastHEALTH, Jackson, MO
| | - Lewis Tian
- Department of Psychiatry, Saint Louis University Hospital, Saint Louis University School of Medicine, St Louis, MO
| | - Joseph Maliakkal
- Department of Pediatrics, Division of Pediatric Nephrology, Cardinal Glennon Children's Hospital, Saint Louis University School of Medicine, Saint Louis, MO
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Ng DM, Haleem M, Mamuchashvili A, Wang KY, Pan JF, Cheng Y, Ma Q. Medical evaluation and pharmacotherapeutical strategies in management of urolithiasis. Ther Adv Urol 2021; 13:1756287221993300. [PMID: 33708261 PMCID: PMC7907714 DOI: 10.1177/1756287221993300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/11/2021] [Indexed: 11/17/2022] Open
Abstract
Treatment of urolithiasis depends on several important factors which include stone location, size, composition, and patient symptoms. Although significant advancements have been made in the surgical management of urolithiasis in the last decade, pharmacotherapy which can prevent the formation of new stones and decrease the recurrence of urolithiasis has not experienced the same level of success. Currently, urolithiasis is regarded as a complicated syndrome that is determined by numerous factors, and any treatment plan for urolithiasis should be individualized while considering any potential damage arising from stone-forming factors. This review introduces the most popular methods currently used to evaluate urolithiasis and the pharmacotherapy of urolithiasis based on patient-specific factors.
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Affiliation(s)
- Derry Minyao Ng
- Translational Research Laboratory for Urology, The Key Laboratory of Ningbo City, Ningbo First Hospital, The Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Maria Haleem
- Translational Research Laboratory for Urology, The Key Laboratory of Ningbo City, Ningbo First Hospital, The Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Anny Mamuchashvili
- Translational Research Laboratory for Urology, The Key Laboratory of Ningbo City, Ningbo First Hospital, The Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Kai-yun Wang
- Translational Research Laboratory for Urology, The Key Laboratory of Ningbo City, Ningbo First Hospital, The Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Jin-Feng Pan
- Translational Research Laboratory for Urology, The Key Laboratory of Ningbo City, Ningbo First Hospital, The Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- School of Medicine, Ningbo University, Ningbo, Zhejiang, China
| | - Yue Cheng
- Department of Urology, Ningbo First Hospital, The Affiliated Hospital of Ningbo University, Ningbo, Zhejiang 315010, China
| | - Qi Ma
- Translational Research Laboratory for Urology, The Key Laboratory of Ningbo City, Ningbo First Hospital, The Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, 315010, China
- Department of Urology, Ningbo First Hospital, The Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, 315010, China
- Comprehensive Urogenital Cancer Center, Ningbo First Hospital, The Affiliated Hospital of Ningbo University, 59, Liuting Street, Ningbo, Zhejiang 315010, China
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5
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Lashhab R, Ullah AS, Cordat E. Renal collecting duct physiology and pathophysiology. Biochem Cell Biol 2019; 97:234-242. [DOI: 10.1139/bcb-2018-0192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Rawad Lashhab
- Department of Physiology and Membrane Protein and Disease Research Group, University of Alberta, Edmonton, AB T6G 2H7, Canada
- Department of Physiology and Membrane Protein and Disease Research Group, University of Alberta, Edmonton, AB T6G 2H7, Canada
| | - A.K.M. Shahid Ullah
- Department of Physiology and Membrane Protein and Disease Research Group, University of Alberta, Edmonton, AB T6G 2H7, Canada
- Department of Physiology and Membrane Protein and Disease Research Group, University of Alberta, Edmonton, AB T6G 2H7, Canada
| | - Emmanuelle Cordat
- Department of Physiology and Membrane Protein and Disease Research Group, University of Alberta, Edmonton, AB T6G 2H7, Canada
- Department of Physiology and Membrane Protein and Disease Research Group, University of Alberta, Edmonton, AB T6G 2H7, Canada
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Systemic Pseudohypoaldosteronism Type I: A Case Report and Review of the Literature. Case Rep Pediatr 2017; 2017:7939854. [PMID: 28484659 PMCID: PMC5412170 DOI: 10.1155/2017/7939854] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 02/15/2017] [Accepted: 03/19/2017] [Indexed: 12/12/2022] Open
Abstract
Systemic pseudohypoaldosteronism (PHA) type I is a rare genetic disorder resulting from mutations in the subunits of the epithelial sodium channel that manifests as severe salt wasting, hyperkalemia, and metabolic acidosis in infancy. In this article we report a patient with systemic PHA type I presenting with severe dehydration due to salt wasting at 6 days of life. She was found to have a known mutation in the SCNN1A gene and subsequently required treatment with sodium supplementation. We also review the clinical presentation, differential diagnosis, and treatment of systemic PHA type I and summarize data from 27 cases with follow-up data.
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Successful Management of Refractory Type 1 Renal Tubular Acidosis with Amiloride. Case Rep Nephrol 2017; 2017:8596169. [PMID: 28127482 PMCID: PMC5239826 DOI: 10.1155/2017/8596169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 12/02/2016] [Accepted: 12/14/2016] [Indexed: 12/31/2022] Open
Abstract
A 28-year-old female with history of hypothyroidism, Sjögren's Syndrome, and Systemic Lupus Erythematosus (SLE) presented with complaints of severe generalized weakness, muscle pain, nausea, vomiting, and anorexia. Physical examination was unremarkable. Laboratory test showed hypokalemia at 1.6 mmol/l, nonanion metabolic acidosis with HCO3 of 11 mmol/l, random urine pH of 7.0, and urine anion gap of 8 mmol/l. CT scan of the abdomen revealed bilateral nephrocalcinosis. A diagnosis of type 1 RTA likely secondary to Sjögren's Syndrome was made. She was started on citric acid potassium citrate with escalating dosages to a maximum dose of 60 mEq daily and potassium chloride over 5 years without significant improvement in serum K+ and HCO3 levels. She had multiple emergency room visits for persistent muscle pain, generalized weakness, and cardiac arrhythmias. Citric acid potassium citrate was then replaced with sodium bicarbonate at 15.5 mEq every 6 hours which was continued for 2 years without significant improvement in her symptoms and electrolytes. Amiloride 5 mg daily was added to her regimen as a potassium sparing treatment with dramatic improvement in her symptoms and electrolyte levels (as shown in the figures). Amiloride was increased to 10 mg daily and potassium supplementation was discontinued without affecting her electrolytes. Her sodium bicarbonate was weaned to 7.7 mEq daily.
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Antonogiannaki EM, Mitrouska I, Amargianitakis V, Georgopoulos D. Evaluation of acid-base status in patients admitted to ED—physicochemical vs traditional approaches. Am J Emerg Med 2015; 33:378-82. [DOI: 10.1016/j.ajem.2014.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 12/05/2014] [Accepted: 12/10/2014] [Indexed: 01/02/2023] Open
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Zhang C, Ren H, Shen P, Xu Y, Zhang W, Wang W, Li X, Ma Y, Chen N. Clinical evaluation of Chinese patients with primary distal renal tubular acidosis. Intern Med 2015; 54:725-30. [PMID: 25832932 DOI: 10.2169/internalmedicine.54.9421] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Distal renal tubular acidosis (dRTA) is a hyperchloremic metabolic acidosis disorder characterized by a normal anion gap with abnormal urinary hydrogen (H(+)) excretion. At present, there are few available reports regarding the clinical status of primary dRTA. The primary objective of this study was to analyze the clinical features and outcomes of primary dRTA. METHODS This was a retrospective study performed in patients with primary dRTA who were hospitalized at Ruijin Hospital between March 1996 and July 2009; the clinical features of these patients were analyzed. RESULTS This study included 95 consecutive inpatients: 40 men (42.11%) and 55 women (57.89%). Among them, 60 had hypokalemia (63.12%), 29 had complete dRTA and 66 had incomplete dRTA. The mean urine calcium levels of the patients with and without urinary lithiasis were 0.10±0.04 and 0.07±0.05 mmol/24 h・kg, respectively (p=0.04). The blood pH values of the patients with and those without bone disease were 7.37±0.06 and 7.32±0.06, respectively (p=0.01). A total of 8.33% (8/27) of the patients had tubular proteinuria. CONCLUSION Hypokalemia is the most common clinical manifestation of primary dRTA. Primary dRTA can also be accompanied by proximal tubular dysfunction. Controlling the urine calcium and citrate levels is crucial for the treatment of nephrocalcinosis and/or nephrolithiasis, while restoring the blood pH to the normal level is essential for controlling bone disease.
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Affiliation(s)
- Chunli Zhang
- Department of Nephrology, Shanghai Ruijin Hospital affiliated to Shanghai Jiaotong University, School of Medicine, China
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10
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Budak H, Kocpinar EF, Gonul N, Ceylan H, Erol HS, Erdogan O. Stimulation of gene expression and activity of antioxidant related enzyme in Sprague Dawley rat kidney induced by long-term iron toxicity. Comp Biochem Physiol C Toxicol Pharmacol 2014; 166:44-50. [PMID: 25038477 DOI: 10.1016/j.cbpc.2014.07.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/09/2014] [Accepted: 07/10/2014] [Indexed: 12/18/2022]
Abstract
The trace elements such as iron are vital for various enzyme activities and for other cellular proteins, but iron toxicity causes the production of reactive oxygen species (ROS) that causes alterations in morphology and function of the nephron. The present study was designed to determine the effect of long-term iron overload on the renal antioxidant system and to determine any possible correlation between enzymatic and molecular levels. Our data showed that reduced glutathione (GSH) levels, which is a marker for oxidative stress, strikingly decreased with a long-term iron overload in rat kidney. While renal mRNA levels of glucose 6-phosphate dehydrogenase (G6pd), 6-phosphogluconate dehydrogenase (6pgd) and glutathione peroxidase (Gpx) were significantly affected in the presence of ferric iron, no changes were seen for glutathione reductase (Gsr) and glutathione S-transferases (Gst). While the iron affected the enzymatic activity of G6PD, GSR, GST, and GPX, it had no significant effect on 6PGD activity in the rat kidney. In conclusion, we reported here that the gene expression of G6pd, 6pgd, Gsr, Gpx, and Gst did not correlate to enzyme activity, and the actual effect of long-term iron overload on renal antioxidant system is observed at protein level. Furthermore, the influence of iron on the renal antioxidant system is different from its effect on the hepatic antioxidant system.
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Affiliation(s)
- Harun Budak
- Atatürk University, Science Faculty, Department of Molecular Biology and Genetics, 25240 Erzurum, Turkey.
| | - Enver Fehim Kocpinar
- Atatürk University, Science Faculty, Department of Chemistry, 25240 Erzurum, Turkey
| | - Nurdan Gonul
- Atatürk University, Science Faculty, Department of Molecular Biology and Genetics, 25240 Erzurum, Turkey
| | - Hamid Ceylan
- Atatürk University, Science Faculty, Department of Molecular Biology and Genetics, 25240 Erzurum, Turkey
| | - Huseyin Serkan Erol
- Atatürk University, Faculty of Veterinary, Department of Biochemistry, 25240 Erzurum, Turkey
| | - Orhan Erdogan
- Atatürk University, Science Faculty, Department of Molecular Biology and Genetics, 25240 Erzurum, Turkey
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11
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Balanced versus unbalanced salt solutions: what difference does it make? Best Pract Res Clin Anaesthesiol 2014; 28:235-47. [PMID: 25208959 DOI: 10.1016/j.bpa.2014.07.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 06/30/2014] [Accepted: 07/02/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND The infusion of crystalloid solutions is a fundamental part of the management of critically ill patients. These solutions are used to maintain the balance of water and essential electrolytes and replace losses when patients have limited gastrointestinal intake. They also act as carriers for intravenous infusion of medication and red cells. The most commonly used solution, 0.9% saline, has equal concentrations of Na(+) and Cl(-) even though the plasma concentration of Na(+) normally is 40 meq/L higher than that of Cl(-). The use of this fluid thus can produce a hyperchloremic acidosis in a dose-dependent manner, but it is not known whether this has clinical significance. APPROACH The first part of this article deals with the significance of Na(+) and Cl(-) in normal physiology. This begins with examination of their roles in the regulation of osmolality, acid-base balance, and generation of electrochemical gradients and why the concentration of Cl(-) normally is considerably lower than that of Na(+). The next part deals with how their concentrations are regulated by the gastrointestinal tract and kidney. Based on the physiology, it would seem that solutions in which the concentration of Na(+) is "balanced" by a substance other than Cl(-) would be advantageous. The final part examines the evidence to support that point. CONCLUSIONS There are strong observational data that support the notion that avoiding an elevated Cl(-) concentration or using fluids that reduce the rise in Cl(-) reduces renal dysfunction, infections, and possibly even mortality. However, observational studies only can indicate an association and cannot indicate causality. Unfortunately, randomized trials to date are far too limited to address this crucial issue. What is clear is that appropriate randomized trials will require very large populations. It also is not known whether the important variable is the concentration of Cl(-), the difference in concentrations of Na(+) and Cl(-), or the total body mass of Cl(-).
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12
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Blanchard A, Lorthioir A, Zhygalina V, Curis E. Approche de Stewart : ou comment faire du neuf avec du vieux ? MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0889-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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13
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Mesa‐Sánchez I, Purzycka K, Isidoro‐Ayza M, Ruiz de Gopegui‐Fernández R. Fanconi syndrome in a Bichon Maltese dog: a quantitative approach to acid–base analysis. VETERINARY RECORD CASE REPORTS 2014. [DOI: 10.1136/vetreccr-2013-000022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Ignacio Mesa‐Sánchez
- Veterinary FacultyDepartment of Animal Medicine and SurgeryUniversitat Autònoma de BarcelonaBarcelona08193Spain
| | - Katarzyna Purzycka
- Veterinary FacultyDepartment of Animal Medicine and SurgeryUniversitat Autònoma de BarcelonaBarcelona08193Spain
| | - Marcos Isidoro‐Ayza
- Veterinary FacultyServei de Diagnòstic de Patologia VeterinàriaUniversitat Autònoma de BarcelonaBarcelona08193Spain
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Al-Haggar M. Cystinosis as a lysosomal storage disease with multiple mutant alleles: Phenotypic-genotypic correlations. World J Nephrol 2013; 2:94-102. [PMID: 24255892 PMCID: PMC3832870 DOI: 10.5527/wjn.v2.i4.94] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Accepted: 10/18/2013] [Indexed: 02/06/2023] Open
Abstract
Cystinosis is an autosomal recessive lysosomal storage disease with an unclear enzymatic defect causing lysosomal cystine accumulation with no corresponding elevation of plasma cystine levels leading to multisystemic dysfunction. The systemic manifestations include a proximal renal tubular defect (Fanconi-like), endocrinal disturbances, eye involvements, with corneal, conjunctival and retinal depositions, and neurological manifestations in the form of brain and muscle dysfunction. Most of the long-term ill effects of cystinosis are observed particularly in patients with long survival as a result of a renal transplant. Its responsible CTNS gene that encodes the lysosomal cystine carrier protein (cystinosin) has been mapped on the short arm of chromosome 17 (Ch17 p13). There are three clinical forms based on the onset of main symptoms: nephropathic infantile form, nephropathic juvenile form and non-nephropathic adult form with predominant ocular manifestations. Avoidance of eye damage from sun exposure, use of cystine chelators (cysteamine) and finally renal transplantation are the main treatment lines. Pre-implantation genetic diagnosis for carrier parents is pivotal in the prevention of recurrence.
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15
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Moviat M, Terpstra AM, van der Hoeven JG, Pickkers P. Impaired renal function is associated with greater urinary strong ion differences in critically ill patients with metabolic acidosis. J Crit Care 2012; 27:255-60. [DOI: 10.1016/j.jcrc.2011.05.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 05/13/2011] [Accepted: 05/29/2011] [Indexed: 10/17/2022]
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16
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Bronicki RA, Chang AC. Management of the postoperative pediatric cardiac surgical patient. Crit Care Med 2011; 39:1974-84. [PMID: 21768801 DOI: 10.1097/ccm.0b013e31821b82a6] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review the salient aspects and latest advances in the management of the postoperative pediatric cardiac patient. DATA SOURCE A Medline-based literature source. CONCLUSION The practice of pediatric cardiac intensive care has evolved considerably over the last several years. These efforts are the result of a collaborative effort from all subspecialties involved in the care of pediatric patients with congenital heart disease. Discoveries and innovations that are representative of this effort include the extension of cerebral oximetry from the operating room into the critical care setting; mechanical circulatory devices designed for pediatric patients; and surgery in very low birth weight neonates. Advances such as these impact postoperative management and make the field of pediatric cardiac intensive care an exciting, demanding, and evolving discipline, necessitating the ongoing commitment of various disciplines to pursue a greater understanding of disease processes and how to best go about treating them.
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17
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Pereira PCB, Miranda DM, Oliveira EA, Silva ACSE. Molecular pathophysiology of renal tubular acidosis. Curr Genomics 2011; 10:51-9. [PMID: 19721811 PMCID: PMC2699831 DOI: 10.2174/138920209787581262] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2008] [Revised: 11/08/2008] [Accepted: 11/12/2008] [Indexed: 01/09/2023] Open
Abstract
Renal tubular acidosis (RTA) is characterized by metabolic acidosis due to renal impaired acid excretion. Hyperchloremic acidosis with normal anion gap and normal or minimally affected glomerular filtration rate defines this disorder. RTA can also present with hypokalemia, medullary nephrocalcinosis and nephrolitiasis, as well as growth retardation and rickets in children, or short stature and osteomalacia in adults. In the past decade, remarkable progress has been made in our understanding of the molecular pathogenesis of RTA and the fundamental molecular physiology of renal tubular transport processes. This review summarizes hereditary diseases caused by mutations in genes encoding transporter or channel proteins operating along the renal tubule. Review of the molecular basis of hereditary tubulopathies reveals various loss-of-function or gain-of-function mutations in genes encoding cotransporter, exchanger, or channel proteins, which are located in the luminal, basolateral, or endosomal membranes of the tubular cell or in paracellular tight junctions. These gene mutations result in a variety of functional defects in transporter/channel proteins, including decreased activity, impaired gating, defective trafficking, impaired endocytosis and degradation, or defective assembly of channel subunits. Further molecular studies of inherited tubular transport disorders may shed more light on the molecular pathophysiology of these diseases and may significantly improve our understanding of the mechanisms underlying renal salt homeostasis, urinary mineral excretion, and blood pressure regulation in health and disease. The identification of the molecular defects in inherited tubulopathies may provide a basis for future design of targeted therapeutic interventions and, possibly, strategies for gene therapy of these complex disorders.
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Affiliation(s)
- P C B Pereira
- Pediatric Nephrology Unit, Department of Pediatrics, School of Medicine - Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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Bench-to-bedside review: Chloride in critical illness. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:226. [PMID: 20663180 PMCID: PMC2945073 DOI: 10.1186/cc9052] [Citation(s) in RCA: 206] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Chloride is the principal anion in the extracellular fluid and is the second main contributor to plasma tonicity. Its concentration is frequently abnormal in intensive care unit patients, often as a consequence of fluid therapy. Yet chloride has received less attention than any other ion in the critical care literature. New insights into its physiological roles have emerged together with progress in understanding the structures and functions of chloride channels. In clinical practice, interest in a physicochemical approach to acid-base physiology has directed renewed attention to chloride as a major determinant of acid-base status. It has also indirectly helped to generate interest in other possible effects of disorders of chloraemia. The present review summarizes key aspects of chloride physiology, including its channels, as well as the clinical relevance of disorders of chloraemia. The paper also highlights current knowledge on the impact of different types of intravenous fluids on chloride concentration and the potential effects of such changes on organ physiology. Finally, the review examines the potential intensive care unit practice implications of a better understanding of chloride.
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Gattinoni L, Carlesso E, Maiocchi G, Polli F, Cadringher P. Dilutional acidosis: where do the protons come from? Intensive Care Med 2009; 35:2033-43. [PMID: 19763537 DOI: 10.1007/s00134-009-1653-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Accepted: 07/31/2009] [Indexed: 02/08/2023]
Abstract
PURPOSE To investigate the mechanism of acidosis developing after saline infusion (dilutional acidosis or hyperchloremic acidosis). METHODS We simulated normal extracellular fluid dilution by infusing distilled water, normal saline and lactated Ringer's solution. Simulations were performed either in a closed system or in a system open to alveolar gases using software based on the standard laws of mass action and mass conservation. In vitro experiments diluting human plasma were performed to validate the model. RESULTS In our computerized model with constant pKs, diluting extracellular fluid modeled as a closed system with distilled water, normal saline or lactated Ringer's solution is not associated with any pH modification, since all its determinants (strong ion difference, CO(2) content and weak acid concentration) decrease at the same degree, maintaining their relative proportions unchanged. Experimental data confirmed the simulation results for normal saline and lactated Ringer's solution, whereas distilled water dilution caused pH to increase. This is due to the increase of carbonic pK induced by the dramatic decrease of ionic strength. Acidosis developed only when the system was open to gases due to the increased CO(2) content, both in its dissociated (bicarbonate) and undissociated form (dissolved CO(2)). CONCLUSIONS The increase in proton concentration observed after dilution of the extracellular system derives from the reaction of CO(2) hydration, which occurs only when the system is open to the gases. Both Stewart's approach and the traditional approach may account for these results.
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Affiliation(s)
- Luciano Gattinoni
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS, Ospedale Maggiore Policlinico Mangiagalli Regina Elena di Milano, Milan, Italy.
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Abstract
The cell-to-cell lactate shuttle was introduced in 1984 and has been repeatedly supported by studies using a variety of experimental approaches. Because of its large mass and metabolic capacity, skeletal muscle is probably the major component of the lactate shuttle in terms of both production and consumption. Muscles exercising in a steady state are avid consumers of lactate, using most of the lactate as an oxidative fuel. Cardiac muscle is highly oxidative and readily uses lactate as a fuel. Lactate is a major gluconeogenic substrate for the liver; the use of lactate to form glucose increases when blood lactate concentration is elevated. Illustrative of the widespread shuttling of lactate, even the brain takes up lactate when the blood level is increased. Recently, an intracellular lactate shuttle has also been proposed. Although disagreements abound, current evidence suggests that lactate is the primary end-product of glycolysis at cellular sites remote from mitochondria. This lactate could subsequently diffuse to areas adjacent to mitochondria. Evidence is against lactate oxidation within the mitochondrial matrix, but a viable hypothesis is that lactate could be converted to pyruvate by a lactate oxidation complex with lactate dehydrogenase located on the outer surface of the inner mitochondrial membrane. In another controversial area, the role of lactic acid in acid-base balance has been hotly debated in recent times. Careful analysis reveals that lactate, not lactic acid, is the substrate/product of metabolic reactions. One view is that lactate formation alleviates acidosis, whereas another is that lactate is a causative factor in acidosis. Surprisingly, there is little direct mechanistic evidence regarding cause and effect in acid-base balance. However, there is insufficient evidence to discard the term "lactic acidosis."
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Affiliation(s)
- L Bruce Gladden
- Department of Kinesiology, Auburn University, Auburn, AL 36849-5323, USA.
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Kurtz I, Kraut J, Ornekian V, Nguyen MK. Acid-base analysis: a critique of the Stewart and bicarbonate-centered approaches. Am J Physiol Renal Physiol 2008; 294:F1009-31. [PMID: 18184741 DOI: 10.1152/ajprenal.00475.2007] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
When approaching the analysis of disorders of acid-base balance, physical chemists, physiologists, and clinicians, tend to focus on different aspects of the relevant phenomenology. The physical chemist focuses on a quantitative understanding of proton hydration and aqueous proton transfer reactions that alter the acidity of a given solution. The physiologist focuses on molecular, cellular, and whole organ transport processes that modulate the acidity of a given body fluid compartment. The clinician emphasizes the diagnosis, clinical causes, and most appropriate treatment of acid-base disturbances. Historically, two different conceptual frameworks have evolved among clinicians and physiologists for interpreting acid-base phenomena. The traditional or bicarbonate-centered framework relies quantitatively on the Henderson-Hasselbalch equation, whereas the Stewart or strong ion approach utilizes either the original Stewart equation or its simplified version derived by Constable. In this review, the concepts underlying the bicarbonate-centered and Stewart formulations are analyzed in detail, emphasizing the differences in how each approach characterizes acid-base phenomenology at the molecular level, tissue level, and in the clinical realm. A quantitative comparison of the equations that are currently used in the literature to calculate H+concentration ([H+]) is included to clear up some of the misconceptions that currently exist in this area. Our analysis demonstrates that while the principle of electroneutrality plays a central role in the strong ion formulation, electroneutrality mechanistically does not dictate a specific [H+], and the strong ion and bicarbonate-centered approaches are quantitatively identical even in the presence of nonbicarbonate buffers. Finally, our analysis indicates that the bicarbonate-centered approach utilizing the Henderson-Hasselbalch equation is a mechanistic formulation that reflects the underlying acid-base phenomenology.
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Gattinoni L, Carlesso E, Cadringher P, Caironi P. Strong ion difference in urine: new perspectives in acid-base assessment. Crit Care 2006; 10:137. [PMID: 16677408 PMCID: PMC1550906 DOI: 10.1186/cc4890] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
The plasmatic strong ion difference (SID) is the difference between positively and negatively charged strong ions. At pH 7.4, temperature 37°C and partial carbon dioxide tension 40 mmHg, the ideal value of SID is 42 mEq/l. The buffer base is the sum of negatively charged weak acids ([HCO3-], [A-], [H2PO4-]) and its normal value is 42 mEq/l. According to the law of electroneutrality, the amount of positive and negative charges must be equal, and therefore the SID value is equal to the buffer base value. The easiest assessment of metabolic acidosis/alkalosis relies on the base excess calculation: buffer baseactual - buffer baseideal = SIDactual - SIDideal. The SID approach allows one to appreciate the relationship between acid–base and electrolyte equilibrium from a unique perspective, and here we describe a comprehensive model of this equilibrium. The extracellular volume is characterized by a given SID, which is a function of baseline conditions, endogenous and exogenous input (endogenous production and infusion), and urinary output. Of note, volume modifications vary the concentration of charges in the solution. An expansion of extracellular volume leads to acidosis (SID decreases), whereas a contraction of extracellular volume leads to alkalosis (SID increases). A thorough understanding of acid–base equilibrium mandates recognition of the importance of urinary SID.
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Affiliation(s)
- Luciano Gattinoni
- Dipartimento di Anestesia, Rianimazione, e Terapia del Dolore, Fondazione IRCCS – 'Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena' di Milano, Istituto di Anestesiologia e Rianimazione, Università degli Studi di Milano, Milano, Italy
| | - Eleonora Carlesso
- Istituto di Anestesiologia e Rianimazione, Università degli Studi di Milano, Milano, Italy
| | - Paolo Cadringher
- Istituto di Anestesiologia e Rianimazione, Università degli Studi di Milano, Milano, Italy
| | - Pietro Caironi
- Istituto di Anestesiologia e Rianimazione, Università degli Studi di Milano, Milano, Italy
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