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Alajjuri OA, Samaha ME, Honemeyer U, Mohammed G, Mousa NA. Balancing Benefits and Risks of Indomethacin in the Management of Antenatal Bartter Syndrome: A Case Report. Front Med (Lausanne) 2022; 9:870503. [PMID: 35847797 PMCID: PMC9276994 DOI: 10.3389/fmed.2022.870503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 05/27/2022] [Indexed: 12/16/2022] Open
Abstract
Background Bartter syndrome, a very rare inherited renal tubular disorder, characterized by urinary salt wastage, hypokalemia, polyuria, and metabolic alkalosis, may manifest antenatally as severe isolated polyhydramnios. Indomethacin is known to reduce salt wastage and subsequent polyhydramnios during pregnancy; however, it reduces the Ductus Arteriosus diameter among other potential complications, such as inhibition of gastrointestinal perfusion and increasing the risk of renal toxicity. Case A 36-year-old multigravida presented with severe isolated polyhydramnios at 30 weeks of gestation. Based on a history of a previous pregnancy affected with Bartter syndrome, indomethacin was initiated. Amniotic fluid volume and Ductus Arteriosus diameter were monitored. As evidence lacks on optimal dose and duration of indomethacin, multiple-dose adjustments were made to reduce the amniotic fluid volume while maintaining normal Ductus Arteriosus diameter. Progressive polyhydramnios led to Cesarean section at 34+ weeks of gestation resulting in a healthy fetus diagnosed with Bartter syndrome in the early neonatal period. Conclusion We share our experience in the adjustment of the dose and duration of Indomethacin therapy in the treatment of severe polyhydramnios associated with antenatal Bartter syndrome. Amniotic fluid index, Ductus Arteriosus diameter, and umbilical artery doppler work together as key indicators to guide the success and safety of the therapy.
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Affiliation(s)
- Omar Ala' Alajjuri
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Mayar Essam Samaha
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Ulrich Honemeyer
- New Medical Center (NMC) Royal Hospital Sharjah, Sharjah, United Arab Emirates
| | - Ghada Mohammed
- Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
| | - Noha A. Mousa
- Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- *Correspondence: Noha A. Mousa
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Konrad M, Nijenhuis T, Ariceta G, Bertholet-Thomas A, Calo LA, Capasso G, Emma F, Schlingmann KP, Singh M, Trepiccione F, Walsh SB, Whitton K, Vargas-Poussou R, Bockenhauer D. Diagnosis and management of Bartter syndrome: executive summary of the consensus and recommendations from the European Rare Kidney Disease Reference Network Working Group for Tubular Disorders. Kidney Int 2021; 99:324-335. [PMID: 33509356 DOI: 10.1016/j.kint.2020.10.035] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/30/2020] [Accepted: 10/29/2020] [Indexed: 12/13/2022]
Abstract
Bartter syndrome is a rare inherited salt-losing renal tubular disorder characterized by secondary hyperaldosteronism with hypokalemic and hypochloremic metabolic alkalosis and low to normal blood pressure. The primary pathogenic mechanism is defective salt reabsorption predominantly in the thick ascending limb of the loop of Henle. There is significant variability in the clinical expression of the disease, which is genetically heterogenous with 5 different genes described to date. Despite considerable phenotypic overlap, correlations of specific clinical characteristics with the underlying molecular defects have been demonstrated, generating gene-specific phenotypes. As with many other rare disease conditions, there is a paucity of clinical studies that could guide diagnosis and therapeutic interventions. In this expert consensus document, the authors have summarized the currently available knowledge and propose clinical indicators to assess and improve quality of care.
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Affiliation(s)
- Martin Konrad
- Department of General Pediatrics, University Hospital Münster, Münster, Germany.
| | - Tom Nijenhuis
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Lorenzo A Calo
- Department of Medicine (DIMED), Nephrology, Dialysis, Transplantation, University of Padova, Padua, Italy
| | - Giovambattista Capasso
- Division of Nephrology, Department of Translational Medical Sciences, School of Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Emma
- Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Karl P Schlingmann
- Department of General Pediatrics, University Hospital Münster, Münster, Germany
| | - Mandeep Singh
- Fetal Medicine Centre, Southend University Hospital NHS Foundation Trust, Essex, UK
| | - Francesco Trepiccione
- Division of Nephrology, Department of Translational Medical Sciences, School of Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Stephen B Walsh
- Department of Renal Medicine, University College London, London, United Kingdom
| | | | - Rosa Vargas-Poussou
- Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Centre d'Investigation Clinique, Paris, France; Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
| | - Detlef Bockenhauer
- Department of Renal Medicine, University College London, London, United Kingdom; Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Verma S, Chanchlani R, Siu VM, Filler G. Transient hyponatremia of prematurity caused by mild Bartter syndrome type II: a case report. BMC Pediatr 2020; 20:311. [PMID: 32590952 PMCID: PMC7318402 DOI: 10.1186/s12887-020-02214-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 06/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bartter syndrome subtypes are a group of rare renal tubular diseases characterized by impaired salt reabsorption in the tubule, specifically the thick ascending limb of Henle's loop. Clinically, they are characterized by the association of hypokalemic metabolic alkalosis, hypercalciuria, nephrocalcinosis, increased levels of plasma renin and aldosterone, low blood pressure and vascular resistance to angiotensin II. Bartter syndrome type II is caused by mutations in the renal outer medullary potassium channel (ROMK) gene (KCNJ1), can present in the newborn period and typically requires lifelong therapy. CASE PRESENTATION We describe a case of a prematurely born female infant presenting with antenatal polyhydramnios, and postnatal dehydration and hyponatremia. After 7 weeks of sodium supplementation, the patient demonstrated complete resolution of her hyponatremia and developed only transient metabolic alkalosis at 2 months of age but continues to be polyuric and exhibits hypercalciuria, without development of nephrocalcinosis. She was found to have two pathogenic variants in the KCNJ1 gene: a frameshift deletion, p.Glu334Glyfs*35 and a missense variant, p. Pro110Leu. While many features of classic ROMK mutations have resolved, the child does have Bartter syndrome type II and needs prolonged pediatric nephrology follow-up. CONCLUSION Transient neonatal hyponatremia warrants a multi-system workup and genetic variants of KCNJ1 should be considered.
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Affiliation(s)
- Subhrata Verma
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, 1151 Richmond Street, London, ON, N6A5C1, Canada
| | - Rahul Chanchlani
- Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, 1200 Main Street West, Hamilton, ON, L8N 3Z5, Canada
| | - Victoria Mok Siu
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, 1151 Richmond Street, London, ON, N6A5C1, Canada.,Division of Medical Genetics, and Department of Biochemistry, London Health Sciences Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada.,Children's Health Research Institute, 750 Baseline Road East, London, ON, N6C 2R5, Canada
| | - Guido Filler
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, 1151 Richmond Street, London, ON, N6A5C1, Canada. .,Children's Health Research Institute, 750 Baseline Road East, London, ON, N6C 2R5, Canada. .,Departments of Pathology and Laboratory Medicine, Division of Nephrology, Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, University of Western Ontario, 800 Commissioners Road East, London, ON, N6A 5W9, Canada.
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Kleta R, Bockenhauer D. Salt-Losing Tubulopathies in Children: What's New, What's Controversial? J Am Soc Nephrol 2018; 29:727-739. [PMID: 29237739 PMCID: PMC5827598 DOI: 10.1681/asn.2017060600] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Renal tubulopathies provide insights into the inner workings of the kidney, yet also pose therapeutic challenges. Because of the central nature of sodium in tubular transport physiology, disorders of sodium handling may affect virtually all aspects of the homeostatic functions of the kidney. Yet, owing to the rarity of these disorders, little clinical evidence regarding treatment exists. Consequently, treatment can vary widely between individual physicians and centers and is based mainly on understanding of renal physiology, reported clinical observations, and individual experiences. Salt-losing tubulopathies can affect all tubular segments, from the proximal tubule to the collecting duct. But the more frequently observed disorders are Bartter and Gitelman syndrome, which affect salt transport in the thick ascending limb of Henle's loop and/or the distal convoluted tubule, and these disorders generate the greatest controversies regarding management. Here, we review clinical and molecular aspects of salt-losing tubulopathies and discuss novel insights provided mainly by genetic investigations and retrospective clinical reviews. Additionally, we discuss controversial topics in the management of these disorders to highlight areas of importance for future clinical trials. International collaboration will be required to perform clinical studies to inform the treatment of these rare disorders.
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Affiliation(s)
- Robert Kleta
- UCL Centre for Nephrology and Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Detlef Bockenhauer
- UCL Centre for Nephrology and Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
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Dorsett D. The Drosophila melanogaster model for Cornelia de Lange syndrome: Implications for etiology and therapeutics. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2016; 172:129-37. [PMID: 27097273 DOI: 10.1002/ajmg.c.31490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Discovery of genetic alterations that cause human birth defects provide key opportunities to improve the diagnosis, treatment, and family counseling. Frequently, however, these opportunities are limited by the lack of knowledge about the normal functions of the affected genes. In many cases, there is more information about the gene's orthologs in model organisms, including Drosophila melanogaster. Despite almost a billion years of evolutionary divergence, over three-quarters of genes linked to human diseases have Drosophila homologs. With a short generation time, a twenty-fold smaller genome, and unique genetic tools, the conserved functions of genes are often more easily elucidated in Drosophila than in other organisms. Here we present how this applies to Cornelia de Lange syndrome, as a model for how Drosophila can be used to increase understanding of genetic syndromes caused by mutations with broad effects on gene transcription and exploited to develop novel therapies. © 2016 Wiley Periodicals, Inc.
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Azzi A, Chehade H, Deschênes G. Neonates with Bartter syndrome have enormous fluid and sodium requirements. Acta Paediatr 2015; 104:e294-9. [PMID: 25703573 DOI: 10.1111/apa.12981] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/07/2014] [Accepted: 02/19/2015] [Indexed: 11/30/2022]
Abstract
AIM Managing neonatal Bartter syndrome by achieving adequate weight gain is challenging. We assessed the correlation between weight gain in neonatal Bartter syndrome and the introduction of fluid and sodium supplementations and indomethacin during the first 4 weeks of life. METHODS Daily fluid and electrolytes requirements were analysed using linear regression and Spearman correlation coefficients. The weight gain coefficient was calculated as daily weight gain after physiological neonatal weight loss. RESULTS We studied seven infants. The highest weight gain coefficients occurred between weeks two and four in the five neonates who either received prompt amounts of fluid (maximum 810 mL/kg/day) and sodium (maximum 70 mmol/kg/day) or were treated with indomethacin. For the two patients with the highest weight gain coefficient, water and sodium supplementations were decreased in weeks two to four leading to a significant negative Spearman correlation between weight gain and fluid supplements (r = -0.55 and -0.68) and weight gain and sodium supplementations (r = -0.96 and -0.72). The two patients with the lowest weight gain coefficient had positive Spearman correlation coefficients between weight gain and fluid and sodium supplementations. CONCLUSION Infants with neonatal Bartter syndrome required rapid and enormous fluid and sodium supplementations or the early introduction of indomethacin treatment to achieve adequate weight gain during the early postnatal period.
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Affiliation(s)
- Antonio Azzi
- Department of Pediatrics; Division of Pediatric Nephrology; Lausanne University Hospital; Lausanne Switzerland
| | - Hassib Chehade
- Department of Pediatrics; Division of Pediatric Nephrology; Lausanne University Hospital; Lausanne Switzerland
| | - Georges Deschênes
- Department of Pediatrics; Division of Pediatric Nephrology; Robert Debré University Hospital; Paris France
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7
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Identification of the Conformational transition pathway in PIP2 Opening Kir Channels. Sci Rep 2015; 5:11289. [PMID: 26063437 PMCID: PMC4462750 DOI: 10.1038/srep11289] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 04/29/2015] [Indexed: 11/08/2022] Open
Abstract
The gating of Kir channels depends critically on phosphatidylinositol 4,5-bisphosphate (PIP2), but the detailed mechanism by which PIP2 regulates Kir channels remains obscure. Here, we performed a series of Targeted molecular dynamics simulations on the full-length Kir2.1 channel and, for the first time, were able to achieve the transition from the closed to the open state. Our data show that with the upward motion of the cytoplasmic domain (CTD) the structure of the C-Linker changes from a loop to a helix. The twisting of the C-linker triggers the rotation of the CTD, which induces a small downward movement of the CTD and an upward motion of the slide helix toward the membrane that pulls the inner helix gate open. At the same time, the rotation of the CTD breaks the interaction between the CD- and G-loops thus releasing the G-loop. The G-loop then bounces away from the CD-loop, which leads to the opening of the G-loop gate and the full opening of the pore. We identified a series of interaction networks, between the N-terminus, CD loop, C linker and G loop one by one, which exquisitely regulates the global conformational changes during the opening of Kir channels by PIP2.
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Abstract
Electrolyte disorders can result in life-threatening complications. The kidneys are tasked with maintaining electrolyte homoeostasis, yet the low glomerular filtration rate of neonatal kidneys, tubular immaturity, and high extrarenal fluid losses contribute to increased occurrence of electrolyte disorders in neonates. Understanding the physiologic basis of renal electrolyte handling is crucial in identifying underlying causes and initiation of proper treatment. This article reviews key aspects of renal physiology, the diagnostic workup of disorders of plasma sodium and potassium, and the appropriate treatment, in addition to inherited disorders associated with neonatal electrolyte disturbances that illuminate the physiology of renal electrolyte handling.
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Affiliation(s)
- Detlef Bockenhauer
- UCL Institute of Child Health, Great Ormond Street Hospital for Children NHS Foundation Trust, Nephrology Unit, 30 Guilford Street, London WC1 3EH, UK.
| | - Jakub Zieg
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 15006 Praha 5, Czech Republic
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Liu Y, Jia Z, Sun Y, Zhou L, Downton M, Chen R, Zhang A, Yang T. Postnatal regulation of 15-hydroxyprostaglandin dehydrogenase in the rat kidney. Am J Physiol Renal Physiol 2014; 307:F388-95. [PMID: 24647712 DOI: 10.1152/ajprenal.00512.2013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Cyclooxygenase 2 (COX-2) has an established role in postnatal kidney development. 15-Hydroxyprostaglandin dehydrogenase (15-PGDH) is recently identified as an endogenous inhibitor of COX-2, limiting the production of COX-2-derived prostanoids in several pathological conditions. The present study was undertaken to examine the regulation of renal 15-PGDH expression during postnatal kidney development in rats compared with COX-2. qRT-PCR and immunoblotting demonstrated that 15-PGDH mRNA and protein in the kidney were present in neonates, peaked in the second postnatal week, and then declined sharply to very low level in adulthood. Immunostaining demonstrated that at the second postnatal week, renal 15-PGDH protein was predominantly found in the proximal tubules stained positive for Na/H exchanger 3 and brush borders (periodic acid-Schiff), whereas COX-2 protein was restricted to macular densa and adjacent thick ascending limbs. Interestingly, in the fourth postnatal week, 15-PGDH protein was redistributed to thick ascending limbs stained positive for the Na-K-2Cl cotransporter. After 6 wk of age, 15-PGDH protein was found in the granules in subsets of the proximal tubules. Overall, these results support a possibility that 15-PGDH may regulate postnatal kidney development through interaction with COX-2.
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Affiliation(s)
- Ying Liu
- Department of Internal Medicine, University of Utah and Veterans Affairs Medical Center, Salt Lke City, Utah
| | - Zhanjun Jia
- Department of Internal Medicine, University of Utah and Veterans Affairs Medical Center, Salt Lke City, Utah
| | - Ying Sun
- Department of Internal Medicine, University of Utah and Veterans Affairs Medical Center, Salt Lke City, Utah
| | - Li Zhou
- Institute of Hypertension, Sun Yat-sen University School of Medicine, Guangzhou, China
| | - Maicy Downton
- Department of Internal Medicine, University of Utah and Veterans Affairs Medical Center, Salt Lke City, Utah
| | - Ren Chen
- Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou, China; and
| | - Aihua Zhang
- Department of Nephrology, Nanjing Children's Hospital, Affiliated to Nanjing Medical University, Nanjing, China
| | - Tianxin Yang
- Department of Internal Medicine, University of Utah and Veterans Affairs Medical Center, Salt Lke City, Utah; Institute of Hypertension, Sun Yat-sen University School of Medicine, Guangzhou, China;
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10
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Antenatal bartter syndrome: a review. Int J Pediatr 2012; 2012:857136. [PMID: 22518185 PMCID: PMC3299276 DOI: 10.1155/2012/857136] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 12/08/2011] [Accepted: 12/21/2011] [Indexed: 12/17/2022] Open
Abstract
Antenatal Bartter syndrome (ABS) is a rare autosomal recessive renal tubular disorder. The defective chloride transport in the loop of Henle leads to fetal polyuria resulting in severe hydramnios and premature delivery. Early onset, unexplained maternal polyhydramnios often challenges the treating obstetrician. Increasing polyhydramnios without apparent fetal or placental abnormalities should lead to the suspicion of this entity. Biochemical analysis of amniotic fluid is suggested as elevated chloride level is usually diagnostic. Awareness, early recognition, maternal treatment with indomethacin, and amniocentesis allow the pregnancy to continue. Affected neonates are usually born premature, have postnatal polyuria, vomiting, failure to thrive, hypercalciuria, and subsequently nephrocalcinosis. Hypokalemia, metabolic alkalosis, secondary hyperaldosteronism and hyperreninaemia are other characteristic features. Volume depletion due to excessive salt and water loss on long term stimulates renin-angiotensin-aldosterone system resulting in juxtaglomerular hyperplasia. Clinical features and electrolyte abnormalities may also depend on the subtype of the syndrome. Prenatal diagnosis and timely indomethacin administration prevent electrolyte imbalance, restitute normal growth, and improve activity. In this paper, authors present classification, pathophysiology, clinical manifestations, laboratory findings, complications, and prognosis of ABS.
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Oğuz SS, Gökmen T, Erdeve O, Uras N, Dilmen U. Acetyl salicylic acid treatment in neonatal Bartter syndrome. Pediatr Nephrol 2011; 26:1339-40. [PMID: 21553351 DOI: 10.1007/s00467-011-1861-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 02/07/2011] [Indexed: 11/27/2022]
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Abstract
Bartter's syndrome is a group of inherited, salt-losing tubulopathies presenting as metabolic alkalosis with normotensive hyperreninemia and hyperaldosteronism. We report here the first case of a neonate with bilateral, sensorineural deafness, a variant of antenatal Bartter's syndrome from an Indian community.
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Affiliation(s)
- R P Bhamkar
- Department of Pediatrics, Gurunanak Hospital, Bandra (E), Mumbai, India
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13
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Hui L, Bianchi DW. Prenatal pharmacotherapy for fetal anomalies: a 2011 update. Prenat Diagn 2011; 31:735-43. [PMID: 21638296 DOI: 10.1002/pd.2777] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 04/12/2011] [Accepted: 04/17/2011] [Indexed: 11/11/2022]
Abstract
Fetal therapy can be defined as any prenatal treatment administered to the mother with the primary indication to improve perinatal or long-term outcomes for the fetus or newborn. This review provides an update of the pharmacological therapies that are solely directed at the fetus with anomalies and outlines a future transcriptomic approach. Fetal anomalies targeted with prenatal pharmacotherapy are a heterogeneous group of structural, endocrine, and metabolic conditions, including congenital cystic adenomatoid malformation (CCAM), congenital adrenal hyperplasia, congenital heart block, fetal tachyarrhythmias, inborn errors of metabolism, fetal thyroid disorders, and polyhydramnios. To date, the majority of pharmacotherapies for fetal anomalies have been evaluated only in retrospective, uncontrolled studies. The way forward will be with an evidence-based approach to prenatal pharmacological interventions.
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Affiliation(s)
- Lisa Hui
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA.
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14
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Dane B, Dane C, Aksoy F, Cetin A, Yayla M. Antenatal Bartter syndrome: analysis of two cases with placental findings. Fetal Pediatr Pathol 2010; 29:121-6. [PMID: 20450264 DOI: 10.3109/15513811003777276] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The prenatal diagnosis of Bartter syndrome can be based on the high chloride level in the amniotic fluid. Microscopic examination of the placenta in untreated cases showed extensive mineralization in the chorionic villi in previous studies. Two cases were presented at 26-29 weeks of gestation with severe polyhydramnios. The mothers were treated with Indomethacin, KCl, and serial amniocentesis in order to reduce the amniotic fluid volume and prevent fetal hypokalemia. The microscopic examination of the placenta revealed focal calcification and acute atherosis in placental vessels. The treatment with Indomethacin in the antenatal period can prevent severe nephrocalcinosis.
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Affiliation(s)
- Banu Dane
- Department of Gynecology & Obstetrics, Haseki Training & Research Hospital, Istanbul, Turkey
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15
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Lin CM, Tsai JD, Lo YF, Yan MT, Yang SS, Lin SH. Chronic renal failure in a boy with classic Bartter's syndrome due to a novel mutation in CLCNKB coding for the chloride channel. Eur J Pediatr 2009; 168:1129-33. [PMID: 19050915 DOI: 10.1007/s00431-008-0883-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2008] [Accepted: 11/17/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Progressive renal failure in patients with classic Bartter's syndrome (cBS) due to inactivating mutations in CLCNKB gene is extraordinarily rare. DISCUSSION We describe a 17-year-old Chinese boy who presented with progressive muscle weakness and renal failure. He was diagnosed as BS of unknown type at the age of 9 months and treated with indomethacin (2 mg/kg/day) and potassium chloride (KCl) supplementation (1.5 mEq/kg/day) for hypokalemia (2.5 mmol/l). At the age of 12 years, serum K+ was 3.0 mmol/l and creatinine reached 2.0 mg/dl. On admission, his blood pressure was normal but volume status was depleted. Urinalysis was essentially normal. Biochemical studies showed hypokalemia (K+ 2.4 mmol/l) with a high transtubular K+ gradient (TTKG) 9.6, metabolic alkalosis (HCO3- 28.4 mmol/l), normomagnesemia (2.0 mg/dl), severe renal failure (BUN 94 mg/dl, Cr 6.3 mg/dl), and hypocalciuria (urine calcium/creatinine ratio 0.02 mg/mg). Abdominal sonography revealed bilateral small size kidneys without nephrocalcinosis or renal stones. After the withdrawal of indomethacin with regular KCl and adequate fluid supplementation for 1 year, serum creatinine and K+ levels have been maintained at 4.0 mg/dl and 3.3 mmol/l, respectively. Direct sequencing of NKCC2, ROMK, ClC-Kb, and NCCT in this patient disclosed a novel homozygous missense mutation (GGG to GAG, G470E) in CLCNKB. This G470E mutation was not identified in 100 healthy Chinese subjects. Long-term therapy of non-steroidal anti-inflammatory drugs (NSAIDs), prolonged hypokalemia, chronic volume depletion, and underlying genetic variety may contribute to the deterioration of his renal function. The cautious use of NSAIDs, aggressive correction of hypokalemia, and avoidance of severe volume depletion may prevent the irreversible renal damage in patients with BS due to a Cl- channel defect.
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Affiliation(s)
- Chien-Ming Lin
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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16
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Ataoglu E, Civilibal M, Ozkul AA, Varal IG, Oktay ER, Murat E. Indomethacin-induced colon perforation in Bartter's syndrome. Indian J Pediatr 2009; 76:322-3. [PMID: 19347676 DOI: 10.1007/s12098-009-0062-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Accepted: 02/08/2008] [Indexed: 10/20/2022]
Abstract
Bartter's syndrome (BS) is an inherited renal tubular disorder characterized by hypokalemia, hypochloremic metabolic alkalosis, and hyperaldosteronism with normal blood pressure. A 22-year-old woman was referred at 23 week of gestation. Polyhydramnios was detected and the chloride level of the amniotic fluid was high. The mother was treated with indomethacin from 26 to 31 week of gestation. The newborn was delivered at 34 week of gestation. At 8th day of life, indomethacin was also started for the baby. After three days, a colonic perforation developed. Indomethacin-induced colon perforation is uncommon in antenatal Bartter's syndrome. This patient indicates that administration of indomethacin in both antenatal and/or early postnatal period may be associated with colonic perforation.
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Affiliation(s)
- Emel Ataoglu
- Department of Neonatology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
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17
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Seyberth HW. An improved terminology and classification of Bartter-like syndromes. ACTA ACUST UNITED AC 2008; 4:560-7. [PMID: 18695706 DOI: 10.1038/ncpneph0912] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2008] [Accepted: 07/04/2008] [Indexed: 12/15/2022]
Abstract
This Review outlines a terminology and classification of Bartter-like syndromes that is based on the underlying causes of these inherited salt-losing tubulopathies and is, therefore, more clinically relevant than the classical definition. Three major types of salt-losing tubulopathy can be defined: distal convoluted tubule dysfunction leading to hypokalemia (currently known as Gitelman or Bartter syndrome), the more-severe condition of polyuric loop dysfunction (often referred to as antenatal Bartter or hyperprostaglandin E syndrome), and the most-severe condition of combined loop and distal convoluted tubule dysfunction (antenatal Bartter or hyperprostaglandin E syndrome with sensorineural deafness). These three subtypes can each be further subdivided according to the identity of the defective ion transporter or channel: the sodium-chloride cotransporter NCCT or the chloride channel ClC-Kb in distal convoluted tubule dysfunction; the sodium-potassium-chloride cotransporter NKCC2 or the renal outer medullary potassium channel in loop dysfunction; and the chloride channels ClC-Ka and ClC-Kb or their beta-subunit Barttin in combined distal convoluted tubule and loop dysfunction. This new classification should help clinicians to better understand the pathophysiology of these syndromes and choose the most appropriate treatment for affected patients, while avoiding potentially harmful diagnostic and therapeutic approaches.
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Affiliation(s)
- Hannsjörg W Seyberth
- Center for Pediatric and Adolescent Medicine, Philipps University, Marburg, Germany.
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Ariceta G, Rodríguez-Soriano J. Inherited Renal Tubulopathies Associated With Metabolic Alkalosis: Effects on Blood Pressure. Semin Nephrol 2006; 26:422-33. [PMID: 17275579 DOI: 10.1016/j.semnephrol.2006.10.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Inherited tubular disorders associated with metabolic alkalosis are caused by several gene mutations encoding different tubular transporters responsible for NaCl renal handling. Body volume and renin-angiotensin-aldosterone system status are determined by NaCl reabsorption in the distal nephron. Two common hallmarks in affected individuals: hypokalemia and normal / high blood pressure, support the differential diagnosis. Bartter's syndrome, characterized by hypokalemia and normal blood pressure, is a heterogenic disease caused by the loss of function of SLC12A1 (type 1), KCNJ1 (type 2), CLCNKB (type 3), or BSND genes (type 4). As a result, patients present with renal salt wasting and hypercalciuria. Gitelman's syndrome is caused by the loss of funcion of the SLC12A3 gene and may resemble Bartter's syndrome, though is associated with the very low urinary calcium. Liddle's syndrome, also with similar phenotype but with hypertension, is produced by the gain of function of the SNCC1B or SNCC1G genes, and must be distinguished from other entities of inherited hypertension such as Apparently Mineralocorticoid Excess, of glucocorticoid remediable hypertension.
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Affiliation(s)
- Gema Ariceta
- Division of Pediatric Nephrology, Department of Pediatrics, Hospital de Cruces and Basque University School of Medicine, Bilbao, Spain.
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Kömhoff M, Tekesin I, Peters M, Leonhard A, Seyberth HW. Perinatal management of a preterm neonate affected by hyperprostaglandin E2 syndrome (HPS). Acta Paediatr 2005; 94:1690-3. [PMID: 16303714 DOI: 10.1080/08035250510043897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Neonates affected by hyperprostaglandin E(2) syndrome (HPS) present with severe polyuria. Both urinary losses as well as prostaglandin synthesis inhibitors may precipitate acute renal failure (ARF). AIM Our goal was to maintain euvolaemia by replacement of urinary losses. PATIENT Our patient was born prematurely with a family history typical of HPS. Urinary salt and water losses and PGE(2) excretion were determined in 2- to 4-h intervals. Salt and water were replaced accordingly. RESULTS Within the first 48 h, urinary losses and PGE(2) increased continuously to 50 ml/kg/h and 374 ng/h/1.73 m(2), respectively. Following exposure to 0.05-0.5 mg/kg/d indomethacin, urinary output decreased steadily to 10-15/ml/kg/h. CONCLUSION In euvolaemic preterm neonates with HPS and the need for excessive replacement of salt and water, inhibition of renal PGE(2) excretion with indomethacin effectively reduces polyuria and natriuresis without acutely compromising renal function.
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Affiliation(s)
- Martin Kömhoff
- Department of Paediatrics, Philipps University Marburg, Marburg, Germany.
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Jeck N, Schlingmann KP, Reinalter SC, Kömhoff M, Peters M, Waldegger S, Seyberth HW. Salt handling in the distal nephron: lessons learned from inherited human disorders. Am J Physiol Regul Integr Comp Physiol 2005; 288:R782-95. [PMID: 15793031 DOI: 10.1152/ajpregu.00600.2004] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The molecular basis of inherited salt-losing tubular disorders with secondary hypokalemia has become much clearer in the past two decades. Two distinct segments along the nephron turned out to be affected, the thick ascending limb of Henle's loop and the distal convoluted tubule, accounting for two major clinical phenotypes, hyperprostaglandin E syndrome and Bartter-Gitelman syndrome. To date, inactivating mutations have been detected in six different genes encoding for proteins involved in renal transepithelial salt transport. Careful examination of genetically defined patients (“human knockouts”) allowed us to determine the individual role of a specific protein and its contribution to the overall process of renal salt reabsorption. The recent generation of several genetically engineered mouse models that are deficient in orthologous genes further enabled us to compare the human phenotype with the animal models, revealing some unexpected interspecies differences. As the first line treatment in hyperprostaglandin E syndrome includes cyclooxygenase inhibitors, we propose some hypotheses about the mysterious role of PGE2in the etiology of renal salt-losing disorders.
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Affiliation(s)
- Nikola Jeck
- MD, Univ. Children's Hospital, Philipps-Univ., Deutschhausstrasse 12, D-35037 Marburg, Germany. )
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Abstract
MORE PRECISE IDENTIFICATION: The progress in molecular genetics has led to better understanding of primitive magnesium deficiency. Transporters of this cation have been identified in the intestines and kidneys. The majority of congential hypomanesemia phenotypes have been correlated with a defect in magnesium transport. The primary deficiency of intestinal absorption of magnesium is responsible for hypomagnesemia and subsequent hypocalcemia. DEPENDING ON THE MECHANISM: Magnesium absorption defects in Henle's loop induce hypomagnesemia with hypercalciuria and nephrocalcinosis, autosomal dominant hypocalcemia or Bartter syndrome. In isolated dominant hypomagnesemia and Gitelman syndrome, an abnormality in the distal convoluted tubule explains the primitive hypomagnesemia, through renal leaking. Conversely, the mechanisms of recessive isolated hypomagnesemia remains unknown. ORIENTING GENETIC DIAGNOSIS: In a context of primitive hypomagnesemia, the clinical and biological presentation will orient genetic research leading to correct diagnosis. However, there are many border-line phenotypes and the pheno-genotype correlation is still imperfect.
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Affiliation(s)
- David Montaigne
- Service d'endocrinologie et métabolisme, Centre hospitalo-universitaire, Lille (59)
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Nüsing RM, Seyberth HW. The role of cyclooxygenases and prostanoid receptorsin furosemide-like salt losing tubulopathy: the hyperprostaglandin E syndrome. ACTA ACUST UNITED AC 2004; 181:523-8. [PMID: 15283766 DOI: 10.1111/j.1365-201x.2004.01326.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hyperprostaglandin E syndrome/antenatal Bartter syndrome is characterized by NaCl wasting and volume depletion, juxtaglomerula hypertrophy, hyperreninism and secondary hyperaldosteronism. Primary causes are mutations in the gene for Na-K-2Cl-cotransporter, NKCC2, or for potassium channel, ROMK, responsible for medullary NaCl malabsorption. Most intriguing aspect of the syndrome is the association with a massively increased renal prostaglandin production which contributes substantially to the clinical picture of the patients. Therefore the term hyperprostaglandin E syndrome has been introduced. It is unclear how prostaglandins aggravate the NaCl transport deficiency. Aspects to prostaglandin synthesis and receptor-mediated function within the kidney in patients suffering from hyperprostaglandin E syndrome/antenatal Bartter syndrome will be discussed.
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Affiliation(s)
- R M Nüsing
- Department of Pediatrics, Philipp's University, Marburg, Germany
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Naesens M, Steels P, Verberckmoes R, Vanrenterghem Y, Kuypers D. Bartter's and Gitelman's syndromes: from gene to clinic. Nephron Clin Pract 2004; 96:p65-78. [PMID: 15056980 DOI: 10.1159/000076752] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Bartter's and Gitelman's syndromes are characterized by hypokalemia, normal to low blood pressure and hypochloremic metabolic alkalosis. Recently, investigators have been able to demonstrate mutations of six genes encoding several renal tubular transporters and ion channels that can be held responsible for Bartter's and Gitelman's syndromes. Neonatal Bartter's syndrome is caused by mutations of NKCC2 or ROMK, classic Bartter's syndrome by mutations of ClC-Kb, Bartter's syndrome associated with sensorineural deafness is due to mutations of BSND, Gitelman's syndrome to mutations of NCCT and Bartter's syndrome associated with autosomal dominant hypocalcemia is linked to mutations of CASR. We review the pathophysiology of these syndromes in relation to their clinical presentation.
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Affiliation(s)
- Maarten Naesens
- Department of Nephrology, Katholieke Universiteit Leuven, Belgium
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Shalev H, Ohali M, Kachko L, Landau D. The neonatal variant of Bartter syndrome and deafness: preservation of renal function. Pediatrics 2003; 112:628-33. [PMID: 12949294 DOI: 10.1542/peds.112.3.628] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A subtype of antenatal Bartter syndrome and sensorineural deafness (BSND) was originally described among families from southern Israel, and its gene (Barttin, OMIM #606412) has recently been identified. A report has suggested that these children develop chronic renal insufficiency during childhood attributable to chronic tubulointerstitial fibrosis and atrophy. METHODS Data from 13 infants with BSND, who were born during a 20-year period in our institution, were retrospectively analyzed. RESULTS All pregnancies were complicated by polyhydramnion and premature birth. All patients have sensorineural deafness, as well as hypokalemic metabolic alkalosis. Persistent hypercalciuria or nephrocalcinosis were absent in most children. All children have been treated with indomethacin (2 mg/kg/d) and potassium supplementation. The current average serum creatinine and calculated creatinine clearance from the older group (n = 8; mean age: 8.8 +/- 1.4 years) is 60.8 +/- 16.5 micro mol/L and 95 +/- 20 mL/min/1.73m(2), respectively. Kidney biopsies from two 7-year-old patients revealed mild focal tubulointerstitial fibrosis and minimal mesangial proliferation but no glomerulosclerosis. CONCLUSIONS Early renal function deterioration is not a uniform finding among children with BSND mutations.
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Affiliation(s)
- Hanna Shalev
- Department of Pediatrics, Soroka University Medical Center, Beer-Sheva, Israel
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Tomimatsu T, Fukuda H, Kanzaki T, Hirano S, Wada K, Murata Y. Neonatal Bartter syndrome with unilateral multicystic dysplastic kidney disease. Pediatr Nephrol 2003; 18:391-3. [PMID: 12700968 DOI: 10.1007/s00467-002-1043-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2002] [Revised: 10/15/2002] [Accepted: 10/15/2002] [Indexed: 10/25/2022]
Abstract
Neonatal Bartter syndrome is characterized by antenatal presentation with polyhydramnios. In this paper, we report a case of neonatal Bartter syndrome associated with unilateral multicystic dysplastic kidney disease. To our knowledge, this is the first case report of such an association.
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Affiliation(s)
- Takuji Tomimatsu
- Department of Obstetrics and Gynecology, Osaka University Faculty of Medicine, 2-2, Yamada-oka, Suita, 565-0871, Osaka, Japan.
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Haas NA, Nossal R, Schneider CH, Lewin MAG, Ocker V, Holder M, Uhlemann F. Successful management of an extreme example of neonatal hyperprostaglandin-E syndrome (Bartter's syndrome) with the new cyclooxygenase-2 inhibitor rofecoxib. Pediatr Crit Care Med 2003; 4:249-51. [PMID: 12749662 DOI: 10.1097/01.pcc.0000059422.26706.64] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the successful treatment of an unusual case of severe neonatal Bartter's syndrome refractory to treatment with indomethacin. DESIGN Case report, clinical. SETTING Tertiary care intensive care unit. PATIENTS A patient with neonatal hyperprostaglandin-E syndrome and excessive requirements of intravenous (via central venous catheter) water and salt supplementation, failure to thrive, vomiting, and massive growth retardation, despite adequate treatment with indomethacin. MAIN RESULT Four weeks after induction of the new cyclooxygenase-2 inhibitor rofecoxib, the patient was well, on full enteral feeds, thriving, and had gained 600 g in weight. A lower supplementary potassium, magnesium, and sodium intake was required. Reinstitution of indomethacin therapy resulted in severe deterioration, despite high indomethacin doses; symptoms improved again after rofecoxib administration. No side effects have been seen thus far. CONCLUSION This report shows that in selected patients with a severe form of neonatal Bartter's syndrome, the new cyclooxygenase-2 inhibitor rofecoxib may control the clinical symptoms of hyperprostaglandin-E syndrome after ineffective indomethacin therapy.
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Affiliation(s)
- Nikolaus A Haas
- Department of Pediatric Cardiology and Pediatric Intensive Care, Olgahospital Stuttgart, Stuttgart, Germany
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Finer G, Shalev H, Birk OS, Galron D, Jeck N, Sinai-Treiman L, Landau D. Transient neonatal hyperkalemia in the antenatal (ROMK defective) Bartter syndrome. J Pediatr 2003; 142:318-23. [PMID: 12640382 DOI: 10.1067/mpd.2003.100] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Identification of neonatal hyperkalemia as a complication of Bartter syndrome (BS), a disorder usually characterized by hypokalemic metabolic alkalosis. Study design Case-series description of a group of 12 infants with mutations in the renal potassium channel ROMK, causing one of the antenatal variants of BS. RESULTS Prematurity, postnatal polyuria, and dehydration were seen in all cases. Plasma potassium was as high as 9.0 +/- 1.2 mmol/L and sodium as low as 124 +/- 3.5 mmol/L, appearing usually at day 3 of life and normalizing by the end of the first postnatal week. No hyperkalemia was found in 12 neonates with the variant of BS and deafness. The mean plasma potassium level during the first week of life among a group of very low-birth-weight infants with similar relative azotemia was 4.9 +/- 1 mmol/L (P <.001). The postneonatal period in the ROMK-defective children with BS was characterized by failure to thrive, hypercalciuria, nephrocalcinosis, and minimal-to-no hypokalemia. CONCLUSIONS Early postnatal hyperkalemia, sometimes severe, may complicate antenatal BS associated with ROMK mutations. Its association with hyponatremia and hyperreninemic hyperaldosteronism may erroneously suggest the diagnosis of pseudohypoaldosteronism type 1. The expression of ROMK in both the thick ascending limb and cortical collecting duct may explain this apparently tubular maturation phenomenon.
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Affiliation(s)
- Gal Finer
- Departments of Pediatrics and Genetics, Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
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Peters M, Jeck N, Reinalter S, Leonhardt A, Tönshoff B, Klaus G GÜ, Konrad M, Seyberth HW. Clinical presentation of genetically defined patients with hypokalemic salt-losing tubulopathies. Am J Med 2002; 112:183-90. [PMID: 11893344 DOI: 10.1016/s0002-9343(01)01086-5] [Citation(s) in RCA: 204] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE Hypokalemic salt-losing tubulopathies (Bartter-like syndromes) comprise a set of clinically and genetically distinct inherited renal disorders. Mutations in four renal membrane proteins involved in electrolyte reabsorption have been identified in these disorders: the furosemide-sensitive sodium-potassium-chloride cotransporter NKCC2, the potassium channel ROMK, the chloride channel ClC-Kb, and the thiazide-sensitive sodium-chloride cotransporter NCCT. The aim of this study was to characterize the clinical features associated with each mutation in a large cohort of genetically defined patients. PATIENTS AND METHODS The phenotypic characteristics of 65 patients with molecular defects in NKCC2, ROMK, ClC-Kb, or NCCT were collected retrospectively. RESULTS ROMK and NKCC2 patients presented with polyhydramnios, nephrocalcinosis, and hypo- or isosthenuria. Hypokalemia was less severe in the ROMK patients compared with the NKCC2 patients. In contrast, NCCT patients had hypocalciuria, hypomagnesemia, and marked hypokalemia. While this dissociation of renal calcium and magnesium handling was also observed in some ClC-Kb patients, a few ClC-Kb patients presented with hypercalciuria and hypo- or isosthenuria. CONCLUSIONS ROMK, NKCC2, and NCCT mutations usually have uniform clinical presentations, whereas mutations in ClC-Kb occasionally lead to phenotypic overlaps with the NCCT or, less commonly, with the ROMK/NKCC2 cohort. Based on these results, we propose an algorithm for the molecular diagnosis of hypokalemic salt-losing tubulopathies.
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Affiliation(s)
- Melanie Peters
- Department of Pediatrics, Philipps University Marburg, Marburg, Germany
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Reinalter SC, Gröne HJ, Konrad M, Seyberth HW, Klaus G. Evaluation of long-term treatment with indomethacin in hereditary hypokalemic salt-losing tubulopathies. J Pediatr 2001; 139:398-406. [PMID: 11562620 DOI: 10.1067/mpd.2001.117007] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Evaluation of the benefit/risk ratio of long-term treatment with indomethacin in salt-losing tubulopathies with special attention to renal function. STUDY DESIGN Twelve patients (median age, 14.9 years) had received indomethacin for a median of 13 years (median cumulative dose, 10.7 g/kg). Creatinine clearance, serum electrolyte levels, endocrine status, and excretion of prostaglandins and electrolytes were examined during indomethacin therapy and after its withdrawal. All patients underwent ultrasound-guided renal biopsy. For statistical evaluation, the Wilcoxon test and Pearson correlation coefficient were used. RESULTS After indomethacin withdrawal, the biochemical features of the tubulopathy reappeared. The median creatinine clearance rose from 67.4 to 96.5 mL/min/1.73 m(2) (P <.05) but remained subnormal in 4 patients. Ultrasonography elucidated medullary nephrocalcinosis in 8 patients. Renal tissue showed slight/moderate focal tubular atrophy and interstitial fibrosis in 8 patients. Comparison with biopsy specimens, obtained 11 to 14 years before study participation from 5 patients, revealed no progression. A correlation between fractional sodium and magnesium excretion and percentage of altered tubulointerstitial compartment was found (P <.001). The 4 patients with mutations in the gene of the inwardly rectifying adenosine triphosphate-regulated potassium channel (ROMK) had almost normal renal histologic findings and normal renal function. CONCLUSION Renal function and histology are unaffected by long-term indomethacin treatment.
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Affiliation(s)
- S C Reinalter
- Department of Pediatrics, Philipps University, Marburg, Germany
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Schnermann J. Sodium transport deficiency and sodium balance in gene-targeted mice. ACTA PHYSIOLOGICA SCANDINAVICA 2001; 173:59-66. [PMID: 11678727 DOI: 10.1046/j.1365-201x.2001.00885.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Animals with induced or natural null mutations in renal NaCl and water transporter genes provide a powerful tool to study the physiological mechanisms that enable the kidney to optimize the match between glomerular filtration rate and tubular reabsorption. Deficiencies in the Na/H exchanger NHE3 and in the water channel aquaporin 1 (AQP1) cause reductions in proximal fluid absorption which are accompanied by proportionate decrements in glomerular filtration rate (GFR). Compensation of the transport defect by a reduction in filtered load is so efficient that clinically symptomatic Na losses are not observed in either NHE3 or AQP1 deficient animals. On the other hand, severe syndromes of salt wasting are caused by loss of function of the Na,K,2Cl-cotransporter (NKCC2) in the thick ascending limb, or of the epithelial Na channel (ENaC) the collecting duct indicating that the severity of Na dysregulation is unrelated to the basal absorption of NaCl in a given nephron segment. In these states, the increased delivery of Na to downstream segments is not monitored by a sensor linked to the site of filtrate formation. In the absence of adaptations in the filtered load intrarenal compensation of a circumscribed NaCl malabsorption by adjustment of NaCl transport in other nephron segments is sometimes insufficient, particularly in the immature kidney of the newborn.
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Affiliation(s)
- J Schnermann
- NIDDK, National Institutes of Health, Bethesda, MD 20892, USA
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Jeck N, Reinalter SC, Henne T, Marg W, Mallmann R, Pasel K, Vollmer M, Klaus G, Leonhardt A, Seyberth HW, Konrad M. Hypokalemic salt-losing tubulopathy with chronic renal failure and sensorineural deafness. Pediatrics 2001; 108:E5. [PMID: 11433084 DOI: 10.1542/peds.108.1.e5] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To characterize a rare inherited hypokalemic salt-losing tubulopathy with linkage to chromosome 1p31. METHODS We conducted a retrospective analysis of the clinical data for 7 patients in whom cosegregation of the disease with chromosome 1p31 had been demonstrated. In addition, in 1 kindred, prenatal diagnosis in the second child was established, allowing a prospective clinical evaluation. RESULTS Clinical presentation of the patients was homogeneous and included premature birth attributable to polyhydramnios, severe renal salt loss, normotensive hyperreninemia, hypokalemic alkalosis, and excessive hyperprostaglandin E-uria, which suggested the diagnosis of hyperprostaglandin E syndrome/antenatal Bartter syndrome. However, the response to indomethacin was only poor, accounting for a more severe variant of the disease. The patients invariably developed chronic renal failure. The majority had extreme growth retardation, and motor development was markedly delayed. In addition, all patients turned out to be deaf. CONCLUSION The hypokalemic salt-losing tubulopathy with chronic renal failure and sensorineural deafness represents not only genetically but also clinically a disease entity distinct from hyperprostaglandin E syndrome/antenatal Bartter syndrome. A pleiotropic effect of a single gene defect is most likely causative for syndromic hearing loss.
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MESH Headings
- Adolescent
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Bartter Syndrome/genetics
- Child
- Child, Preschool
- Chromosomes, Human, Pair 1/genetics
- Consanguinity
- Creatinine/blood
- Cyclooxygenase Inhibitors/therapeutic use
- Deafness/genetics
- Dinoprostone/metabolism
- Dinoprostone/urine
- Diuresis
- Female
- Genetic Linkage
- Growth Disorders/genetics
- Haplotypes
- Humans
- Hypokalemia/drug therapy
- Hypokalemia/genetics
- Indomethacin/therapeutic use
- Infant
- Kidney/diagnostic imaging
- Kidney/pathology
- Kidney/ultrastructure
- Kidney Failure, Chronic/diagnosis
- Kidney Failure, Chronic/drug therapy
- Kidney Failure, Chronic/genetics
- Lebanon
- Male
- Pedigree
- Phenotype
- Renal Tubular Transport, Inborn Errors/diagnosis
- Renal Tubular Transport, Inborn Errors/diagnostic imaging
- Renal Tubular Transport, Inborn Errors/drug therapy
- Renal Tubular Transport, Inborn Errors/genetics
- Renal Tubular Transport, Inborn Errors/pathology
- Retrospective Studies
- Syndrome
- Treatment Outcome
- Turkey
- Ultrasonography
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Affiliation(s)
- N Jeck
- Departments of Pediatrics, Marburg, Germany
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Abstract
INTRODUCTION Hypokalemia is the most frequent electrolytic disturbance in hospitalized patients. It is sometimes familial. Careful clinical and biological evaluation may guide further genetic analysis. CURRENT KNOWLEDGE AND KEY POINTS Genetic hypokalemia is linked to disorders of mineralocorticoid hormone synthesis or action (glucocorticoid-remediable hyperaldosteronism, congenital adrenal hyperplasia, apparent excess of mineralocorticoids), to renal tubular disorders (Liddle's syndrome, Bartter's and Gitelmann's syndrome, tubular acidosis) or to disorders of cellular transfer of potassium (hypokalemic periodic paralysis). FUTURE PROSPECTS AND PROJECTS Molecular mechanisms of adult Bartter's syndrome are probably different from pediatric syndromes. A better clinical and biological evaluation with longitudinal follow-up could allow significant progress in the knowledge of the natural history and prognosis of these syndromes.
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Affiliation(s)
- B Goichot
- Service de médecine interne et nutrition, hôpital de Hautepierre, CHRU, avenue Molière, 67098 Strasbourg, France.
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Narchi H, Santos M, Kulaylat N. Polyhydramnios as a sign of fetal pseudohypoaldosteronism. Int J Gynaecol Obstet 2000; 69:53-4. [PMID: 10760533 DOI: 10.1016/s0020-7292(00)00180-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- H Narchi
- Pediatric Department, Sandwell District General Hospital, West Midlands, UK.
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Abstract
Hypophosphatasia (HP) is an inborn error of metabolism that is characterized by reduced bone mineralization. The aim of this investigation was to evaluate treatment of incapacitating lower limb pain in patients with childhood HP using nonsteroidal antiinflammatory drugs (NSAID). All patients (seven boys; age 32 months to 16 years) presented with delayed walking, the typical waddling gait, muscular weakness of the lower limbs, and a limited walking distance. Six patients had severe diffuse lower limb pain following physical activity and were therefore treated with NSAID. The benefit of this treatment was evaluated clinically and by measurement of renally (PGE2) and systemically (PGE-M) derived prostaglandins (PG) in urine before and during therapy. After treatment with NSAID all six patients showed marked clinical improvement with reduced pain, increased muscle strength, and a normalized walking distance. Levels of PGE-M, which had been elevated in four patients prior to therapy, returned to normal. The use of NSAID in childhood HP should be considered as a possible therapeutic approach because the quality of life in these patients is markedly impaired by pain of the limbs. Elevated PG might play a role in the bone metabolism of HP patients.
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Affiliation(s)
- H J Girschick
- Children's Hospital, University of Würzburg, Germany.
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Affiliation(s)
- J Rodriguez-Soriano
- Department of Pediatrics, Hospital de Cruces, Basque University School of Medicine, País Vasco, Spain
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