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Lebel A, Ben Shalom E, Mokatern R, Halevy R, Zehavi Y, Magen D. Apparent mineralocorticoid excess in Israel: a case series and literature review. Eur J Endocrinol 2024; 190:347-353. [PMID: 38652803 DOI: 10.1093/ejendo/lvae049] [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: 11/30/2023] [Revised: 03/04/2024] [Accepted: 03/20/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND OBJECTIVE Apparent mineralocorticoid excess (AME) syndrome is an ultra-rare autosomal-recessive tubulopathy, caused by mutations in HSD11B2, leading to excessive activation of the kidney mineralocorticoid receptor, and characterized by early-onset low-renin hypertension, hypokalemia, and risk of chronic kidney disease (CKD). To date, most reports included few patients, and none described patients from Israel. We aimed to describe AME patients from Israel and to review the relevant literature. DESIGN Retrospective cohort study. METHODS Clinical, laboratory, and molecular data from patients' records were collected. RESULTS Five patients presented at early childhood with normal estimated glomerular filtration rate (eGFR), while 2 patients presented during late childhood with CKD. Molecular analysis revealed 2 novel homozygous mutations in HSD11B2. All patients presented with severe hypertension and hypokalemia. While all patients developed nephrocalcinosis, only 1 showed hypercalciuria. All individuals were managed with potassium supplements, mineralocorticoid receptor antagonists, and various antihypertensive medications. One patient survived cardiac arrest secondary to severe hyperkalemia. At last follow-up, those 5 patients who presented early exhibited normal eGFR and near-normal blood pressure, but 2 have hypertension complications. The 2 patients who presented with CKD progressed to end-stage kidney disease (ESKD) necessitating dialysis and kidney transplantation. CONCLUSIONS In this 11-year follow-up report of 2 Israeli families with AME, patients who presented early maintained long-term normal kidney function, while those who presented late progressed to ESKD. Nevertheless, despite early diagnosis and management, AME is commonly associated with serious complications of the disease or its treatment.
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Affiliation(s)
- Asaf Lebel
- Pediatric Nephrology Unit, HaEmek Medical Center, Afula 1834111, Israel
| | - Efrat Ben Shalom
- Pediatric Nephrology Unit, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9103102, Israel
| | - Rozan Mokatern
- Pediatric Nephrology Unit, HaEmek Medical Center, Afula 1834111, Israel
| | - Raphael Halevy
- Pediatric Nephrology Unit, HaEmek Medical Center, Afula 1834111, Israel
| | - Yoav Zehavi
- Pediatric Department B, HaEmek Medical Center, Afula 1834111, Israel
| | - Daniela Magen
- Technion Faculty of Medicine, Pediatric Nephrology Institute, Ruth Children's Hospital, Rambam Health Care Campus, Haifa 3109601, Israel
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2
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Fernandes-Rosa FL, Boulkroun S, Fedlaoui B, Hureaux M, Travers-Allard S, Drossart T, Favier J, Zennaro MC. New advances in endocrine hypertension: from genes to biomarkers. Kidney Int 2023; 103:485-500. [PMID: 36646167 DOI: 10.1016/j.kint.2022.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 01/15/2023]
Abstract
Hypertension (HT) is a major cardiovascular risk factor that affects 10% to 40% of the general population in an age-dependent manner. Detection of secondary forms of HT is particularly important because it allows the targeted management of the underlying disease. Among hypertensive patients, the prevalence of endocrine HT reaches up to 10%. Adrenal diseases are the most frequent cause of endocrine HT and are associated with excess production of mineralocorticoids (mainly primary aldosteronism), glucocorticoids (Cushing syndrome), and catecholamines (pheochromocytoma). In addition, a few rare diseases directly affecting the action of mineralocorticoids and glucocorticoids in the kidney also lead to endocrine HT. Over the past years, genomic and genetic studies have allowed improving our knowledge on the molecular mechanisms of endocrine HT. Those discoveries have opened new opportunities to transfer knowledge to clinical practice for better diagnosis and specific treatment of affected subjects. In this review, we describe the physiology of adrenal hormone biosynthesis and action, the clinical and biochemical characteristics of different forms of endocrine HT, and their underlying genetic defects. We discuss the impact of these discoveries on diagnosis and management of patients, as well as new perspectives related to the use of new biomarkers for improved patient care.
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Affiliation(s)
| | | | | | - Marguerite Hureaux
- Université Paris Cité, PARCC, Inserm, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France
| | - Simon Travers-Allard
- Université Paris Cité, PARCC, Inserm, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Physiologie, Paris, France
| | - Tom Drossart
- Université Paris Cité, PARCC, Inserm, Paris, France; Université de Paris Cité, PARCC, Inserm, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
| | - Judith Favier
- Université Paris Cité, PARCC, Inserm, Paris, France; Université de Paris Cité, PARCC, Inserm, Equipe Labellisée par la Ligue contre le Cancer, Paris, France
| | - Maria-Christina Zennaro
- Université Paris Cité, PARCC, Inserm, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service de Génétique, Paris, France.
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3
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Garimella PS, du Toit C, Le NN, Padmanabhan S. A genomic deep field view of hypertension. Kidney Int 2023; 103:42-52. [PMID: 36377113 DOI: 10.1016/j.kint.2022.09.029] [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: 04/03/2022] [Revised: 09/06/2022] [Accepted: 09/09/2022] [Indexed: 11/06/2022]
Abstract
Blood pressure is regulated by a complex neurohumoral system including the renin-angiotensin-aldosterone system, natriuretic peptides, endothelial pathways, the sympathetic nervous system, and the immune system. This review charts the evolution of our understanding of the genomic basis of hypertension at increasing resolution over the last 5 decades from monogenic causes to polygenic associations, spanning ∼30 monogenic rare variants and >1500 single nucleotide variants. Unexpected early wins from blood pressure genomics include deepening of our understanding of the complex causation of hypertension; refinement of causal estimates bidirectionally between blood pressure, risk factors, and outcomes through Mendelian randomization; risk stratification using polygenic risk scores; and opportunities for precision medicine and drug repurposing.
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Affiliation(s)
- Pranav S Garimella
- Division of Nephrology and Hypertension, University of California San Diego, San Diego, California, USA
| | - Clea du Toit
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Nhu Ngoc Le
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Sandosh Padmanabhan
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.
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4
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Caruso BJ, Cotant CL, Mielke BA, Pfeiffer DC. Hypertension With Hypokalemia: A Quiz. Am J Kidney Dis 2022; 80:A12-A14. [PMID: 36410927 DOI: 10.1053/j.ajkd.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/06/2022] [Indexed: 11/19/2022]
Affiliation(s)
- Bailey J Caruso
- WWAMI Medical Education Program, School of Medicine, University of Washington, Seattle, Washington
| | - Casey L Cotant
- Kootenai Clinic, Nephrology Kidney and Hypertension Services, Kootenai Health, Coeur d'Alene, Idaho
| | - Brendan A Mielke
- Kootenai Clinic, Nephrology Kidney and Hypertension Services, Kootenai Health, Coeur d'Alene, Idaho
| | - David C Pfeiffer
- WWAMI Medical Education Program, University of Idaho, Moscow, Idaho.
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5
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Lu YT, Zhang D, Zhang QY, Zhou ZM, Yang KQ, Zhou XL, Peng F. Apparent mineralocorticoid excess: comprehensive overview of molecular genetics. J Transl Med 2022; 20:500. [PMID: 36329487 PMCID: PMC9632093 DOI: 10.1186/s12967-022-03698-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/17/2022] [Accepted: 10/09/2022] [Indexed: 11/06/2022] Open
Abstract
Apparent mineralocorticoid excess is an autosomal recessive form of monogenic disease characterized by juvenile resistant low-renin hypertension, marked hypokalemic alkalosis, low aldosterone levels, and high ratios of cortisol to cortisone metabolites. It is caused by defects in the HSD11B2 gene, encoding the enzyme 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2), which is primarily involved in the peripheral conversion of cortisol to cortisone. To date, over 50 deleterious HSD11B2 mutations have been identified worldwide. Multiple molecular mechanisms function in the lowering of 11β-HSD2 activity, including damaging protein stability, lowered affinity for the substrate and cofactor, and disrupting the dimer interface. Genetic polymorphism, environmental factors as well as epigenetic modifications may also offer an implicit explanation for the molecular pathogenesis of AME. A precise diagnosis depends on genetic testing, which allows for early and specific management to avoid the morbidity and mortality from target organ damage. In this review, we provide insights into the molecular genetics of classic and non-classic apparent mineralocorticoid excess and aim to offer a comprehensive overview of this monogenic disease.
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Affiliation(s)
- Yi-Ting Lu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Di Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiong-Yu Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ze-Ming Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kun-Qi Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xian-Liang Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Fan Peng
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Leventoğlu E, Döğer E, Büyükkaragöz B, Nalçacı S, Öner G, Alpman BN, Fidan K, Söylemezoğlu O, Bakkaloğlu SA. Late-onset hypertension in a child with growth retardation: Answers. Pediatr Nephrol 2022; 37:2341-2345. [PMID: 35288793 DOI: 10.1007/s00467-022-05510-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 12/25/2022]
Affiliation(s)
- Emre Leventoğlu
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey.
| | - Esra Döğer
- Department of Pediatric Endocrinology, Gazi University, Ankara, Turkey
| | - Bahar Büyükkaragöz
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Sinem Nalçacı
- Department of Pediatric Endocrinology, Gazi University, Ankara, Turkey
| | - Ganimet Öner
- Department of Pediatric Endocrinology, Gazi University, Ankara, Turkey
| | - Bedriye Nuray Alpman
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Kibriya Fidan
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Oğuz Söylemezoğlu
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Sevcan A Bakkaloğlu
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
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Khandelwal P, Deinum J. Monogenic forms of low-renin hypertension: clinical and molecular insights. Pediatr Nephrol 2022; 37:1495-1509. [PMID: 34414500 DOI: 10.1007/s00467-021-05246-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/16/2021] [Accepted: 07/19/2021] [Indexed: 11/25/2022]
Abstract
Monogenic disorders of hypertension are a distinct group of diseases causing dysregulation of the renin-angiotensin-aldosterone system and are characterized by low plasma renin activity. These can chiefly be classified as causing (i) excessive aldosterone synthesis (familial hyperaldosteronism), (ii) dysregulated adrenal steroid metabolism and action (apparent mineralocorticoid excess, congenital adrenal hyperplasia, activating mineralocorticoid receptor mutation, primary glucocorticoid resistance), and (iii) hyperactivity of sodium and chloride transporters in the distal tubule (Liddle syndrome and pseudohypoaldosteronism type 2). The final common pathway is plasma volume expansion and catecholamine/sympathetic excess that causes urinary potassium wasting; hypokalemia and early-onset refractory hypertension are characteristic. However, several single gene defects may show phenotypic heterogeneity, presenting with mild hypertension with normal electrolytes. Evaluation is based on careful attention to family history, physical examination, and measurement of blood levels of potassium, renin, and aldosterone. Genetic sequencing is essential for precise diagnosis and individualized therapy. Early recognition and specific management improves prognosis and prevents long-term sequelae of severe hypertension.
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Affiliation(s)
- Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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8
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Impaired Distal Tubular Acidification, Renal Cysts and Nephrocalcinosis in Monogenic Hypertension. Indian J Pediatr 2021; 88:579-581. [PMID: 33236328 DOI: 10.1007/s12098-020-03516-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 09/25/2020] [Indexed: 10/22/2022]
Abstract
Monogenic defects in tubular sodium handling contribute a small proportion to hypertension in childhood. Presentation varies from severe hypertension manifesting at birth to asymptomatic hypertension and hypokalemic metabolic alkalosis detected incidentally in adulthood. A 12-y-old girl presenting with polyuria, polydipsia, severe hypertension and seizures, was found to have hypokalemia, renal medullary cysts and nephrocalcinosis. Clinical exome revealed a homozygous variation of unknown significance in exon 5 of the HSD11B2 gene, indicating the diagnosis of apparent mineralocorticoid excess. Therapy with spironolactone was associated with resolution of hypokalemia and normal blood pressure during two-year follow up.
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De Santis D, Castagna A, Danese E, Udali S, Martinelli N, Morandini F, Veneri M, Bertolone L, Olivieri O, Friso S, Pizzolo F. Detection of Urinary Exosomal HSD11B2 mRNA Expression: A Useful Novel Tool for the Diagnostic Approach of Dysfunctional 11β-HSD2-Related Hypertension. Front Endocrinol (Lausanne) 2021; 12:681974. [PMID: 34497581 PMCID: PMC8419411 DOI: 10.3389/fendo.2021.681974] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/29/2021] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Apparent mineralocorticoid excess (AME) is an autosomal recessive disorder caused by the 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) enzyme deficiency, traditionally assessed by measuring either the urinary cortisol metabolites ratio (tetrahydrocortisol+allotetrahydrocortisol/tetrahydrocortisone, THF+5αTHF/THE) or the urinary cortisol/cortisone (F/E) ratio. Exosomal mRNA is an emerging diagnostic tool due to its stability in body fluids and its biological regulatory function. It is unknown whether urinary exosomal HSD11B2 mRNA is related to steroid ratio or the HSD11B2 662 C>G genotype (corresponding to a 221 A>G substitution) in patients with AME and essential hypertension (EH). AIM OF THE STUDY To detect and quantify HSD11B2 mRNA from urinary exosomes in samples from family members affected by AME and EH, and to evaluate the relationship between exosomal HSD11B2 mRNA, steroid ratio, 662C>G genotype, and hypertension. METHODS In this observational case-control study, urinary steroid ratios and biochemical parameters were measured. Urinary exosomes were extracted from urine and exosomal HSD11B2 mRNA was quantified by Droplet Digital PCR (ddPCR). B2M (β-2 microglobulin) gene was selected as the reference housekeeping gene. RESULTS Among family members affected by AME, exosomal urinary HSD11B2 mRNA expression was strictly related to genotypes. The two homozygous mutant probands showed the highest HSD11B2 mRNA levels (median 169, range 118-220 copies/µl) that progressively decreased in 221 AG heterozygous with hypertension (108, range 92-124 copies/µl), 221 AG heterozygous normotensives (23.35, range 8-38.7 copies/µl), and wild-type 221 AA subjects (5.5, range 4.5-14 copies/µl). Heterozygous hypertensive subjects had more HSD11B2 mRNA than heterozygous normotensive subjects. The F/E urinary ratio correlated with HSD11B2 mRNA copy number (p < 0.05); HSD11B2 mRNA strongly decreased while THF+5αTHF/THE increased in the two probands after therapy. In the AME family, HSD11B2 copy number correlated with both F/E and THF+5αTHF/THE ratios, whereas in EH patients, a high F/E ratio reflected a reduced HSD11B2 mRNA expression. CONCLUSIONS HSD11B2 mRNA is detectable and quantifiable in urinary exosomes; its expression varies according to the 662 C>G genotype with the highest levels in homozygous mutant subjects. The HSD11B2 mRNA overexpression in AME could be due to a compensatory mechanism of the enzyme impairment. Exosomal mRNA is a useful tool to investigate HSD11B2 dysregulation in hypertension.
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Affiliation(s)
- Domenica De Santis
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Annalisa Castagna
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Elisa Danese
- Section of Clinical Biochemistry, University and Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Silvia Udali
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Nicola Martinelli
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Francesca Morandini
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Mariangela Veneri
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Lorenzo Bertolone
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Oliviero Olivieri
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Simonetta Friso
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
| | - Francesca Pizzolo
- Unit of Internal Medicine, Department of Medicine, University of Verona, Verona, Italy
- *Correspondence: Francesca Pizzolo,
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Brower RK, Ghlichloo IA, Shabgahi V, Elsholz D, Menon RK, Vyas AK. Liddle Syndrome due to a Novel c.1713 Deletion in the Epithelial Sodium Channel β-Subunit in a Normotensive Adolescent. AACE Clin Case Rep 2020; 7:65-68. [PMID: 33851023 PMCID: PMC7924163 DOI: 10.1016/j.aace.2020.11.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective Liddle syndrome (LS) is a rare autosomal dominant condition secondary to a gain-of-function mutation affecting the epithelial sodium channels (ENaCs) in the distal nephron. It presents with early-onset hypertension, hypokalemia, and metabolic alkalosis in the face of hyporeninemia and hypoaldosteronism. We report a novel mutation affecting the ENaCs in a normotensive adolescent with LS. Methods We describe a pediatric case of LS with a novel mutation and review the condition’s presentation and management. To date, 31 different mutations in the β- or γ-subunit of ENaCs have been reported as associated with LS. Results We describe a 16-year-old girl presenting with muscle cramps with a strong family history of hypertension and hypokalemia. Initial investigations revealed hypokalemia together with hypoaldosteronism and hyporeninemia. Subsequent genetic testing revealed a novel mutation in SCNN1B (deletion: c.1713delC), leading to the premature termination of the sodium channel epithelial 1 subunit-β protein and the LS phenotype. Treatment with triamterene (50 mg, twice daily) and potassium chloride (20 mEq, once daily) normalized the serum potassium and led to resolution of her muscle cramps. Conclusion It is essential to consider investigating the presence of rare genetic syndromes, like LS, when a patient presents with hypokalemia. Further studies are needed to understand the variable presentation of this condition.
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Affiliation(s)
- Raven K. Brower
- College of Medicine, California Northstate University, Elk Grove, California
| | - Ida A. Ghlichloo
- College of Medicine, California Northstate University, Elk Grove, California
| | - Venus Shabgahi
- College of Medicine, California Northstate University, Elk Grove, California
| | | | - Ram K. Menon
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Arpita K. Vyas
- College of Medicine, California Northstate University, Elk Grove, California
- Address correspondence and reprint requests to Dr Arpita K Vyas, Elk Grove, CA 95757.
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Fan P, Lu YT, Yang KQ, Zhang D, Liu XY, Tian T, Luo F, Wang LP, Ma WJ, Liu YX, Zhang HM, Song L, Cai J, Lou Y, Zhou XL. Apparent mineralocorticoid excess caused by novel compound heterozygous mutations in HSD11B2 and characterized by early-onset hypertension and hypokalemia. Endocrine 2020; 70:607-615. [PMID: 32816205 PMCID: PMC7674368 DOI: 10.1007/s12020-020-02460-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 08/08/2020] [Indexed: 11/22/2022]
Abstract
PURPOSE Apparent mineralocorticoid excess (AME) is an ultrarare autosomal recessive disorder resulting from deficiency of 11β-hydroxysteroid dehydrogenase type 2 (11βHSD2) caused by mutations in HSD11B2. The purpose of this study was to identify novel compound heterozygous HSD11B2 mutations in a Chinese pedigree with AME and conduct a systematic review evaluating the AME clinical features associated with HSD11B2 mutations. METHODS Next-generation sequencing was performed in the proband, and Sanger sequencing was used to identify candidate variants in family members, 100 hypertensives, and 100 healthy controls. A predicted structure of 11βHSD2 was constructed by in silico modeling. A systematic review was used to identify cases of HSD11B2-related AME. Data for genotyping and clinical characterizations and complications were extracted. RESULTS Next-generation sequencing showed novel compound heterozygous mutations (c.343_348del and c.1099_1101del) in the proband with early-onset hypertension and hypokalemia. Sanger sequencing verified the monoallelic form of the same mutations in five other relatives but not in 100 hypertensives or 100 healthy subjects. In silico structural modeling showed that compound mutations may simultaneously perturb the substrate and coenzyme binding pocket. A systematic review of 101 AME patients with 54 HSD11B2 mutations revealed early-onset hypertension, hypokalemia and homozygous mutations as common features. The homozygous HSD11B2 mutations correlated with low birth weight (r = 0.285, P = 0.02). CONCLUSIONS We report novel compound heterozygous HSD11B2 mutations in a Chinese teenager with early-onset hypertension, and enriched genotypic and phenotypic spectrums in AME. Genetic testing helps early diagnosis and treatment for AME patients, which may avoid target organ damage.
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Affiliation(s)
- Peng Fan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi-Ting Lu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kun-Qi Yang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Di Zhang
- Emergency and Critical Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xue-Ying Liu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Tian
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fang Luo
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lin-Ping Wang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen-Jun Ma
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ya-Xin Liu
- Emergency and Critical Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui-Min Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Song
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Cai
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Lou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Xian-Liang Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Bertulli C, Hureaux M, De Mutiis C, Pasini A, Bockenhauer D, Vargas-Poussou R, La Scola C. A Rare Cause of Chronic Hypokalemia with Metabolic Alkalosis: Case Report and Differential Diagnosis. CHILDREN-BASEL 2020; 7:children7110212. [PMID: 33167351 PMCID: PMC7694404 DOI: 10.3390/children7110212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 10/08/2020] [Accepted: 10/28/2020] [Indexed: 11/16/2022]
Abstract
Hypokalemia and metabolic alkalosis can be present in different rare diseases, and the differential diagnosis of these forms is challenging. Apparent mineralcorticoid (AME) excess syndrome is one of these conditions. Characterized by increased blood pressure due to excessive sodium retention and plasma volume, it is caused by a mutation in the HSD11B2 gene encoding the oxydoreductase enzyme 11β-hydroxysteroide dehydrogenase type 2. We report the case of a child presenting with failure to thrive associated with early detection of hypokalemia, metabolic alkalosis, nephrocalcinosis and hypertension in which AME syndrome was detected. A novel mutation in the HSD11B2 gene was identified in this patient. In clinical pictures characterized by metabolic alkalosis and hypokalemia, the evaluation of renin, aldosterone and blood pressure is crucial for accurate diagnosis. AME syndrome is a rare disorder that can be an insidious but lethal disease, if untreated. With clinical signs appearing during the first days of life. Early diagnosis is imperative in order to enable prompt and adequate treatment to improve the outcome of these patients.
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Affiliation(s)
- Cristina Bertulli
- Nephrology and Dialysis Unit, Department of Pediatrics, Azienda Ospedaliero Universitaria Sant’Orsola-Malpighi, 40138 Bologna, Italy; (C.B.); (C.D.M.); (A.P.)
| | - Marguerite Hureaux
- Assistance Publique Hôpitaux de Paris, Department of Genetics, Hôpital Européen Georges-Pompidou, 75015 Paris, France; (M.H.); (R.V.-P.)
| | - Chiara De Mutiis
- Nephrology and Dialysis Unit, Department of Pediatrics, Azienda Ospedaliero Universitaria Sant’Orsola-Malpighi, 40138 Bologna, Italy; (C.B.); (C.D.M.); (A.P.)
| | - Andrea Pasini
- Nephrology and Dialysis Unit, Department of Pediatrics, Azienda Ospedaliero Universitaria Sant’Orsola-Malpighi, 40138 Bologna, Italy; (C.B.); (C.D.M.); (A.P.)
| | - Detlef Bockenhauer
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK;
- Department of Renal Medicine, University College London, London WC1E 6BT, UK
| | - Rosa Vargas-Poussou
- Assistance Publique Hôpitaux de Paris, Department of Genetics, Hôpital Européen Georges-Pompidou, 75015 Paris, France; (M.H.); (R.V.-P.)
| | - Claudio La Scola
- Nephrology and Dialysis Unit, Department of Pediatrics, Azienda Ospedaliero Universitaria Sant’Orsola-Malpighi, 40138 Bologna, Italy; (C.B.); (C.D.M.); (A.P.)
- Correspondence:
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Carvajal CA, Tapia-Castillo A, Vecchiola A, Baudrand R, Fardella CE. Classic and Nonclassic Apparent Mineralocorticoid Excess Syndrome. J Clin Endocrinol Metab 2020; 105:5691192. [PMID: 31909799 DOI: 10.1210/clinem/dgz315] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 12/28/2019] [Indexed: 02/13/2023]
Abstract
CONTEXT Arterial hypertension (AHT) is one of the most frequent pathologies in the general population. Subtypes of essential hypertension characterized by low renin levels allowed the identification of 2 different clinical entities: aldosterone-mediated mineralocorticoid receptor (MR) activation and cortisol-mediated MR activation. EVIDENCE ACQUISITION This review is based upon a search of Pubmed and Google Scholar databases, up to August 2019, for all publications relating to endocrine hypertension, apparent mineralocorticoid excess (AME) and cortisol (F) to cortisone (E) metabolism. EVIDENCE SYNTHESIS The spectrum of cortisol-mediated MR activation includes the classic AME syndrome to milder (nonclassic) forms of AME, the latter with a much higher prevalence (7.1%) than classic AME but different phenotype and genotype. Nonclassic AME (NC-AME) is mainly related to partial 11βHSD2 deficiency associated with genetic variations and epigenetic modifications (first hit) and potential additive actions of endogenous or exogenous inhibitors (ie, glycyrrhetinic acid-like factors [GALFS]) and other factors (ie, age, high sodium intake) (second hit). Subjects with NC-AME are characterized by a high F/E ratio, low E levels, normal to elevated blood pressure, low plasma renin and increased urinary potassium excretion. NC-AME condition should benefit from low-sodium and potassium diet recommendations and monotherapy with MR antagonists. CONCLUSION NC-AME has a higher prevalence and a milder phenotypical spectrum than AME. NC-AME etiology is associated to a first hit (gene and epigene level) and an additive second hit. NC-AME subjects are candidates to be treated with MR antagonists aimed to improve blood pressure, end-organ damage, and modulate the renin levels.
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Affiliation(s)
- Cristian A Carvajal
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy (IMII-ICM), Santiago, Chile
- Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Alejandra Tapia-Castillo
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy (IMII-ICM), Santiago, Chile
- Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Andrea Vecchiola
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy (IMII-ICM), Santiago, Chile
- Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rene Baudrand
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Carlos E Fardella
- Department of Endocrinology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy (IMII-ICM), Santiago, Chile
- Centro Traslacional de Endocrinología UC (CETREN), Pontificia Universidad Catolica de Chile, Santiago, Chile
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Zhang J, Gopinath SCB. Quantification of cortisol for the medical diagnosis of multiple pregnancy-related diseases. 3 Biotech 2020; 10:35. [PMID: 31988829 PMCID: PMC6946767 DOI: 10.1007/s13205-019-2030-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 12/20/2019] [Indexed: 01/03/2023] Open
Abstract
Cortisol is a stress hormone released from the adrenal glands and is responsible for both hyperglycemia and hypertension during pregnancy. These factors make it mandatory to detect the levels of cortisol during pregnancy to identify and treat hypoglycemia and hypertension. In this study, cortisol levels were quantified with an aptamer-conjugated gold nanorod using an electrochemical interdigitated electrode sensor. The surface uniformity was analyzed by high-power microscopy and 3D-nanoprofiler imaging. The detection limit was determined to be 0.01 ng/mL, and a linear regression indicated that the sensitivity range was in the range of 0.01-0.1 ng/mL, based on a 3σ calculation. Moreover, the specificity of the aptamer was determined by a binding analysis against norepinephrine and progesterone, and it was clearly found that the aptamer specifically recognizes only cortisol. Further, the presence of cortisol was detected in the serum in a dose-dependent manner. This method is useful to detect and correlate multiple pregnancy-related diseases by quantifying the levels of cortisol.
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Affiliation(s)
- Junna Zhang
- Department of Gynaecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, 050000 Hebei China
| | - Subash C. B. Gopinath
- School of Bioprocess Engineering, Universiti Malaysia Perlis, 02600 Arau, Perlis Malaysia
- Institute of Nano Electronic Engineering, Universiti Malaysia Perlis, 01000 Kangar, Perlis Malaysia
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Mumford E, Unwin RJ, Walsh SB. Liquorice, Liddle, Bartter or Gitelman-how to differentiate? Nephrol Dial Transplant 2019; 34:38-39. [PMID: 29982819 DOI: 10.1093/ndt/gfy199] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 05/15/2018] [Indexed: 11/12/2022] Open
Abstract
Hypokalaemia with alkalosis can suggest excess aldosterone. Aldosterone stimulates the collecting duct mineralocorticoid receptor (MR) to upregulate the epithelial sodium channel (ENaC) and stimulate electrogenic sodium reabsorption, with secretion of potassium and protons. Gitelman, Bartter and Liddle syndrome, and liquorice ingestion all cause hypokalaemic alkalosis. This mini-review outlines the pathophysiology of these conditions as well as how to differentiate them.
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Affiliation(s)
- Elizabeth Mumford
- UCL Centre for Nephrology, Royal Free Hospital, University College, London, UK
| | - Robert J Unwin
- UCL Centre for Nephrology, Royal Free Hospital, University College, London, UK
| | - Stephen B Walsh
- UCL Centre for Nephrology, Royal Free Hospital, University College, London, UK
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Najafi M, Kordi-Tamandani DM, Behjati F, Sadeghi-Bojd S, Bakey Z, Karimiani EG, Schüle I, Azarfar A, Schmidts M. Mimicry and well known genetic friends: molecular diagnosis in an Iranian cohort of suspected Bartter syndrome and proposition of an algorithm for clinical differential diagnosis. Orphanet J Rare Dis 2019; 14:41. [PMID: 30760291 PMCID: PMC6375149 DOI: 10.1186/s13023-018-0981-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 12/14/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Bartter Syndrome is a rare, genetically heterogeneous, mainly autosomal recessively inherited condition characterized by hypochloremic hypokalemic metabolic alkalosis. Mutations in several genes encoding for ion channels localizing to the renal tubules including SLC12A1, KCNJ1, BSND, CLCNKA, CLCNKB, MAGED2 and CASR have been identified as underlying molecular cause. No genetically defined cases have been described in the Iranian population to date. Like for other rare genetic disorders, implementation of Next Generation Sequencing (NGS) technologies has greatly facilitated genetic diagnostics and counseling over the last years. In this study, we describe the clinical, biochemical and genetic characteristics of patients from 15 Iranian families with a clinical diagnosis of Bartter Syndrome. RESULTS Age range of patients included in this study was 3 months to 6 years and all patients showed hypokalemic metabolic alkalosis. 3 patients additionally displayed hypercalciuria, with evidence of nephrocalcinosis in one case. Screening by Whole Exome Sequencing (WES) and long range PCR revealed that 12/17 patients (70%) had a deletion of the entire CLCNKB gene that was previously identified as the most common cause of Bartter Syndrome in other populations. 4/17 individuals (approximately 25% of cases) were found to suffer in fact from pseudo-Bartter syndrome resulting from congenital chloride diarrhea due to a novel homozygous mutation in the SLC26A3 gene, Pendred syndrome due to a known homozygous mutation in SLC26A4, Cystic Fibrosis (CF) due to a novel mutation in CFTR and apparent mineralocorticoid excess syndrome due to a novel homozygous loss of function mutation in HSD11B2 gene. 1 case (5%) remained unsolved. CONCLUSIONS Our findings demonstrate deletion of CLCNKB is the most common cause of Bartter syndrome in Iranian patients and we show that age of onset of clinical symptoms as well as clinical features amongst those patients are variable. Further, using WES we were able to prove that nearly 1/4 patients in fact suffered from Pseudo-Bartter Syndrome, reversing the initial clinical diagnosis with important impact on the subsequent treatment and clinical follow up pathway. Finally, we propose an algorithm for clinical differential diagnosis of Bartter Syndrome.
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Affiliation(s)
- Maryam Najafi
- Genome Research Division, Human Genetics department, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525KL, Nijmegen, The Netherlands.,Departement of Biology, University of Sistan and Baluchestan, Zahedan, Iran
| | | | - Farkhondeh Behjati
- Genetics Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Simin Sadeghi-Bojd
- Children and Adolescents Health Research Center, resistant tuberculosis institute, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Zeineb Bakey
- Genome Research Division, Human Genetics department, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525KL, Nijmegen, The Netherlands.,Center for Pediatrics and Adolescent Medicine, Freiburg University Hospital, Freiburg University Faculty of Medicine, Mathildenstrasse 1, 79112, Freiburg, Germany
| | - Ehsan Ghayoor Karimiani
- Razavi Cancer Research, Razavi Hospital, Imam Reza International University, Mashhad, Iran.,Next Generation Genetic Polyclinic, Mashhad, Iran
| | - Isabel Schüle
- Center for Pediatrics and Adolescent Medicine, Freiburg University Hospital, Freiburg University Faculty of Medicine, Mathildenstrasse 1, 79112, Freiburg, Germany
| | - Anoush Azarfar
- Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Miriam Schmidts
- Genome Research Division, Human Genetics department, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525KL, Nijmegen, The Netherlands. .,Center for Pediatrics and Adolescent Medicine, Freiburg University Hospital, Freiburg University Faculty of Medicine, Mathildenstrasse 1, 79112, Freiburg, Germany. .,Center for Pediatrics and Adolescent Medicine, University Hospital Freiburg, 79112, Freiburg, Germany.
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Monogene Formen der arteriellen Hypertonie. MED GENET-BERLIN 2018. [DOI: 10.1007/s11825-018-0217-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Zusammenfassung
Hintergrund
Die Grundlage der arteriellen Hypertonie bei der überwiegenden Mehrzahl der Patienten ist multifaktorieller, zum großen Teil umweltbedingter Genese und derzeit in der Routinediagnostik nicht sinnvoll molekulargenetisch untersuchbar. Bei einem kleinen Teil der Patienten (<1 %) ist die arterielle Hypertonie aber Folge hereditärer, monogener Defekte. Hierzu gehören das Liddle-Syndrom, familiärer Hyperaldosteronismus, apparenter Mineralkortikoidexzess und Pseudohypoaldosteronismus. Diese und andere hereditäre Hypertonien gehen pathomechanistisch auf Störungen in den renalen Regelkreisen der Elektrolyt- und Volumenhomöostase zurück.
Ziel der Arbeit
Die bekannten Typen der hereditären Hypertonien sollen verständlich und schematisch erläutert werden. Besonderer Fokus liegt dabei auch auf dem klinischen Bild der jeweiligen Unterformen sowie der therapeutischen Konsequenz, die sich in dieser Krankheitsgruppe direkt aus dem molekulargenetischen Befund ergeben kann. Eine Auswahl weiterer genetischer Syndrome mit arterieller Hypertonie als Begleit- oder Spätsymptom wird zusammenfassend behandelt.
Fazit
Die korrekte Diagnose eines Betroffenen mit einer Form der hier beschriebenen hereditären Hypertonien ermöglicht eine gezielte und effektive medikamentöse Therapie auf Basis der inzwischen insgesamt gut verstandenen jeweiligen Pathomechanismen.
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White PC. Alterations of Cortisol Metabolism in Human Disorders. Horm Res Paediatr 2018; 89:320-330. [PMID: 29843121 DOI: 10.1159/000485508] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 11/21/2017] [Indexed: 11/19/2022] Open
Abstract
The interconversion of active and inactive corticosteroids - cortisol and cortisone, respectively, in humans - is modulated by isozymes of 11β-hydroxysteroid dehydrogenase (11-HSD). Studies of this process have provided crucial insights into glucocorticoid effects in a wide variety of tissues. The 11-HSD1 isozyme functions mainly as an oxoreductase (cortisone to cortisol) and is expressed at high levels in the liver and other glucocorticoid target tissues. Because it is required for full physiological effects of cortisol, it has emerged as a drug target for metabolic syndrome and type 2 diabetes. Mutations in the corresponding HSD11B1 gene, or in the H6PD gene encoding hexose-6-phosphate dehydrogenase (which supplies the NADPH required for the oxoreductase activity of 11-HSD1), cause apparent cortisone reductase deficiency, a rare syndrome of adrenocortical hyperactivity and hyperandrogenism. In contrast, the 11-HSD2 isozyme functions as a dehydrogenase (cortisol to cortisone) and is expressed mainly in mineralocorticoid target tissues, where it bars access of cortisol to the mineralocorticoid receptor. Mutations in the HSD11B2 gene encoding 11-HSD2 cause the syndrome of apparent mineralocorticoid excess, a severe form of familial hypertension. The role of this enzyme in the pathogenesis of common forms of low-renin hypertension remains uncertain.
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Hypertensive Crisis with Neurological Impairment Mimicking a Guillain-Barrè Syndrome: Searching for a Link. High Blood Press Cardiovasc Prev 2018; 25:421-424. [PMID: 30298226 DOI: 10.1007/s40292-018-0283-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 09/26/2018] [Indexed: 01/04/2023] Open
Abstract
Guillain-Barré syndrome (GBS) may be complicated by severe hypertension (HT) and in turns severe HT can occur with neurological damage mimicking a GBS, so that underlying causes should be investigated. We describe a case of a 62-year-old woman presented to the emergency department for hypertensive crisis with symmetric flaccid paralysis, hypotonia and hyporeflexia of both upper and lower limbs. Brain computed tomography, magnetic resonance imaging and lumbar puncture were normal. Laboratory investigations revealed severe hypokalemia, renal failure, liver impairment, rabdomyolysis, metabolic alkalosis, and low plasma renin and aldosterone levels. Continuous potassium replacement led to complete clinical resolution. A detailed history revealed chronic intake of 250 g/day black liquorice. Hypokalaemic muscle weakness may simulate a GBS. When serum potassium level falls below 2.5 mmol/l, rhabdomyolysis may occur. In this clinical case, an apparent mineralocorticoid excess syndrome was induced by chronic ingestion of liquorice. This latter contains the glycyrrhetic acid that inhibits the enzyme 11-β-hydroxysteroid dehydrogenase enzyme type-2 leading an aldosterone-like effect and causing hypertension, hypokalemia, metabolic alkalosis and low renin values. The clinical presentation is similar to that observed in the primary aldosteronism, but in this syndrome plasma aldosterone levels are low rather than elevated as in primary aldosteronism. Liquorice-induced hypertension with severe hypokalemia and rhabdomyolysis is a rare condition and the initial presentation with acute muscle paralysis is still more unusual. Before performing instrumental examinations in middle-aged peoples with hypertension crisis and neurological impairment, a detailed clinical history is mandatory.
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Vitellius G, Trabado S, Hoeffel C, Bouligand J, Bennet A, Castinetti F, Decoudier B, Guiochon-Mantel A, Lombes M, Delemer B. Significant prevalence of NR3C1 mutations in incidentally discovered bilateral adrenal hyperplasia: results of the French MUTA-GR Study. Eur J Endocrinol 2018; 178:411-423. [PMID: 29444898 DOI: 10.1530/eje-17-1071] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 02/14/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Recently discovered mutations of NR3C1 gene, encoding for the GR, in patients with glucocorticoid resistance and bilateral adrenal incidentalomas prompted us to investigate whether GR mutations might be associated with adrenal hyperplasia. OBJECTIVE The multicenter French Clinical Research Program (Muta-GR) was set up to determine the prevalence of GR mutations and polymorphisms in patients harboring bilateral adrenal incidentalomas associated with hypertension and/or biological hypercortisolism without clinical Cushing's signs. RESULTS One hundred patients were included in whom NR3C1 sequencing revealed five original heterozygous GR mutations that impaired GR signaling in vitro. Mutated patients presented with mild glucocorticoid resistance defined as elevated urinary free cortisol (1.7 ± 0.7 vs 0.9 ± 0.8 upper limit of normal range, P = 0.006), incomplete 1 mg dexamethasone suppression test without suppressed 8-AM adrenocorticotrophin levels (30.9 ± 31.2 vs 16.2 ± 17.5 pg/mL) compared to the non-mutated patients. Potassium and aldosterone levels were lower in mutated patients (3.6 ± 0.2 vs 4.1 ± 0.5 mmol/L, P = 0.01, and 17.3 ± 9.9 vs 98.6 ± 115.4 pg/mL, P = 0.0011, respectively) without elevated renin levels, consistent with pseudohypermineralocorticism. Ex vivo characterization of mutated patients' fibroblasts demonstrated GR haploinsufficiency as revealed by below-normal glucocorticoid induction of FKBP5 gene expression. There was no association between GR polymorphisms and adrenal hyperplasia in this cohort, except an over-representation of BclI polymorphism. CONCLUSION The 5% prevalence of heterozygous NR3C1 mutations discovered in our series is higher than initially thought and encourages GR mutation screening in patients with adrenal incidentalomas to unambiguously differentiate from Cushing's states and to optimize personalized follow-up.
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Affiliation(s)
- Géraldine Vitellius
- INSERM UMR_S U1185, Fac Med Paris Sud, Université Paris Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France
- Service d'Endocrinologie-Diabète-Nutrition, Hôpital Robert Debré, CHU Reims, Reims, France
| | - Séverine Trabado
- INSERM UMR_S U1185, Fac Med Paris Sud, Université Paris Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpitaux Universitaires Paris Sud, AH-HP, CHU Bicêtre, Le Kremlin Bicêtre, France
| | - Christine Hoeffel
- Service de Radiologie, Hôpital Robert Debré, CRESTIC, CHU Reims-URCA, Reims, France
| | - Jérôme Bouligand
- INSERM UMR_S U1185, Fac Med Paris Sud, Université Paris Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpitaux Universitaires Paris Sud, AH-HP, CHU Bicêtre, Le Kremlin Bicêtre, France
| | - Antoine Bennet
- Service d'Endocrinologie, Maladies Métaboliques et Nutrition, CHU Toulouse, Toulouse, France
| | | | - Bénédicte Decoudier
- Service d'Endocrinologie-Diabète-Nutrition, Hôpital Robert Debré, CHU Reims, Reims, France
| | - Anne Guiochon-Mantel
- INSERM UMR_S U1185, Fac Med Paris Sud, Université Paris Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France
- Service de Génétique Moléculaire, Pharmacogénétique et Hormonologie, Hôpitaux Universitaires Paris Sud, AH-HP, CHU Bicêtre, Le Kremlin Bicêtre, France
| | - Marc Lombes
- INSERM UMR_S U1185, Fac Med Paris Sud, Université Paris Sud, Université Paris-Saclay, Le Kremlin Bicêtre, France
- Service d'Endocrinologie et des Maladies de la Reproduction, Hôpitaux Universitaires Paris Sud, AH-HP, CHU Bicêtre, Le Kremlin Bicêtre, France
| | - Brigitte Delemer
- Service d'Endocrinologie-Diabète-Nutrition, Hôpital Robert Debré, CHU Reims, Reims, France
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Analysis of the genes involved in Mendelian forms of low-renin hypertension in Chinese early-onset hypertensive patients. J Hypertens 2018; 36:502-509. [DOI: 10.1097/hjh.0000000000001556] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Clinical, genetic, and structural basis of apparent mineralocorticoid excess due to 11β-hydroxysteroid dehydrogenase type 2 deficiency. Proc Natl Acad Sci U S A 2017; 114:E11248-E11256. [PMID: 29229831 DOI: 10.1073/pnas.1716621115] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Mutations in 11β-hydroxysteroid dehydrogenase type 2 gene (HSD11B2) cause an extraordinarily rare autosomal recessive disorder, apparent mineralocorticoid excess (AME). AME is a form of low renin hypertension that is potentially fatal if untreated. Mutations in the HSD11B2 gene result either in severe AME or a milder phenotype (type 2 AME). To date, ∼40 causative mutations have been identified. As part of the International Consortium for Rare Steroid Disorders, we have diagnosed and followed the largest single worldwide cohort of 36 AME patients. Here, we present the genotype and clinical phenotype of these patients, prominently from consanguineous marriages in the Middle East, who display profound hypertension and hypokalemic alkalosis. To correlate mutations with phenotypic severity, we constructed a computational model of the HSD11B2 protein. Having used a similar strategy for the in silico evaluation of 150 mutations of CYP21A2, the disease-causing gene in congenital adrenal hyperplasia, we now provide a full structural explanation for the clinical severity of AME resulting from each known HSD11B2 missense mutation. We find that mutations that allow the formation of an inactive dimer, alter substrate/coenzyme binding, or impair structural stability of HSD11B2 yield severe AME. In contrast, mutations that cause an indirect disruption of substrate binding or mildly alter intramolecular interactions result in type 2 AME. A simple in silico evaluation of novel missense mutations could help predict the often-diverse phenotypes of an extremely rare monogenic disorder.
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Seidel E, Scholl UI. Genetic mechanisms of human hypertension and their implications for blood pressure physiology. Physiol Genomics 2017; 49:630-652. [PMID: 28887369 DOI: 10.1152/physiolgenomics.00032.2017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Hypertension, or elevated blood pressure, constitutes a major public health burden that affects more than 1 billion people worldwide and contributes to ~9 million deaths annually. Hereditary factors are thought to contribute to up to 50% of interindividual blood pressure variability. Blood pressure in the general population approximately shows a normal distribution and is thought to be a polygenic trait. In rare cases, early-onset hypertension or hypotension are inherited as Mendelian traits. The identification of the underlying Mendelian genes and variants has contributed to our understanding of the physiology of blood pressure regulation, emphasizing renal salt handling and the renin angiotensin aldosterone system as players in the determination of blood pressure. Genome-wide association studies (GWAS) have revealed more than 100 variants that are associated with blood pressure, typically with small effect sizes, which cumulatively explain ~3.5% of blood pressure trait variability. Several GWAS associations point to a role of the vasculature in the pathogenesis of hypertension. Despite these advances, the majority of the genetic contributors to blood pressure regulation are currently unknown; whether large-scale exome or genome sequencing studies will unravel these factors remains to be determined.
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Affiliation(s)
- Eric Seidel
- Department of Nephrology, Medical School, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ute I Scholl
- Department of Nephrology, Medical School, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1885] [Impact Index Per Article: 269.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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Abstract
The heritability of hypertension (HTN) is widely recognized and as a result, extensive studies ranging from genetic linkage analyses to genome-wide association studies are actively ongoing to elucidate the etiology of both monogenic and polygenic forms of HTN. Due to the complex nature of essential HTN, however, single genes affecting blood pressure (BP) variability remain difficult to isolate and identify and have rendered the development of single-gene targeted therapies challenging. The roles of other causative factors in modulating BP, such as gene-environment interactions and epigenetic factors, are increasingly being brought to the forefront. In this review, we discuss the various monogenic HTN syndromes and corresponding pathophysiologic mechanisms, the different methodologies employed in genetic studies of essential HTN, the mechanisms for epigenetic modulation of essential HTN, pharmacogenomics and HTN, and finally, recent advances in genetic studies of essential HTN in the pediatric population.
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Affiliation(s)
- Sun-Young Ahn
- Department of Nephrology, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States
| | - Charu Gupta
- Department of Nephrology, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States
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26
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Zieg J, Gonsorcikova L, Landau D. Current views on the diagnosis and management of hypokalaemia in children. Acta Paediatr 2016; 105:762-72. [PMID: 26972906 DOI: 10.1111/apa.13398] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/13/2016] [Accepted: 03/08/2016] [Indexed: 12/20/2022]
Abstract
UNLABELLED Hypokalaemia is a common electrolyte disorder in children, caused by decreased potassium intake, increased gastrointestinal and urinary losses or transcellular shift. Patients with severe hypokalaemia may suffer from symptoms such as life-threatening cardiac arrhythmias. The aim of our study was to review the aetiology of hypokalaemia, suggest a diagnostic algorithm and discuss the management of patients with various aetiologies of hypokalaemia. CONCLUSION Understanding the pathophysiology of hypokalaemic states, along with a detailed medical history, physical examination and specific laboratory tests are required for proper diagnosis and appropriate treatment.
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Affiliation(s)
- Jakub Zieg
- Department of Paediatrics; 2 Faculty of Medicine; Motol University Hospital; Charles University in Prague; Praha Czech Republic
| | - Lucie Gonsorcikova
- Department of Paediatrics; 2 Faculty of Medicine; Motol University Hospital; Charles University in Prague; Praha Czech Republic
| | - Daniel Landau
- Paediatrics Department B; Faculty of Health Sciences; Schneider Children's Medical Center of Israel; Ben-Gurion University; Beer Sheva Israel
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27
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Esche J, Shi L, Sánchez-Guijo A, Hartmann MF, Wudy SA, Remer T. Higher diet-dependent renal acid load associates with higher glucocorticoid secretion and potentially bioactive free glucocorticoids in healthy children. Kidney Int 2016; 90:325-333. [PMID: 27165611 DOI: 10.1016/j.kint.2016.02.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 02/23/2016] [Accepted: 02/25/2016] [Indexed: 10/21/2022]
Abstract
Metabolic acidosis induces elevated glucocorticoid (GC) levels. However, the influence of less strong daily acid loads on GCs is largely unexplored. To investigate this, we studied whether higher acid loads in children, fully within the normal range of habitual diets, associate with endogenous GCs. In a specific quasi-experimental design, we examined 200 6- to 10-year-old healthy participants of the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study equally divided to either high or low 24-hour renal net acid excretion. Major urinary GC metabolites were analyzed by gas chromatography-mass spectrometry to assess daily adrenal GC secretion and metabolites of tissue cortisol catabolism (6β-hydroxycortisol and 20α-dihydrocortisol). Liquid chromatography-mass spectrometry was used to quantify urinary free cortisol and cortisone. After confounder adjustment, significant positive associations were unmasked for urinary potential renal acid load and net acid excretion with adrenal GC secretion, free cortisone, free cortisone plus cortisol, 6β-hydroxycortisol, and 20α-dihydrocortisol. An inverse association emerged for an enzymatic marker (5β-reductase) of irreversible GC inactivation. Our data suggest that existing moderate elevations in diet-dependent acid loads suffice to raise GCs and affect cortisol metabolism. Thus, potential detrimental effects of high acid loading appear to be mediated, in part, by increased GC activity via increased GC secretion and/or reduced GC inactivation. Higher cortisone levels, directly available for intracrine activation to cortisol may play a special role.
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Affiliation(s)
- Jonas Esche
- Department of Nutritional Epidemiology, Institute of Nutrition and Food Science, University of Bonn, DONALD Study Center, Dortmund, Germany
| | - Lijie Shi
- Department of Nutritional Epidemiology, Institute of Nutrition and Food Science, University of Bonn, DONALD Study Center, Dortmund, Germany
| | - Alberto Sánchez-Guijo
- Steroid Research and Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus-Liebig-University, Giessen, Germany
| | - Michaela F Hartmann
- Steroid Research and Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus-Liebig-University, Giessen, Germany
| | - Stefan A Wudy
- Steroid Research and Mass Spectrometry Unit, Center of Child and Adolescent Medicine, Justus-Liebig-University, Giessen, Germany
| | - Thomas Remer
- Department of Nutritional Epidemiology, Institute of Nutrition and Food Science, University of Bonn, DONALD Study Center, Dortmund, Germany.
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28
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Kosicka K, Siemiątkowska A, Krzyścin M, Bręborowicz GH, Resztak M, Majchrzak-Celińska A, Chuchracki M, Główka FK. Glucocorticoid Metabolism in Hypertensive Disorders of Pregnancy: Analysis of Plasma and Urinary Cortisol and Cortisone. PLoS One 2015; 10:e0144343. [PMID: 26637176 PMCID: PMC4670176 DOI: 10.1371/journal.pone.0144343] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 11/17/2015] [Indexed: 01/01/2023] Open
Abstract
Objectives The aim of the study was to analyze the plasma and urinary cortisol (F) and cortisone (E) levels in normotensive and hypertensive pregnant women. The parameters known to reflect the function of 11β-hydroxysteroid dehydrogenase type 2 (11β-HSD2) were calculated to verify the changes in glucocorticoid balance over the course of gestational hypertension (GH) and pre-eclampsia (PE). Materials and Methods This retrospective case-control study included women in the third trimester of pregnancy, diagnosed with: GH (n = 29), PE (n = 26), or chronic hypertension (CH; n = 22). Normotensive women in their third trimester of pregnancy were also included (controls; n = 43). The plasma and urinary F and E levels were measured with the HPLC-FLD method. The 11β-HSD2 function was estimated by calculating the following ratios: plasma F/E and urinary free F to urinary free E (UFF/UFE). A statistical analysis was performed based on case-control structure. Results and Discussion PE was characterized by lower plasma F levels (639.0 nmol/L), UFF/Cr levels (3.80 μg/mmol) and F/E ratio (3.46) compared with that of the controls (811.7 nmol/L, 6.28 μg/mmol and 5.19, respectively) with marked abnormalities observed in the changes of F/E and UFF/UFE ratios with advancing gestation. GH patients showed significant disparities in the urinary steroid profile with lower UFF/UFE ratio (0.330 vs. 0.401) compared with the normotensive controls and abnormal changes in the UFF/UFE throughout pregnancy. The observed tendency towards lower F/E and UFF/UFE ratios in PE and GH patients may reflect more intensive F metabolism over the course of those disorders. In the normal pregnancy group, the plasma F/E and UFF/UFE ratios tended to present inverse correlations with advancing gestation. This trend was much less marked in PE and GH patients, suggesting that the abnormalities in 11β-HSD2 functions progressed with the GA. The birth weights of neonates born from pre-eclamptic pregnancies were lower than those from uncomplicated pregnancies, although only when the babies were born prematurely. Children born at term to normotensive mothers or mothers suffering from PE had comparable birth weights.
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Affiliation(s)
- Katarzyna Kosicka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
- * E-mail:
| | - Anna Siemiątkowska
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | - Mariola Krzyścin
- Department of Perinatology and Gynecology, Poznan University of Medical Sciences, Poznań, Poland
| | - Grzegorz H. Bręborowicz
- Department of Perinatology and Gynecology, Poznan University of Medical Sciences, Poznań, Poland
| | - Matylda Resztak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Marek Chuchracki
- Department of Perinatology and Gynecology, Poznan University of Medical Sciences, Poznań, Poland
| | - Franciszek K. Główka
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, Poznań, Poland
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29
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Hunter RW, Ivy JR, Flatman PW, Kenyon CJ, Craigie E, Mullins LJ, Bailey MA, Mullins JJ. Hypertrophy in the Distal Convoluted Tubule of an 11β-Hydroxysteroid Dehydrogenase Type 2 Knockout Model. J Am Soc Nephrol 2015; 26:1537-48. [PMID: 25349206 PMCID: PMC4483573 DOI: 10.1681/asn.2013060634] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 08/12/2014] [Indexed: 11/03/2022] Open
Abstract
Na(+) transport in the renal distal convoluted tubule (DCT) by the thiazide-sensitive NaCl cotransporter (NCC) is a major determinant of total body Na(+) and BP. NCC-mediated transport is stimulated by aldosterone, the dominant regulator of chronic Na(+) homeostasis, but the mechanism is controversial. Transport may also be affected by epithelial remodeling, which occurs in the DCT in response to chronic perturbations in electrolyte homeostasis. Hsd11b2(-/-) mice, which lack the enzyme 11β-hydroxysteroid dehydrogenase type 2 (11βHSD2) and thus exhibit the syndrome of apparent mineralocorticoid excess, provided an ideal model in which to investigate the potential for DCT hypertrophy to contribute to Na(+) retention in a hypertensive condition. The DCTs of Hsd11b2(-/-) mice exhibited hypertrophy and hyperplasia and the kidneys expressed higher levels of total and phosphorylated NCC compared with those of wild-type mice. However, the striking structural and molecular phenotypes were not associated with an increase in the natriuretic effect of thiazide. In wild-type mice, Hsd11b2 mRNA was detected in some tubule segments expressing Slc12a3, but 11βHSD2 and NCC did not colocalize at the protein level. Thus, the phosphorylation status of NCC may not necessarily equate to its activity in vivo, and the structural remodeling of the DCT in the knockout mouse may not be a direct consequence of aberrant corticosteroid signaling in DCT cells. These observations suggest that the conventional concept of mineralocorticoid signaling in the DCT should be revised to recognize the complexity of NCC regulation by corticosteroids.
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Affiliation(s)
- Robert W Hunter
- British Heart Foundation Centre for Cardiovascular Science and
| | - Jessica R Ivy
- British Heart Foundation Centre for Cardiovascular Science and
| | - Peter W Flatman
- Centre for Integrative Physiology, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Eilidh Craigie
- British Heart Foundation Centre for Cardiovascular Science and
| | - Linda J Mullins
- British Heart Foundation Centre for Cardiovascular Science and
| | | | - John J Mullins
- British Heart Foundation Centre for Cardiovascular Science and
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30
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Ardhanari S, Kannuswamy R, Chaudhary K, Lockette W, Whaley-Connell A. Mineralocorticoid and apparent mineralocorticoid syndromes of secondary hypertension. Adv Chronic Kidney Dis 2015; 22:185-95. [PMID: 25908467 DOI: 10.1053/j.ackd.2015.03.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 03/02/2015] [Accepted: 03/04/2015] [Indexed: 11/11/2022]
Abstract
The mineralocorticoid aldosterone is a key hormone in the regulation of plasma volume and blood pressure in man. Excessive levels of this mineralocorticoid have been shown to mediate metabolic disorders and end-organ damage more than what can be attributed to its effects on blood pressure alone. Inappropriate excess levels of aldosterone contribute significantly to the cardiorenal metabolic syndrome and target organ injury that include atherosclerosis, myocardial hypertrophy, fibrosis, heart failure, and kidney disease. The importance of understanding the role of excess mineralocorticoid hormones such as aldosterone in resistant hypertension and in those with secondary hypertension should be visited. Primary aldosteronism is one of the commonly identified causes of hypertension and is treatable and/or potentially curable. We intend to review the management of mineralocorticoid-induced hypertension in the adult population along with other disease entities that mimic primary aldosteronism.
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31
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Khosravi M, Walsh SB. The long-term complications of the inherited tubulopathies: an adult perspective. Pediatr Nephrol 2015; 30:385-95. [PMID: 24566812 DOI: 10.1007/s00467-014-2779-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/23/2014] [Accepted: 01/27/2014] [Indexed: 11/25/2022]
Abstract
The inherited tubulopathies are lifelong disorders and their clinical features and complications may present quite different challenges in adulthood from those in childhood. In this review we outline the pathophysiology and documented complications (including the late and unusual) of the monogenic tubulopathies from the perspective of the adult nephrologist.
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Affiliation(s)
- Maryam Khosravi
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
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32
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Zahraldin K, Janahi IA, Ben-Omran T, Alsulaiman R, Hamad B, Imam A. Two Qatari siblings with cystic fibrosis and apparent mineralocorticoid excess. Ann Thorac Med 2015; 10:69-72. [PMID: 25593612 PMCID: PMC4286850 DOI: 10.4103/1817-1737.146892] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/25/2014] [Indexed: 11/04/2022] Open
Abstract
Cystic fibrosis (CF) and apparent mineralocorticoid excess (AME) syndrome are both autosomal recessive disorders that result from mutations of specific identified genes for each condition. CF is caused by defects in the Cystic fibrosis trans membrane conductance regulator (CFTR) gene which encodes for a protein that functions as a chloride channel and regulates the flow of other ions across the apical surface of epithelial cells. AME is due to the deficiency of 11β-hydroxysteroid dehydrogenase type 2 enzyme (11βHSD2), which is responsible for the peripheral inactivation of cortisol to cortisone. Cortisol excess stimulates the mineralocoritoid receptors (MR) resulting in intense sodium retention, hypokalemia and hypertension. We report on a consanguineous Arab family, in which two sibs inherited both CF and AME. Gene testing for AME revealed previously unreported mutation in the 11βHSD2 gene. This report draws attention to the importance of recognizing the possibility of two recessive disorders in the same child in complex consanguineous families. Moreover, it provides a unique opportunity to highlight the implications of the coexistence of two genetic disorders on patient care and genetic counseling of the family.
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Affiliation(s)
- Khalid Zahraldin
- Pulmonary Section, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Ibrahim Ahmed Janahi
- Pulmonary Section, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Tawfeg Ben-Omran
- Section of Clinical and Metabolic Genetics, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Reem Alsulaiman
- Section of Clinical and Metabolic Genetics, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Bajes Hamad
- Nephrology Section, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
| | - Abubakr Imam
- Nephrology Section, Department of Pediatrics, Hamad Medical Corporation, Doha, Qatar
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33
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Alzahrani AS, Aljuhani N, Qasem E, Almohanna M, Hamoudh E, AlOmair A, Alharbi N. Apparent Mineralocorticoid Excess Caused by a Novel Mutation in 11-β Hydroxysteroid Dehydrogenase Type 2 Enzyme: Its Genetics and Response to Therapy. Endocr Pract 2014; 20:e151-6. [PMID: 24936560 DOI: 10.4158/ep14094.cr] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present a case of apparent mineralocorticoid excess (AME) due to a novel mutation in the HSD11B2 gene and describe the patient's response to therapy. METHODS The clinical, biochemical, and genetic features of the proband and his family are presented. For the genetic study, DNA was extracted from peripheral leucocytes. The exons and exon-intron boundaries were polymerase chain reaction (PCR)-amplified and directly sequenced. RESULTS A 10-year-old male presented with hypertension (HTN) and weakness and was found to have hypokalemia of 2.6 mmol/L. Plasma renin was undetectable, and plasma and urinary aldosterone were low. Serum cortisol and deoxycorticosterone were normal. Daily urinary excretion of cortisol was normal, but urinary and serum cortisone levels were undetectable. The patient was treated with spiranolactone with inadequate response. A small dose of dexamethasone was added and led to excellent control of HTN and hypokalemia. Genetic studies showed a novel missense biallelic mutation changing guanine to adenine in exon 3 (c.G526A) of the HSD11B2. This mutation changes the amino acid aspartic acid to asparagine at codon 176 (p.D176N). A monoallelic form of the same mutation was found in the parents and 3 of his 4 healthy siblings but not in a healthy sister or 100 normal subjects. CONCLUSIONS A case of AME due to a novel mutation in HSD11B2 showed the usual features of AME but exhibited an inadequate response to spironolactone. A small dose of dexamethasone resulted in an excellent response.
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Affiliation(s)
- Ali S Alzahrani
- Department of Medicine, King Faisal Specialist Hospital & Research Center Department of Molecular Oncology, King Faisal Specialist Hospital & Research Center
| | | | - Ebtesam Qasem
- Department of Molecular Oncology, King Faisal Specialist Hospital & Research Center
| | - Mai Almohanna
- Department of Molecular Oncology, King Faisal Specialist Hospital & Research Center
| | - Eman Hamoudh
- Department of Molecular Oncology, King Faisal Specialist Hospital & Research Center
| | - Abeer AlOmair
- Department of Molecular Oncology, King Faisal Specialist Hospital & Research Center
| | - Naffaa Alharbi
- Department of Pediatrics, King Faisal Specialist Hospital & Research Center, Jeddah
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34
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Abstract
Hereditary disorders of potassium homeostasis are an interesting group of disorders, affecting people from the newborn period to adults of all ages. The clinical presentation varies from severe hypotension at birth to uncontrolled hypertension in adults, often associated with abnormal potassium values, although many patients may have a normal serum potassium concentration despite being affected by the genetic disorder. A basic understanding of these disorders and their underlying mechanisms has significant clinical implications, especially in the few patients with subtle clinical signs and symptoms. We present a summary of these disorders, with emphasis on the clinical presentation and genetic mechanisms of these disorders.
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Affiliation(s)
- Gaurav Jain
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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35
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Chapman K, Holmes M, Seckl J. 11β-hydroxysteroid dehydrogenases: intracellular gate-keepers of tissue glucocorticoid action. Physiol Rev 2013; 93:1139-206. [PMID: 23899562 DOI: 10.1152/physrev.00020.2012] [Citation(s) in RCA: 553] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Glucocorticoid action on target tissues is determined by the density of "nuclear" receptors and intracellular metabolism by the two isozymes of 11β-hydroxysteroid dehydrogenase (11β-HSD) which catalyze interconversion of active cortisol and corticosterone with inert cortisone and 11-dehydrocorticosterone. 11β-HSD type 1, a predominant reductase in most intact cells, catalyzes the regeneration of active glucocorticoids, thus amplifying cellular action. 11β-HSD1 is widely expressed in liver, adipose tissue, muscle, pancreatic islets, adult brain, inflammatory cells, and gonads. 11β-HSD1 is selectively elevated in adipose tissue in obesity where it contributes to metabolic complications. Similarly, 11β-HSD1 is elevated in the ageing brain where it exacerbates glucocorticoid-associated cognitive decline. Deficiency or selective inhibition of 11β-HSD1 improves multiple metabolic syndrome parameters in rodent models and human clinical trials and similarly improves cognitive function with ageing. The efficacy of inhibitors in human therapy remains unclear. 11β-HSD2 is a high-affinity dehydrogenase that inactivates glucocorticoids. In the distal nephron, 11β-HSD2 ensures that only aldosterone is an agonist at mineralocorticoid receptors (MR). 11β-HSD2 inhibition or genetic deficiency causes apparent mineralocorticoid excess and hypertension due to inappropriate glucocorticoid activation of renal MR. The placenta and fetus also highly express 11β-HSD2 which, by inactivating glucocorticoids, prevents premature maturation of fetal tissues and consequent developmental "programming." The role of 11β-HSD2 as a marker of programming is being explored. The 11β-HSDs thus illuminate the emerging biology of intracrine control, afford important insights into human pathogenesis, and offer new tissue-restricted therapeutic avenues.
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Affiliation(s)
- Karen Chapman
- Endocrinology Unit, Centre for Cardiovascular Science, The Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
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36
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37
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Abstract
Arterial hypertension in childhood is less frequent as compared to adulthood but is more likely to be secondary to an underlying disorder. After ruling out more obvious causes, some patients still present with strongly suspected secondary hypertension of yet unknown etiology. A number of these children have hypertension due to single gene mutations inherited in an autosomal dominant or recessive fashion. The finding of abnormal potassium levels (low or high) in the presence of suppressed renin secretion, and metabolic alkalosis or acidosis should prompt consideration of these familial diseases. However, mild hypertension and the absence of electrolyte abnormalities do not exclude hereditary conditions. In monogenic hypertensive disorders, three distinct mechanisms leading to the common final pathway of increased sodium reabsorption, volume expansion, and low plasma renin activity are documented. The first mechanism relates to gain-of-function mutations with a subsequent hyperactivity of renal sodium and chloride reabsorption leading to plasma volume expansion (e.g., Liddle's syndrome, Gordon's syndrome). The second mechanism involves deficiencies of enzymes that regulate adrenal steroid hormone synthesis and deactivation (e.g., subtypes of congenital adrenal hyperplasia, apparent mineralocorticoid excess (AME)). The third mechanism is characterized by excessive aldosterone synthesis that escapes normal regulatory mechanisms and leading to volume-dependent hypertension in the presence of suppressed renin release (glucocorticoid remediable aldosteronism). Hormonal studies coupled with genetic testing can help in the early diagnosis of these disorders.
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38
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Abstract
Low renin hypertension is an important and often underdiagnosed cause of hypertension. It may be associated with high aldosterone levels as in Conn's syndrome or low aldosterone levels as in Liddle syndrome, and syndrome of apparent mineralocorticoid excess, glucocorticoid remediable hypertension etc. Some forms of essential hypertension are also associated with low renin levels. Hypokalemia may be an important finding in low renin hypertension. The aldosterone to renin ratio helps in correct diagnosis. The treatment varies with etiology hence an accurate diagnosis is essential. Aldosterone antagonists play an important role in medical management of some varieties of low renin hypertension.
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Affiliation(s)
- Manisha Sahay
- Deparment of Nephrology, Osmania General Hospital, Hyderabad, Andhra Pradesh, India
| | - Rakesh K. Sahay
- Deparment of Nephrology, Osmania General Hospital, Hyderabad, Andhra Pradesh, India
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39
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Craigie E, Evans LC, Mullins JJ, Bailey MA. Failure to downregulate the epithelial sodium channel causes salt sensitivity in Hsd11b2 heterozygote mice. Hypertension 2012; 60:684-90. [PMID: 22777941 DOI: 10.1161/hypertensionaha.112.196410] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In vivo, the enzyme 11β-hydroxysteroid dehydrogenase type 2 influences ligand access to the mineralocorticoid receptor. Ablation of the encoding gene, HSD11B2, causes the hypertensive syndrome of apparent mineralocorticoid excess. Studies in humans and experimental animals have linked reduced 11β-hydroxysteroid dehydrogenase type 2 activity and salt sensitivity of blood pressure. In the present study, renal mechanisms underpinning salt sensitivity were investigated in Hsd11b2(+/-) mice fed low-, standard-, and high-sodium diets. In wild-type mice, there was a strong correlation between dietary sodium content and fractional sodium excretion but not blood pressure. High sodium feeding abolished amiloride-sensitive sodium reabsorption, consistent with downregulation of the epithelial sodium channel. In Hsd11b2(+/-) mice, the natriuretic response to increased dietary sodium content was blunted, and epithelial sodium channel activity persisted. High-sodium diet also reduced renal blood flow and increased blood pressure in Hsd11b2(+/-) mice. Aldosterone was modulated by dietary sodium in both genotypes, and salt sensitivity in Hsd11b2(+/-) mice was associated with increased plasma corticosterone levels. Chronic administration of an epithelial sodium channel blocker or a glucocorticoid receptor antagonist prevented salt sensitivity in Hsd11b2(+/-) mice, whereas mineralocorticoid receptor blockade with spironolactone did not. This study shows that reduced 11β-hydroxysteroid dehydrogenase type 2 causes salt sensitivity of blood pressure because of impaired renal natriuretic capacity. This reflects deregulation of epithelial sodium channels and increased renal vascular resistance. The phenotype is not caused by illicit activation of mineralocorticoid receptors by glucocorticoids but by direct activation of glucocorticoid receptors.
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Affiliation(s)
- Eilidh Craigie
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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Bogdanović R, Kuburović V, Stajić N, Mughal SS, Hilger A, Ninić S, Prijić S, Ludwig M. Liddle syndrome in a Serbian family and literature review of underlying mutations. Eur J Pediatr 2012; 171:471-8. [PMID: 21956615 DOI: 10.1007/s00431-011-1581-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 09/08/2011] [Indexed: 12/13/2022]
Abstract
UNLABELLED Severe and reproducible low-renin hypertension responsive to salt restriction and amiloride-thiazide therapy in a 13-year-old otherwise asymptomatic boy suggested Liddle syndrome. This assumption was strengthened by a positive family history of hypertension poorly responsive to conventional treatment or sudden deaths under 40 years of age in four generations. DNA analysis of the beta and gamma subunits of the epithelial sodium channel revealed a heterozygous mutation c.C1852T (p.Pro618Ser) in the SCNN1B gene in the patient and in both his hypertensive mother and uncle. A PubMed search revealed 21 different disease-causing mutations reported to date, all but two clustering in the cytoplasmic C-terminal regions of either beta (16 mutations) or gamma (5) subunit, leading to a three- to eightfold increase in the amiloride-sensitive sodium current. Inter- and intrafamilial variability in both hypertension and hypokalemia were disclosed, which may not be obligatory among the subjects carrying a Liddle mutation. CONCLUSION Liddle syndrome should be considered as a cause of hypertension in children or adolescents particularly with suppressed renin activity. Early diagnosis and appropriately tailored treatment avoid complications of long-term unrecognized or inappropriately managed hypertension.
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Abstract
Endocrine causes of hypertension are rare in children and screening for endocrine hypertension in children should be carried out only after ruling out renal and renovascular causes. Excess levels and/or action of mineralocorticoids associated with low renin levels lead to childhood hypertension and this can be caused by various conditions which are discussed in detail in the article. Childhood pheochromocytomas are being increasingly diagnosed because of the improved application of genetic testing for familial syndromes associated with pheochromocytomas. Adolescents with polycystic ovarian syndrome (PCOS) can also have hypertension associated with their obese phenotype.
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Affiliation(s)
- Nisha Bhavani
- Department of Endocrinology and Diabetes, Amrita Institute of Medical Sciences, Cochin, Kerala, India
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Gennari FJ. Pathophysiology of Metabolic Alkalosis: A New Classification Based on the Centrality of Stimulated Collecting Duct Ion Transport. Am J Kidney Dis 2011; 58:626-36. [DOI: 10.1053/j.ajkd.2011.06.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 06/14/2011] [Indexed: 11/11/2022]
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Abstract
Low-renin hypertension occurs in children as a result of several genetic mutations that cause mineralocorticoid excess or excess stimulation of the mineralocorticoid receptor. This article discusses the genetic disorders that cause low-renin hypertension.
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Affiliation(s)
- Alan A Parsa
- Department of Pediatrics, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA
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Knops NBB, Monnens LA, Lenders JW, Levtchenko EN. Apparent mineralocorticoid excess: time of manifestation and complications despite treatment. Pediatrics 2011; 127:e1610-4. [PMID: 21536617 DOI: 10.1542/peds.2010-1928] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Here we describe the case of a patient followed from birth because of a positive family history for apparent mineralocorticoid excess (AME) in an older brother. The patient, a girl, had normal serum electrolyte and blood pressure measurements in the first months after birth. Not until the age of 11 months did she develop anorexia and failure to thrive in combination with hypertension, hypokalemia, and metabolic alkalosis, which are consistent with the diagnosis of AME. This diagnosis was confirmed by mutation analysis of the HSD11B2 gene (C1228T). Treatment with amiloride and furosemide electrolyte disturbances normalized her blood pressure. At the age of 19 years she unexpectedly suffered a stroke. Additional investigations revealed no accepted risk factor for stroke. We discuss the possible underlying mechanisms for the delayed manifestation of hypertension and electrolyte disturbances in AME, propose an additional explanation for the stroke in this patient, and advise treatment with a mineralocorticoid receptor antagonist to reduce stroke risk in patients with AME.
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Affiliation(s)
- Noël B B Knops
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium.
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Abstract
PURPOSE OF REVIEW Inherited forms of mineralocorticoid hypertension are a group of monogenic disorders that, although rare, have enlightened our understanding of normal physiology, and subsequent processes implicated in the pathogenesis of 'essential' hypertension. They often present in early life and can be a cause of major morbidity and mortality that can be effectively treated with simple but targeted pharmacological therapy. Interestingly, all the conditions centre on the regulation of sodium transport through its epithelial channel, either directly or through mediators that act via the mineralocorticoid receptor. RECENT FINDINGS In recent years, molecular mechanisms of these conditions and their functional consequences have been elucidated. Diagnosis has been facilitated by plasma and urinary biomarkers. SUMMARY We provide an overview and diagnostic approach to apparent mineralocorticoid excess, glucocorticoid remediable aldosteronism, familial hyperaldosteronism type 2, Liddle's syndrome, Gordon's syndrome, activating mutations of the mineralocorticoid receptor, generalized glucocorticoid resistance and hypertensive forms of congenital adrenal hyperplasia.
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Affiliation(s)
- Zaki Hassan-Smith
- Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
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Gennari FJ, Hussain-Khan S, Segal A. An Unusual Case of Metabolic Alkalosis: A Window Into the Pathophysiology and Diagnosis of This Common Acid-Base Disturbance. Am J Kidney Dis 2010; 55:1130-5. [DOI: 10.1053/j.ajkd.2009.11.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Accepted: 11/30/2009] [Indexed: 11/11/2022]
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Paize F, Isherwood D, Honour J, Jones CA. Abnormal urinary steroid profiles in four hypertensive obese children. J Pediatr Endocrinol Metab 2010; 23:237-44. [PMID: 20480722 DOI: 10.1515/jpem.2010.23.3.237] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND There is a poorly understood association between obesity and hypertension. We demonstrated abnormalities of adrenal androgen and cortisol metabolites in four hypertensive obese children. PATIENTS Four males (aged 10 to 15 years) were evaluated for systolic blood pressures consistently above the 99.6th percentile. All were overweight with BMI ranging from 27-35. Clinical examinations, renal ultrasound and DMSA scans were normal. Plasma electrolytes, renin, aldosterone, cortisol, testosterone, ACTH and TSH were normal. 24-Hour urinary steroid profiles showed a generalised excess of adrenal androgen and cortisol metabolites in all cases. Relevant recognised disorders of adrenal androgen and cortisol metabolism were excluded. CONCLUSION There is no clinical condition explaining these abnormal urinary steroid profiles. These results support previous findings and provide new data on abnormal urinary adrenal androgen excretion in obese hypertensive patients. Further studies may determine the relationship between obesity, hypertension and the observed abnormalities of urinary steroid excretion.
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Affiliation(s)
- F Paize
- Institute of Child Health, University of Liverpool, Royal Liverpool Children's Hospital, Liverpool, UK.
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Coeli FB, Ferraz LFC, Lemos-Marini SHVD, Rigatto SZP, Belangero VMS, de-Mello MP. Apparent mineralocorticoid excess syndrome in a Brazilian boy caused by the homozygous missense mutation p.R186C in the HSD11B2 gene. ACTA ACUST UNITED AC 2009; 52:1277-81. [PMID: 19169481 DOI: 10.1590/s0004-27302008000800012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 10/14/2008] [Indexed: 11/21/2022]
Abstract
The apparent mineralocorticoid excess syndrome (AME) is a rare autosomal recessive disorder due to the deficiency of 11beta-hydroxysteroid dehydrogenase type 2 enzyme (11beta-HSD2). The 11beta-HSD2 enzyme, encoded by HSD11B2 gene, metabolizes active cortisol in cortisone. Mutations on HSD11B2 gene affect the enzyme activity by leading to an excess of cortisol, which causes its inappropriate access to mineralocorticoid receptor. Therefore, cortisol will bind mineralocorticoid receptor. The human HSD11B2 gene maps to chromosome 16q22 and consists of five exons encoding a protein of 405 amino acids. We present here clinical and molecular studies on a Brazilian boy who was born pre-term after an oligodramnious pregnancy. He was diagnosed as having AME at the age of 26 months. His parents are second cousins. Molecular characterization of the HSD11B2 gene revealed the homozygous mutation p.R186C. The patient described here is the second case of HDS11B2 gene mutation reported in Brazilian patients with AME.
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Affiliation(s)
- Fernanda Borchers Coeli
- Centro de Biologia Molecular e Engenharia Genética, Universidade Estadual de Campinas, SP, Brasil
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Honour JW. Diagnosis of diseases of steroid hormone production, metabolism and action. J Clin Res Pediatr Endocrinol 2009; 1:209-26. [PMID: 21274298 PMCID: PMC3005746 DOI: 10.4274/jcrpe.v1i5.209] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Accepted: 08/24/2009] [Indexed: 12/01/2022] Open
Abstract
Biochemical tests have been the basis for investigations of disorders affecting steroid hormones. In recent years it has been possible however to study the genes that determine functional enzymes, cofactors, receptors, transcription factors and signaling systems that are involved in the process. Analyses of mutations are available as a diagnostic service for only a few of these genes although research laboratories may be able to provide a service. Both biochemical and genetic research have brought to light new disorders. Some genes for transcription factors involved in the development of the endocrine organs have also been identified and patients with defects in these processes have been found. This paper will review general aspects of adrenal disorders with emphasis on clinical and laboratory findings. As with all endocrine investigations there are few single measurements that provide a definitive answer to a diagnosis. Timing of samples in relation to age, gender and time of day needs to be considered.
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Abstract
Among the causes of secondary hypertension are a group of disorders with a Mendelian inheritance pattern. Recent advances in molecular biology have unveiled the pathogenesis of hypertension in many of these conditions. Remarkably, the mechanism in every case has proved to be upregulation of sodium (Na) reabsorption in the distal nephron, with accompanying expansion of extracellular volume. In one group, the mutations involve the Na-transport machinery in distal tubule cells themselves: the distal convoluted tubule (DCT) cell and the principal cell of the collecting duct. Examples include Liddle's syndrome, with an activating mutation of epithelial Na channel (ENaC); two types of Gordon's syndrome, with mutations in two regulatory kinases [with no lysine (K) serine/threonine protein kinases (WNK)1 or WNK4]; and apparent mineralocorticoid excess (AME), with an inactivating mutation in the glucocorticoid-metabolizing 11beta-hydroxysteroid dehydrogenase type 2 enzyme (11HD2). In another group, abnormal adrenal steroid production leads to inappropriate stimulation of the mineralocorticoid receptor (MR) in the distal nephron. The pathophysiology may involve inappropriate production of aldosterone [in glucocorticoid-remediable aldosteronism (GRA) and familial hyperaldosteronism type II (FH II)], of cortisol (in familial glucocorticoid resistance), or of other steroid metabolites (in congenital adrenal hyperplasia and GRA). In contrast to earlier beliefs, hypertension in many of the inherited disorders may be mild, and electrolyte and acid-base abnormalities are often not present. Monogenic hypertension should therefore enter the differential diagnosis of any child or adolescent with hypertension. Plasma renin activity (PRA) is the appropriate screening tool for all types of inherited hypertension.
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Affiliation(s)
- V Matti Vehaskari
- Department of Pediatrics, Louisiana State University Health Sciences Center, New Orleans, LA 70118, USA.
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