1
|
Ji X, Zhao N, Liu H, Wu Y, Liu L. Case report: Two novel compound heterozygous variant of SLC12A3 gene in a gitelman syndrome family and literature review. Front Genet 2024; 15:1391015. [PMID: 39055258 PMCID: PMC11269260 DOI: 10.3389/fgene.2024.1391015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 06/06/2024] [Indexed: 07/27/2024] Open
Abstract
A 36-year-old unmarried male chef was incidentally diagnosed with hypokalemia during an evaluation for an acute perianal abscess. Despite potassium supplementation, he developed progressive weakness in his lower limbs, culminating in an inability to stand. Investigations confirmed severe hypokalemia, metabolic alkalosis, hypomagnesemia, secondary hyperaldosteronism, and low urinary calcium excretion, with normotension. The patient's long-standing stunted growth and lean physique since childhood were noted. Biochemical assays further identified type 2 diabetes mellitus and metabolic syndrome. Genetic analysis revealed three heterozygous SLC12A3 mutations (M1: c.421G>A: p.G141R, M2: c.509T>A:p.L170Q, and M3: c.704C>A: p.T235K), compound heterozygo us and derived from both parents, with M1 and M3 reported here for the first time. Treatment with spironolactone and oral potassium chloride stabilized his potassium levels. Following the administration of SGLT2 inhibitors in patients receiving hypoglycemic therapy, we observed a mild decrease in serum sodium levels. This case highlights the criticality of vigilant metabolic surveillance in Gitelman syndrome and advises prudence with SGLT2 inhibitors in those with concurrent type 2 diabetes, given the risk of potentially aggravate sodium loss.
Collapse
Affiliation(s)
- Xiaochen Ji
- Department of Internal Medicine, Dalian Medical University, Dalian, China
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Nan Zhao
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Haixia Liu
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Yutong Wu
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| | - Lichao Liu
- Department of Endocrinology and Metabolism, the Second Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China
| |
Collapse
|
2
|
You R, Jia Z. Pathophysiological role of Na-Cl cotransporter in kidneys, blood pressure, and metabolism. Hum Cell 2024:10.1007/s13577-024-01099-2. [PMID: 38985392 DOI: 10.1007/s13577-024-01099-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 07/02/2024] [Indexed: 07/11/2024]
Abstract
The Na-Cl cotransporter (NCC) is a well-recognized regulator of ion transportation in the kidneys that facilitates Na+ reabsorption in the distal convoluted tubule. It is also the pharmacologic inhibitory target of thiazide diuretics, a class of front-line antihypertensive agents that have been widely used for decades. NCC is a potent regulator of Na+ reabsorption and homeostasis. Hence, its overactivation and suppression lead to hypertension and hypotension, respectively. Genetic mutations that affect NCC function contribute to several diseases such as Gordon and Gitelman syndromes. We summarized the role of NCC in various physiologic processes and pathological conditions, such as maintaining ion and water homeostasis, controlling blood pressure, and influencing renal physiology and injury. In addition, we discussed the recent advancements in understanding cryo-EM structure of NCC, the regulatory mechanisms and binding mode of thiazides with NCC, and novel physiologic implications of NCC in regulating the cross-talk between the immune system and adipose tissue or the kidneys. This review contributes to a comprehensive understanding of the pivotal role of NCC in maintaining ion homeostasis, regulating blood pressure, and facilitating kidney function and NCC's novel role in immune and metabolic regulation.
Collapse
Affiliation(s)
- Ran You
- Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China.
- Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China.
| | - Zhanjun Jia
- Nanjing Key Laboratory of Pediatrics, Children's Hospital of Nanjing Medical University, 72 Guangzhou Road, Nanjing, 210008, China.
- Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China.
| |
Collapse
|
3
|
Li Y, Wang Z, Xu H, Hong Y, Shi M, Hu B, Wang X, Ma S, Wang M, Cao C, Zhu H, Hu D, Xu C, Lin Y, Xu G, Yao Y, Zeng R. Targeting the transmembrane cytokine co-receptor neuropilin-1 in distal tubules improves renal injury and fibrosis. Nat Commun 2024; 15:5731. [PMID: 38977708 PMCID: PMC11231174 DOI: 10.1038/s41467-024-50121-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 07/02/2024] [Indexed: 07/10/2024] Open
Abstract
Neuropilin-1 (NRP1), a co-receptor for various cytokines, including TGF-β, has been identified as a potential therapeutic target for fibrosis. However, its role and mechanism in renal fibrosis remains elusive. Here, we show that NRP1 is upregulated in distal tubular (DT) cells of patients with transplant renal insufficiency and mice with renal ischemia-reperfusion (I-R) injury. Knockout of Nrp1 reduces multiple endpoints of renal injury and fibrosis. We find that Nrp1 facilitates the binding of TNF-α to its receptor in DT cells after renal injury. This signaling results in a downregulation of lysine crotonylation of the metabolic enzyme Cox4i1, decreases cellular energetics and exacerbation of renal injury. Furthermore, by single-cell RNA-sequencing we find that Nrp1-positive DT cells secrete collagen and communicate with myofibroblasts, exacerbating acute kidney injury (AKI)-induced renal fibrosis by activating Smad3. Dual genetic deletion of Nrp1 and Tgfbr1 in DT cells better improves renal injury and fibrosis than either single knockout. Together, these results reveal that targeting of NRP1 represents a promising strategy for the treatment of AKI and subsequent chronic kidney disease.
Collapse
Affiliation(s)
- Yinzheng Li
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Zheng Wang
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Huzi Xu
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Yu Hong
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Mengxia Shi
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Bin Hu
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Xiuru Wang
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Shulin Ma
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Meng Wang
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Chujin Cao
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Han Zhu
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Danni Hu
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Chang Xu
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Yanping Lin
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China
| | - Gang Xu
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China.
| | - Ying Yao
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China.
- Department of Nutrition, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China.
| | - Rui Zeng
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430030, China.
- Key Laboratory of Organ Transplantation, Ministry of Education, NHC Key Laboratory of Organ Transplantation, Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, 430030, China.
| |
Collapse
|
4
|
Cheng YYW, Cheng CJ. Mitochondrial bioenergetics: coupling of transport to tubular mitochondrial metabolism. Curr Opin Nephrol Hypertens 2024; 33:405-413. [PMID: 38573234 PMCID: PMC11145760 DOI: 10.1097/mnh.0000000000000986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Renal tubules have robust active transport and mitochondrial metabolism, which are functionally coupled to maintain energy homeostasis. Here, I review the current literature and our recent efforts to examine mitochondrial adaptation to different transport activities in renal tubules. RECENT FINDINGS The advance of extracellular flux analysis (EFA) allows real-time assessments of mitochondrial respiration, glycolysis, and oxidation of energy substrates. We applied EFA assays to freshly isolated mouse proximal tubules, thick ascending limbs (TALs), and distal convoluted tubules (DCTs) and successfully differentiated their unique metabolic features. We found that TALs and DCTs adjusted their mitochondrial bioenergetics and biogenesis in response to acute and chronic alterations of transport activity. Based on the literature and our recent findings, I discuss working models and mechanisms underlying acute and chronic tubular adaptations to transport activity. The potential roles of peroxisome proliferator-activated receptor-γ coactivator 1α (PGC-1α), AMP-activated protein kinase (AMPK), and uncoupling protein 2 (UCP2) are discussed. SUMMARY Mitochondria in renal tubules are highly plastic to accommodate different transport activities. Understanding the mechanisms may improve the treatment of renal tubulopathies.
Collapse
Affiliation(s)
- Yong-Yao W. Cheng
- Division of Nephrology, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Chih-Jen Cheng
- Division of Nephrology, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| |
Collapse
|
5
|
Rioux AV, Nsimba-Batomene TR, Slimani S, Bergeron NAD, Gravel MAM, Schreiber SV, Fiola MJ, Haydock L, Garneau AP, Isenring P. Navigating the multifaceted intricacies of the Na +-Cl - cotransporter, a highly regulated key effector in the control of hydromineral homeostasis. Physiol Rev 2024; 104:1147-1204. [PMID: 38329422 DOI: 10.1152/physrev.00027.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 01/01/2024] [Accepted: 02/03/2024] [Indexed: 02/09/2024] Open
Abstract
The Na+-Cl- cotransporter (NCC; SLC12A3) is a highly regulated integral membrane protein that is known to exist as three splice variants in primates. Its primary role in the kidney is to mediate the cosymport of Na+ and Cl- across the apical membrane of the distal convoluted tubule. Through this role and the involvement of other ion transport systems, NCC allows the systemic circulation to reclaim a fraction of the ultrafiltered Na+, K+, Cl-, and Mg+ loads in exchange for Ca2+ and [Formula: see text]. The physiological relevance of the Na+-Cl- cotransport mechanism in humans is illustrated by several abnormalities that result from NCC inactivation through the administration of thiazides or in the setting of hereditary disorders. The purpose of the present review is to discuss the molecular mechanisms and overall roles of Na+-Cl- cotransport as the main topics of interest. On reading the narrative proposed, one will realize that the knowledge gained in regard to these themes will continue to progress unrelentingly no matter how refined it has now become.
Collapse
Affiliation(s)
- A V Rioux
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - T R Nsimba-Batomene
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - S Slimani
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - N A D Bergeron
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - M A M Gravel
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - S V Schreiber
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - M J Fiola
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - L Haydock
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
- Service de Néphrologie-Transplantation Rénale Adultes, Hôpital Necker-Enfants Malades, AP-HP, INSERM U1151, Université Paris Cité, Paris, France
| | - A P Garneau
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
- Service de Néphrologie-Transplantation Rénale Adultes, Hôpital Necker-Enfants Malades, AP-HP, INSERM U1151, Université Paris Cité, Paris, France
| | - P Isenring
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| |
Collapse
|
6
|
Touyz RM, de Baaij JHF, Hoenderop JGJ. Magnesium Disorders. N Engl J Med 2024; 390:1998-2009. [PMID: 38838313 DOI: 10.1056/nejmra1510603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Affiliation(s)
- Rhian M Touyz
- From the Research Institute of McGill University Health Centre, Departments of Medicine and Family Medicine, McGill University, Montreal (R.M.T.); and the Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, the Netherlands (J.H.F.B., J.G.J.H.)
| | - Jeroen H F de Baaij
- From the Research Institute of McGill University Health Centre, Departments of Medicine and Family Medicine, McGill University, Montreal (R.M.T.); and the Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, the Netherlands (J.H.F.B., J.G.J.H.)
| | - Joost G J Hoenderop
- From the Research Institute of McGill University Health Centre, Departments of Medicine and Family Medicine, McGill University, Montreal (R.M.T.); and the Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, the Netherlands (J.H.F.B., J.G.J.H.)
| |
Collapse
|
7
|
Cheng CJ, Nizar JM, Dai DF, Huang CL. Transport activity regulates mitochondrial bioenergetics and biogenesis in renal tubules. FASEB J 2024; 38:e23703. [PMID: 38805156 PMCID: PMC11147170 DOI: 10.1096/fj.202400358rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024]
Abstract
Renal tubules are featured with copious mitochondria and robust transport activity. Mutations in mitochondrial genes cause congenital renal tubulopathies, and changes in transport activity affect mitochondrial morphology, suggesting mitochondrial function and transport activity are tightly coupled. Current methods of using bulk kidney tissues or cultured cells to study mitochondrial bioenergetics are limited. Here, we optimized an extracellular flux analysis (EFA) to study mitochondrial respiration and energy metabolism using microdissected mouse renal tubule segments. EFA detects mitochondrial respiration and glycolysis by measuring oxygen consumption and extracellular acidification rates, respectively. We show that both measurements positively correlate with sample sizes of a few centimeter-length renal tubules. The thick ascending limbs (TALs) and distal convoluted tubules (DCTs) critically utilize glucose/pyruvate as energy substrates, whereas proximal tubules (PTs) are significantly much less so. Acute inhibition of TALs' transport activity by ouabain treatment reduces basal and ATP-linked mitochondrial respiration. Chronic inhibition of transport activity by 2-week furosemide treatment or deletion of with-no-lysine kinase 4 (Wnk4) decreases maximal mitochondrial capacity. In addition, chronic inhibition downregulates mitochondrial DNA mass and mitochondrial length/density in TALs and DCTs. Conversely, gain-of-function Wnk4 mutation increases maximal mitochondrial capacity and mitochondrial length/density without increasing mitochondrial DNA mass. In conclusion, EFA is a sensitive and reliable method to investigate mitochondrial functions in isolated renal tubules. Transport activity tightly regulates mitochondrial bioenergetics and biogenesis to meet the energy demand in renal tubules. The system allows future investigation into whether and how mitochondria contribute to tubular remodeling adapted to changes in transport activity.
Collapse
Affiliation(s)
- Chih-Jen Cheng
- Division of Nephrology, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, U.S.A
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jonathan M Nizar
- Division of Nephrology, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, U.S.A
| | - Dao-Fu Dai
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, U.S.A
| | - Chou-Long Huang
- Division of Nephrology, Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, U.S.A
| |
Collapse
|
8
|
Jefferis J, Mallett AJ. Exploring the impact and utility of genomic sequencing in established CKD. Clin Kidney J 2024; 17:sfae043. [PMID: 38464959 PMCID: PMC10921391 DOI: 10.1093/ckj/sfae043] [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: 10/09/2023] [Indexed: 03/12/2024] Open
Abstract
Clinical genetics is increasingly recognized as an important area within nephrology care. Clinicians require awareness of genetic kidney disease to recognize clinical phenotypes, consider use of genomics to aid diagnosis, and inform treatment decisions. Understanding the broad spectrum of clinical phenotypes and principles of genomic sequencing is becoming increasingly required in clinical nephrology, with nephrologists requiring education and support to achieve meaningful patient outcomes. Establishment of effective clinical resources, multi-disciplinary teams and education is important to increase application of genomics in clinical care, for the benefit of patients and their families. Novel applications of genomics in chronic kidney disease include pharmacogenomics and clinical translation of polygenic risk scores. This review explores established and emerging impacts and utility of genomics in kidney disease.
Collapse
Affiliation(s)
- Julia Jefferis
- Genetic Health Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Andrew J Mallett
- Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
- Department of Renal Medicine, Townsville University Hospital, Douglas, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, Australia
| |
Collapse
|
9
|
Hoogstraten CA, Hoenderop JG, de Baaij JHF. Mitochondrial Dysfunction in Kidney Tubulopathies. Annu Rev Physiol 2024; 86:379-403. [PMID: 38012047 DOI: 10.1146/annurev-physiol-042222-025000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Mitochondria play a key role in kidney physiology and pathology. They produce ATP to fuel energy-demanding water and solute reabsorption processes along the nephron. Moreover, mitochondria contribute to cellular health by the regulation of autophagy, (oxidative) stress responses, and apoptosis. Mitochondrial abundance is particularly high in cortical segments, including proximal and distal convoluted tubules. Dysfunction of the mitochondria has been described for tubulopathies such as Fanconi, Gitelman, and Bartter-like syndromes and renal tubular acidosis. In addition, mitochondrial cytopathies often affect renal (tubular) tissues, such as in Kearns-Sayre and Leigh syndromes. Nevertheless, the mechanisms by which mitochondrial dysfunction results in renal tubular diseases are only scarcely being explored. This review provides an overview of mitochondrial dysfunction in the development and progression of kidney tubulopathies. Furthermore, it emphasizes the need for further mechanistic investigations to identify links between mitochondrial function and renal electrolyte reabsorption.
Collapse
Affiliation(s)
- Charlotte A Hoogstraten
- Department of Medical Biosciences, Radboud University Medical Center, Nijmegen, The Netherlands;
| | - Joost G Hoenderop
- Department of Medical Biosciences, Radboud University Medical Center, Nijmegen, The Netherlands;
| | - Jeroen H F de Baaij
- Department of Medical Biosciences, Radboud University Medical Center, Nijmegen, The Netherlands;
| |
Collapse
|
10
|
Cheng CJ, Nizar JM, Dai DF, Huang CL. Transport activity regulates mitochondrial bioenergetics and biogenesis in renal tubules. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.02.04.578838. [PMID: 38370657 PMCID: PMC10871199 DOI: 10.1101/2024.02.04.578838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
Renal tubules are featured with copious mitochondria and robust transport activity. Mutations in mitochondrial genes cause congenital renal tubulopathies, and changes in transport activity affect mitochondrial morphology, suggesting mitochondrial function and transport activity are tightly coupled. Current methods of using bulk kidney tissues or cultured cells to study mitochondrial bioenergetics are limited. Here, we optimized an extracellular flux analysis (EFA) to study mitochondrial respiration and energy metabolism using microdissected mouse renal tubule segments. EFA detects mitochondrial respiration and glycolysis by measuring oxygen consumption and extracellular acidification rates, respectively. We show that both measurements positively correlate with sample sizes of a few centimeter-length renal tubules. The thick ascending limbs (TALs) and distal convoluted tubules (DCTs) predominantly utilize glucose/pyruvate as energy substrates, whereas proximal tubules (PTs) are significantly much less so. Acute inhibition of TALs' transport activity by ouabain treatment reduces basal and ATP-linked mitochondrial respiration. Chronic inhibition of transport activity by 2-week furosemide treatment or deletion of with-no-lysine kinase 4 (Wnk4) decreases maximal mitochondrial capacity. In addition, chronic inhibition downregulates mitochondrial DNA mass and mitochondrial length/density in TALs and DCTs. Conversely, gain-of-function Wnk4 mutation increases maximal mitochondrial capacity and mitochondrial length/density without increasing mitochondrial DNA mass. In conclusion, EFA is a sensitive and reliable method to investigate mitochondrial functions in isolated renal tubules. Transport activity tightly regulates mitochondrial bioenergetics and biogenesis to meet the energy demand in renal tubules. The system allows future investigation into whether and how mitochondria contribute to tubular remodeling adapted to changes in transport activity. Key points A positive correlation between salt reabsorption and oxygen consumption in mammalian kidneys hints at a potential interaction between transport activity and mitochondrial respiration in renal tubules.Renal tubules are heterogeneous in transport activity and mitochondrial metabolism, and traditional assays using bulk kidney tissues cannot provide segment-specific information.Here, we applied an extracellular flux analysis to investigate mitochondrial respiration and energy metabolism in isolated renal tubules. This assay is sensitive in detecting oxygen consumption and acid production in centimeter-length renal tubules and reliably recapitulates segment-specific metabolic features.Acute inhibition of transport activity reduces basal and ATP-linked mitochondrial respirations without changing maximal mitochondrial respiratory capacity. Chronic alterations of transport activity further adjust maximal mitochondrial respiratory capacity via regulating mitochondrial biogenesis or non-transcriptional mechanisms.Our findings support the concept that renal tubular cells finely adjust mitochondrial bioenergetics and biogenesis to match the new steady state of transport activity.
Collapse
|
11
|
Huang X, Wu M, Mou L, Zhang Y, Jiang J. Gitelman syndrome combined with diabetes mellitus: A case report and literature review. Medicine (Baltimore) 2023; 102:e36663. [PMID: 38115360 PMCID: PMC10727606 DOI: 10.1097/md.0000000000036663] [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: 09/18/2023] [Accepted: 11/23/2023] [Indexed: 12/21/2023] Open
Abstract
RATIONALE Gitelman syndrome (GS) is an uncommon autosomal recessive tubulopathy resulting from a functional deletion mutation in the SLC12A3 gene. Its onset is typically insidious and challenging to discern, and it is characterized by hypokalemia, metabolic alkalosis, and reduced urinary calcium excretion. There is limited literature on the diagnosis and management of GS in individuals with concomitant diabetes. PATIENT CONCERNS A 36-year-old male patient with a longstanding history of diabetes exhibited suboptimal glycemic control. Additionally, he presented with concurrent findings of hypokalemia, hypomagnesemia, hypocalciuria, and metabolic alkalosis. DIAGNOSIS Building upon the patient's clinical manifestations and extensive laboratory evaluations, we conducted thorough genetic testing, leading to the identification of a compound heterozygous mutation within the SLC12A3 gene. This definitive finding confirmed the diagnosis of GS. INTERVENTIONS We have formulated a detailed medication regimen for patients, encompassing personalized selection of hypoglycemic medications and targeted electrolyte supplementation. OUTCOMES Following 1 week of comprehensive therapeutic intervention, the patient's serum potassium level effectively normalized to 3.79 mmol/L, blood glucose parameters stabilized, and there was significant alleviation of clinical symptoms. LESSONS GS has a hidden onset and requires early diagnosis and intervention based on patient related symptoms and laboratory indicators in clinical practice, and personalized medication plans need to be provided according to the specific situation of the patient.
Collapse
Affiliation(s)
- Xiaoyan Huang
- Department of Endocrinology, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Miaohui Wu
- School of Pharmacy, Fujian Medical University, Quanzhou, China
| | - Lunpan Mou
- Department of Endocrinology, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Yaping Zhang
- Department of Endocrinology, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Jianjia Jiang
- Department of Endocrinology, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| |
Collapse
|
12
|
Viering DH, Vermeltfoort L, Bindels RJ, Deinum J, de Baaij JH. Electrolyte Disorders in Mitochondrial Cytopathies: A Systematic Review. J Am Soc Nephrol 2023; 34:1875-1888. [PMID: 37678265 PMCID: PMC10631606 DOI: 10.1681/asn.0000000000000224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023] Open
Abstract
SIGNIFICANCE STATEMENT Several recent studies identified mitochondrial mutations in patients with Gitelman or Fanconi syndrome. Mitochondrial cytopathies are generally not considered in the diagnostic workup of patients with electrolyte disorders. In this systematic review, we investigated the presence of electrolyte disorders in patients with mitochondrial cytopathies to determine the relevance of mitochondrial mutation screening in this population. Our analysis demonstrates that electrolyte disorders are commonly reported in mitochondrial cytopathies, often as presenting symptoms. Consequently, more clinical attention should be raised for mitochondrial disease as cause for disturbances in electrolyte homeostasis. Further prospective cohort studies are required to determine the exact prevalence of electrolyte disorders in mitochondrial cytopathies. BACKGROUND Electrolyte reabsorption in the kidney has a high energy demand. Proximal and distal tubular epithelial cells have a high mitochondrial density for energy release. Recently, electrolyte disorders have been reported as the primary presentation of some mitochondrial cytopathies. However, the prevalence and the pathophysiology of electrolyte disturbances in mitochondrial disease are unknown. Therefore, we systematically investigated electrolyte disorders in patients with mitochondrial cytopathies. METHODS We searched PubMed, Embase, and Google Scholar for articles on genetically confirmed mitochondrial disease in patients for whom at least one electrolyte is reported. Patients with a known second genetic anomaly were excluded. We evaluated 214 case series and reports (362 patients) as well as nine observational studies. Joanna Briggs Institute criteria were used to evaluate the quality of included studies. RESULTS Of 362 reported patients, 289 had an electrolyte disorder, with it being the presenting or main symptom in 38 patients. The average number of different electrolyte abnormalities per patient ranged from 2.4 to 1.0, depending on genotype. Patients with mitochondrial DNA structural variants seemed most affected. Reported pathophysiologic mechanisms included renal tubulopathies and hormonal, gastrointestinal, and iatrogenic causes. CONCLUSIONS Mitochondrial diseases should be considered in the evaluation of unexplained electrolyte disorders. Furthermore, clinicians should be aware of electrolyte abnormalities in patients with mitochondrial disease.
Collapse
Affiliation(s)
- Daan H.H.M. Viering
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lars Vermeltfoort
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - René J.M. Bindels
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen H.F. de Baaij
- Department of Medical BioSciences, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
13
|
García-Castaño A, Gómez-Conde S, Gondra L, Herrero M, Aguirre M, de la Hoz AB, Castaño L, Madariaga L. Genotypic variability in patients with clinical diagnosis of Bartter syndrome type 3. Sci Rep 2023; 13:12587. [PMID: 37537162 PMCID: PMC10400606 DOI: 10.1038/s41598-023-38179-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 07/04/2023] [Indexed: 08/05/2023] Open
Abstract
Bartter syndrome (BS) is a salt-losing hereditary tubulopathy characterized by hypokalemic metabolic alkalosis with secondary hyperaldosteronism. Confirmatory molecular diagnosis may be difficult due to genetic heterogeneity and overlapping of clinical symptoms. The aim of our study was to describe the different molecular findings in patients with a clinical diagnosis of classic BS. We included 27 patients (26 families) with no identified pathogenic variants in CLCNKB. We used a customized Ion AmpliSeq Next-Generation Sequencing panel including 44 genes related to renal tubulopathies. We detected pathogenic or likely pathogenic variants in 12 patients (44%), reaching a conclusive genetic diagnosis. Variants in SLC12A3 were found in 6 (Gitelman syndrome). Median age at diagnosis was 14.6 years (range 0.1-31), with no history of prematurity or polyhydramnios. Serum magnesium level was low in 2 patients (33%) but urinary calcium excretion was normal or low in all, with no nephrocalcinosis. Variants in SLC12A1 were found in 3 (BS type 1); and in KCNJ1 in 1 (BS type 2). These patients had a history of polyhydramnios in 3 (75%), and the mean gestational age was 34.2 weeks (SD 1.7). The median age at diagnosis was 1.8 years (range 0.1-6). Chronic kidney disease and nephrocalcinosis were present in 1 (25%) and 3 (75%) patients, respectively. A variant in CLCN5 was found in one patient (Dent disease), and in NR3C2 in another patient (Geller syndrome). Genetic diagnosis of BS is heterogeneous as different tubulopathies can present with a similar clinical picture. The use of gene panels in these diseases becomes more efficient than the study gene by gene with Sanger sequencing.
Collapse
Affiliation(s)
- Alejandro García-Castaño
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain
| | - Sara Gómez-Conde
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain
- Pediatric Department, University of the Basque Country UPV/EHU, Bizkaia, Spain
| | - Leire Gondra
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain
- Pediatric Department, University of the Basque Country UPV/EHU, Bizkaia, Spain
- Pediatric Nephrology Department, Cruces University Hospital, Plaza de Cruces, 48903, Barakaldo, Bizkaia, Spain
| | - María Herrero
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Pediatric Nephrology Department, Cruces University Hospital, Plaza de Cruces, 48903, Barakaldo, Bizkaia, Spain
| | - Mireia Aguirre
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- Pediatric Nephrology Department, Cruces University Hospital, Plaza de Cruces, 48903, Barakaldo, Bizkaia, Spain
| | - Ana-Belén de la Hoz
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain
| | - Luis Castaño
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
- CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain
- Pediatric Department, University of the Basque Country UPV/EHU, Bizkaia, Spain
| | - Leire Madariaga
- Biocruces Bizkaia Health Research Institute, Barakaldo, Spain.
- CIBERDEM, CIBERER, Endo-ERN, Madrid, Spain.
- Pediatric Department, University of the Basque Country UPV/EHU, Bizkaia, Spain.
- Pediatric Nephrology Department, Cruces University Hospital, Plaza de Cruces, 48903, Barakaldo, Bizkaia, Spain.
| |
Collapse
|
14
|
Wang Y, Song D, Tang L. Mitophagy, Inflammasomes and Their Interaction in Kidney Diseases: A Comprehensive Review of Experimental Studies. J Inflamm Res 2023; 16:1457-1469. [PMID: 37042016 PMCID: PMC10083013 DOI: 10.2147/jir.s402290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/17/2023] [Indexed: 04/08/2023] Open
Abstract
Mitophagy is an important mechanism for mitochondrial quality control by regulating autophagosome-specific phagocytosis, degradation and clearance of damaged mitochondria, and involved in cell damage and diseases. Inflammasomes are important inflammation-related factors newly discovered in recent years, which are involved in cell innate immunity and inflammatory response, and play an important role in kidney diseases. Based on the current studies, we reviewed the progress of mitophagy, inflammasomes and their interaction in kidney diseases.
Collapse
Affiliation(s)
- Yulin Wang
- Department of Nephrology, Zhengzhou University First Affiliated Hospital, Zhengzhou, Henan, 450052, People’s Republic of China
| | - Dongxu Song
- Department of Nephrology, Zhengzhou University First Affiliated Hospital, Zhengzhou, Henan, 450052, People’s Republic of China
| | - Lin Tang
- Department of Nephrology, Zhengzhou University First Affiliated Hospital, Zhengzhou, Henan, 450052, People’s Republic of China
- Correspondence: Lin Tang, Department of Nephrology, Zhengzhou University First Affiliated Hospital, 1 Jianshe Road, Zhengzhou, Henan, 450052, People’s Republic of China, Email
| |
Collapse
|
15
|
Van Beusecum JP, Rianto F, Teakell J, Kon V, Sparks MA, Hoorn EJ, Kirabo A, Ramkumar N. Novel Concepts in Nephron Sodium Transport: A Physiological and Clinical Perspective. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:124-136. [PMID: 36868728 DOI: 10.1053/j.akdh.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 04/13/2023]
Abstract
The kidneys play a critical role in maintaining total body sodium (Na+) balance across a wide range of dietary intake, accomplished by a concerted effort involving multiple Na+ transporters along the nephron. Furthermore, nephron Na+ reabsorption and urinary Na+ excretion are closely linked to renal blood flow and glomerular filtration such that perturbations in either of them can modify Na+ transport along the nephron, ultimately resulting in hypertension and other Na+-retentive states. In this article, we provide a brief physiological overview of nephron Na+ transport and illustrate clinical syndromes and therapeutic agents that affect Na+ transporter function. We highlight recent advances in kidney Na+ transport, particularly the role of immune cells, lymphatics, and interstitial Na+ in regulating Na+ reabsorption, the emergence of potassium (K+) as a regulator of Na+ transport, and the evolution of the nephron to modulate Na+ transport.
Collapse
Affiliation(s)
- Justin P Van Beusecum
- Ralph H. Johnson VA Medical Center, Charleston, SC; Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Fitra Rianto
- Division of Nephrology, Department of Medicine, Duke University School of Medicine and Renal Section, Durham VA Health Care System Durham, Durham, NC
| | - Jade Teakell
- Division of Renal Diseases and Hypertension, Department of Medicine, McGovern Medical School, University of Texas Health Science Center, Houston, TX
| | - Valentina Kon
- Division of Nephrology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew A Sparks
- Division of Nephrology, Department of Medicine, Duke University School of Medicine and Renal Section, Durham VA Health Care System Durham, Durham, NC
| | - Ewout J Hoorn
- Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Annet Kirabo
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN; Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN
| | - Nirupama Ramkumar
- Division of Nephrology and Hypertension, Department of Medicine, University of Utah Health, Salt Lake City, UT.
| |
Collapse
|
16
|
Ray E, Mohan K, Ahmad S, Wolf MTF. Physiology of a Forgotten Electrolyte-Magnesium Disorders. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:148-163. [PMID: 36868730 DOI: 10.1053/j.akdh.2022.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/26/2022] [Accepted: 12/06/2022] [Indexed: 03/05/2023]
Abstract
Magnesium (Mg2+) is the second most common intracellular cation and the fourth most abundant element on earth. However, Mg2+ is a frequently overlooked electrolyte and often not measured in patients. While hypomagnesemia is common in 15% of the general population, hypermagnesemia is typically only found in preeclamptic women after Mg2+ therapy and in patients with ESRD. Mild to moderate hypomagnesemia has been associated with hypertension, metabolic syndrome, type 2 diabetes mellitus, CKD, and cancer. Nutritional Mg2+ intake and enteral Mg2+ absorption are important for Mg2+ homeostasis, but the kidneys are the key regulators of Mg2+ homeostasis by limiting urinary excretion to less than 4% while the gastrointestinal tract loses over 50% of the Mg2+ intake in the feces. Here, we review the physiological relevance of Mg2+, the current knowledge of Mg2+ absorption in the kidneys and the gut, the different causes of hypomagnesemia, and a diagnostic approach on how to assess Mg2+ status. We highlight the latest discoveries of monogenetic conditions causing hypomagnesemia, which have enhanced our understanding of tubular Mg2+ absorption. We will also discuss external and iatrogenic causes of hypomagnesemia and advances in the treatment of hypomagnesemia.
Collapse
Affiliation(s)
- Evan Ray
- Renal-Electrolyte Division, Department of Internal Medicine, University of Pittsburgh, PA
| | - Krithika Mohan
- Department of Nephrology, Hosmat Hospital, HBR Layout, Bangalore, India
| | - Syeda Ahmad
- Renal-Electrolyte Division, Department of Internal Medicine, University of Pittsburgh, PA
| | - Matthias T F Wolf
- Pediatric Nephrology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX.
| |
Collapse
|
17
|
Abstract
Mg2+ is essential for many cellular and physiological processes, including muscle contraction, neuronal activity, and metabolism. Consequently, the blood Mg2+ concentration is tightly regulated by balanced intestinal Mg2+ absorption, renal Mg2+ excretion, and Mg2+ storage in bone and soft tissues. In recent years, the development of novel transgenic animal models and identification of Mendelian disorders has advanced our current insight in the molecular mechanisms of Mg2+ reabsorption in the kidney. In the proximal tubule, Mg2+ reabsorption is dependent on paracellular permeability by claudin-2/12. In the thick ascending limb of Henle's loop, the claudin-16/19 complex provides a cation-selective pore for paracellular Mg2+ reabsorption. The paracellular Mg2+ reabsorption in this segment is regulated by the Ca2+-sensing receptor, parathyroid hormone, and mechanistic target of rapamycin (mTOR) signaling. In the distal convoluted tubule, the fine tuning of Mg2+ reabsorption takes place by transcellular Mg2+ reabsorption via transient receptor potential melastatin-like types 6 and 7 (TRPM6/TRPM7) divalent cation channels. Activity of TRPM6/TRPM7 is dependent on hormonal regulation, metabolic activity, and interacting proteins. Basolateral Mg2+ extrusion is still poorly understood but is probably dependent on the Na+ gradient. Cyclin M2 and SLC41A3 are the main candidates to act as Na+/Mg2+ exchangers. Consequently, disturbances of basolateral Na+/K+ transport indirectly result in impaired renal Mg2+ reabsorption in the distal convoluted tubule. Altogether, this review aims to provide an overview of the molecular mechanisms of Mg2+ reabsorption in the kidney, specifically focusing on transgenic mouse models and human hereditary diseases.
Collapse
Affiliation(s)
- Jeroen H F de Baaij
- Department of Physiology, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
18
|
Morrison AR. Magnesium Homeostasis: Lessons from Human Genetics. Clin J Am Soc Nephrol 2023; 18:01277230-990000000-00067. [PMID: 36723340 PMCID: PMC10356123 DOI: 10.2215/cjn.0000000000000103] [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: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 02/02/2023]
Abstract
Mg2+, the fourth most abundant cation in the body, serves as a co-factor for about 600 cellular enzymes. One third of ingested Mg2+ is absorbed from the gut through a saturable transcellular process and a concentration-dependent paracellular process. Absorbed Mg2+ is excreted by the kidney and maintains serum Mg2+ within a narrow range of 0.7 to 1.25 mmol/L. The reabsorption of Mg2+ by the nephron is characterized by paracellular transport in the proximal tubule and thick ascending limb. The nature of the transport pathways in the gut epithelia and thick ascending limb has emerged from an understanding of the molecular mechanisms responsible for rare monogenetic disorders presenting with clinical hypomagnesemia. These human disorders due to loss-of function mutations, in concert with mouse models have led to a deeper understanding of Mg2+ transport in the gut and renal tubule. This review focuses on the nature of the transporters and channels revealed by human and mouse genetics and how they are integrated into an understanding of human Mg2+ physiology.
Collapse
Affiliation(s)
- Aubrey R Morrison
- Division of Nephrology Department of Medicine and Developmental Biology Washington University School of Medicine, St Louis MO, 63110 USA
| |
Collapse
|
19
|
Viering DH, Hureaux M, Neveling K, Latta F, Kwint M, Blanchard A, Konrad M, Bindels RJ, Schlingmann KP, Vargas-Poussou R, de Baaij JH. Long-Read Sequencing Identifies Novel Pathogenic Intronic Variants in Gitelman Syndrome. J Am Soc Nephrol 2023; 34:333-345. [PMID: 36302598 PMCID: PMC10103101 DOI: 10.1681/asn.2022050627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/17/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Gitelman syndrome is a salt-losing tubulopathy characterized by hypokalemic alkalosis and hypomagnesemia. It is caused by homozygous recessive or compound heterozygous pathogenic variants in SLC12A3 , which encodes the Na + -Cl - cotransporter (NCC). In up to 10% of patients with Gitelman syndrome, current genetic techniques detect only one specific pathogenic variant. This study aimed to identify a second pathogenic variant in introns, splice sites, or promoters to increase the diagnostic yield. METHODS Long-read sequencing of SLC12A3 was performed in 67 DNA samples from individuals with suspected Gitelman syndrome in whom a single likely pathogenic or pathogenic variant was previously detected. In addition, we sequenced DNA samples from 28 individuals with one variant of uncertain significance or no candidate variant. Midigene splice assays assessed the pathogenicity of novel intronic variants. RESULTS A second likely pathogenic/pathogenic variant was identified in 45 (67%) patients. Those with two likely pathogenic/pathogenic variants had a more severe electrolyte phenotype than other patients. Of the 45 patients, 16 had intronic variants outside of canonic splice sites (nine variants, mostly deep intronic, six novel), whereas 29 patients had an exonic variant or canonic splice site variant. Midigene splice assays of the previously known c.1670-191C>T variant and intronic candidate variants demonstrated aberrant splicing patterns. CONCLUSION Intronic pathogenic variants explain an important part of the missing heritability in Gitelman syndrome. Long-read sequencing should be considered in diagnostic workflows for Gitelman syndrome.
Collapse
Affiliation(s)
- Daan H.H.M. Viering
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Marguerite Hureaux
- Reference Center for Hereditary Kidney and Childhood Diseases (Maladies Rénales Héréditaires de l’Enfant et de l’Adulte, MARHEA), Paris, France
- Department of Genetics, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
- Paris CardioVascular Research Center, Institut National de la Santé et de Recherche Médicale (INSERM) U970, Paris City University, Paris, France
| | - Kornelia Neveling
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Femke Latta
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michael Kwint
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anne Blanchard
- Reference Center for Hereditary Kidney and Childhood Diseases (Maladies Rénales Héréditaires de l’Enfant et de l’Adulte, MARHEA), Paris, France
- Clinical Investigations Center, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
- Centre de Recherche des Cordeliers, Sorbonne Université, INSERM, University of Paris, Centre National de la Recherche Scientifique (CNRS), Paris, France
| | - Martin Konrad
- Department of General Pediatrics, University Children’s Hospital, Münster, Germany
| | - René J.M. Bindels
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Rosa Vargas-Poussou
- Reference Center for Hereditary Kidney and Childhood Diseases (Maladies Rénales Héréditaires de l’Enfant et de l’Adulte, MARHEA), Paris, France
- Department of Genetics, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
- Clinical Investigations Center, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Jeroen H.F. de Baaij
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
20
|
Kermond R, Mallett A, McCarthy H. A clinical approach to tubulopathies in children and young adults. Pediatr Nephrol 2023; 38:651-662. [PMID: 35585366 PMCID: PMC9842573 DOI: 10.1007/s00467-022-05606-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 01/21/2023]
Abstract
Kidney tubules are responsible for the preservation of fluid, electrolyte and acid-base homeostasis via passive and active mechanisms. These physiological processes can be disrupted by inherited or acquired aetiologies. The net result is a tubulopathy. It is important to make a prompt and accurate diagnosis of tubulopathies in children and young adults. This allows timely and appropriate management, including disease-specific therapies, and avoids complications such as growth failure. Tubulopathies can present with a variety of non-specific clinical features which can be diagnostically challenging. In this review, we build from this common anatomical and physiological understanding to present a tangible appreciation of tubulopathies as they are likely to be clinically encountered among affected children and young adults.
Collapse
Affiliation(s)
- Rachael Kermond
- Department of Renal Medicine, Sydney Children’s Hospital Network, Sydney, NSW Australia
| | - Andrew Mallett
- Department of Renal Medicine, Townsville University Hospital, Douglas, QLD, Australia. .,College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia. .,Institute for Molecular Bioscience & Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Hugh McCarthy
- Department of Renal Medicine, Sydney Children's Hospital Network, Sydney, NSW, Australia. .,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia. .,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.
| |
Collapse
|
21
|
Ilenwabor BP, Franken GAC, Sponder G, Bos C, Racay P, Kolisek M, Hoenderop JGJ, de Baaij JHF. SLC41A1 knockout mice display normal magnesium homeostasis. Am J Physiol Renal Physiol 2022; 323:F553-F563. [PMID: 36049064 DOI: 10.1152/ajprenal.00101.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Transcellular Mg2+ reabsorption in the distal convoluted tubule (DCT) of the kidneys plays an important role in maintaining systemic Mg2+ homeostasis. SLC41A1 is a Na+/Mg2+ exchanger that mediates Mg2+ efflux from cells and is hypothesized to facilitate basolateral extrusion of Mg2+ in the DCT. In this study, we generated a SLC41A1 knockout mouse model to examine the role of SLC41A1 in Mg2+ homeostasis. Slc41a1-/- mice exhibited similar serum and urine Mg2+ levels as their wild-type littermates. Dietary restriction of Mg2+ resulted in reduced serum Mg2+ concentration and urinary Mg2+ excretion, which was similar in the wild-type and knockout groups. Expression of genes encoding Mg2+ channels and transporters such as transient receptor potential melastatin 6 (Trpm6), transient receptor potential melastatin 7 (Trpm7), cyclin and CBS domain divalent metal cation transport mediator 2 (Cnnm2), and Slc41a3 were unchanged based on genotype. We investigated the potential redundancy of SLC41A1 and its homolog SLC41A3 by generating a double knockout mouse. Although Slc41a3-/- knockout mice showed significantly reduced serum Mg2+ compared with wild-type and Slc41a1-/- knockout groups, double knockout mice displayed similar serum Mg2+ levels as Slc41a3-/- knockout mice. In conclusion, our data show that SLC41A1 is not involved in the regulation of systemic Mg2+ homeostasis in mice. Our data also demonstrate that SLC41A1 does not compensate for the loss of SLC41A3, suggesting different functions of these SLC41 proteins in vivo.NEW & NOTEWORTHY SLC41A1 has been hypothesized to mediate Mg2+ extrusion in the distal convoluted tubule and thus regulate Mg2+ homeostasis. This study investigated the role of SLC41A1 in Mg2+ homeostasis in vivo using a transgenic mouse model. Our results demonstrate that SLC41A1 is not required to maintain normal Mg2+ balance in mice. We also show that SLC41A3 is more important than SLC41A1 in regulating systemic Mg2+ levels.
Collapse
Affiliation(s)
- Barnabas P Ilenwabor
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gijs A C Franken
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerhard Sponder
- Institute of Veterinary Physiology, Freie Universität Berlin, Berlin, Germany
| | - Caro Bos
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Racay
- Department of Medical Biochemistry, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia.,Biomedical Center Martin, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Martin Kolisek
- Biomedical Center Martin, Jessenius Faculty of Medicine, Comenius University in Bratislava, Martin, Slovakia
| | - Joost G J Hoenderop
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jeroen H F de Baaij
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
22
|
Which patients with CKD will benefit from genomic sequencing? Synthesizing progress to illuminate the future. Curr Opin Nephrol Hypertens 2022; 31:541-547. [PMID: 36093902 PMCID: PMC9594128 DOI: 10.1097/mnh.0000000000000836] [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] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW This review will summarize and synthesize recent findings in regard to monogenic kidney disorders, including how that evidence is being translated into practice. It will add to existing key knowledge to provide context for clinicians in consolidating existing practice and approaches. RECENT FINDINGS Whilst there are long established factors, which indicate increased likelihood of identifying a monogenic cause for kidney disease, these can now be framed in terms of the identification of new genes, new indications for genomic testing and new evidence for clinical utility of genomic testing in nephrology. Further, inherent in the use of genomics in nephrology are key concepts including robust informed consent, variant interpretation and return of results. Recent findings of variants in genes related to complex or broader kidney phenotypes are emerging in addition to understanding of de novo variants. Phenocopy phenomena are indicating a more pragmatic use of broader gene panels whilst evidence is emerging of a role in unexplained kidney disease. Clinical utility is evolving but is being successfully demonstrated across multiple domains of outcome and practice. SUMMARY We provide an updated framework of evidence to guide application of genomic testing in chronic kidney disease (CKD), building upon existing principles and knowledge to indicate how the practice and implementation of this can be applied today. There are clearly established roles for genomic testing for some patients with CKD, largely those with suspected heritable forms, with these continuing to expand as new evidence emerges.
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW Gitelman syndrome is a recessive salt-wasting disorder characterized by hypomagnesemia, hypokalemia, metabolic alkalosis and hypocalciuria. The majority of patients are explained by mutations and deletions in the SLC12A3 gene, encoding the Na+-Cl--co-transporter (NCC). Recently, additional genetic causes of Gitelman-like syndromes have been identified that should be considered in genetic screening. This review aims to provide a comprehensive overview of the clinical, genetic and mechanistic aspects of Gitelman(-like) syndromes. RECENT FINDINGS Disturbed Na+ reabsorption in the distal convoluted tubule (DCT) is associated with hypomagnesemia and hypokalemic alkalosis. In Gitelman syndrome, loss-of-function mutations in SLC12A3 cause impaired NCC-mediated Na+ reabsorption. In addition, patients with mutations in CLCKNB, KCNJ10, FXYD2 or HNF1B may present with a similar phenotype, as these mutations indirectly reduce NCC activity. Furthermore, genetic investigations of patients with Na+-wasting tubulopathy have resulted in the identification of pathogenic variants in MT-TI, MT-TF, KCNJ16 and ATP1A1. These novel findings highlight the importance of cell metabolism and basolateral membrane potential for Na+ reabsorption in the DCT. SUMMARY Altogether, these findings extend the genetic spectrum of Gitelman-like electrolyte alterations. Genetic testing of patients with hypomagnesemia and hypokalemia should cover a panel of genes involved in Gitelman-like syndromes, including the mitochondrial genome.
Collapse
Affiliation(s)
- Karl P Schlingmann
- Department of General Pediatrics, University Children's Hospital, Münster, Germany
| | - Jeroen H F de Baaij
- Department of Physiology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
24
|
Clinical and Genetic Characterization of Patients with Bartter and Gitelman Syndrome. Int J Mol Sci 2022; 23:ijms23105641. [PMID: 35628451 PMCID: PMC9144947 DOI: 10.3390/ijms23105641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 02/04/2023] Open
Abstract
Bartter (BS) and Gitelman (GS) syndrome are autosomal recessive inherited tubulopathies, whose clinical diagnosis can be challenging, due to rarity and phenotypic overlap. Genotype-phenotype correlations have important implications in defining kidney and global outcomes. The aim of our study was to assess the diagnostic rate of whole-exome sequencing (WES) coupled with a bioinformatic analysis of copy number variations in a population of 63 patients with BS and GS from a single institution, and to explore genotype-phenotype correlations. We obtained a diagnostic yield of 86% (54/63 patients), allowing disease reclassification in about 14% of patients. Although some clinical and laboratory features were more commonly reported in patients with BS or GS, a significant overlap does exist, and age at onset, preterm birth, gestational age and nephro-calcinosis are frequently misleading. Finally, chronic kidney disease (CKD) occurs in about 30% of patients with BS or GS, suggesting that the long-term prognosis can be unfavorable. In our cohort the features associated with CKD were lower gestational age at birth and a molecular diagnosis of BS, especially BS type 1. The results of our study demonstrate that WES is useful in dealing with the phenotypic heterogeneity of these disorders, improving differential diagnosis and genotype-phenotype correlation.
Collapse
|
25
|
Stevenson M, Pagnamenta AT, Mack HG, Savige J, Giacopuzzi E, Lines KE, Taylor JC, Thakker RV. The Bartter-Gitelman Spectrum: Fifty Year Follow-up with Revision of Diagnosis after Whole Genome Sequencing. J Endocr Soc 2022; 6:bvac079. [PMID: 35668994 PMCID: PMC9155595 DOI: 10.1210/jendso/bvac079] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Indexed: 11/26/2022] Open
Abstract
Bartter syndrome (BS) and Gitelman syndrome (GS) are renal tubular disorders affecting sodium, potassium, and chloride reabsorption. Clinical features include muscle cramps and weakness, in association with hypokalemia, hypochloremic metabolic alkalosis, and hyperreninemic hyperaldosteronism. Hypomagnesemia and hypocalciuria are typical of GS, while juxtaglomerular hyperplasia is characteristic of BS. GS is due to SLC12A3 variants, whereas BS is due to variants in SLC12A1, KCNJ1, CLCNKA, CLCNKB, BSND, MAGED2, or CASR. We had the opportunity to follow up one of the first reported cases of a salt-wasting tubulopathy, who based on clinical features was diagnosed with GS. The patient had presented at age 10 years with tetany precipitated by vomiting or diarrhea. She had hypokalemia, a hypochloremic metabolic alkalosis, hyponatremia, mild hypercalcemia, and normomagnesemia, and subsequently developed hypocalciuria and hypomagnesemia. A renal biopsy showed no evidence for juxtaglomerular hyperplasia. She developed chronic kidney failure at age 55 years, and ocular sclerochoroidal calcification, associated with BS and GS, at older than 65 years. Our aim was therefore to establish the genetic diagnosis in this patient using whole-genome sequencing (WGS). Leukocyte DNA was used for WGS analysis, and this revealed a homozygous c.226C > T (p.Arg76Ter) nonsense CLCNKB mutation, thereby establishing a diagnosis of BS type-3. WGS also identified 2 greater than 5-Mb regions of homozygosity that suggested likely mutational heterozygosity in her parents, who originated from a Greek island with fewer than 1500 inhabitants and may therefore have shared a common ancestor. Our results demonstrate the utility of WGS in establishing the correct diagnosis in renal tubular disorders with overlapping phenotypes.
Collapse
Affiliation(s)
- Mark Stevenson
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology & Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Alistair T Pagnamenta
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Heather G Mack
- Department of Surgery (Ophthalmology), University of Melbourne, Parkville, Australia
| | - Judith Savige
- The University of Melbourne Department of Medicine (Melbourne Health) and Northern Health, Epping, Australia
| | - Edoardo Giacopuzzi
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Kate E Lines
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology & Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Jenny C Taylor
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Rajesh V Thakker
- Academic Endocrine Unit, Oxford Centre for Diabetes, Endocrinology & Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| |
Collapse
|
26
|
Mechanisms of ion transport regulation by HNF1β in the kidney: beyond transcriptional regulation of channels and transporters. Pflugers Arch 2022; 474:901-916. [PMID: 35554666 PMCID: PMC9338905 DOI: 10.1007/s00424-022-02697-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/19/2022] [Accepted: 04/22/2022] [Indexed: 01/01/2023]
Abstract
Hepatocyte nuclear factor 1β (HNF1β) is a transcription factor essential for the development and function of the kidney. Mutations in and deletions of HNF1β cause autosomal dominant tubule interstitial kidney disease (ADTKD) subtype HNF1β, which is characterized by renal cysts, diabetes, genital tract malformations, and neurodevelopmental disorders. Electrolyte disturbances including hypomagnesemia, hyperuricemia, and hypocalciuria are common in patients with ADTKD-HNF1β. Traditionally, these electrolyte disturbances have been attributed to HNF1β-mediated transcriptional regulation of gene networks involved in ion transport in the distal part of the nephron including FXYD2, CASR, KCNJ16, and FXR. In this review, we propose additional mechanisms that may contribute to the electrolyte disturbances observed in ADTKD-HNF1β patients. Firstly, kidney development is severely affected in Hnf1b-deficient mice. HNF1β is required for nephron segmentation, and the absence of the transcription factor results in rudimentary nephrons lacking mature proximal tubule, loop of Henle, and distal convoluted tubule cluster. In addition, HNF1β is proposed to be important for apical-basolateral polarity and tight junction integrity in the kidney. Interestingly, cilia formation is unaffected by Hnf1b defects in several models, despite the HNF1β-mediated transcriptional regulation of many ciliary genes. To what extent impaired nephron segmentation, apical-basolateral polarity, and cilia function contribute to electrolyte disturbances in HNF1β patients remains elusive. Systematic phenotyping of Hnf1b mouse models and the development of patient-specific kidney organoid models will be essential to advance future HNF1β research.
Collapse
|
27
|
Tseng MH, Konrad M, Ding JJ, Lin SH. Clinical and Genetic Approach to Renal Hypomagnesemia. Biomed J 2021; 45:74-87. [PMID: 34767995 PMCID: PMC9133307 DOI: 10.1016/j.bj.2021.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 12/03/2022] Open
Abstract
Magnesium (Mg2+) is an important intracellular cation and essential to maintain cell function including cell proliferation, immunity, cellular energy metabolism, protein and nucleic acid synthesis, and regulation of ion channels. Consequences of hypomagnesemia affecting multiple organs can be in overt or subtle presentations. Besides detailed history and complete physical examination, the assessment of urinary Mg2+ excretion is help to differentiate renal from extra-renal (gastrointestinal, tissue sequestration, and shifting) causes of hypomagnesemia. Renal hypomagnesemia can be caused by an increased glomerular filtration and impaired reabsorption in proximal tubular cells, thick ascending limb of the loop of Henle or distal convoluted tubules. A combination of renal Mg2+ wasting, familial history, age of onset, associated features, and exclusion of acquired etiologies point to inherited forms of renal hypomagnesemia. Based on clinical phenotypes, its definite genetic diagnosis can be simply grouped into specific, uncertain, and unknown gene mutations with a priority of genetic approach methods. An unequivocal molecular diagnosis could allow for prediction of clinical outcome, providing genetic counseling, avoiding unnecessary studies or interventions, and possibly uncovering the pathogenic mechanism. Given numerous identified genes responsible for Mg2+ transport in renal hypomagnesemia over the past two decades, several potential and specific molecular and cellular therapeutic strategies to correct hypomagnesemia are promising.
Collapse
Affiliation(s)
- Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Department of Pediatrics, Xiamen Chang Gung Hospital, China
| | - Martin Konrad
- Department of General Pediatrics, University Children's Hospital Münster, Münster, Germany
| | - Jhao-Jhuang Ding
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
| |
Collapse
|
28
|
Allison S. mtDNA variants in Gitelman-like syndrome. Nat Rev Nephrol 2021; 17:794. [PMID: 34663984 DOI: 10.1038/s41581-021-00508-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
|