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Costello J, Bourke E. Bartter's Syndrome - the Case for a Primary Potassium-Losing Tubulopathy: Discussion Paper. J R Soc Med 2018; 76:53-6. [PMID: 6827500 PMCID: PMC1438538 DOI: 10.1177/014107688307600112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Molecular defects affecting the transport of sodium, potassium and chloride in the nephron through the ROMK K+ channel, Na+/K+/2Cl- cotransporter, the Na+/Cl- cotransporter and chloride channel have been identified in patients with Bartter's and Gitelman's syndromes. Defects of the angiotensin II type I receptor and CFTR have also being described. These defects are simple (i.e., most are single amino acid substitutions) but affect key elements in tubular transport. The simplicity of the genetic defects may explain why the inheritance of these conditions remains unclear in most kindreds (i.e., not just recessive or dominant) and emphasises the crucial importance of the conformational structure of these channels. Application of this molecular information will allow the early genetic identification of patients with these syndromes and enable us to differentiate between the various disorders at a functional level. It may also identify a subgroup in which the heterozygous form may make patients potentially exquisitely sensitive to diuretics.
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Affiliation(s)
- S Bhandari
- School of Biomedical Sciences, Department of Physiology, University of Leeds, UK
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Konrad M, Leonhardt A, Hensen P, Seyberth HW, Köckerling A. Prenatal and postnatal management of hyperprostaglandin E syndrome after genetic diagnosis from amniocytes. Pediatrics 1999; 103:678-83. [PMID: 10049979 DOI: 10.1542/peds.103.3.678] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe prenatal genetic diagnosis in hyperprostaglandin E syndrome (HPS) and the effect of indomethacin therapy on the course of the disease before birth and in the neonatal period. METHODS Mutational analysis of the ROMK channel gene (KCNJ1) from amniocytes by single-strand conformational analysis and direct sequencing. Review of the clinical and laboratory findings during pregnancy and the neonatal period in two siblings affected with HPS. RESULTS Compound heterozygosity of the fetus in KCNJ1 (D74Y/P110L) confirmed the clinical diagnosis of HPS at 26 weeks of gestation. Indomethacin therapy from 26 to 31 weeks prevented further progression of polyhydramnios without major side effects. In contrast to the elder brother, who had been diagnosed at the age of 2 months, the neonatal course was uncomplicated. Hypovolemic renal failure after excessive renal loss of salt and water could be prevented and severe nephrocalcinosis did not occur. CONCLUSIONS Genetic diagnosis of HPS and subsequent prenatal indomethacin therapy seems to have a beneficial effect on the natural course of HPS, especially progression of polyhydramnios; therefore, extreme prematurity could be prevented. Also, postnatally the early diagnosis allows the effective water and electrolyte substitution before severe volume depletion.
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Affiliation(s)
- M Konrad
- Department of Pediatrics, Philipps University, Marburg, Germany
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Abstract
Familial hypokalemic, hypochloremic metabolic alkalosis, or Bartter syndrome, is not a single disorder but rather a set of closely related disorders. These Bartter-like syndromes share many of the same physiologic derangements, but differ with regard to the age of onset, the presenting symptoms, the magnitude of urinary potassium (K) and prostaglandin excretion, and the extent of urinary calcium excretion. At least three clinical phenotypes have been distinguished: (1) classic Bartter syndrome; (2) the hypocalciuric-hypomagnesemic Gitelman variant; and (3) the antenatal hypercalciuric variant (also termed hyperprostaglandin E syndrome). The fundamental pathogenesis of this complex set of disorders has long fascinated and stymied investigators. Physiologic investigations have suggested numerous pathogenic models. The cloning of genes encoding renal transport proteins has provided molecular tools to begin testing these hypotheses. To date, molecular genetic analyses have determined that mutations in the gene encoding the thiazide-sensitive sodium-chloride (Na-Cl) cotransporter underlie the pathogenesis of the Gitelman variant. In comparison, the antenatal variant is genetically heterogeneous with mutations in the genes encoding either the bumetanide-sensitive sodium-potassium-chloride (Na-K-2Cl) cotransporter or the luminal, ATP-regulated, K channel. With these data, investigators have begun to unravel the pathophysiologic enigma of the Bartter-like syndromes. Further studies will help refine pathogenic models for this set of disorders as well as provide new insights into the normal mechanisms of renal electrolyte transport.
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Affiliation(s)
- L M Guay-Woodford
- Department of Medicine, University of Alabama at Birmingham, 35294, USA
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Nishikawa T, Dohi S. Baroreflex function in a patient with Bartter's syndrome. CANADIAN ANAESTHETISTS' SOCIETY JOURNAL 1985; 32:646-50. [PMID: 3907793 DOI: 10.1007/bf03011413] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
There is little information regarding circulatory responses in Bartter's syndrome, with the exception of marked resistance to vasopressors. We investigated baroreflex function in a 40-year-old woman with this syndrome. The patient showed oscillation of heart rate even with a small increase in blood pressure after administration of vasopressor agents. Variations in heart rate and blood pressure were exaggerated during halothane, nitrous oxide and oxygen anaesthesia. Although the mechanism of the unstable baroreflex in this syndrome remains to be proved, the instability may be attributable to many factors such as prostaglandins, hypovolemia, hypokalemia, halothane, nitrous oxide and positive pressure ventilation.
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Boer P, Koomans HA, Hené RJ, Geyskes GG, Van Shaik BA, Roos JC, Dorhout Mees EJ. Blood to interstitial fluid volume ratio in chronic hypokalaemic states. Eur J Clin Invest 1985; 15:276-80. [PMID: 3935459 DOI: 10.1111/j.1365-2362.1985.tb00184.x] [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: 01/08/2023]
Abstract
The distribution of extracellular fluid over the intra- and extravascular spaces was determined in hypokalaemic and normokalaemic patients. In six patients with Bartter's syndrome, four with pseudo-Bartter's syndrome, and twenty with essential hypertension (EH) chronically treated with chlorthalidone, serum potassium (serum K+) and extracellular fluid volume (ECFV) were decreased, while plasma volume (PV) and blood volume (BV) were normal (see Table 1 for means, standard deviations, and levels of significance). Consequently, the ratio of BV to interstitial fluid volume (IFV) was increased. In ten patients with EH on long-term combined enalapril chlorthalidone therapy, eight EH patients on long-term spironolactone treatment, and twenty-three EH patients treated by short-term sodium restriction, PV, BV, and ECFV were decreased, but serum K+ and BV/IFV were normal. In six patients with primary hyperaldosteronism (PHA) serum K+ was decreased, while PV, BV, and BV/IFV were elevated. Significant negative correlations between sK and BV/IFV were found in the Bartter patients (r = -0.88) and the pooled data of all patients (r = -0.50). These findings suggest an association between chronic hypokalaemia and a fluid shift from the extra- into the intravascular space. The hypothesis that this phenomenon is due to a decreased venous resistance as a consequence of chronic hypokalaemia is discussed.
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Abstract
Around 1% of 8806 volunteers taking gossypol as a male contraceptive had hypokalaemic paralysis and more had simple hypokalaemia, the direct cause being renal potassium loss. In gossypol takers not showing hypokalaemia, serum potassium levels were within the normal range but were significantly lower than levels in controls. In the majority of patients suffering from gossypol-induced hypokalaemia, recovery was prompt and complete following potassium repletion, but in some men there were recurrent attacks of hypokalaemia during a period of several months to years after cessation of gossypol treatment. The incidence of hypokalaemic paralysis in gossypol takers showed distinct regional differences, being much higher in Nanjing, where the dietary potassium level of the inhabitants was low, than in Taian, where the dietary potassium level was high. In rats fed a low-K fodder, gossypol reduced the intracellular Mg and K concentrations of the skeletal muscle, while in regularly fed rats, this effect of gossypol was not observed. A potassium deficient diet could thus be considered a contributing factor in the development of gossypol-induced hypokalaemia. Potassium deficiency has also been shown to enhance the anti-spermatogenic effect of gossypol. Suggested mechanisms for the development of gossypol-induced hypokalaemia include inhibition of Na-K-ATPase activity, stimulation of prostaglandin biosynthesis, damage to the renal tubule, and modification of membrane transport.
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Watson ML, Gill JR, Branch RA, Oates JA, Brash AR. Systemic prostaglandin I2 synthesis is normal in patients with Bartter's syndrome. Lancet 1983; 2:368-70. [PMID: 6135873 DOI: 10.1016/s0140-6736(83)90344-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Urinary excretion of 2, 3 dinor-6-keto-PGF1 alpha, a metabolite of prostacyclin (PGI2), was measured in 9 patients with Bartter's syndrome. The rate of excretion of this metabolite was normal in these patients during ingestion of both a normal and high dietary intake of potassium. This suggests that in Bartter's syndrome the rate of entry of PGI2 into the circulation is normal. Excessive systemic synthesis of PGI2 is therefore unlikely to be an explanation for either the vascular insensitivity to angiotensin II or the defect in platelet aggregation characteristic of the syndrome.
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Düsing R, Bartter FC, Gill JR, Krück F, Kramer HJ. [Bartter's syndrome]. KLINISCHE WOCHENSCHRIFT 1983; 61:311-9. [PMID: 6345917 DOI: 10.1007/bf01485021] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Gill JR. The role of chloride transport in the thick ascending limb in the pathogenesis of Bartter's syndrome. KLINISCHE WOCHENSCHRIFT 1982; 60:1212-4. [PMID: 6755050 DOI: 10.1007/bf01716724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Fractional chloride reabsorption in the thick ascending limb of the loop of Henle, measured by clearance techniques, is subnormal in patients with Bartter's syndrome. This defect is a marker for the syndrome and, presumably, is the cause of the supranormal tubular secretion of potassium that characterizes the disorder. The potassium depletion that results from excessive potassium excretion is probably the stimulus for the increased synthesis of prostacyclin by blood vessels and prostaglandin E2 by kidneys that occurs in Bartter's syndrome. The overproduction of prostaglandins mediates hyperreninemia, supranormal plasma bradykinin, supranormal plasma norepinephrine and vascular resistance to the pressor effects of angiotensin II and norepinephrine; treatment with a prostaglandin synthetase inhibitor corrects these abnormalities. Increases in angiotensin II and in norepinephrine appear to be compensatory changes, occurring in response to vasodilatation induced by vascular prostaglandins to maintain blood pressure. The hyperreninemia also stimulates production of aldosterone with aggravation of potassium loss.
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Düsing R, Scherhag R, Tippelmann R, Budde U, Glänzer K, Kramer H. Arachidonic acid metabolism in isolated rat aorta. Dependence of prostacyclin biosynthesis on extracellular potassium concentration. J Biol Chem 1982. [DOI: 10.1016/s0021-9258(19)68137-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Düsing R, Harrison LC, Bhathena S, Recant L, Bartter FC. Impairment of insulin secretion during experimental potassium depletion is not corrected by the prostaglandin synthesis inhibitor, indomethacin. Clin Endocrinol (Oxf) 1981; 15:567-72. [PMID: 7035014 DOI: 10.1111/j.1365-2265.1981.tb00702.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Adamick R, Gold ME, Hayes S, Coleman R, McCreary JT, Sabatini S, Arruda JA, Kurtzman NA. Factors influencing vascular hyporesponsiveness to angiotensin II. Circ Res 1981; 49:932-9. [PMID: 7273363 DOI: 10.1161/01.res.49.4.932] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Bartter's syndrome is characterized, in part, by hyporesponsiveness to the pressor effect of exogenous angiotensin II (AII). This has been attributed to volume contraction, hypokalemia, and/or increased prostaglandin (PG) levels. In order to investigate factors responsible for a diminished response to the pressor effect of AII, rats were made hypokalemic or volume contracted and hypokalemic (VCHK) by dietary restriction. AII sensitivity was examined by determining the dose of AII required to raise the mean arterial pressure 20 mm Hg. When compared with control rats. VCHK and hypokalemic rats were significantly less sensitive to AII. VCHK rats were significantly less sensitive to AII than hypokalemic rats. Both experimental groups were similarly hypokalemic, but plasma renin activity (PRA) of VCHK only was greater than control values. In VCHK rats, acute K+ restoration partially corrected AII hyporesponsiveness, although plasma K+ increased to normal. In VCHK rats, acute volume expansion with normal saline similarly achieved only partial correction of AII hyporesponsiveness although PRA values fell to the control range. Simultaneous K+ restoration and volume expansion to VCHK rats successfully restored AII sensitivity to the control range. Dietary sodium, chloride, and potassium restriction did not increase urinary excretion to PGE2. Indomethacin (5 mg/kg, iv) given acutely to VCHK rats did not significantly after baseline hyporesponsiveness to AII. Norepinephrine vascular sensitivity was not affected by either volume contraction or hypokalemia. These data demonstrate that volume contraction and hypokalemia individually depress exogenous AII sensitivity in the rat and do so by separate and additive mechanisms. Furthermore, these mechanisms appear to be independent of PG.
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Abstract
The etiology of persistent hypokalemia and renal potassium loss was investigated in three children. Each had normal blood pressure but low plasma aldosterone values in relation to elevated plasma renin activity. None had a history of licorice abuse, laxative or diuretic use, persistent vomiting or diarrhea, pyelonephritis, or diabetes insipidus. Additional studies in one patient showed low prostaglandin E excretion and a normal platelet aggregation response to epinephrine and ADP. Although certain aspects of this condition resemble Bartter syndrome, the low concentrations of aldosterone and the absence of evidence for mineralocorticoid excess suggest a previously undescribed syndrome.
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Bartter FC. Bartter's syndrome: a disorder of vascular reactivity. Arthur C. Corcoran Memorial Lecture. Hypertension 1981; 3:I69-73. [PMID: 7262981 DOI: 10.1161/01.hyp.3.3_pt_2.i69] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Düsing R, Bartter FC, Gill JR, Güllner HG, Lake CR. Effects of moderate short-term potassium depletion in normal humans. The role of prostaglandins. PROSTAGLANDINS 1980; 20:971-9. [PMID: 7010450 DOI: 10.1016/0090-6980(80)90052-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The role of prostaglandins (PG) in the effects of potassium (K+)depletion was studied in six normal women. A mean K+-deficit of 220 mEq was induced with and without concomitant treatment with indomethacin (150 mg/day). Mean serum K+ concentration decreased from 4.2 +/- (S.E.) 0.1 to 3.2 +/- 0.1 mEq/L without indomethacin and from 4.1 +/- 0.1 to 3.2 +/- 0.1 mEq/L with indomethacin. "Supine" and "upright" plasma renin activity (PRA) and plasma norepinephrine concentration (NE) were unaltered by K+ -depletion alone but decreased with indomethacin. Plasma aldosterone (PA) was suppressed during K+-depletion (control: 7.2 +/- 2.6 ng/dl supine, 19.3 +/- 8.1 ng/dl upright; K+-depletion: 2.6 +/- 0.3 ng/dl supine, 5.5 +/- 1.3 ng/dl upright) and was paralleled by a decrease in urinary aldosterone. K+- depletion decreased urinary PGE2 from 667 +/- 133 to 343 +/- 60 ng/day (P less than 0.025) without a change in PGF2 alpha. The dose of exogenous angiotensin II (A II) which increased diastolic blood pressure by 20 mm Hg (pressor dose) was 7.1 +/- 1.4 ng/kg/min during control and increased to 11.0 +/- 0.7 ng/kg/min during K+-depletion (P less than 0.05). Indomethacin increased the sensitivity to A II both during control (pressor dose: 4.9 +/- 0.6 ng/kg/min) and K+ - depletion (pressor dose: 6.0 +/- 1.0 ng/kg/min). These results indicate that in healthy subjects, moderate short-term K+-depletion does not affect PRA or NE but decreases production of aldosterone and PGE2 by the kidney. The changes in vascular sensitivity to exogenous A II during K+-depletion and indomethacin and the decreases in plasma NE and PRA during indomethacin may be explained by changes in vascular vasodilator PG.
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Düsing R, Bartter FC, Gill JR, Harrison L, Bhathena SJ, Recant L, Kramer HJ. [Experimental potassium depletion in normal man (author's transl)]. KLINISCHE WOCHENSCHRIFT 1980; 58:881-7. [PMID: 7003236 DOI: 10.1007/bf01477000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Vierhapper H, Waldhäusl W. Effect of indomethacin upon the renin--angiotensin system in patients with Bartter's syndrome. Eur J Clin Invest 1980; 10:119-24. [PMID: 6780358 DOI: 10.1111/j.1365-2362.1980.tb02070.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
This study reports on the influence of indomethacin upon the renin--angiotensin system in three patients with Bartter's syndrome. An analogue of angiotensin II with weak agonistic properties (succinamyl1-val5-phenylglycine-acetate8-angiotensin II) induced a fall of blood pressure and a rise of plasma renin concentration but no change in plasma aldosterone. Pretreatment with indomethacin (75 mg/day) reversed the hypotensive effect of the analogue of angiotensin II and abolished the increase of plasma renin concentration. It is concluded that elevated levels of endogenous angiotensin II are of major importance for the maintenance of blood pressure in patients with Bartter's syndrome. The inhibition of the synthesis of prostaglandins reversed some, though not all, of the metabolic abnormalities in this syndrome.
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