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Eder M, Darmann E, Haller MC, Bojic M, Peck-Radosavljevic M, Huditz R, Bond G, Vychytil A, Reindl-Schwaighofer R, Kikić Ž. Markers of potassium homeostasis in salt losing tubulopathies- associations with hyperaldosteronism and hypomagnesemia. BMC Nephrol 2020; 21:256. [PMID: 32631286 PMCID: PMC7336449 DOI: 10.1186/s12882-020-01905-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 06/24/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Renal loss of potassium (K+) and magnesium (Mg2+) in salt losing tubulopathies (SLT) leads to significantly reduced Quality of Life (QoL) and higher risks of cardiac arrhythmia. The normalization of K+ is currently the most widely accepted treatment target, however in even excellently designed RCTs the increase of K+ was only mild and rarely normalized. These findings question the role of K+ as the ideal marker of potassium homeostasis in SLT. Aim of this hypothesis-generating study was to define surrogate endpoints for future treatment trials in SLT in terms of their usefulness to determine QoL and important clinical outcomes. METHODS Within this prospective cross-sectional study including 11 patients with SLTs we assessed the biochemical, clinical and cardiological parameters and their relationship with QoL (RAND SF-36). The primary hypothesis was that QoL would be more dependent of higher aldosterone concentration, assessed by the transtubular-potassium-gradient (TTKG). Correlations were evaluated using Pearson's correlation coefficient. RESULTS Included patients were mainly female (82%, mean age 34 ± 12 years). Serum K+ and Mg2+ was 3.3 ± 0.6 mmol/l and 0.7 ± 0.1 mmol/l (mean ± SD). TTKG was 9.5/3.4-20.2 (median/range). While dimensions of mental health mostly correlated with serum Mg2+ (r = 0.68, p = 0.04) and K+ (r = 0.55, p = 0.08), better physical health was associated with lower aldosterone levels (r = -0.61, p = 0.06). TTKG was neither associated with aldosterone levels nor with QoL parameters. No relevant abnormalities were observed in neither 24 h-ECG nor echocardiography. CONCLUSIONS Hyperaldosteronism, K+ and Mg2+ were the most important parameters of QoL. TTKG was no suitable marker for hyperaldosteronism or QoL. Future confirmatory studies in SLT should assess QoL as well as aldosterone, K+ and Mg2+.
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Affiliation(s)
- Michael Eder
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Elisabeth Darmann
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Maria C Haller
- Institute of Biometrics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Marija Bojic
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology, Nephrology and Emergency Medicine (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Rainer Huditz
- Department of Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology, Nephrology and Emergency Medicine (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Gregor Bond
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Andreas Vychytil
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Roman Reindl-Schwaighofer
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria
| | - Željko Kikić
- Division of Nephrology and Dialysis, Department of Medicine III, Medical University Vienna, Währinger Gürtel 18-20, A-1090, Vienna, Austria.
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Calò LA, Rigato M, Bertoldi G. ACE2/Angiotensin 1-7 protective anti-inflammatory and antioxidant role in hyperoxic lung injury: support from studies in Bartter's and Gitelman's syndromes. QJM 2020; 113:440-441. [PMID: 31851364 DOI: 10.1093/qjmed/hcz319] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- L A Calò
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Padova, Italy
| | - M Rigato
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Padova, Italy
| | - G Bertoldi
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Padova, Italy
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Yaqub S, Arif MS. A Case of Bartter's Syndrome Presenting in Adulthood. Iran J Kidney Dis 2020; 14:65-67. [PMID: 32156844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 10/10/2019] [Indexed: 06/10/2023]
Abstract
Bartter's syndrome is a rare disorder usually presenting antenatal or in childhood and is characterized by hypokalemia, metabolic alkalosis, hyperaldosteronism and normal blood pressure. We report a case of adult-onset Bartter's syndrome in a 38 year old male who presented with lower limb weakness.
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Conte E, Imbrici P, Sahbani D, Liantonio A, Conte D. [Bartter syndrome, severe rare orphan kidney disease: a step towards therapy through pharmacogenetic and epidemiological studies]. G Ital Nefrol 2018; 35:2018-vol3-2. [PMID: 29786180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Bartter syndromes (BS) types 1-5 are rare salt-losing tubulopathies presenting with overlapping clinical phenotypes including marked salt wasting and hypokalemia leading to polyuria, polydipsia, volume contraction, muscle weakness and growth retardation. These diseases are due to an impairment of sodium, potassium, chloride reabsorption caused by mutations in genes encoding for ion channel or transporters expressed in specific nephron tubule segments. Particularly, BS type 3 is a clinically heterogeneous form caused by mutations in CLCNKB gene which encodes the ClC-Kb chloride channel involved in NaCl reabsorption in the renal tubule. Specific therapy for BS is lacking and the only pharmacotherapy up today available is purely symptomatic and characterized by limiting side effects. The improvement of our understanding of the phenotype/genotype correlation and of the precise pathogenic mechanisms associated with BS type 3 as well as the pharmacological characterization of ClC-K chloride channels are fundamental to design therapies tailored upon patients' mutation. This mini review focused on recent studies representing relevant forward steps in the field as well as noteworthy examples of how basic and clinical research can cooperate to gain insight into the pathophysiology of this renal channelopathy, paving the way for a personalized therapy.
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Affiliation(s)
- Elena Conte
- Dipartimento di Farmacia - Scienze del Farmaco, Università di Bari, Italia
| | - Paola Imbrici
- Dipartimento di Farmacia - Scienze del Farmaco, Università di Bari, Italia
| | - Dalila Sahbani
- Dipartimento di Farmacia - Scienze del Farmaco, Università di Bari, Italia
| | | | - Diana Conte
- Dipartimento di Farmacia - Scienze del Farmaco, Università di Bari, Italia
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Abstract
Renal tubulopathies provide insights into the inner workings of the kidney, yet also pose therapeutic challenges. Because of the central nature of sodium in tubular transport physiology, disorders of sodium handling may affect virtually all aspects of the homeostatic functions of the kidney. Yet, owing to the rarity of these disorders, little clinical evidence regarding treatment exists. Consequently, treatment can vary widely between individual physicians and centers and is based mainly on understanding of renal physiology, reported clinical observations, and individual experiences. Salt-losing tubulopathies can affect all tubular segments, from the proximal tubule to the collecting duct. But the more frequently observed disorders are Bartter and Gitelman syndrome, which affect salt transport in the thick ascending limb of Henle's loop and/or the distal convoluted tubule, and these disorders generate the greatest controversies regarding management. Here, we review clinical and molecular aspects of salt-losing tubulopathies and discuss novel insights provided mainly by genetic investigations and retrospective clinical reviews. Additionally, we discuss controversial topics in the management of these disorders to highlight areas of importance for future clinical trials. International collaboration will be required to perform clinical studies to inform the treatment of these rare disorders.
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Affiliation(s)
- Robert Kleta
- UCL Centre for Nephrology and Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Detlef Bockenhauer
- UCL Centre for Nephrology and Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
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Galešić K, Horvatić I, Ilić M, Ćuk M, Crnogorac M, Ljubanović DG. [HYPOKALEMIC METABOLIC ALKALOSIS – A REPORT OF SIX CASES]. Lijec Vjesn 2016; 138:260-265. [PMID: 30148552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In this article six patients with hypokalemic metabolic alkalosis, classified as Bartter or Gitelman syndrome are presented. Both syndromes result from different gene mutation inducing impaired function of the transporters involved in sodium, chloride and potassium reapsorption in thick ascending limb of the loop of Henle and distal convoluted tubules. These syndromes typically present with hypokalemia, metabolic alkalosis, hyperreninemic hyperaldosteronism without hypertension, polyuria and muscle weakness. Other clinical characteristics may vary considerably, depending on the gene expression. Correct diagnosis is only possible using expensive and not-routinely available genetic testing. Routine laboratory tests, especially those considering serum and urine electrolytes, can help in recognizing these syndromes and therefore in timely beginning of treatment. The most important distinctive laboratory findings are serum magnesium concentration and urine calcium excretion. In Bartter syndrome typically there is hypercalciuria with or without hypomagnesemia, while in Gitelman syndrome typical findings are hypocalciuria and hypomagnesemia. Recognizing and treating these patients is important due to possible increased morbidity and mortality induced by severe electrolyte imbalance.
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Affiliation(s)
- Lucy Anne Plumb
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - William Van't Hoff
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Robert Kleta
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; UCL Centre for Nephrology, London, UK
| | | | - Emma Ashton
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Martin Samuels
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Detlef Bockenhauer
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; UCL Centre for Nephrology, London, UK.
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Maiolino G, Azzolini M, Rossi GP, Davis PA, Calò LA. Bartter/Gitelman syndromes as a model to study systemic oxidative stress in humans. Free Radic Biol Med 2015; 88:51-8. [PMID: 25770663 DOI: 10.1016/j.freeradbiomed.2015.02.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 02/24/2015] [Accepted: 02/26/2015] [Indexed: 02/07/2023]
Abstract
Reactive oxygen species (ROS) are intermediates in reduction-oxidation reactions that begin with the addition of one electron to molecular oxygen, generating the primary ROS superoxide, which in turn interacts with other molecules to produce secondary ROS, such as hydrogen peroxide, hydroxyl radical, and peroxynitrite. ROS are continuously produced during metabolic processes and are deemed to play an important role in cardiovascular diseases, namely, myocardial hypertrophy and fibrosis and atherosclerosis, via oxidative damage of lipids, proteins, and deoxyribonucleic acid. Angiotensin II (Ang II) is a potent vasoactive agent that also exerts mitogenic, proinflammatory, and profibrotic effects through several signaling pathways, in part involving ROS, particularly superoxide and hydrogen peroxide. Moreover, Ang II stimulates NADPH oxidases, leading to higher ROS generation and oxidative stress. Bartter/Gitelman syndrome patients, despite elevated plasma renin activity, Ang II, and aldosterone levels, exhibit reduced peripheral resistance, normal/low blood pressure, and blunted pressor effect of vasoconstrictors. In addition, notwithstanding the activation of the renin-angiotensin system and the increased plasma levels of Ang II, these patients display decreased production of ROS, reduced oxidative stress, and increased antioxidant defenses. In fact, Bartter/Gitelman syndrome patients are characterized by reduced levels of p22(phox) gene expression and undetectable plasma peroxynitrite levels, while showing increased plasma antioxidant power and expression of antioxidant enzymes, such as heme oxygenase-1. In conclusion, multifarious data suggest that Bartter and Gitelman syndrome patients are a model of low oxidative stress and high antioxidant defenses. The contribution offered by the study of these syndromes in elucidating the molecular mechanisms underlying this favorable status could offer chances for new therapeutic targets in disease characterized by high levels of reactive oxygen species.
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Affiliation(s)
- Giuseppe Maiolino
- Nephrology and Hypertension Clinic, Department of Medicine, University of Padova, 35126 Padova, Italy
| | - Matteo Azzolini
- Nephrology and Hypertension Clinic, Department of Medicine, University of Padova, 35126 Padova, Italy
| | - Gian Paolo Rossi
- Nephrology and Hypertension Clinic, Department of Medicine, University of Padova, 35126 Padova, Italy
| | - Paul A Davis
- Department of Nutrition, University of California at Davis, Davis, CA 95616, USA
| | - Lorenzo A Calò
- Nephrology and Hypertension Clinic, Department of Medicine, University of Padova, 35126 Padova, Italy.
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Wang LJ, Kong SM, Li WN. [CLC-K chloride channel in the thick ascending limb of kidney and Bartter's syndrome]. Sheng Li Ke Xue Jin Zhan 2012; 43:51-54. [PMID: 22582601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Walsh SB, Unwin E, Vargas-Poussou R, Houillier P, Unwin R. Does hypokalaemia cause nephropathy? An observational study of renal function in patients with Bartter or Gitelman syndrome. QJM 2011; 104:939-44. [PMID: 21705784 DOI: 10.1093/qjmed/hcr095] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Hypokalaemic nephropathy has been described in patients with chronic potassium depletion; it is a condition in which proximal tubular vacuolization and interstitial fibrosis occur, resulting in a decline in glomerular filtration rate (GFR) and, in some cases, renal failure. It has been described in patients with chronic diarrhoea, eating disorders, laxative abuse and primary hyperaldosteronism; also occasionally in Bartter syndrome (BS), in which severe hypokalaemia accompanies significant renal sodium and water losses, though rarely in Gitelman syndrome (GS), in which there is equally severe hypokalaemia, but only modest sodium losses. AIM We hypothesized that hypokalaemic nephropathy may not be due to potassium depletion per se, but persistently elevated circulating levels of aldosterone, possibly with superimposed episodes of renal hypoperfusion. DESIGN AND METHODS We searched UK and European data sets to retrospectively compare serum and urinary parameters in patients with GS and BS. RESULTS The patients with GS often had lower serum potassium concentrations than patients with BS, but the BS patients had significantly higher serum creatinine concentrations and lower estimated GFRs (eGFR). BS patients had significantly higher fractional excretions of sodium compared with GS patients, as well as higher plasma renin activities and serum aldosterone levels. CONCLUSION These findings show that in genetically confirmed cases of BS and GS, the degree of hypokalaemia (as an index of chronic potassium depletion) does not correlate with GFR, and that on-going sodium and water losses, and consequent secondary hyperaldosteronism, may play a more important role in the aetiology of hypokalaemic nephropathy.
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Affiliation(s)
- S B Walsh
- UCL Centre for Nephrology, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK.
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Oğuz SS, Gökmen T, Erdeve O, Uras N, Dilmen U. Acetyl salicylic acid treatment in neonatal Bartter syndrome. Pediatr Nephrol 2011; 26:1339-40. [PMID: 21553351 DOI: 10.1007/s00467-011-1861-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 02/07/2011] [Indexed: 11/27/2022]
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Park CW, Lim JH, Youn DY, Chung S, Lim MH, Kim YK, Chang YS, Lee JH. Renal dysfunction and barttin expression in Bartter syndrome Type IV associated with a G47R mutation in BSND in a family. Clin Nephrol 2011; 75 Suppl 1:69-74. [PMID: 21269598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
Bartter syndrome (BS) Type IV, associated with a G47R mutation in the BSND gene, is known to result in a mild renal phenotype. However, we report here on three brothers with varying degrees of renal dysfunction from mild to end-stage renal disease associated with renal barttin and ClC-K expression. The brothers had histories of polyhydramnios, prematurity, polyuria, deafness, and small body size. Laboratory findings showed hypokalemic metabolic alkalosis, normotensive hyperreninemic hyperaldosteronism, and an increased urinary excretion of sodium, potassium and chloride, consistent with BS Type IV. Microscopic examination of renal tissue showed hyperplasia of cells at the juxtaglomerular apparatus with dilated atrophic tubules and tubulointerstitial fibrosis. A weak barttin signal related to CIC-K expression in the cytoplasm of tubule cells, but not the basement membrane, was noted. A sequence analysis of the BSND gene showed that the affected males were homozygous for a missense G47R mutation in exon 1 of BSND. These findings suggest that the G47R mutation results in a dramatic decrease in barttin expression, which appears to be related to the location of CIC-K being changed from the basement membrane to the cytoplasm in the tubule and might have varying effects on renal function associated with factors other than this gene.
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Affiliation(s)
- C W Park
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Sui HY, Wu P, Liu YJ. [The involvement of potassium channels in the thick ascending limb of renal Henle's loop]. Sheng Li Ke Xue Jin Zhan 2010; 41:446-448. [PMID: 21416964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Nozu K, Iijima K, Kanda K, Nakanishi K, Yoshikawa N, Satomura K, Kaito H, Hashimura Y, Ninchoji T, Komatsu H, Kamei K, Miyashita R, Kugo M, Ohashi H, Yamazaki H, Mabe H, Otsubo A, Igarashi T, Matsuo M. The pharmacological characteristics of molecular-based inherited salt-losing tubulopathies. J Clin Endocrinol Metab 2010; 95:E511-8. [PMID: 20810575 DOI: 10.1210/jc.2010-0392] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
CONTEXT Our understanding of inherited salt-losing tubulopathies has improved with recent advances in molecular genetics. However, the terminology of Bartter syndrome and Gitelman syndrome does not always accurately reflect their pathophysiological basis or clinical presentation, and some patients are difficult to diagnose from their clinical presentations. OBJECTIVE In the present study, we conducted molecular analysis and diuretic tests for patients with inherited salt-losing tubulopathies to clarify the pharmacological characteristics of these disorders. PATIENTS We detected mutations and subsequently conducted diuretic tests using furosemide and thiazide for 16 patients with salt-losing tubulopathies (two with SLC12A1; two with KCNJ1; nine with CLCNKB; and three with SLC12A3). RESULTS Patients with SLC12A1 mutations showed no response to furosemide, whereas those with SLC12A3 mutations showed no response to thiazide. However, patients with CLCNKB mutations showed no response to thiazide and a normal response to furosemide, and those with KCNJ1 mutations showed a good response to both diuretics. This study revealed the following characteristics of these disorders: 1) subjects with CLCNKB mutations showed one or more biochemical features of Gitelman syndrome (including hypomagnesemia, hypocalciuria, and fractional chloride excretion insensitivity to thiazide administration); and 2) subjects with KCNJ1 mutations appeared to show normal fractional chloride excretion sensitivity to furosemide and thiazide administration. CONCLUSIONS These results indicate that these disorders are difficult to distinguish in some patients, even when using diuretic challenge. This clinical report provides important findings that can improve our understanding of inherited salt-losing tubulopathies and renal tubular physiology.
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Affiliation(s)
- Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe 650-0017, Kusunokicho 7-5-1, Chuo, Kobe, Hyogo, Japan.
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Calò LA, Schiavo S, Davis PA, Pagnin E, Mormino P, D'Angelo A, Pessina AC. ACE2 and angiotensin 1-7 are increased in a human model of cardiovascular hyporeactivity: pathophysiological implications. J Nephrol 2010; 23:472-477. [PMID: 20349406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2009] [Indexed: 05/29/2023]
Abstract
BACKGROUND ACE and ACE2 produce angiotensin II (Ang II), a vasopressor that induces cardiovascular remodeling, and Ang 1-7, a vasodilator with an antiremodeling effect. While Ang 1-7 has antiarrhythmic properties, at higher concentration it may induce ventricular tachycardia and sudden death. ACE2, therefore, may play an essential role in blood pressure homeostasis, in the long-term complications of hypertension (cardiovascular remodeling), and in the induction of cardiac electric abnormalities. This study evaluated the levels of ACE2 and Ang 1-7 in Bartter's/Gitelman's patients (BS/GS) who have elevated Ang II and endogenous blockade of Ang II type 1 receptor signaling compared with healthy subjects (C) and essential hypertensives (EH). BS/ GS patients were also considered because of their predisposition to cardiac arrhythmias, which has yet to be completely clarified. METHODS Mononuclear cell ACE2 and Ang 1-7 were evaluated using western blot. RESULTS One-way ANOVA showed that ACE2 and Ang 1-7 levels were significantly different between the three groups (p=0.0074 and p=0.0001, respectively). Post-hoc analysis (Tukey's HSD) showed that both ACE2 (1.59+/-0.63) and Ang1-7 (2.26+/-1.18) were significantly elevated in BS/GS compared with either C (0.98+/-0.45; p=0.008; 1.12+/-0.48, p=0.002, respectively) or EH (1.06+/-0.24; p=0.043; 0.72+/-0.28; p=0.0001, respectively). ACE2 and Ang 1-7 directly correlated only in BS/GS (r=0.91, p<0.0003). CONCLUSIONS The elevated ACE2 and Ang 1-7 in BS/ GS patients mirror those in hypertensives and are in line with the clinical, hemodynamic and pathophysiological characteristics of BS/GS, likely contributing to them. In consideration of the clinical picture of these syndromes, the opposite of hypertension, the results of this study further strengthen the importance of the ACE2/Ang 1-7 system in the regulation of vascular tone and cardiovascular biology.
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Affiliation(s)
- Lorenzo A Calò
- Department of Clinical and Experimental Medicine, Medical Clinic 4, University of Padua, Padua, Italy.
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Calò LA, Davis PA. The PGC1alpha-PPARdelta-HO-1 system: supporting evidence from studies in Bartter's/Gitelman's syndromes. Cardiovasc Res 2010; 86:535. [PMID: 20228397 DOI: 10.1093/cvr/cvq085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Riccardi D, Brown EM. Physiology and pathophysiology of the calcium-sensing receptor in the kidney. Am J Physiol Renal Physiol 2010; 298:F485-99. [PMID: 19923405 PMCID: PMC2838589 DOI: 10.1152/ajprenal.00608.2009] [Citation(s) in RCA: 264] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2009] [Accepted: 11/13/2009] [Indexed: 12/21/2022] Open
Abstract
The extracellular calcium-sensing receptor (CaSR) plays a major role in the maintenance of a physiological serum ionized calcium (Ca2+) concentration by regulating the circulating levels of parathyroid hormone. It was molecularly identified in 1993 by Brown et al. in the laboratory of Dr. Steven Hebert with an expression cloning strategy. Subsequent studies have demonstrated that the CaSR is highly expressed in the kidney, where it is capable of integrating signals deriving from the tubular fluid and/or the interstitial plasma. Additional studies elucidating inherited and acquired mutations in the CaSR gene, the existence of activating and inactivating autoantibodies, and genetic polymorphisms of the CaSR have greatly enhanced our understanding of the role of the CaSR in mineral ion metabolism. Allosteric modulators of the CaSR are the first drugs in their class to become available for clinical use and have been shown to treat successfully hyperparathyroidism secondary to advanced renal failure. In addition, preclinical and clinical studies suggest the possibility of using such compounds in various forms of hypercalcemic hyperparathyroidism, such as primary and lithium-induced hyperparathyroidism and that occurring after renal transplantation. This review addresses the role of the CaSR in kidney physiology and pathophysiology as well as current and in-the-pipeline treatments utilizing CaSR-based therapeutics.
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Affiliation(s)
- Daniela Riccardi
- School of Biosciences, Cardiff University, Cardiff, United Kingdom.
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Tremblay AM, Dufour CR, Ghahremani M, Reudelhuber TL, Giguère V. Physiological genomics identifies estrogen-related receptor alpha as a regulator of renal sodium and potassium homeostasis and the renin-angiotensin pathway. Mol Endocrinol 2010; 24:22-32. [PMID: 19901197 PMCID: PMC5428150 DOI: 10.1210/me.2009-0254] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 10/05/2009] [Indexed: 01/15/2023] Open
Abstract
Estrogen-related receptor alpha (ERRalpha) is an orphan nuclear receptor highly expressed in the kidney, an organ playing a central role in blood pressure regulation through electrolyte homeostasis and the renin-angiotensin system. Physiological analysis revealed that, relative to wild-type mice, ERRalpha null mice are hypotensive despite significant hypernatremia, hypokalemia, and slight hyperreninemia. Using a combination of genome-wide location analysis and expression profiling, we demonstrate that ERRalpha regulates the expression of channels involved in renal Na(+) and K(+) handling (Scnn1a, Atp1a1, Atp1b1) and altered in Bartter syndrome (Bsnd, Kcnq1). In addition, ERRalpha regulates the expression of receptors implicated in the systemic regulation of blood pressure (Ghr, Gcgr, Lepr, Npy1r) and of genes within the renin-angiotensin pathway (Ren1, Agt, Ace2). Our study thus identifies ERRalpha as a pleiotropic regulator of renal control of blood pressure, renal Na(+)/K(+) homeostasis, and renin-angiotensin pathway and suggests that modulation of ERRalpha activity could represent a potential avenue for the management of hypertension.
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Affiliation(s)
- Annie M Tremblay
- Rosalind and Goodman Cancer Centre, McGill University, Montréal, Québec, Canada
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Wagner CA. New roles for renal potassium channels. J Nephrol 2010; 23:5-8. [PMID: 20091480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The role of the kidney in controlling and maintaining plasma potassium levels in the normal range requires the presence and activity of renal potassium channels, and their importance has been highlighted in patients with Bartter syndrome harboring mutations in the ROMK (Kir1.1, KCJN1) channel and hyperkalemia. However, the kidney expresses far more potassium channels than ROMK. Their functions are slowly emerging from studies in animal models and human rare inherited disorders that allow a better understanding of the plethora of functions that potassium channels fulfill in the kidney. Three recent studies shed light on the function of 2 members of the family of voltage-gated potassium channels. The group of René Bindels demonstrates that patients with isolated hypomagnesemia and inappropriately normal magnesuria carry mutations in the Kv1.1 (KCNA) potassium channel (Glaudemans B, et al. J Clin Invest. 2009;119:936-942). Two other studies elucidate a rather complex syndrome involving seizures, ataxia, deafness and renal salt loss, and show that mutations in the Kir4.1 (KCNJ10) potassium channel are responsible (Scholl UI, et al. Proc Natl Acad Sci U S A. 2009;106:5842-5847; Bockenhauer D, et al. N Engl J Med. 2009;360:1960-1970). This human disease is recapitulated by a mouse model deficient for the Kir4.1 channel presenting with similar symptoms. These studies together show that potassium channels in the kidney serve purposes far beyond controlling systemic potassium homeostasis, and are involved in various essential functions of the kidney. Moreover, defects of 2 different potassium channels expressed on opposing membrane domains of the same cells cause distinct symptoms.
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Affiliation(s)
- Carsten A Wagner
- Institute of Physiology and Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland.
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Calò LA, Montisci R, Scognamiglio R, Davis PA, Pagnin E, Schiavo S, Mormino P, Semplicini A, Palatini P, D'Angelo A, Pessina AC. High angiotensin II state without cardiac remodeling (Bartter's and Gitelman's syndromes): are angiotensin II type 2 receptors involved? J Endocrinol Invest 2009; 32:832-6. [PMID: 19605975 DOI: 10.1007/bf03345754] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND/AIMS While Angiotensin II (Ang II) is a major factor in the development of cardiomyocyte hypertrophy and a pivotal role for Ang II signals via ERK1/2 has been identified, mechanism(s) responsible are still unclear. As Bartter's and Gitelman's syndrome patients (BS/GS) have increased Ang II, and yet normo/hypotension, hyporesponsiveness to pressors and blunted Ang II signaling via type 1 receptors (AT1R), this study assesses BS/GS's left ventricular (LV) mass and structure as well as Ang II induced ERK1/2 phosphorylation compared with essential hypertensive patients (EH) and normotensive healthy subjects (C) to gain insight into Ang II mediated processes. METHODS Indices of cardiac hypertrophy were determined by M-mode, two-dimensional echo Doppler and ERK phosphorylation by Western blot. RESULTS None of BS/GS exhibited LV remodelling; LV mass, LV end-diastolic volume and mass/volume ratio were unchanged vs C (60+/-14 g/m2 vs 64+/-12, 64+/-12 ml/m2 vs 60+/-8 and 0.95+/-0.2 vs 1.0+/-0.2, respectively) and reduced vs EH (119+/-15, p<0.001, 78+/-9, p<0.05 and 1.52+/-0.15, p<0.01). Despite BS/GS's higher plasma renin activity and aldosterone and unchanged level of AT1R, Ang II induced ERK1/2 phosphorylation was reduced vs both C and EH: 0.64 d.u.+/-0.08 vs 0.90+/-0.06 in C, p<0.006, and vs 1.45+/-0.07 in EH, p<0.001. CONCLUSION The data point to a direct cardioremodeling role for Ang II and support a role of Ang II type 2 receptor (AT2R) signaling as involved in the lack of cardiovascular remodeling in BS/GS. However, further studies using more direct approaches to demonstrate the effects of AT2R signaling must be pursued.
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Affiliation(s)
- L A Calò
- Department of Clinical and Experimental Medicine, Clinica Medica 4, Cagliari, Italy.
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Cetinkaya M, Köksal N, Ozkan H, Dönmez O, Sağlam H, Kiriştioğlu I. Hyperprostaglandin E syndrome: use of indomethacin and steroid, and death due to necrotizing enterocolitis and sepsis. Turk J Pediatr 2008; 50:386-390. [PMID: 19014056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Hyperprostaglandin E syndrome (HPS) is the antenatal variant of Bartter syndrome and characterized by polyhydramnios and preterm delivery in the antenatal period and salt-wasting, isosthenuric or hyposthenuric polyuria, hypercalciuria and nephrocalcinosis in the postnatal period. We report a one-month-old infant with HPS with a 15-year-old sister with Bartter syndrome. The infant's birth weight was 2750 g and she had severe dehydration on the 2nd day of life. She had hypercalcemia, hyponatremia, hypokalemia, metabolic alkalosis and elevated plasma renin and aldosterone levels. We instituted indomethacin therapy accompanied by steroid therapy for hypercalcemia. However, the patient developed abdominal distention on the 30th day, which was due to diffuse pneumatosis in sigmoid colon revealed by a subsequent surgical intervention. Following surgery, the patient developed fever, electrolyte abnormalities and subsequently sepsis. The patient died due to sepsis 10 days after surgery. We conclude that indomethacin and steroid therapy must be used cautiously in infants with HPS.
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Affiliation(s)
- Merih Cetinkaya
- Division of Neonatology, Department of Pediatrics, Uludağ University Faculty of Medicine, Bursa, Turkey
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Iskandar SB, Jordan RM, Peiris AN. Electrocardiographic abnormalities and endocrine diseases--part D: adrenal gland, diabetes, and other endocrine disorders. Tenn Med 2008; 101:35-41. [PMID: 18236852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Said B Iskandar
- Cardiology Department, Halifax Heart Center South Boston, VA, USA.
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24
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Mantan M, Bagga A, Virdi VS, Menon S, Hari P. Etiology of nephrocalcinosis in northern Indian children. Pediatr Nephrol 2007; 22:829-33. [PMID: 17285294 DOI: 10.1007/s00467-006-0425-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2006] [Revised: 12/14/2006] [Accepted: 12/15/2006] [Indexed: 12/12/2022]
Abstract
This retrospective survey examines the etiology of nephrocalcinosis (NC) in 40 patients (26 boys), over an 8-year period. The median age at onset of symptoms and presentation was 36 months and 72 months, respectively. Clinical features included marked failure to thrive (82.5%), polyuria (60%) and bony deformities (52.5%). The etiology of NC included distal renal tubular acidosis (RTA) in 50% patients and idiopathic hypercalciuria and hyperoxaluria in 7.5% each. Other causes were Bartter syndrome, primary hypomagnesemia with hypercalciuria, severe hypothyroidism and vitamin D excess. No cause for NC was found in 12.5% patients. Specific therapy, where possible, ameliorated the biochemical aberrations, although the extent of NC remained unchanged. At a median (range) follow up of 35 (14-240) months, glomerular filtration rate (GFR) had declined from 82.0 (42-114) ml/min per 1.73 m2 body surface area to 70.8 (21.3-126.5) ml/min per 1.73 m2 body surface area (P = 0.001). Our findings confirm that, even with limited diagnostic facilities, protocol-based evaluation permits determination of the etiology of NC in most patients.
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Affiliation(s)
- Mukta Mantan
- Department of Pediatrics, Maulana Azad Medical College and Associated Hospitals, New Delhi, India
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25
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Calò LA, Davis PA, Palatini P, Semplicini A, Pessina AC. Urinary albumin excretion, endothelial dysfunction and cardiovascular risk: study in Bartter's/Gitelman's syndromes and relevance for hypertension. J Hum Hypertens 2007; 21:904-6. [PMID: 17495949 DOI: 10.1038/sj.jhh.1002231] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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Ma DY, Chen XM. [Hoarseness as the initial manifestation of Bartter syndrome in a case]. Zhonghua Er Ke Za Zhi 2007; 45:316-7. [PMID: 17706081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
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27
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Sartori M, Parotto E, Bonso E, Semplicini A, Palatini P, Pessina AC, Calò LA. Autonomic nervous system function in chronic hypotension associated with Bartter and Gitelman syndromes. Am J Kidney Dis 2007; 49:330-5. [PMID: 17261437 DOI: 10.1053/j.ajkd.2006.10.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2006] [Accepted: 10/26/2006] [Indexed: 12/26/2022]
Abstract
Autonomic nervous system dysfunction has a major role in the blood pressure (BP) decrease associated with orthostatic hypotension and syncope. The clinical picture of Bartter and Gitelman syndromes includes reduced extracellular fluid volume and normotension or hypotension, but no study has explored autonomic nervous system status in patients with hypotensive episodes associated with these diseases. We tested sympathetic and parasympathetic nervous system function in 4 patients with Bartter and Gitelman syndromes with chronic hypotension. Each patient underwent a battery of autonomic reflex tests, including BP and heart rate response to orthostatism, Valsalva maneuver, cold-pressor test, hand-grip test, and deep breathing. Plasma catecholamines also were measured. BP was monitored during tests by means of continuous noninvasive finger BP recording. Orthostatic hypotension was observed in 1 patient who experienced syncope episodes. Valsalva ratio ranged from 1.21 to 1.61. During the cold-pressor test, the range of systolic and diastolic BP increases were 8 to 31 and 6 to 24 mm Hg, respectively. During the hand-grip test, systolic and diastolic BP increases ranged from 10 to 39 and 8 to 32 mm Hg, respectively. During hyperventilation, the difference between the highest and lowest heart rates was 12 or more beats/min in all patients. Patients' plasma norepinephrine concentrations increased during standing. Our preliminary results suggest that chronic hypotension in patients with Bartter and Gitelman syndromes is not associated with sympathetic and parasympathetic nervous system dysfunction, even when orthostatic hypotension is present. This normal autonomic function suggests that other pathophysiological mechanisms, such as the characteristic vasoconstrictor abnormal cell signaling, may account for hypotension in patients with Bartter and Gitelman syndromes.
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Affiliation(s)
- Michelangelo Sartori
- Department of Clinical and Experimental Medicine, Clinica Medica 4, University of Padova, Italy
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Dane B, Yayla M, Dane C, Cetin A. Prenatal diagnosis of Bartter syndrome with biochemical examination of amniotic fluid: case report. Fetal Diagn Ther 2007; 22:206-8. [PMID: 17228161 DOI: 10.1159/000098719] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2006] [Accepted: 05/18/2006] [Indexed: 11/19/2022]
Abstract
Antenatal Bartter syndrome typically presents with marked fetal polyuria that leads to polyhydramnios and premature delivery. In our case, polyhydramnios was detected at 26 weeks of gestation and amniotic fluid chloride level was high. Serial amnion-drains were performed. During indomethacine treatment, fetal bradycardia developed. The mother was given daily oral potassium to maintain normal serum level and prevent fetal arrhythmias. After birth, hypokalaemic alkalosis, low chloride, hyper-reninemia and hyperaldosteronemia were detected.
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Affiliation(s)
- Banu Dane
- Department of Perinatology, Clinics of Gynecology and Obstetrics, Haseki Education and Research Hospital, Istanbul, Turkey
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Abstract
The story, described here in detail, started in 1962 with the publication of a seminal paper by Frederic Bartter et al. in the December issue of the American Journal of Medicine. The authors reported two pediatric patients with hitherto undescribed features, namely growth and developmental delay associated with hypokalemic alkalosis and normal blood pressure despite high aldosterone production. It soon became clear that this condition was not so exceptional. The syndrome named after Bartter was actually identified in children as well as in adults, females as well as males and in all five continents. It took almost four decades to clarify the exact nature of the disease. Bartter disease is an autosomal recessive disorder with four genotypes and mainly two phenotypes. Moreover, there are acquired secondary forms of Bartter syndrome as well as pseudo-Bartter syndromes. The history demonstrates the power of genetics but also illustrates the fundamental and irreplaceable contributions from nephrologists and renal physiologists.
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Affiliation(s)
- Willem Proesmans
- Pediatric Nephrology, University of Leuven, 3000, Leuven, Belgium.
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Abstract
Genetic studies into rare inborn errors of renal tubular sodium handling in man have brought many interesting, sometimes surprising insights into how we can maintain our bodies' electrolytes and fluids homeostasis. The cloning and identification of sodium transporting genes and proteins like NHE3, NKCC2, ROMK, CLCNKB, NCC, and EnaC has considerably improved our understanding of renal salt handling. Subsequently, studies of genetically engineered animals provided even more insight into the complex renal physiology. The recent discovery of the WNK kinases as regulators and integrators of specific renal transport pathways helped elucidate this further and lets us start to appreciate the full complexity of renal sodium handling. We summarize recent findings in the field in the context of human diseases and a pathophysiologic basis for their treatment.
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Affiliation(s)
- Robert Kleta
- Section on Human Biochemical Genetics, Medical Genetics Branch, National Human Genome Research Institute, Bethesda, Md 20892, USA.
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García-Nieto V, Flores C, Luis-Yanes MI, Gallego E, Villar J, Claverie-Martín F. Mutation G47R in the BSND gene causes Bartter syndrome with deafness in two Spanish families. Pediatr Nephrol 2006; 21:643-8. [PMID: 16572343 DOI: 10.1007/s00467-006-0062-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2005] [Revised: 12/07/2005] [Accepted: 12/09/2005] [Indexed: 12/26/2022]
Abstract
Bartter syndrome (BS) is a heterogeneous group of autosomal recessive hypokalaemic salt-losing tubulopathies. Five types of BS caused by different genetic defects have been identified, and one of them is associated with sensorineural deafness (BSND). Mutations in the recently described BSND gene, mapped in chromosome 1p31, have been reported to be associated with BSND. This gene encodes barttin, an essential beta-subunit subunit for ClC-Ka and ClC-Kb channels. Both subunits are co-expressed in basolateral membranes of renal tubules, in the ascending limb of the loop of Henle, and in the stria vascularis of the inner ear. We studied two apparently unrelated Spanish families from the Canary Islands, with five members showing this pathology. Sequence analysis of the BSND gene showed that the affected members were homozygous for a C-to-T transition in exon 1, while their parents were heterozygous. This alteration results in a missense mutation, G47R, which has been previously shown to abolish the stimulatory effect on the subunit barttin of the ClC-Kb channel. Our results indicate that families with the G47R mutation indeed present polyhydramnios, premature birth and salt loss. Nevertheless, glomerular filtration rate was normal in all patients. Clinical manifestations are moderate in patients with the G47R mutation compared to other published data form patients with BSND. This constitutes the first report of BSND cases in Spain.
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Affiliation(s)
- Víctor García-Nieto
- Unidad de Investigación-Asociada al Centro de Investigaciones Biológicas (CSIC), Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain.
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Pagnin E, Davis PA, Semplicini A, Calò LA. The search for a link between inflammation and hypertension—contribution from Bartter's/Gitelman's syndromes. Nephrol Dial Transplant 2006; 21:2340-2. [PMID: 16611677 DOI: 10.1093/ndt/gfl173] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Abstract
Studies in patients with Bartter's and Gitelman's syndromes performed in the last 10 years have provided important insights into the mechanistic details of relevant pathways of angiotensin II signaling and vascular tone regulation, therefore making these syndromes a good human model to gain insight into the mechanisms responsible for maintaining/controlling vascular tone. Extensive studies of patients with Bartter's/Gitelman's syndromes have, in fact, shown biochemical abnormalities of angiotensin II short- and long-term cell signaling, which depict a mirror image of those found in hypertension. The information obtained from the study of this human model of altered vascular tone regulation show that it can be used to gather more general data and/or confirm mechanistic details of the cellular and biochemical events involved in the pathophysiology of vascular tone control and to shed light on the multiplicity of the angiotensin II signaling-related mechanisms responsible for the pathophysiology of hypertension and its long-term complication such as cardiovascular remodeling and atherogenesis.
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Affiliation(s)
- L A Calò
- Department of Clinical and Experimental Medicine, Clinica Medica 4, University of Padova, Padova, Italy.
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Abstract
Bartter's syndrome (BS) is an incurable genetic disease, with variable response to supportive therapy relating to fluid and electrolyte management. Poor control or therapy non-compliance may result in frequent life threatening episodes of dehydration, acidosis and hypokalemia, with resultant adverse effects on patient quality of life (QOL). We report, for the first time, pre-emptive bilateral native nephrectomies and successful renal transplantation, prior to the onset of ESRD, for severe, clinically brittle, neonatal BS, resulting in correction of metabolic abnormalities and excellent graft function. We propose that fragile BS should be considered as a possible indication for early native nephrectomies and pre-emptive renal transplantation, procedures that results in a 'cure' for the underlying disease and significant improvements in patient QOL.
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Affiliation(s)
- Abanti Chaudhuri
- Department of Pediatrics and Surgery, Stanford University, CA, USA
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35
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Unwin RJ, Capasso G. Bartter's and Gitelman's syndromes: their relationship to the actions of loop and thiazide diuretics. Curr Opin Pharmacol 2006; 6:208-13. [PMID: 16490401 DOI: 10.1016/j.coph.2006.01.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Accepted: 01/27/2006] [Indexed: 11/23/2022]
Abstract
The wider recognition of inherited Bartter's and Bartter's-like syndromes, especially Gitelman's, has come largely as a result of the advances in, and application of, molecular genetics. By exploiting pre-existing renal cell models of ion transport, specifically for sodium and potassium, the known mechanisms and sites of action of loop and thiazide diuretics and the similarity of their chronic effects to these syndromes, it was possible for geneticists to take a candidate gene approach. This was initially successful but, when not all cases could be explained on this basis, it forced a more detailed clinical appraisal and better phenotyping, resulting in the discovery of novel genes involved in controlling renal sodium, potassium and chloride transport, and new insights into renal tubular physiology. This is a good example of one form of 'translational research', the message being the importance of our ability to link (in this instance) basic renal physiology and pharmacology, with clinical nephrology and genetics.
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Affiliation(s)
- Robert J Unwin
- Centre for Nephrology and Department of Physiology, Royal Free and University College Medical School, University College London, Hampstead Campus, Rowland Hill Street, London NW3 2PF, UK.
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Watanabe S, Uchida S. [Bartter's syndrome and Gitelman's syndrome: Pathogenesis, pathophysiology, and therapy]. Nihon Rinsho 2006; 64 Suppl 2:504-7. [PMID: 16523943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Bartter's syndrome was reported in 1962, and Gitelman's syndrome, which is subtype of Bartter's syndrome was described later. These syndromes are characterized by hypokalemia, hypochloremic metabolic alkalosis, normal to low blood pressure, although they show hyperreninemia, and hyperaldosteronemia. The cause of these diseases have been unexplained for a long time. Recently however, from 1996 to 2002, several causes have identified. Bartter's syndrome can occur due to a loss of function mutation in NKCC2, ROMK, CLC-Kb and barttin, or a gain of function mutation of calcium-sensing receptor. Gitelman's syndrome can occur due to a loss of function mutation in NCC. Different causes need different treatment and have different prognosis. In fact, we cannot examine all DNA sequences in regular hospitals. So it is our goal to make a clinical diagnostic standard to appropriate treatment.
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Affiliation(s)
- Sumiyo Watanabe
- Division of Endocrinology and Nephrology, Department of Medicine, University of Tokyo School of Medicine
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37
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Davis PA, Pagnin E, Semplicini A, Avogaro A, Calò LA. Insulin signaling, glucose metabolism, and the angiotensin II signaling system: studies in Bartter's/Gitelman's syndromes. Diabetes Care 2006; 29:469-71. [PMID: 16443917 DOI: 10.2337/diacare.29.02.06.dc05-2048] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Briet M, Vargas-Poussou R, Lourdel S, Houillier P, Blanchard A. How Bartter's and Gitelman's syndromes, and Dent's disease have provided important insights into the function of three renal chloride channels: ClC-Ka/b and ClC-5. Nephron Clin Pract 2005; 103:p7-13. [PMID: 16352917 DOI: 10.1159/000090218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Chloride channels are expressed in almost all cell membranes and are potentially involved in a wide variety of functions. The kidney expresses 8 of the 9 chloride channels of the ClC family that have been cloned so far to date in mammals. This review focuses on the pathophysiology of two renal disorders that have contributed recently to our understanding of the physiological role of chloride channels belonging to the ClC family. First are the related syndromes of Bartter's and Gitelman's, in which inactivating mutations of the genes encoding either of the ClC-Ks, or their regulatory beta-subunit barttin, have shown the important contribution of these chloride channels to renal tubular sodium and chloride (NaCl) transport along the loop of Henle and distal tubule. Second is the renal Fanconi syndrome known as Dent's disease, in which ClC-5 disruption has revealed the key role of this endosomal chloride channel in the megalin-mediated endocytotic pathway in the proximal tubule. The underlying pathophysiology of this inherited disorder demonstrates how ClC-5 is directly or indirectly required for the reabsorption of filtered low-molecular-weight proteins and bioactive peptides, also expression of membrane transporters, and clearance of calcium-based stone-forming crystals.
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Affiliation(s)
- Marie Briet
- Départementde Physiologie, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris; INSERM U.356, IFR 58, and Rene Descartes University and School of Medicine, Paris, France
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Shibagaki Y. [Bartter' s syndrome]. Nihon Rinsho 2005; 63 Suppl 3:172-9. [PMID: 15813064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Affiliation(s)
- Yugo Shibagaki
- Department of Nephrology and Endocrinology, The University of Tokyo Hospital
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40
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Velásquez-Forero F. [Hyperprostaglandin E syndrome in rabbits]. Nefrologia 2005; 25:428-33. [PMID: 16231511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023] Open
Affiliation(s)
- F Velásquez-Forero
- Laboratorio de Metabolismo Mineral Oseo del Hospital Infantil de México Federico Gómez y División de Ciencias Biológicas de la Universidad Autónoma Metropolitana, México, D. F. México.
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Nüsing RM, Seyberth HW. The role of cyclooxygenases and prostanoid receptorsin furosemide-like salt losing tubulopathy: the hyperprostaglandin E syndrome. ACTA ACUST UNITED AC 2004; 181:523-8. [PMID: 15283766 DOI: 10.1111/j.1365-201x.2004.01326.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hyperprostaglandin E syndrome/antenatal Bartter syndrome is characterized by NaCl wasting and volume depletion, juxtaglomerula hypertrophy, hyperreninism and secondary hyperaldosteronism. Primary causes are mutations in the gene for Na-K-2Cl-cotransporter, NKCC2, or for potassium channel, ROMK, responsible for medullary NaCl malabsorption. Most intriguing aspect of the syndrome is the association with a massively increased renal prostaglandin production which contributes substantially to the clinical picture of the patients. Therefore the term hyperprostaglandin E syndrome has been introduced. It is unclear how prostaglandins aggravate the NaCl transport deficiency. Aspects to prostaglandin synthesis and receptor-mediated function within the kidney in patients suffering from hyperprostaglandin E syndrome/antenatal Bartter syndrome will be discussed.
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Affiliation(s)
- R M Nüsing
- Department of Pediatrics, Philipp's University, Marburg, Germany
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Daniluk U, Kaczmarski M, Wasilewska J, Matuszewska E, Semeniuk J, Sidor K, Krasnow A. [Bartter syndrome--case report]. Pol Merkur Lekarski 2004; 16:375-7. [PMID: 15517937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
The authors present the case of 4-month-old girl, who was admitted to our hospital with hypokalemia, metabolic alkalosis, hyperaldosteronism, hyperreninism with normal blood pressure and high urine concentration of PGE2. All the clinical and biochemical features have led to the diagnosis of Bartter syndrome. Treatment consisted of 15% KCI, spironolacton and indometacin.
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Abstract
PURPOSE OF REVIEW This review describes recent advances in our understanding of the genetic heterogeneity, pathophysiology and treatment of Bartter syndrome, a group of autosomal recessive disorders that are characterized by markedly reduced or absent salt transport by the thick ascending limb of Henle. Consequently, individuals with Bartter syndrome exhibit renal salt wasting and lowered blood pressure, hypokalemic metabolic alkalosis and hypercalciuria with a variable risk of renal stones. RECENT FINDINGS Previously, three genes (SLC12A2, the sodium-potassium-chloride co-transporter; KCNJ1, the ROMK potassium ion channel; ClC-Kb, the basolateral chloride ion channel) had been identified as causing antenatal and 'classic' Bartter syndrome. Two additional genes have now been identified. Barttin is a beta-subunit that is required for the trafficking of CLC-K (both ClC-Ka and ClC-Kb) channels to the plasma membrane in both the thick ascending limb and the marginal cells in the scala media of the inner ear that secrete potassium ion-rich endolymph. Loss-of-function mutations in barttin thus cause Bartter syndrome with sensorineural deafness. In addition, severe gain-of-function mutations in the extracellular calcium ion-sensing receptor can result in a Bartter phenotype because activation of this G protein-coupled receptor inhibits salt transport in the thick ascending limb (a furosemide-like effect). SUMMARY Five genes have been identified as causing Bartter syndrome (types I-V), with the unifying pathophysiology being the loss of salt transport by the thick ascending limb. Phenotypic differences in Bartter types I-V relate to the specific physiological roles of the individual genes in the kidney and other organ systems.
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Affiliation(s)
- Steven C Hebert
- Department of Cellular and Molecular Physiology and Medicine, Yale University, School of Medicine, New Haeven, Connecticut 06520-8026, USA.
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Affiliation(s)
- Israel Zelikovic
- Pediatric Nephrology Unit, Rambam Medical Center, Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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Calò LA, Pagnin E, Davis PA, Sartori M, Semplicini A. Oxidative stress-related factors in Bartter's and Gitelman's syndromes: relevance for angiotensin II signalling. Nephrol Dial Transplant 2003; 18:1518-25. [PMID: 12897089 DOI: 10.1093/ndt/gfg204] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Bartter's and Gitelman's syndromes (BS/GS) have a blunted Gq protein-mediated cell signalling despite high circulating angiotensin II (Ang II) levels. This is associated with reduced Galphaq gene expression, intracellular inositol trisphosphate and Ca(++) release, PKC activity and cell reactivity. Ang II is a powerful stimulator of vascular oxidases but BS/GS patients show reduced total volatile LDL oxidation products and reduced LDL susceptibility to oxidation suggesting low level of oxidative stress. Therefore, we evaluated oxidative stress-related proteins in plasma and monocytes of patients with BS/GS, at baseline and after Ang II stimulation. METHODS In two BS and seven GS patients, biochemically and genetically characterized, and in 10 age- and sex-matched control subjects, we measured total plasma antioxidant power (AOP), plasma peroxynitrite level and gene expression of the NADH/NADPH oxidase subunit p22(phox), TGFbeta and haeme oxygenase-1 (HO-1) in circulating monocytes in basal condition and after stimulation with Ang II. Furthermore, we investigated the C(242)T polymorphism of p22(phox), whose topography in a potential haeme-binding site suggests a role in the regulation of oxidative stress. RESULTS AOP was higher in BS/GS patients than in controls (3.27 +/- 0.95 mmol/l vs 1.05 +/- 0.16, P = 0.002), together with higher plasma renin activity and aldosterone level (9.88 +/- 4.64 vs 0.95 +/- 0.08 nmol Ang I/h/ml, P < 0.0001; and 0.73 +/- 0.13 vs 0.18 +/- 0.01 nmol/l, P < 0.0001, respectively). The plasma peroxynitrite level was undetectable both in patients and controls. mRNA expression of p22(phox) and TGFbeta was reduced in BS/GS patients compared to controls [0.35 +/- 0.08 vs 0.53+/-0.05 densitometric units (d.u.), P = 0.005, and 0.82 +/- 0.07 vs 1.15 +/- 0.25 d.u., P = 0.006, respectively]. HO-1 mRNA was increased in BS/GS patients in comparison to controls (0.88 +/- 0.07 vs 0.78 +/- 0.11 d.u., P = 0.037). After acute Ang II exposure, p22(phox), TGFbeta and HO-1 gene expression significantly increased only in controls (from 0.59 +/- 0.12 to 0.96 +/- 0.11, P < 0.001, from 0.97 +/- 0.1 to 1.27 +/- 0.22, P < 0.008, and from 0.62 +/- 0.1 to 0.82 +/- 0.09, P < 0.001, respectively). Finally, C(242)T polymorphism of p22(phox) was undetectable. CONCLUSIONS The intracellular responses to Ang II mediated by reactive oxygen species are reduced in BS/GS patients. This may contribute to their vascular hyporeactivity.
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Affiliation(s)
- Lorenzo A Calò
- Department of Clinical and Experimental Medicine, Clinica Medica 4, University of Padova, Italy.
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Gazdíková K, Gazdík F. [Bartter's syndrome--hypokalemic renal tubular syndrome]. Cas Lek Cesk 2003; 142:474-8. [PMID: 14626562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
Hypokalemia is associated with some renal diseases manifested by renal tubular acidosis (type I and II) or by renal tubular syndrome (Bartter's, Gitelman's and Liddle's syndrome). Bartter's syndrome, originally described by Batter and colleagues in 1962, is a set of closely related renal tubular disorders characterized by hypokalemia, hypochloremia, metabolic alkalosis and hyperreninemia with normal blood pressure. The underlying renal abnormality results in excessive urinary losses of sodium, chloride, potassium and calcium. Muscle weakness, polydipsia, polyuria and mental retardation can be also present. Affected children have poor growth rates and they appear malnourished. The article is focused on ethiopathogenesis, laboratory and clinical characteristics and on the treatment of Bartter's syndrome.
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Affiliation(s)
- K Gazdíková
- Klinika farmakoterapie Ustavu preventívnej a klinickej medicíny, Bratislava.
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Kamel KS, Oh MS, Halperin ML. Bartter's, Gitelman's, and Gordon's syndromes. From physiology to molecular biology and back, yet still some unanswered questions. Nephron Clin Pract 2003; 92 Suppl 1:18-27. [PMID: 12401934 DOI: 10.1159/000065373] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The molecular basis of many of the inherited disorders of potassium homeostasis has become much clearer in the last two decades. Despite these new insights into the physiology of renal potassium handling, a number of questions remain to be answered. The examples we use to illustrate these issues are Gordon's syndrome, Bartter's syndrome, and Gitelman's syndrome. Our objective is to integrate these new insights into an understanding of the pathophysiology of renal potassium handling. We also propose different ways to think about some of the unresolved issues in this area.
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Affiliation(s)
- Kamel S Kamel
- Renal Division, St. Michael's Hospital, University of Toronto, Toronto, Ont., Canada
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Haas NA, Nossal R, Schneider CH, Lewin MAG, Ocker V, Holder M, Uhlemann F. Successful management of an extreme example of neonatal hyperprostaglandin-E syndrome (Bartter's syndrome) with the new cyclooxygenase-2 inhibitor rofecoxib. Pediatr Crit Care Med 2003; 4:249-51. [PMID: 12749662 DOI: 10.1097/01.pcc.0000059422.26706.64] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the successful treatment of an unusual case of severe neonatal Bartter's syndrome refractory to treatment with indomethacin. DESIGN Case report, clinical. SETTING Tertiary care intensive care unit. PATIENTS A patient with neonatal hyperprostaglandin-E syndrome and excessive requirements of intravenous (via central venous catheter) water and salt supplementation, failure to thrive, vomiting, and massive growth retardation, despite adequate treatment with indomethacin. MAIN RESULT Four weeks after induction of the new cyclooxygenase-2 inhibitor rofecoxib, the patient was well, on full enteral feeds, thriving, and had gained 600 g in weight. A lower supplementary potassium, magnesium, and sodium intake was required. Reinstitution of indomethacin therapy resulted in severe deterioration, despite high indomethacin doses; symptoms improved again after rofecoxib administration. No side effects have been seen thus far. CONCLUSION This report shows that in selected patients with a severe form of neonatal Bartter's syndrome, the new cyclooxygenase-2 inhibitor rofecoxib may control the clinical symptoms of hyperprostaglandin-E syndrome after ineffective indomethacin therapy.
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Affiliation(s)
- Nikolaus A Haas
- Department of Pediatric Cardiology and Pediatric Intensive Care, Olgahospital Stuttgart, Stuttgart, Germany
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Meade P, Sabath E, Gamba G. [Molecular physiopathology of Bartter's syndrome]. Rev Invest Clin 2003; 55:74-83. [PMID: 12708166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Bartter's syndrome is an autosomic recessive disease characterized by hypokalemic metabolic alkalosis accompanied with hypercalciuria, polyuria and hypotension due to volume depletion. The pathophysiology of this hereditary disease was largely unknown until the last few years in which inactivating mutations in up to five different genes have been shown to produce or be associated with the development of this syndrome. All the involved proteins are expressed either in the apical or basolateral membrane of the thick ascending limb of Henle's loop. These clinical and molecular findings have increased our understanding of the Bartter's disease and also of the thick ascending limb physiology.
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Affiliation(s)
- Patricia Meade
- Unidad de Fisiología Molecular, Departamento de Nefrología y Metabolismo Mineral, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México.
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