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Rioux AV, Nsimba-Batomene TR, Slimani S, Bergeron NAD, Gravel MAM, Schreiber SV, Fiola MJ, Haydock L, Garneau AP, Isenring P. Navigating the multifaceted intricacies of the Na +-Cl - cotransporter, a highly regulated key effector in the control of hydromineral homeostasis. Physiol Rev 2024; 104:1147-1204. [PMID: 38329422 DOI: 10.1152/physrev.00027.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 01/01/2024] [Accepted: 02/03/2024] [Indexed: 02/09/2024] Open
Abstract
The Na+-Cl- cotransporter (NCC; SLC12A3) is a highly regulated integral membrane protein that is known to exist as three splice variants in primates. Its primary role in the kidney is to mediate the cosymport of Na+ and Cl- across the apical membrane of the distal convoluted tubule. Through this role and the involvement of other ion transport systems, NCC allows the systemic circulation to reclaim a fraction of the ultrafiltered Na+, K+, Cl-, and Mg+ loads in exchange for Ca2+ and [Formula: see text]. The physiological relevance of the Na+-Cl- cotransport mechanism in humans is illustrated by several abnormalities that result from NCC inactivation through the administration of thiazides or in the setting of hereditary disorders. The purpose of the present review is to discuss the molecular mechanisms and overall roles of Na+-Cl- cotransport as the main topics of interest. On reading the narrative proposed, one will realize that the knowledge gained in regard to these themes will continue to progress unrelentingly no matter how refined it has now become.
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Affiliation(s)
- A V Rioux
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - T R Nsimba-Batomene
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - S Slimani
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - N A D Bergeron
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - M A M Gravel
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - S V Schreiber
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - M J Fiola
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
| | - L Haydock
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
- Service de Néphrologie-Transplantation Rénale Adultes, Hôpital Necker-Enfants Malades, AP-HP, INSERM U1151, Université Paris Cité, Paris, France
| | - A P Garneau
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
- Service de Néphrologie-Transplantation Rénale Adultes, Hôpital Necker-Enfants Malades, AP-HP, INSERM U1151, Université Paris Cité, Paris, France
| | - P Isenring
- Department of Medicine, Nephrology Research Group, Laval University, Quebec City, Quebec, Canada
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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] [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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3
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Syndromes de Bartter–Gitelman. Nephrol Ther 2020; 16:233-243. [DOI: 10.1016/j.nephro.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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4
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Başer H, Topaloğlu O, Çakır B. A Rare Reason of Hypokalemia in a Hyperthyroid Patient: Gitelman Syndrome. ANKARA MEDICAL JOURNAL 2018. [DOI: 10.17098/amj.461663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Lü Q, Zhang Y, Song C, An Z, Wei S, Huang J, Huang L, Tang L, Tong N. A novel SLC12A3 gene homozygous mutation of Gitelman syndrome in an Asian pedigree and literature review. J Endocrinol Invest 2016; 39:333-40. [PMID: 26260218 DOI: 10.1007/s40618-015-0371-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 07/24/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Gitelman syndrome (GS) is an autosomal recessive disease characterized by hypokalemic metabolic alkalosis in combination with significant hypomagnesemia and hypocalciuria which is caused by mutations in the SLC12A3 gene. In this study, we reported a case of GS pedigree and reviewed pertinent literature so as to explore the relationship between clinical characteristics and genotype meanwhile provide recommendations for the diagnosis and treatment of GS. DESIGN AND METHODS This is a pedigree-based genetic study of GS and 11 members from one family were included. We summarized their clinical features, analyzed laboratory parameters related to GS and SLC12A3 gene. RESULTS The proband experienced intermittent severe symptoms of weakness accompanied by significant hypokalemia, hypomagnesemia and hypocalciuria in laboratory test with poor treatments. His mother had more slight symptoms of weakness than him with mild hypokalemia and hypocalciuria. Mild hypomagnesemia was also observed in his sister with occasional weakness. All other pedigree members had normal laboratory test with no GS-related symptoms. A homozygous mutation of SLC12A3 gene (c.488C > T) was detected by genetic testing in three members, and six were carriers of this mutation. CONCLUSIONS Genotype and phenotype vary significantly among GS patients. Male patients tend to experience more severe symptoms and poor treatment effect. Further large-scale population, animal, and molecular biology experiments are required to investigate the complexity of GS and to find a better treatment regimen for this disease.
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Affiliation(s)
- Q Lü
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Chengdu, 610041, China
| | - Y Zhang
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Chengdu, 610041, China
| | - C Song
- West China School of Medicine, Sichuan University, No.17, the 3rd section of the south of Renmin road, Chengdu, 610041, China
| | - Z An
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Chengdu, 610041, China
| | - S Wei
- West China School of Medicine, Sichuan University, No.17, the 3rd section of the south of Renmin road, Chengdu, 610041, China
| | - J Huang
- West China School of Medicine, Sichuan University, No.17, the 3rd section of the south of Renmin road, Chengdu, 610041, China
| | - L Huang
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Chengdu, 610041, China
| | - L Tang
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Chengdu, 610041, China
| | - N Tong
- Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, No. 37 Guoxue Lane, Chengdu, 610041, China.
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Blanchard A, Vargas-Poussou R, Vallet M, Caumont-Prim A, Allard J, Desport E, Dubourg L, Monge M, Bergerot D, Baron S, Essig M, Bridoux F, Tack I, Azizi M. Indomethacin, amiloride, or eplerenone for treating hypokalemia in Gitelman syndrome. J Am Soc Nephrol 2014; 26:468-75. [PMID: 25012174 DOI: 10.1681/asn.2014030293] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Patients with Gitelman syndrome (GS), an inherited salt-losing tubulopathy, are usually treated with potassium-sparing diuretics or nonsteroidal anti-inflammatory drugs and oral potassium and magnesium supplementations. However, evidence supporting these treatment options is limited to case series studies. We designed an open-label, randomized, crossover study with blind end point evaluation to compare the efficacy and safety of 6-week treatments with one time daily 75 mg slow-release indomethacin, 150 mg eplerenone, or 20 mg amiloride added to constant potassium and magnesium supplementation in 30 patients with GS (individual participation: 48 weeks). Baseline plasma potassium concentration was 2.8±0.4 mmol/L and increased by 0.38 mmol/L (95% confidence interval [95% CI], 0.23 to 0.53; P<0.001) with indomethacin, 0.15 mmol/L (95% CI, 0.02 to 0.29; P=0.03) with eplerenone, and 0.19 mmol/L (95% CI, 0.05 to 0.33; P<0.01) with amiloride. Fifteen patients became normokalemic: six with indomethacin, three with eplerenone, and six with amiloride. Indomethacin significantly reduced eGFR and plasma renin concentration. Eplerenone and amiloride each increased plasma aldosterone by 3-fold and renin concentration slightly but did not significantly change eGFR. BP did not significantly change. Eight patients discontinued treatment early because of gastrointestinal intolerance to indomethacin (six patients) and hypotension with eplerenone (two patients). In conclusion, each drug increases plasma potassium concentration in patients with GS. Indomethacin was the most effective but can cause gastrointestinal intolerance and decreased eGFR. Amiloride and eplerenone have similar but lower efficacies and increase sodium depletion. The benefit/risk ratio of each drug should be carefully evaluated for each patient.
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Affiliation(s)
- Anne Blanchard
- Université Paris Descartes, Faculté de Médecine, Sorbonne Paris Cité, Paris, France; Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Centre d'Investigation Clinique, Paris, France; Institut National de la Santé et de la Recherche Médicale, Centre d'Investigation Clinique 1418, Paris, France;
| | - Rosa Vargas-Poussou
- Département de génétique and Institut National de la Santé et de la Recherche Médicale, UMR970, Paris-Cardiovascular Research Center, Paris, France
| | - Marion Vallet
- Service des explorations fonctionnelles physiologiques, Hôpital de Rangueil, Toulouse, France
| | - Aurore Caumont-Prim
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Unité d'Épidémiologie et de Recherche Clinique, Paris, France; Institut National de la Santé et de la Recherche Médicale, Centre d'Investigation Épidémiologique 4, Paris, France
| | - Julien Allard
- Centre Hospitalier Universitaire Dupuytren, Service de néphrologie, Centre d'Investigation Clinique Centre d'Investigation Clinique Institut National de la Santé et de la Recherche Médicale 0801, Limoges, France
| | - Estelle Desport
- Centre Hospitalier Universitaire de Poitiers, Service de néphrologie, Centre d'Investigation Clinique Centre d'Investigation Clinique Institut National de la Santé et de la Recherche Médicale 1402, Université de Poitiers, Poitiers, France; and
| | - Laurence Dubourg
- Hôpital Edouard Herriot, Lyon, Paris, Hospices civils de Lyon, Lyon, France
| | - Matthieu Monge
- Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Centre d'Investigation Clinique, Paris, France
| | - Damien Bergerot
- Institut National de la Santé et de la Recherche Médicale, Centre d'Investigation Clinique 1418, Paris, France
| | - Stéphanie Baron
- Université Paris Descartes, Faculté de Médecine, Sorbonne Paris Cité, Paris, France; Service d'explorations fonctionnelles, Hôpital Européen Georges Pompidou, Paris, France
| | - Marie Essig
- Centre Hospitalier Universitaire Dupuytren, Service de néphrologie, Centre d'Investigation Clinique Centre d'Investigation Clinique Institut National de la Santé et de la Recherche Médicale 0801, Limoges, France
| | - Frank Bridoux
- Centre Hospitalier Universitaire de Poitiers, Service de néphrologie, Centre d'Investigation Clinique Centre d'Investigation Clinique Institut National de la Santé et de la Recherche Médicale 1402, Université de Poitiers, Poitiers, France; and
| | - Ivan Tack
- Service des explorations fonctionnelles physiologiques, Hôpital de Rangueil, Toulouse, France
| | - Michel Azizi
- Université Paris Descartes, Faculté de Médecine, Sorbonne Paris Cité, Paris, France; Assistance Publique Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Centre d'Investigation Clinique, Paris, France; Institut National de la Santé et de la Recherche Médicale, Centre d'Investigation Clinique 1418, Paris, France
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Caiata-Zufferey M, Zanini CA, Schulz PJ, Syren ML, Bianchetti MG, Bettinelli A. Living with Gitelman disease: an insight into patients' daily experiences. Nephrol Dial Transplant 2012; 27:3196-3201. [DOI: 10.1093/ndt/gfs017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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8
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Gennari FJ. Pathophysiology of Metabolic Alkalosis: A New Classification Based on the Centrality of Stimulated Collecting Duct Ion Transport. Am J Kidney Dis 2011; 58:626-36. [DOI: 10.1053/j.ajkd.2011.06.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 06/14/2011] [Indexed: 11/11/2022]
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9
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Eren MA, Tabur S, Sezgin B, Sabuncu T. A Rare Cause of Hypokalemia:
Gitelman Syndrome. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2011. [DOI: 10.29333/ejgm/82719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Herrero-Morín JD, Rodríguez J, Coto E, Gil-Peña H, Alvarez V, Espinosa L, Loris C, Gil-Calvo M, Santos F. Gitelman syndrome in Gypsy paediatric patients carrying the same intron 9 + 1 G>T mutation. Clinical features and impact on quality of life. Nephrol Dial Transplant 2010; 26:151-5. [PMID: 20571093 DOI: 10.1093/ndt/gfq352] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Gitelman syndrome is a primary tubular disorder causing hypokalaemic metabolic alkalosis with hypocalciuria. Its prevalence is high in Gypsies, who harbour an identical mutation, intron 9 + 1 G>T, in the SLC12A3 gene. METHODS To better define the Gitelman syndrome in Gypsies, the clinical and biochemical features of 34 Spanish paediatric Gypsy patients were analysed. At diagnosis, symptoms, height and weight as well as serum and urinary biochemical data were collected. During a follow-up of 4.5 ± 2.4 years [X ± standard deviation (SD)], therapy, treatment compliance, symptoms, frequency of hospital admissions and, at the last visit, growth and biochemical work-up of 29 patients followed for at least 6 months were analysed. Quality of life items were also assessed by a questionnaire. RESULTS Muscle cramps (41%) and asthenia (35%) were the most frequent presenting symptoms. Biochemical data at diagnosis were serum K 2.76 ± 0.46 mEq/L, serum Mg 1.32 ± 0.28 mg/dL, blood pH 7.45 ± 0.06, serum bicarbonate 28.2 ± 2.9 mEq/L, urinary calcium/creatinine ratio 0.03 ± 0.04 mg/mg, fractional K excretion 24.4 ± 17.1% and fractional Mg excretion 8.9 ± 8.3%. During follow-up, Mg and K supplements were prescribed to 79 and 86% of patients, respectively; compliance with treatment was good in 35%. Hospital admission rate was 0.03/patient/month. Muscle cramps were the symptom most often referred by the patients (45%) during the follow-up, and 71% of patients considered their health status as excellent or good. Twenty-one patients stated that their disease did not adversely interfere with their mood or social relationships. Height and weight of patients at diagnosis were -0.60 ± 1.17 and -0.49 ± 1.32 SD, respectively, and improved to -0.44 ± 1.28 (P < 0.05) and 0.18 ± 1.79 SD (P < 0.01) at the last visit. CONCLUSIONS Gypsy children with Gitelman syndrome mostly exhibit muscle symptoms and asthenia although the disease is not particularly severe in this ethnic group. Body growth improves with treatment and close follow-up.
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Chong L, Baikunje S, Poller DN, Roberts ISD, Venkat-Raman G. An unusual cause of acute renal failure with volume depletion due to renal losses. Am J Kidney Dis 2008; 52:366-9. [PMID: 18585834 DOI: 10.1053/j.ajkd.2008.04.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 04/22/2008] [Indexed: 11/11/2022]
Affiliation(s)
- Lin Chong
- Wessex Renal & Transplant Service, Queen Alexandra Hospital, Portsmouth, UK
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Ducarme G, Davitian C, Uzan M, Belenfant X, Poncelet C. Syndrome de Gitelman et grossesse: à propos d'un cas et revue de la littérature. ACTA ACUST UNITED AC 2007; 36:310-3. [PMID: 17466223 DOI: 10.1016/j.jgyn.2006.10.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Revised: 09/19/2006] [Accepted: 10/11/2006] [Indexed: 11/29/2022]
Abstract
Gitelman syndrome (GS) is a tubulopathy characterized by hypokaliemia, hypomagnesiemia, metabolic alkalosis and hypocalciuria. We report a case of a 33-year-old pregnant woman with Gitelman Syndrome. Oral potassium chloride and magnesium citrate were prescribed and the course of the pregnancy was uneventful with vaginal delivery at term. The impact of GS on the physiologic adaptations to pregnancy is not well-known, with few reports to date. Monitoring of serum potassium and magnesium levels with supplementation, amniotic fluid and fetal growth is required to prevent obstetrical and fetal complications in a patient with GS.
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Affiliation(s)
- G Ducarme
- Service de Gynécologie et d'Obstétrique, CHU Jean-Verdier, APHP, Avenue du 14-Juillet, Bondy Cedex, France.
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13
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Slyper AH. Growth, growth hormone testing and response to growth hormone treatment in Gitelman syndrome. J Pediatr Endocrinol Metab 2007; 20:257-9. [PMID: 17396444 DOI: 10.1515/jpem.2007.20.2.257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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14
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Godefroid N, Riveira-Munoz E, Saint-Martin C, Nassogne MC, Dahan K, Devuyst O. A Novel Splicing Mutation in SLC12A3 Associated With Gitelman Syndrome and Idiopathic Intracranial Hypertension. Am J Kidney Dis 2006; 48:e73-9. [PMID: 17059986 DOI: 10.1053/j.ajkd.2006.08.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2006] [Accepted: 08/14/2006] [Indexed: 11/11/2022]
Abstract
We report a case of Gitelman syndrome (GS) in a dizygotic twin who presented at 12 years of age with growth delay, metabolic alkalosis, hypomagnesemia and hypokalemia with inappropriate kaliuresis, and idiopathic intracranial hypertension with bilateral papilledema (pseudotumor cerebri). The patient, her twin sister, and her mother also presented with cerebral cavernous malformations. Based on the early onset and normocalciuria, Bartter syndrome was diagnosed first. However, mutation analysis showed that the proband is a compound heterozygote for 2 mutations in SLC12A3: a substitution of serine by leucine at amino acid position 555 (p.Ser555Leu) and a novel guanine to cytosine transition at the 5' splice site of intron 22 (c.2633+1G>C), providing the molecular diagnosis of GS. These mutations were not detected in 200 normal chromosomes and cosegregated within the family. Analysis of complementary DNA showed that the heterozygous nucleotide change c.2633+1G>C caused the appearance of 2 RNA molecules, 1 normal transcript and 1 skipping the entire exon 22 (r.2521_2634del). Supplementation with potassium and magnesium improved clinical symptoms and resulted in catch-up growth, but vision remained impaired. Three similar associations of Bartter syndrome/GS with pseudotumor cerebri were found in the literature, suggesting that electrolyte abnormalities and secondary aldosteronism may have a role in idiopathic intracranial hypertension. This study provides further evidence for the phenotypical heterogeneity of GS and its association with severe manifestations in children. It also shows the independent segregation of familial cavernomatosis and GS.
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Affiliation(s)
- Nathalie Godefroid
- Department of Pediatrics, Division of Nephrology, Center for Human Genetics, Université catholique de Louvain Medical School, Saint-Luc Academic Hospital, Brussels, Belgium
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Gupta R, Hu V, Reynolds T, Harrison R. Sclerochoroidal calcification associated with Gitelman syndrome and calcium pyrophosphate dihydrate deposition. J Clin Pathol 2006; 58:1334-5. [PMID: 16311360 PMCID: PMC1770796 DOI: 10.1136/jcp.2005.027300] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Sclerochoroidal calcification is an uncommon condition. Metabolic evaluation and clinical examination are important to exclude associated systemic conditions such as the Bartter and Gitelman syndromes. It has been suggested that the lesions seen in sclerochoroidal calcification are calcium pyrophosphate dihydrate crystals. This report describes the first documented case in the UK of sclerochoroidal calcification associated with Gitelman syndrome and calcium pyrophosphate dihydrate deposition.
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Affiliation(s)
- R Gupta
- Birmingham and Midland Eye Centre, City Hospital NHS Trust, Dudley Road, Birmingham B18 7QU, UK.
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Abstract
BACKGROUND Gitelman syndrome is a rare autosomal recessive disorder that presents in early adulthood with fatigue, muscle cramps and electrolyte abnormalities. CASE A 17-year-old African-American woman presented at 17 weeks of pregnancy with nausea, emesis, profound lower extremity proximal muscle weakness, hypokalemia, and hypomagnesemia. After a thorough evaluation, Gitelman syndrome was diagnosed. The patient was maintained on high levels of potassium and magnesium supplementation throughout the rest of her pregnancy and delivered a healthy infant. CONCLUSION In pregnancy, nausea and emesis is most commonly attributed to hyperemesis gravidarum. However, an atypical presentation of these symptoms and/or the coexistence of less common complaints warrant further investigation.
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Affiliation(s)
- Sindhu K Srinivas
- Department of Obstetrics and Gynecology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104, USA.
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Abstract
A 56-year-old mentally retarded Japanese woman (intelligence quotient: 49) was admitted to our hospital with the chief complaints of headache, dizziness, vomiting, and lower limb paralysis. Laboratory tests showed severe hypokalemia, metabolic alkalosis, hypomagnesemia, and hypocalciuria. These findings suggested a diagnosis of Gitelman's syndrome (GS). We examined the thiazide-sensitive Na-Cl cotransporter (TSC) gene for the mutations that can be responsible for Gitelman's syndrome, and confirmed the diagnosis. After potassium and magnesium supplementation, her paralysis improved dramatically. The marriage of her parents was consanguineous. She had nine siblings (all with mental retardation), among whom five had died of unknown causes during childhood. Familial mental retardation has never been detected before in Gitelman's syndrome. Here we report a rare case of Gitelman's syndrome with familial mental retardation.
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Affiliation(s)
- Rena Morita
- Division of Internal Medicine, Takikawa City Hospital, Takikawa, Hokkaido
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Abstract
Ca(2+) is an essential ion in all organisms, where it plays a crucial role in processes ranging from the formation and maintenance of the skeleton to the temporal and spatial regulation of neuronal function. The Ca(2+) balance is maintained by the concerted action of three organ systems, including the gastrointestinal tract, bone, and kidney. An adult ingests on average 1 g Ca(2+) daily from which 0.35 g is absorbed in the small intestine by a mechanism that is controlled primarily by the calciotropic hormones. To maintain the Ca(2+) balance, the kidney must excrete the same amount of Ca(2+) that the small intestine absorbs. This is accomplished by a combination of filtration of Ca(2+) across the glomeruli and subsequent reabsorption of the filtered Ca(2+) along the renal tubules. Bone turnover is a continuous process involving both resorption of existing bone and deposition of new bone. The above-mentioned Ca(2+) fluxes are stimulated by the synergistic actions of active vitamin D (1,25-dihydroxyvitamin D(3)) and parathyroid hormone. Until recently, the mechanism by which Ca(2+) enter the absorptive epithelia was unknown. A major breakthrough in completing the molecular details of these pathways was the identification of the epithelial Ca(2+) channel family consisting of two members: TRPV5 and TRPV6. Functional analysis indicated that these Ca(2+) channels constitute the rate-limiting step in Ca(2+)-transporting epithelia. They form the prime target for hormonal control of the active Ca(2+) flux from the intestinal lumen or urine space to the blood compartment. This review describes the characteristics of epithelial Ca(2+) transport in general and highlights in particular the distinctive features and the physiological relevance of the new epithelial Ca(2+) channels accumulating in a comprehensive model for epithelial Ca(2+) absorption.
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Affiliation(s)
- Joost G J Hoenderop
- Department of Physiology, Nijmegen Center for Moecular Life Sciences, University Medical Center Nijmegen, The Netherlands
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19
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Knepper MA, Kleyman T, Gamba G. Diuretics: Mechanisms of Action. Hypertension 2005. [DOI: 10.1016/b978-0-7216-0258-5.50152-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Foglia PEG, Bettinelli A, Tosetto C, Cortesi C, Crosazzo L, Edefonti A, Bianchetti MG. Cardiac work up in primary renal hypokalaemia-hypomagnesaemia (Gitelman syndrome). Nephrol Dial Transplant 2004; 19:1398-402. [PMID: 15034158 DOI: 10.1093/ndt/gfh204] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Potassium and magnesium depletion prolongs the duration of the action potential of the cardiomyocyte, which predisposes to ventricular arrhythmias. In addition, potassium or magnesium depletion might impair cardiac performance and facilitate coronary artery thrombosis. METHODS Continuous 24-h ambulatory electrocardiographic monitoring, treadmill exercise testing and echocardiography were assessed in 21 patients (11 female and 10 male subjects, aged 5.9-39, median 19 years) with primary renal hypokalaemia-hypomagnesaemia. RESULTS The QT interval corrected for heart rate was normal (between 379 and 430 ms) in 10 and slightly to moderately prolonged in the remaining 11 patients (between 446 and 509 ms). Plasma potassium, magnesium and bicarbonate were similar in patients with normal and in those with prolonged QT interval. Continuous ambulatory electrocardiography over 24 h and exercise testing did not detect significant abnormalities of cardiac rhythm or features suggestive of myocardial ischaemia. Finally, echocardiographic and Doppler assessment failed to reveal any abnormalities in myocardial morphology and function. CONCLUSION The QT interval is often prolonged in primary renal hypokalaemia-hypomagnesaemia, confirming that potassium and magnesium depletion tends to prolong the duration of the action potential of the cardiomyocyte. The results of continuous ambulatory electrocardiography, exercise testing and echocardiography are reassuring. Nonetheless, we assume that dangerous cardiac arrhythmias may occur in patients with very severe hypokalaemia, during medication with drugs that prolong the QT interval or in the context of short-term non-adherence to the recommended regimen of care.
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Affiliation(s)
- Pietro E G Foglia
- Pediatric Renal Unit, University of Milan Medical School, Clinica De Marchi, Italy
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21
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Abstract
Sclerochoroidal calcification is a recently recognized ocular condition that is characterized by typical geographic yellow-white fundus lesions that usually occur bilaterally in adults. It can clinically simulate a number of intraocular tumors like choroidal metastasis, choroidal melanoma, and choroidal osteoma. Clinical evaluation with ultrasonography, computed tomography, and some histopathologic studies have supported the fact the condition represents calcium deposition in the sclera and choroid. Early reports suggested that sclerochoroidal calcification was usually associated with hypercalcemic conditions such as hyperparathyroidism and pseudohypoparathyroidism. Subsequently, many patients with sclerochoroidal calcification have had no apparent systemic associations and have been classified as idiopathic. However, very recent studies have suggested that this ocular condition can also be associated with Gitelman syndrome or Bartter syndrome. These are autosomal recessive conditions of hypokalemic alkalosis associated with hypomagnesemia and deposition of calcium salts in various tissues. Ophthalmologists should be familiar with fundus features and systemic associations of sclerochoroidal calcification.
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Affiliation(s)
- Jerry A Shields
- Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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22
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Shaer AJ. Inherited primary renal tubular hypokalemic alkalosis: a review of Gitelman and Bartter syndromes. Am J Med Sci 2001; 322:316-32. [PMID: 11780689 DOI: 10.1097/00000441-200112000-00004] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Inherited hypokalemic metabolic alkalosis, or Bartter syndrome, comprises several closely related disorders of renal tubular electrolyte transport. Recent advances in the field of molecular genetics have demonstrated that there are four genetically distinct abnormalities, which result from mutations in renal electrolyte transporters and channels. Neonatal Bartter syndrome affects neonates and is characterized by polyhydramnios, premature delivery, severe electrolyte derangements, growth retardation, and hypercalciuria leading to nephrocalcinosis. It may be caused by a mutation in the gene encoding the Na-K-2Cl cotransporter (NKCC2) or the outwardly rectifying potassium channel (ROMK), a regulator of NKCC2. Classic Bartter syndrome is due to a mutation in the gene encoding the chloride channel (CLCNKB), also a regulator of NKCC2, and typically presents in infancy or early childhood with failure to thrive. Nephrocalcinosis is typically absent despite hypercalciuria. The hypocalciuric, hypomagnesemic variant of Bartter syndrome (Gitelman syndrome), presents in early adulthood with predominantly musculoskeletal symptoms and is due to mutations in the gene encoding the Na-Cl cotransporter (NCCT). Even though our understanding of these disorders has been greatly advanced by these discoveries, the pathophysiology remains to be completely defined. Genotype-phenotype correlations among the four disorders are quite variable and continue to be studied. A comprehensive review of Bartter and Gitelman syndromes will be provided here.
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Affiliation(s)
- A J Shaer
- Division of Nephrology, Medical University of South Carolina, Charleston 29425, USA.
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Schepkens H, Lameire N. Gitelman's syndrome: an overlooked cause of chronic hypokalemia and hypomagnesemia in adults. Acta Clin Belg 2001; 56:248-54. [PMID: 11603254 DOI: 10.1179/acb.2001.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In 1966, Gitelman described a benign variant of classical Bartter's syndrome in adults characterized by consistent hypomagnesemia and hypocalciuria, hypokalemic metabolic alkalosis and hyperreninemic hyperaldosteronism with normal blood pressure. A specific gene has been found responsible for this disorder, encoding the thiazide-sensitve Na-Cl coporter (TSC) in the distal convoluted tubule. Mutant alleles result in loss of normal TSC function and the phenotype is identical to patients with chronic use of thiazide diuretics. Gitelman's syndrome is a more common cause of chronic hypokalemia than Bartter's syndrome, with which it is often confused. The distinguishing features between both syndromes are discussed.
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Affiliation(s)
- H Schepkens
- Dienst voor Inwendige Ziekten-Afdeling Nefrologie Universitair Ziekenhuis De Pintelaan 185-9000 Gent.
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Abstract
INTRODUCTION Hypokalemia is the most frequent electrolytic disturbance in hospitalized patients. It is sometimes familial. Careful clinical and biological evaluation may guide further genetic analysis. CURRENT KNOWLEDGE AND KEY POINTS Genetic hypokalemia is linked to disorders of mineralocorticoid hormone synthesis or action (glucocorticoid-remediable hyperaldosteronism, congenital adrenal hyperplasia, apparent excess of mineralocorticoids), to renal tubular disorders (Liddle's syndrome, Bartter's and Gitelmann's syndrome, tubular acidosis) or to disorders of cellular transfer of potassium (hypokalemic periodic paralysis). FUTURE PROSPECTS AND PROJECTS Molecular mechanisms of adult Bartter's syndrome are probably different from pediatric syndromes. A better clinical and biological evaluation with longitudinal follow-up could allow significant progress in the knowledge of the natural history and prognosis of these syndromes.
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Affiliation(s)
- B Goichot
- Service de médecine interne et nutrition, hôpital de Hautepierre, CHRU, avenue Molière, 67098 Strasbourg, France.
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Cruz DN, Shaer AJ, Bia MJ, Lifton RP, Simon DB. Gitelman's syndrome revisited: an evaluation of symptoms and health-related quality of life. Kidney Int 2001; 59:710-7. [PMID: 11168953 DOI: 10.1046/j.1523-1755.2001.059002710.x] [Citation(s) in RCA: 201] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gitelman's syndrome (GS), also called Gitelman's variant of Bartter's syndrome, is an autosomal recessive renal disorder characterized by hypokalemia, hypomagnesemia, metabolic alkalosis, and hypocalciuria. GS is caused by inactivating mutations in the thiazide-sensitive sodium chloride cotransporter gene (NCCT). It is also known as the "milder" form of Bartter's syndrome, as patients with GS are usually diagnosed in adulthood during routine investigation. Symptoms reported in the literature range from asymptomatic, to mild symptoms of cramps and fatigue, to severe manifestations such as tetany, paralysis, and rhabdomyolysis. This is the first systematic evaluation of a large group of patients with genetically defined GS. METHODS We evaluated the symptoms and quality of life (QOL) in 50 adult GS patients with confirmed mutations in NCCT, using a standardized questionnaire. This cohort was compared with 25 age- and sex-matched controls. RESULTS GS patients were significantly more symptomatic than controls. The most common symptoms were salt craving, with musculoskeletal symptoms such as cramps, muscle weakness, and aches and constitutional symptoms such as fatigue, generalized weakness and dizziness, and nocturia and polydipsia. Forty-five percent of GS patients consider their symptoms a moderate to big problem. Measures of health-related QOL were significantly lower in GS patients compared with controls, particularly in terms of role limitations caused by physical health, emotion, level of energy, and general health perception. CONCLUSIONS This descriptive study indicates that GS is not an asymptomatic disease and adversely affects QOL in these patients. Further studies are needed to assess the impact of therapy on symptoms and QOL.
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Affiliation(s)
- D N Cruz
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut 06520-8029, USA.
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Deliyska B, Lazarov V, Minkova V, Nikolov D, Tishkov I. Association of Bartter's syndrome with vasculitis. Nephrol Dial Transplant 2000; 15:102-3. [PMID: 10607776 DOI: 10.1093/ndt/15.1.102] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- B Deliyska
- Clinical Center of Nephrology and Department of Pathology, Medical University, Sofia, Bulgaria
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Affiliation(s)
- G Gamba
- Instituto de Investigaciones Biomédicas of the Universidad Nacional Autónoma de México at the Instituto Nacional de la Nutritión Salvador Zubirán, Mexico City
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