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Zieg J, Tavačová T, Balaščáková M, Peldová P, Fencl F, Kubuš P. Sudden cardiac arrest in a child with Gitelman syndrome: a case report and literature review. Front Pediatr 2023; 11:1188098. [PMID: 37351317 PMCID: PMC10282639 DOI: 10.3389/fped.2023.1188098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/23/2023] [Indexed: 06/24/2023] Open
Abstract
Salt-losing tubulopathies are well-recognised diseases predisposing to metabolic disturbances in affected patients. One of the most severe complications can be life-threatening arrhythmias causing sudden cardiac arrest. We present here the first case of a pediatric patient with Gitelman syndrome associated sudden cardiac arrest without precipitating event. A 10-year-old boy collapsed due to ventricular fibrillation in the Prague tram. Lay cardiopulmonary resuscitation was initiated and external defibrillation restored sinus rhythm within minutes. Initial laboratory examination revealed severe hypokalemia requiring large amounts of electrolyte supplementation. Genetic testing focused to tubulopathies was performed and the diagnosis of Gitelman syndrome was made following the identification of two pathogenic variants in SLC12A3 gene (c.2633 + 1G>A and c.2221G>A). Implantable cardioverter-defibrillator was implanted to prevent sudden cardiac death. The patient was in a good clinical condition with satisfactory electrolyte serum levels at the last follow-up. Causes of electrolyte abnormalities in children should be identified early to prevent the development of rare but potentially fatal complications.
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Affiliation(s)
- Jakub Zieg
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
| | - Terezia Tavačová
- Children's Heart Centre, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
| | - Miroslava Balaščáková
- Department of Biology and Medical Genetics, University Hospital Motol, Second Medical Faculty, Charles University, Prague, Czechia
| | - Petra Peldová
- Department of Biology and Medical Genetics, University Hospital Motol, Second Medical Faculty, Charles University, Prague, Czechia
| | - Filip Fencl
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
| | - Peter Kubuš
- Children's Heart Centre, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czechia
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Muacevic A, Adler JR, Roche M, Ngassa M. Cardiac Arrest as the First Presentation of Gitelman Syndrome. Cureus 2023; 15:e33565. [PMID: 36779094 PMCID: PMC9908823 DOI: 10.7759/cureus.33565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/09/2023] [Indexed: 01/11/2023] Open
Abstract
Gitelman syndrome is a salt-wasting tubulopathy characterized by profound hypokalemia, hypomagnesemia, metabolic alkalosis, and hypocalciuria. Cardiac arrest is a relatively rare manifestation of Gitelman syndrome. Here we present a case of Gitelman syndrome in a patient with recurrent cardiac arrest. A 43-year-old female was admitted for out-of-hospital cardiac arrest secondary to ventricular fibrillation. Initial workup revealed severe hypokalemia, hypomagnesemia, metabolic alkalosis, and prolonged QTc. The workup revealed a picture of salt-wasting tubulopathy with hypokalemia, hypomagnesemia, and hypocalciuria. Potassium was repleted aggressively, and the patient received potassium-sparing agents resulting in the stabilization of potassium levels. Before discharge, an implantable cardioverter defibrillator (ICD) was placed for secondary prevention of cardiac arrest. The patient remained symptom-free, and electrolytes remained stable. This case highlights the diagnostic challenges of Gitelman syndrome and the importance of accurate diagnosis in improving patient outcomes.
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Smith KA, Reynolds ML, Chang EH, Strauss RA, Straube LE. Anesthetic Considerations for Cesarean Delivery in a Parturient With Severe Gitelman Syndrome. Cureus 2022; 14:e26260. [PMID: 35911322 PMCID: PMC9313132 DOI: 10.7759/cureus.26260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2022] [Indexed: 11/05/2022] Open
Abstract
Gitelman syndrome is an autosomal recessive inherited disorder that impairs the function of thiazide-sensitive sodium-chloride cotransporters in the distal convoluted tubule of the nephron. During labor and delivery, avoidance of sympathetic overactivity, meticulous hemodynamic monitoring, and expedited repletion of potassium and magnesium are required to avoid adverse outcomes. We present a parturient with severe Gitelman syndrome, requiring continuous electrolyte and fluid infusions, who underwent successful cesarean delivery. Potential severe morbidity was avoided with multidisciplinary planning and management.
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Patni N, Fatima M, Lamis A, Siddiqui SW, Ashok T, Muhammad A. Magnesium and Hypertension: Decoding Novel Anti-hypertensives. Cureus 2022; 14:e25839. [PMID: 35836446 PMCID: PMC9273175 DOI: 10.7759/cureus.25839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2022] [Indexed: 11/26/2022] Open
Abstract
Hypertension (HTN) is a complex multifactorial disease that is one of the most prevalent disorders in our modern world. It can lead to fatal complications like coronary artery disease (CAD) and congestive heart failure (CHF) in high-risk individuals. The silent nature of HTN also contributes to its immense caseload and, today, with a number of combinations and various antihypertensive agents, patient compliance is becoming increasingly difficult. This article has reviewed the role and mechanisms of magnesium (Mg) in reducing HTN in the human body so as to provide more information that may help include it as a mainstream antihypertensive regimen. This review has also shed light on the cardioprotective nature of Mg against pathologies like CHF with special mention to patient groups who are at high risk for low Mg levels. Many studies included in this article solidify the former link, but some also provide contradicting data.
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Examination of the predicted prevalence of Gitelman syndrome by ethnicity based on genome databases. Sci Rep 2021; 11:16099. [PMID: 34373523 PMCID: PMC8352941 DOI: 10.1038/s41598-021-95521-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 07/27/2021] [Indexed: 01/19/2023] Open
Abstract
Gitelman syndrome is an autosomal recessive inherited salt-losing tubulopathy. It has a prevalence of around 1 in 40,000 people, and heterozygous carriers are estimated at approximately 1%, although the exact prevalence is unknown. We estimated the predicted prevalence of Gitelman syndrome based on multiple genome databases, HGVD and jMorp for the Japanese population and gnomAD for other ethnicities, and included all 274 pathogenic missense or nonsense variants registered in HGMD Professional. The frequencies of all these alleles were summed to calculate the total variant allele frequency in SLC12A3. The carrier frequency and the disease prevalence were assumed to be twice and the square of the total allele frequency, respectively, according to the Hardy–Weinberg principle. In the Japanese population, the total carrier frequencies were 0.0948 (9.5%) and 0.0868 (8.7%) and the calculated prevalence was 0.00225 (2.3 in 1000 people) and 0.00188 (1.9 in 1000 people) in HGVD and jMorp, respectively. Other ethnicities showed a prevalence varying from 0.000012 to 0.00083. These findings indicate that the prevalence of Gitelman syndrome in the Japanese population is higher than expected and that some other ethnicities also have a higher prevalence than has previously been considered.
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Konrad M, Nijenhuis T, Ariceta G, Bertholet-Thomas A, Calo LA, Capasso G, Emma F, Schlingmann KP, Singh M, Trepiccione F, Walsh SB, Whitton K, Vargas-Poussou R, Bockenhauer D. Diagnosis and management of Bartter syndrome: executive summary of the consensus and recommendations from the European Rare Kidney Disease Reference Network Working Group for Tubular Disorders. Kidney Int 2021; 99:324-335. [PMID: 33509356 DOI: 10.1016/j.kint.2020.10.035] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/30/2020] [Accepted: 10/29/2020] [Indexed: 12/13/2022]
Abstract
Bartter syndrome is a rare inherited salt-losing renal tubular disorder characterized by secondary hyperaldosteronism with hypokalemic and hypochloremic metabolic alkalosis and low to normal blood pressure. The primary pathogenic mechanism is defective salt reabsorption predominantly in the thick ascending limb of the loop of Henle. There is significant variability in the clinical expression of the disease, which is genetically heterogenous with 5 different genes described to date. Despite considerable phenotypic overlap, correlations of specific clinical characteristics with the underlying molecular defects have been demonstrated, generating gene-specific phenotypes. As with many other rare disease conditions, there is a paucity of clinical studies that could guide diagnosis and therapeutic interventions. In this expert consensus document, the authors have summarized the currently available knowledge and propose clinical indicators to assess and improve quality of care.
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Affiliation(s)
- Martin Konrad
- Department of General Pediatrics, University Hospital Münster, Münster, Germany.
| | - Tom Nijenhuis
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gema Ariceta
- Pediatric Nephrology, Hospital Universitari Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | | | - Lorenzo A Calo
- Department of Medicine (DIMED), Nephrology, Dialysis, Transplantation, University of Padova, Padua, Italy
| | - Giovambattista Capasso
- Division of Nephrology, Department of Translational Medical Sciences, School of Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Emma
- Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Karl P Schlingmann
- Department of General Pediatrics, University Hospital Münster, Münster, Germany
| | - Mandeep Singh
- Fetal Medicine Centre, Southend University Hospital NHS Foundation Trust, Essex, UK
| | - Francesco Trepiccione
- Division of Nephrology, Department of Translational Medical Sciences, School of Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Stephen B Walsh
- Department of Renal Medicine, University College London, London, United Kingdom
| | | | - Rosa Vargas-Poussou
- Hôpital Européen Georges Pompidou, Assistance Publique Hôpitaux de Paris, Centre d'Investigation Clinique, Paris, France; Centre de Référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte, Paris, France
| | - Detlef Bockenhauer
- Department of Renal Medicine, University College London, London, United Kingdom; Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Abstract
OBJECTIVE To evaluate maternal and fetal outcomes in women with Gitelman syndrome (GS). METHODS Retrospective analysis of the clinical data of five patients with the clinical diagnosis of GS during pregnancy, who were admitted to Beijing Shijitan Hospital, Capital Medical University between 2013 and 2019, was conducted. RESULTS Five women with GS during pregnancy who finally gave birth to a total of eight newborns have been included. Three cases were primiparas and two cases were multiparas. Two cases were diagnosed before pregnancy and three cases were diagnosed in first or second trimester. The primary treatment was oral or intravenous electrolytes supplement. Three patients delivered through the vagina, and shoulder dystocia occurred in one patient. Two patients delivered by cesarean section, with one because of symptom of limb weakness during the course of labor and the other owing to gestational diabetes with fetal macrosomia. Postpartum hemorrhage and urinary retention were not reported in these cases. In perinatal period all the infants had good outcome. The children, aged between six months and five years, were healthy and well-developed during follow-up. CONCLUSION The maternal and perinatal outcome is usually favorable. We should pay attention to electrolyte examination in the first trimester in order to diagnose and manage the GS efficiently. Well-controlled patients with Gitelman syndrome can deliver through the vagina.
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Affiliation(s)
- Jingfei Zhang
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Feiran Liu
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jinghui Tu
- Department of Obstetrics and Gynecology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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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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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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Al Banna R, Husain A, Al-Ghamdi B. Ventricular arrhythmia and tachycardia-induced cardiomyopathy in Gitelman syndrome, hypokalaemia is not the only culpable. BMJ Case Rep 2019; 12:12/12/e232086. [PMID: 31843774 DOI: 10.1136/bcr-2019-232086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Gitelman syndrome (GS) is an autosomal recessive tubulopathy recently implicated in cases with ventricular arrhythmias (VAs), the latter being considered linked to electrolytes' imbalance. However, a direct causal relationship is considered to be an oversimplification for a complex molecular dysfunction. Recent work has suggested a degree of microvascular dysfunction in patients with GS that might be attributed as a mechanism of arrhythmia. We report a case of GS presenting with VAs complicated by cardiomyopathy. The high load of premature ventricular contractions that were attributed to the hypokalaemia has masked the presence of the left ventricular (LV) outflow tract tachycardia. Her LV systolic function recovered after successful electrophysiology ablation procedure. Atrioventricular nodal re-entry tachycardia was discovered incidentally during the study and was ablated successfully.
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Affiliation(s)
- Rashed Al Banna
- Medical Department, Salmaniya Medical Complex, Manama, Bahrain
| | - Aysha Husain
- Internal Medicine cardiology unit, Salmaniya Medical Complex, Manama, Bahrain
| | - Bandar Al-Ghamdi
- Heart Centre, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Sukhera FI, Middleman AB. Chasing Electrolytes After a Diagnosis of Disordered Eating. Clin Pediatr (Phila) 2019; 58:374-376. [PMID: 30596279 DOI: 10.1177/0009922818821882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | - Amy B Middleman
- 1 University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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12
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Abstract
Bartter and Gitelman syndromes are conditions characterized by renal salt-wasting. Clinical presentations range from severe antenatal disease to asymptomatic with incidental diagnosis. Hypokalemic hypochloremic metabolic alkalosis is the common feature. Bartter variants may be associated with polyuria and weakness. Gitelman syndrome is often subtle, and typically diagnosed later life with incidental hypokalemia and hypomagnesemia. Treatment may involve fluid and electrolyte replenishment, prostaglandin inhibition, and renin-angiotensin-aldosterone system axis disruption. Investigators have identified causative mutations but genotypic-phenotypic correlations are still being characterized. Collaborative registries will allow improved classification schema and development of effective treatments.
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Affiliation(s)
- Rosanna Fulchiero
- Department of Pediatrics, Inova Children's Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Patricia Seo-Mayer
- Department of Pediatrics, Inova Children's Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA; Division of Nephrology and Hypertension, Pediatric Specialists of Virginia, 3023 Hamaker Court, Suite 600, Fairfax, VA 22031, USA; Virginia Commonwealth School of Medicine, Richmond, VA, USA.
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13
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Tsukakoshi T, Lin L, Murakami T, Shiono J, Izumi I, Horigome H. Persistent QT Prolongation in a Child with Gitelman Syndrome and SCN5A H558R Polymorphism. Int Heart J 2018; 59:1466-1468. [PMID: 30305584 DOI: 10.1536/ihj.17-686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Gitelman syndrome (GS) is an inherited renal tubular disorder characterized by hypokalemic metabolic alkalosis, hypomagnesemia, and low urinary calcium excretion. While it is considered a benign disease, severe ventricular arrhythmia and sudden cardiac death related to the prolongation of the QT interval have been reported in rare cases. Herein we report a 13-year-old girl with GS who presented with persistent prolongation of the QT interval, even after being treated for hypokalemia and hypomagnesemia. Genetic analysis identified SCN5A H558R polymorphism, which modulates the function of myocardial sodium channel, and SLC12A3 A588V mutation, which causes GS. The SCN5A polymorphism and GS-related electrolyte disturbance might have contributed to the persistent QT prolongation in this patient. Although no ventricular arrhythmias were recorded in this case, careful cardiac surveillance should be applied for avoiding life-threatening cardiac events.
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Affiliation(s)
| | - Lisheng Lin
- Department of Pediatric Cardiology, Ibaraki Children's Hospital.,Department of Child Health, University of Tsukuba
| | | | - Junko Shiono
- Department of Pediatric Cardiology, Ibaraki Children's Hospital
| | - Isho Izumi
- Department of Pediatrics, Ibaraki Children's Hospital
| | - Hitoshi Horigome
- Department of Pediatric Cardiology, Ibaraki Children's Hospital.,Department of Child Health, University of Tsukuba
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Gallagher H, Soar J, Tomson C. New guideline for perioperative management of people with inherited salt-wasting alkaloses. Br J Anaesth 2018; 116:746-9. [PMID: 27199308 DOI: 10.1093/bja/aew102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- H Gallagher
- South West Thames Renal Unit, Epsom and St Helier NHS Trust, Carshalton, UK
| | - J Soar
- Anaesthetics Department, Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
| | - C Tomson
- Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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15
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Tangvoraphonkchai K, Davenport A. Magnesium and Cardiovascular Disease. Adv Chronic Kidney Dis 2018; 25:251-260. [PMID: 29793664 DOI: 10.1053/j.ackd.2018.02.010] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 02/12/2018] [Accepted: 02/13/2018] [Indexed: 12/21/2022]
Abstract
Magnesium is the most abundant intracellular divalent cation and essential for maintaining normal cellular physiology and metabolism, acting as a cofactor of numerous enzymes, regulating ion channels and energy generation. In the heart, magnesium plays a key role in modulating neuronal excitation, intracardiac conduction, and myocardial contraction by regulating a number of ion transporters, including potassium and calcium channels. Magnesium also has a role in regulating vascular tone, atherogenesis and thrombosis, vascular calcification, and proliferation and migration of endothelial and vascular smooth muscle cells. As such, magnesium potentially has a major influence on the pathogenesis of cardiovascular disease. As the kidney is a major regulator of magnesium homeostasis, kidney disorders can potentially lead to both magnesium depletion and overload, and as such increase the risk of cardiovascular disease. Observational data have shown an association between low serum magnesium concentrations or magnesium intake and increased atherosclerosis, coronary artery disease, arrhythmias, and heart failure. However, major trials of supplementation with magnesium have reported inconsistent benefits and also raised potential adverse effects of magnesium overload. As such, there is currently no firm recommendation for routine magnesium supplementation except when hypomagnesemia has been proven or suspected as a cause for cardiac arrhythmias.
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Kleta R, Bockenhauer D. Salt-Losing Tubulopathies in Children: What's New, What's Controversial? J Am Soc Nephrol 2018; 29:727-739. [PMID: 29237739 PMCID: PMC5827598 DOI: 10.1681/asn.2017060600] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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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17
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Nabi Aslan A, Sivri S, Can Güney M, Keleş Prof T. Coexistence of Gitelman Syndrome and Hypertrophic Cardiomyopathy in a Pregnant Woman. ACTA CARDIOLOGICA SINICA 2018; 34:92-95. [PMID: 29375229 DOI: 10.6515/acs.201801_34(1).20170515a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Gitelman syndrome (GS) is transmitted as an autosomal recessive trait and characterized by hypokalemic metabolic alkalosis in combination with significant hypomagnesemia and low urinary calcium excretion. The symptoms and severity of the disease can vary greatly from one person to another and can range from mild to severe. Sudden cardiac arrest has been reported occasionally as well. Here, for the first time, we reported a 34-year-old pregnant GS woman who was diagnosed to have hypertrophic obstructive cardiomyopathy during her cardiac examination for the complaints of palpitation and presyncope.
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Affiliation(s)
| | - Serkan Sivri
- Department of Cardiology, Atatürk Education and Research Hospital
| | - Murat Can Güney
- Faculty of Medicine, Department of Cardiology, Yıldırım Beyazıt University, Ankara, Turkey
| | - Telat Keleş Prof
- Faculty of Medicine, Department of Cardiology, Yıldırım Beyazıt University, Ankara, Turkey
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18
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Chen Y, Zhang Z, Lin X, Pan Q, Zheng F, Li H. A novel compound heterozygous variant of the SLC12A3 gene in Gitelman syndrome pedigree. BMC MEDICAL GENETICS 2018; 19:17. [PMID: 29378538 PMCID: PMC5789536 DOI: 10.1186/s12881-018-0527-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 01/16/2018] [Indexed: 02/07/2023]
Abstract
Background Gitelman syndrome (GS) is an autosomal recessive disorder caused by genic mutations of SLC12A3 (Solute carrier family 12 member 3), which encodes the Na-Cl cotransporter (NCC), and presents with characteristic metabolic abnormalities, including hypokalemia, metabolic alkalosis, hypomagnesemia, and hypocalciuria. In this study, we report a case of a GS pedigree, including analysis of GS-associated gene mutations. Methods We performed next-generation sequencing analysis and Sanger sequencing to explore the SLC12A3 mutations in a GS pedigree that included a 35-year-old female patient with GS and five family members within three generations. Furthermore, we summarized their clinical manifestations and analyzed laboratory parameters related to GS. Results The female proband (the patient with GS) presented with intermittent fatigue and transient periods of tetany, along with significant hypokalemia, hypomagnesemia, and hypocalciuria. All other members of the pedigree had normal laboratory results without obvious GS-related symptoms. Genetic analysis of the SLC12A3 gene identified two novel missense mutations (c.1919A > G, p.N640S in exon 15; c.2522A > G, p.D841G in exon 21) in the patient with GS. Moreover, we demonstrated that her mother, younger maternal uncle, and cousin were carriers of one mutation (c.1919A > G), and her father was the carrier of the other (c.2522A > G). Conclusion This is the first report of these two novel pathogenic variants of SLC12A3 and their contribution to GS. Further functional studies are particularly warranted to explore the underlying molecular mechanisms. Electronic supplementary material The online version of this article (10.1186/s12881-018-0527-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yixin Chen
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, 3 East Qing Chun Road, Zhejiang, Hangzhou, 310016, China
| | - Ziyi Zhang
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, 3 East Qing Chun Road, Zhejiang, Hangzhou, 310016, China
| | - Xihua Lin
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, 3 East Qing Chun Road, Zhejiang, Hangzhou, 310016, China
| | - Qianqian Pan
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, 3 East Qing Chun Road, Zhejiang, Hangzhou, 310016, China
| | - Fenping Zheng
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, 3 East Qing Chun Road, Zhejiang, Hangzhou, 310016, China
| | - Hong Li
- Department of Endocrinology, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, 3 East Qing Chun Road, Zhejiang, Hangzhou, 310016, China.
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Elkoundi A, Kartite N, Bensghir M, Doghmi N, Lalaoui SJ. Gitelman syndrome: a rare life-threatening case of hypokalemic paralysis mimicking Guillain-Barré syndrome during pregnancy and review of the literature. Clin Case Rep 2017; 5:1597-1603. [PMID: 29026553 PMCID: PMC5628240 DOI: 10.1002/ccr3.1122] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 04/26/2017] [Accepted: 07/20/2017] [Indexed: 11/29/2022] Open
Abstract
In rare cases, patients with Gitelman syndrome may present with hypokalemic paralysis mimicking Guillain–Barré syndrome. The severity of resultant symptoms may be life‐threatening. Controversial drugs such as aldactone, amiloride, and eplerenone should be used in this situation despite the lack of safety data.
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Affiliation(s)
- Abdelghafour Elkoundi
- Department of Anesthesiology and Intensive Care Military Hospital Mohammed V Faculty of Medicine and Pharmacy of Rabat Mohammed V University Rabat Morocco
| | - Noureddine Kartite
- Department of Anesthesiology and Intensive Care Military Hospital Mohammed V Faculty of Medicine and Pharmacy of Rabat Mohammed V University Rabat Morocco
| | - Mustapha Bensghir
- Department of Anesthesiology and Intensive Care Military Hospital Mohammed V Faculty of Medicine and Pharmacy of Rabat Mohammed V University Rabat Morocco
| | - Nawfal Doghmi
- Department of Anesthesiology and Intensive Care Military Hospital Mohammed V Faculty of Medicine and Pharmacy of Rabat Mohammed V University Rabat Morocco
| | - Salim Jaafar Lalaoui
- Department of Anesthesiology and Intensive Care Military Hospital Mohammed V Faculty of Medicine and Pharmacy of Rabat Mohammed V University Rabat Morocco
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van der Merwe PDT, Rensburg MA, Haylett WL, Bardien S, Davids MR. Gitelman syndrome in a South African family presenting with hypokalaemia and unusual food cravings. BMC Nephrol 2017; 18:38. [PMID: 28125972 PMCID: PMC5270235 DOI: 10.1186/s12882-017-0455-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 01/19/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Gitelman syndrome (GS) is an autosomal recessive renal tubular disorder characterised by renal salt wasting with hypokalaemia, metabolic alkalosis, hypomagnesaemia and hypocalciuria. It is caused by mutations in SLC12A3 encoding the sodium-chloride cotransporter on the apical membrane of the distal convoluted tubule. We report a South African family with five affected individuals presenting with hypokalaemia and unusual food cravings. METHODS The affected individuals and two unaffected first degree relatives were enrolled into the study. Phenotypes were evaluated through history, physical examination and biochemical analysis of blood and urine. Mutation screening was performed by sequencing of SLC12A3, and determining the allele frequencies of the sequence variants found in this family in 117 ethnically matched controls. RESULTS The index patient, her sister, father and two aunts had a history of severe salt cravings, fatigue and tetanic episodes, leading to consumption of large quantities of salt and vinegar. All affected individuals demonstrated hypokalaemia with renal potassium wasting. Genetic analysis revealed that the pseudo-dominant pattern of inheritance was due to compound heterozygosity with two novel mutations: a S546G substitution in exon 13, and insertion of AGCCCC at c.1930 in exon 16. These variants were present in the five affected individuals, but only one variant each in the unaffected family members. Neither variant was found in any of the controls. CONCLUSIONS The diagnosis of GS was established in five members of a South African family through clinical assessment, biochemical analysis and mutation screening of the SLC12A3 gene, which identified two novel putative pathogenic mutations.
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Affiliation(s)
- Pieter Du Toit van der Merwe
- Division of Nephrology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Megan A Rensburg
- Division of Chemical Pathology, Stellenbosch University and National Health Laboratory Service, Cape Town, South Africa
| | - William L Haylett
- Division of Molecular Biology and Human Genetics, Stellenbosch University, Cape Town, South Africa
| | - Soraya Bardien
- Division of Molecular Biology and Human Genetics, Stellenbosch University, Cape Town, South Africa
| | - M Razeen Davids
- Division of Nephrology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa.
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Shibli AA, Narchi H. Bartter and Gitelman syndromes: Spectrum of clinical manifestations caused by different mutations. World J Methodol 2015; 5:55-61. [PMID: 26140272 PMCID: PMC4482822 DOI: 10.5662/wjm.v5.i2.55] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 05/14/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023] Open
Abstract
Bartter and Gitelman syndromes (BS and GS) are inherited disorders resulting in defects in renal tubular handling of sodium, potassium and chloride. Previously considered as genotypic and phenotypic heterogeneous diseases, recent evidence suggests that they constitute a spectrum of disease caused by different genetic mutations with the molecular defects of chloride reabsorption originating at different sites of the nephron in each condition. Although they share some characteristic metabolic abnormalities such as hypokalemia, metabolic alkalosis, hyperplasia of the juxtaglomerular apparatus with hyperreninemia, hyperaldosteronism, the clinical and laboratory manifestations may not always allow distinction between them. Diuretics tests, measuring the changes in urinary fractional excretion of chloride from baseline after administration of either hydrochlorothiazide or furosemide show very little change (< 2.3%) in the fractional excretion of chloride from baseline in GS when compared with BS, except when BS is associated with KCNJ1 mutations where a good response to both diuretics exists. The diuretic test is not recommended for infants or young children with suspected BS because of a higher risk of volume depletion in such children. Clinical symptoms and biochemical markers of GS and classic form of BS (type III) may overlap and thus genetic analysis may specify the real cause of symptoms. However, although genetic analysis is available, its use remains limited because of limited availability, large gene dimensions, lack of hot-spot mutations, heavy workup time and costs involved. Furthermore, considerable overlap exists between the different genotypes and phenotypes. Although BS and GS usually have distinct presentations and are associated with specific gene mutations, there remains considerable overlap between their phenotypes and genotypes. Thus, they are better described as a spectrum of clinical manifestations caused by different gene mutations.
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Palatinus JA, Lieber SB, Joyce KE, Richards JB. Extracorporeal Membrane Oxygenation Support for Hypokalemia-induced Cardiac Arrest: A Case Report and Review of the Literature. J Emerg Med 2015; 49:159-64. [PMID: 26004853 DOI: 10.1016/j.jemermed.2015.02.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 02/24/2015] [Accepted: 02/27/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Hypokalemia is a reversible cause of cardiac arrest in patients presenting to the emergency department (ED). Extracorporeal membrane oxygenation (ECMO) is an established technology for cardiopulmonary support with emerging roles in resuscitation. Here, we review the literature of hypokalemic-induced cardiac arrests and discuss one such case successfully managed with ECMO. CASE REPORT A 23-year-old Central American man who presented to a community ED under federal custody with several days of nausea and vomiting was found to have a serum potassium level of 1.5 mEq/L. Repeat serum potassium level was 1.1 mEq/L upon arrival to our facility. Within 2 h of arrival, despite electrolyte repletion, he suffered cardiac arrest. Advanced cardiac life support was performed for 45 min. ECMO was initiated while active chest compressions were performed. After aggressive potassium repletion, return of spontaneous circulation was achieved and ECMO was eventually discontinued. Further investigation ultimately confirmed the presence of a potassium-wasting nephropathy, for which the patient had been treated with chronic potassium supplementation prior to entering federal custody. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ECMO is a well-established modality for cardiopulmonary support, with an emerging role for patients in undifferentiated cardiac arrest presenting to the ED. There is a growing interest in the utility of ECMO in these circumstances. This report highlights hypokalemia as an important cause of cardiac arrest, reviews the treatment and causes of hypokalemia, and demonstrates a potential role for ECMO as a critical temporizing measure to provide time for potassium repletion.
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Affiliation(s)
- Joseph A Palatinus
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Sarah B Lieber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Katherine E Joyce
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jeremy B Richards
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Khosravi M, Walsh SB. The long-term complications of the inherited tubulopathies: an adult perspective. Pediatr Nephrol 2015; 30:385-95. [PMID: 24566812 DOI: 10.1007/s00467-014-2779-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 01/23/2014] [Accepted: 01/27/2014] [Indexed: 11/25/2022]
Abstract
The inherited tubulopathies are lifelong disorders and their clinical features and complications may present quite different challenges in adulthood from those in childhood. In this review we outline the pathophysiology and documented complications (including the late and unusual) of the monogenic tubulopathies from the perspective of the adult nephrologist.
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Affiliation(s)
- Maryam Khosravi
- UCL Centre for Nephrology, Royal Free Hospital, University College London, London, UK
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24
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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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Garcipérez de Vargas FJ, Mendoza J, Ortiz C, Sánchez-Calderón P. [Gitelman's syndrome: a wolf in sheep's clothing]. Rev Clin Esp 2014; 214:229-30. [PMID: 24564992 DOI: 10.1016/j.rce.2014.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 01/27/2014] [Indexed: 11/27/2022]
Affiliation(s)
| | - J Mendoza
- Servicio de Cardiología, Hospital San Pedro de Alcántara, Cáceres, España
| | - C Ortiz
- Servicio de Cardiología, Hospital San Pedro de Alcántara, Cáceres, España
| | - P Sánchez-Calderón
- Servicio de Cardiología, Hospital San Pedro de Alcántara, Cáceres, España
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QT and JT dispersion and cardiac performance in children with neonatal Bartter syndrome: a pilot study. Pediatr Nephrol 2013; 28:1969-74. [PMID: 23760993 DOI: 10.1007/s00467-013-2517-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 05/03/2013] [Accepted: 05/16/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND QT dispersion and JT dispersion are simple noninvasive arrhythmogenic markers that can be used to assess the homogeneity of cardiac repolarization. The aim of this study was to assess QT and JT dispersion and their relation with left ventricular systolic and diastolic functions in children with Bartter syndrome (BS). METHODS Nine neonatal patients with BS (median age 9.7 years) and 20 controls (median age 8 years) were investigated at rest. Both study and control subjects underwent electrocardiography (ECG) in which the interval between two R waves and QT intervals, corrected QT, QT dispersion, corrected QT dispersion, JT, corrected JT, JT dispersion and corrected JT dispersion were measured with 12-lead ECG. Two-dimensional, Doppler echocardiographic examinations were performed. RESULTS Patients and controls did not differ for gender and for serum levels of potassium, magnesium, and calcium (p > 0.05). Both study and control subjects had normal echocardiographic examination and baseline myocardial performance indexes. The QT dispersion and JT dispersion were significantly prolonged in patients with BS compared to those of the controls {37.5 ms [interquartile range (IQR) 32.5-40] vs. 25.5 ms (IQR 20-30), respectively, p = 0.014 and 37.5 ms (IQR 27.5-40) vs. 22.5 ms (IQR 20-30), respectively, p = 0.003}. CONCLUSIONS Elevated QT and JT dispersion during asymptomatic and normokalemic periods may be risk factors for the development of cardiac complications and arrhythmias in children with BS. In these patients the need for systematic cardiac screening and management protocol is extremely important for effective prevention.
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Koçkara AŞ, Candan F, Hüzmeli C, Kayataş M, Alaygut D. Gitelman's syndrome associated with chondrocalcinosis: a case report. Ren Fail 2013; 35:1285-8. [PMID: 24021031 DOI: 10.3109/0886022x.2013.824380] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Gitelman's syndrome (GS) is a rare disease with autosomal recessive trait, characterized by hypokalemia, hypomagnesemia, metabolic alkalosis, hypocalciuria and hyperkinemic hyperaldosteronism. While muscle weakness, tetany, stomachache, nausea and fever are very common, it could sometimes be completely asymptomatic as is the case in our patient. It is generally benign, but some severe complications like growth retardation and, though rare, paralysis and cardiac arrest could also be seen. A 57-year-old male patient sent to our hospital for further examination because of hypokalemia was diagnosed with GS as a result of clinical and laboratory assessments. Potassium and magnesium replacement was started. We are presenting our case seeing that GS is not a syndrome to be overlooked as it bears a risk of severe complications, although it might be asymptomatic until advanced ages.
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Perioperative considerations in patients with Gitelman syndrome: a case series. J Clin Anesth 2012; 24:14-8. [DOI: 10.1016/j.jclinane.2011.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 03/24/2011] [Accepted: 04/20/2011] [Indexed: 12/11/2022]
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Calò LA, Caielli P. Gitelman’s syndrome and pregnancy: new potential pathophysiological influencing factors, therapeutic approach and materno-fetal outcome. J Matern Fetal Neonatal Med 2011; 25:1511-3. [DOI: 10.3109/14767058.2011.629254] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Balavoine AS, Bataille P, Vanhille P, Azar R, Noël C, Asseman P, Soudan B, Wémeau JL, Vantyghem MC. Phenotype-genotype correlation and follow-up in adult patients with hypokalaemia of renal origin suggesting Gitelman syndrome. Eur J Endocrinol 2011; 165:665-73. [PMID: 21753071 DOI: 10.1530/eje-11-0224] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Gitelman syndrome (GS) is a tubulopathy caused by SLC12A3 gene mutations, which lead to hypokalaemic alkalosis, secondary hyperaldosteronism, hypomagnesaemia and hypocalciuria. AIM The aim of this study was to assess the prevalence of SLC12A3 gene mutations in adult hypokalaemic patients; to compare the phenotype of homozygous, heterozygous and non-mutated patients; and to determine the efficiency of treatment. METHODS Clinical, biological and genetic data were recorded in 26 patients. RESULTS Screening for the SLC12A3 gene detected two mutations in 15 patients (six homozygous and nine compound heterozygous), one mutation in six patients and no mutation in five patients. There was no statistical difference in clinical symptoms at diagnosis between the three groups. Systolic blood pressure tended to be lower in patients with two mutations (P=0.16). Hypertension was unexpectedly detected in four patients. Five patients with two mutated alleles and two with heterozygosity had severe manifestations of GS. Significant differences were observed between the three groups in blood potassium, chloride, magnesium, supine aldosterone, 24 h urine chloride and magnesium levels and in modification of the diet in renal disease. Mean blood potassium levels increased from 2.8 ± 0.3, 3.5 ± 0.5 and 3.2 ± 0.3 before treatment to 3.2 ± 0.5, 3.7 ± 0.6 and 3.7 ± 0.3 mmol/l with treatment in groups with two (P=0.003), one and no mutated alleles respectively. CONCLUSION In adult patients referred for renal hypokalaemia, we confirmed the presence of mutations of the SLC12A3 gene in 80% of cases. GS was more severe in patients with two mutated alleles than in those with one or no mutated alleles. High blood pressure should not rule out the diagnosis, especially in older patients.
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Affiliation(s)
- A S Balavoine
- Service d'Endocrinologie et Maladies Métaboliques, CHRU de Lille, 59037 Lille Cedex, France.
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Seyberth HW, Schlingmann KP. Bartter- and Gitelman-like syndromes: salt-losing tubulopathies with loop or DCT defects. Pediatr Nephrol 2011; 26:1789-802. [PMID: 21503667 PMCID: PMC3163795 DOI: 10.1007/s00467-011-1871-4] [Citation(s) in RCA: 111] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 03/09/2011] [Accepted: 03/09/2011] [Indexed: 12/11/2022]
Abstract
Salt-losing tubulopathies with secondary hyperaldosteronism (SLT) comprise a set of well-defined inherited tubular disorders. Two segments along the distal nephron are primarily involved in the pathogenesis of SLTs: the thick ascending limb of Henle's loop, and the distal convoluted tubule (DCT). The functions of these pre- and postmacula densa segments are quite distinct, and this has a major impact on the clinical presentation of loop and DCT disorders - the Bartter- and Gitelman-like syndromes. Defects in the water-impermeable thick ascending limb, with its greater salt reabsorption capacity, lead to major salt and water losses similar to the effect of loop diuretics. In contrast, defects in the DCT, with its minor capacity of salt reabsorption and its crucial role in fine-tuning of urinary calcium and magnesium excretion, provoke more chronic solute imbalances similar to the effects of chronic treatment with thiazides. The most severe disorder is a combination of a loop and DCT disorder similar to the enhanced diuretic effect of a co-medication of loop diuretics with thiazides. Besides salt and water supplementation, prostaglandin E2-synthase inhibition is the most effective therapeutic option in polyuric loop disorders (e.g., pure furosemide and mixed furosemide-amiloride type), especially in preterm infants with severe volume depletion. In DCT disorders (e.g., pure thiazide and mixed thiazide-furosemide type), renin-angiotensin-aldosterone system (RAAS) blockers might be indicated after salt, potassium, and magnesium supplementation are deemed insufficient. It appears that in most patients with SLT, a combination of solute supplementation with some drug treatment (e.g., indomethacin) is needed for a lifetime.
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Affiliation(s)
- Hannsjörg W. Seyberth
- Department of Pediatrics and Adolescent Medicine, Philipps University, Marburg, Germany ,Lazarettgarten 23, 76829 Landau, Germany
| | - Karl P. Schlingmann
- Department of General Pediatrics, University Children’s Hospital, Münster, Germany
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Deschênes G, Fila M. Primary molecular disorders and secondary biological adaptations in bartter syndrome. Int J Nephrol 2011; 2011:396209. [PMID: 21941653 PMCID: PMC3177086 DOI: 10.4061/2011/396209] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Accepted: 06/01/2011] [Indexed: 12/17/2022] Open
Abstract
Bartter syndrome is a hereditary disorder that has been characterized by the association of hypokalemia, alkalosis, and the hypertrophy of the juxtaglomerular complex with secondary hyperaldosteronism and normal blood pressure. By contrast, the genetic causes of Bartter syndrome primarily affect molecular structures directly involved in the sodium reabsorption at the level of the Henle loop. The ensuing urinary sodium wasting and chronic sodium depletion are responsible for the contraction of the extracellular volume, the activation of the renin-aldosterone axis, the secretion of prostaglandins, and the biological adaptations of downstream tubular segments, meaning the distal convoluted tubule and the collecting duct. These secondary biological adaptations lead to hypokalemia and alkalosis, illustrating a close integration of the solutes regulation in the tubular structures.
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Affiliation(s)
- Georges Deschênes
- Pediatric Nephrology Unit, Hôpital Robert-Debré, 48 Bd Sérurier, 75019 Paris, France
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Cortesi C, Lava SAG, Bettinelli A, Tammaro F, Giannini O, Caiata-Zufferey M, Bianchetti MG. Cardiac arrhythmias and rhabdomyolysis in Bartter-Gitelman patients. Pediatr Nephrol 2010; 25:2005-8. [PMID: 20549246 DOI: 10.1007/s00467-010-1580-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Revised: 05/11/2010] [Accepted: 05/17/2010] [Indexed: 11/28/2022]
Abstract
Recent data demonstrate that patients affected with hypokalemic salt-losing tubulopathies are prone to acute cardiac arrhythmias and rhabdomyolysis. The tendency to these potentially fatal complications is especially high if chronic hypokalemia is severe, in patients with diarrhea, vomiting or a prolonged QT interval on standard electrocardiography, in patients on drug management with compounds prolonging the electrocardiographic QT interval (including antiarrhythmic agents, some antihistamines, macrolides, antifungals, psychotropics, beta2-adrenergic agonists or cisapride), following acute alcohol abuse and during exercise. Cardiac arrhythmias and rhabdomyolysis occur with sufficient frequency in hypokalemic salt-losing tubulopathies to merit wider awareness of their presence and the preparation of specific prevention and management recommendations.
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Bansal T, Abeygunasekara S, Ezzat V. An unusual presentation of primary renal hypokalemia-hypomagnesemia (Gitelman's syndrome). Ren Fail 2010; 32:407-10. [PMID: 20370462 DOI: 10.3109/08860221003632873] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Gitelman's syndrome, or congenital hypokalemic hypomagnesemic hypocalciuria with metabolic alkalosis, is widely described as a benign or milder variant of Bartter's syndrome and most commonly presents with transient periods of weakness and fatigue, presyncope, vertigo, ataxia, and blurred vision, though aborted sudden cardiac death has also been rarely reported. Despite this there are limited data in the literature regarding the formal cardiac evaluation of patients with Gitelman's syndrome. We present the case of a gentleman with Gitelman's syndrome who initially presented to his primary physician with symptoms suggestive of an upper respiratory tract infection and subsequently survived a ventricular fibrillation (VF) cardiac arrest in the community. We review the literature regarding possible life-threatening cardiac complications in these patients.
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Affiliation(s)
- Tarun Bansal
- Sheffield Kidney Institute, Northern General Hospital, Sheffield, South Yorkshire, UK.
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Ellison DH, Loffing J. Thiazide effects and adverse effects: insights from molecular genetics. Hypertension 2009; 54:196-202. [PMID: 19564550 DOI: 10.1161/hypertensionaha.109.129171] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- David H Ellison
- Division of Nephrology and Hypertension, Oregon Health & Science University, 3314 SW US Veterans Hospital Rd, Portland, OR 97239, USA.
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Knoers NVAM. Inherited forms of renal hypomagnesemia: an update. Pediatr Nephrol 2009; 24:697-705. [PMID: 18818955 PMCID: PMC7811505 DOI: 10.1007/s00467-008-0968-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2008] [Revised: 07/22/2008] [Accepted: 07/23/2008] [Indexed: 12/19/2022]
Abstract
The kidney plays an important role in ion homeostasis in the human body. Several hereditary disorders characterized by perturbations in renal magnesium reabsorption leading to hypomagnesemia have been described over the past 50 years, with the most important of these being Gitelman syndrome, familial hypomagnesemia with hypercalciuria and nephrocalcinosis, familial hypomagnesemia with secondary hypocalcemia, autosomal dominant hypomagnesemia with hypocalciuria, and autosomal recessive hypomagnesemia. Only recently, following positional cloning strategies in affected families, have mutations in renal ion channels and transporters been identified in these diseases. In this short review, I give an update on these hypomagnesemic disorders. Elucidation of the genetic etiology and, for most of these disorders, also the underlying pathophysiology of the disease, has greatly increased our understanding of the normal physiology of renal magnesium handling. This is yet another example of the importance of studying rare disorders in order to unravel physiological and pathophysiological processes in the human body.
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Affiliation(s)
- Nine V. A. M. Knoers
- grid.10417.330000000404449382Department of Human Genetics 849, Radboud University Nijmegen Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
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Scognamiglio R, Calò LA, Negut C, Coccato M, Mormino P, Pessina AC. Myocardial perfusion defects in Bartter and Gitelman syndromes. Eur J Clin Invest 2008; 38:888-95. [PMID: 19021712 DOI: 10.1111/j.1365-2362.2008.02034.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Normotensive hypokalaemic tubulopathies (Bartter and Gitelman syndromes (BS/GS)) are genetic diseases that are considered benign. However, QT prolongation, left ventricular dysfunction and reduction of cardiac index upon exercise leading to arrhythmias and sudden cardiac death have been reported in these patients. Hence, we aimed to verifying whether an isometric exercise could represent a useful tool for the identification of patients at risk for future cardiac events. PATIENTS AND METHODS Myocardial function (MF) and perfusion, evaluated as myocardial blood flow (MBF) of 10 BS/GS patients and 10 healthy controls, were investigated at rest and during isometric exercise. MF and MBF were evaluated using quantitative two-dimensional and myocardial contrast echocardiography. RESULTS BS/GS patients had normal baseline MF and MBF. During exercise in BS/GS patients, corrected QT (QTc) was prolonged to peak value of 494 +/- 9.1 ms (P < 0.001). In controls, MF increased from resting to peak exercise (left ventricular ejection fraction: 65 +/- 4% to 78 +/- 5%, P < 0.003) while in seven BS/GS patients (Group 1) it declined (64 +/- 5% to 43 +/- 9%, P < 0.001). Myocardial perfusion increased upon exercise in controls as shown by changes of its markers: beta (a measure of myocardial flow velocity; 0.89 +/- 0.12 vs. 0.99 +/- 0.12, P < 0.001) and myocardial blood volume (14.4 +/- 2 vs. 20.2 +/- 0.25, P < 0.001), while in Group 1 BS/GS it decreased (0.87 +/- 0.15 vs. 0.67 +/- 0.15, P < 0.001; and 14.5 +/- 1.9 vs. 8.3 +/- 0.22, P < 0.001, respectively). CONCLUSIONS Our results document for the first time that exercise induce coronary microvascular and myocardial defects in BS/GS patients. Therefore, this may challenge the idea that BS/GS are benign diseases. In addition, the diagnostic approach to these syndromes should include an in-depth cardiac assessment in order to identify patients at higher risk.
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Affiliation(s)
- R Scognamiglio
- Policlinico Abano Terme, Metabolic Cardiology, University Hospital, University of Padova, Padova, Italy
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Abstract
Gitelman syndrome (GS), also referred to as familial hypokalemia-hypomagnesemia, is characterized by hypokalemic metabolic alkalosis in combination with significant hypomagnesemia and low urinary calcium excretion. The prevalence is estimated at approximately 1:40,000 and accordingly, the prevalence of heterozygotes is approximately 1% in Caucasian populations, making it one of the most frequent inherited renal tubular disorders. In the majority of cases, symptoms do not appear before the age of six years and the disease is usually diagnosed during adolescence or adulthood. Transient periods of muscle weakness and tetany, sometimes accompanied by abdominal pain, vomiting and fever are often seen in GS patients. Paresthesias, especially in the face, frequently occur. Remarkably, some patients are completely asymptomatic except for the appearance at adult age of chondrocalcinosis that causes swelling, local heat, and tenderness over the affected joints. Blood pressure is lower than that in the general population. Sudden cardiac arrest has been reported occasionally. In general, growth is normal but can be delayed in those GS patients with severe hypokalemia and hypomagnesemia. GS is transmitted as an autosomal recessive trait. Mutations in the solute carrier family12, member 3 gene, SLC12A3, which encodes the thiazide-sensitive NaCl cotransporter (NCC), are found in the majority of GS patients. At present, more than 140 different NCC mutations throughout the whole protein have been identified. In a small minority of GS patients, mutations in the CLCNKB gene, encoding the chloride channel ClC-Kb have been identified. Diagnosis is based on the clinical symptoms and biochemical abnormalities (hypokalemia, metabolic alkalosis, hypomagnesemia and hypocalciuria). Bartter syndrome (especially type III) is the most important genetic disorder to consider in the differential diagnosis of GS. Genetic counseling is important. Antenatal diagnosis for GS is technically feasible but not advised because of the good prognosis in the majority of patients. Most asymptomatic patients with GS remain untreated and undergo ambulatory monitoring, once a year, generally by nephrologists. Lifelong supplementation of magnesium (magnesium-oxide and magnesium-sulfate) is recommended. Cardiac work-up should be offered to screen for risk factors of cardiac arrhythmias. All GS patients are encouraged to maintain a high-sodium and high potassium diet. In general, the long-term prognosis of GS is excellent.
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Affiliation(s)
- Nine V A M Knoers
- Department of Human Genetics, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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