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Coexistence of Normotensive Primary Aldosteronism in Two Patients With European Journal of Endocrinology (2009) 161 275–283 ISSN 0804-4643 CLINICAL STUDY Coexistence of normotensive primary aldosteronism in two patients with Gitelman’s syndrome and novel thiazide-sensitive Na–Cl cotransporter mutations Zhimin Miao1, Yufang Gao2, Rene´ J M Bindels3, Wendong Yu4, Yanhua Lang2, Nan Chen5, Hong Ren5, Fang Sun1, Yushan Li6, Xianghua Wang6 and Leping Shao5,6 Divisions of 1Endocrinology and Metabolism and 2Nursing, Affiliated Hospital of Qingdao University School of Medicine, No. 16, Jiangsu Road, Qingdao 266003, People’s Republic of China, 3Department of Cell Physiology, Institute of Cellular Signalling, University Medical Center Nijmegen, Nijmegen 9101, The Netherlands, 4Department of Pathology, Baylor College of Medicine, Houston, Texas 77030, USA, 5Department of Nephrology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200025, People’s Republic of China and 6Division of Nephrology, Affiliated Hospital of Qingdao University School of Medicine, No. 16, Jiangsu Road, Qingdao 266003, People’s Republic of China (Correspondence should be addressed to L Shao at Division of Nephrology, Affiliated Hospital of Qingdao University School of Medicine; Email: [email protected]) Abstract Background: Primary aldosteronism (PA) is the most common form of secondary hypertension, while Gitelman’s syndrome (GS) is the most common inherited renal tubular disease. However, coexistence of these two diseases has never been previously reported. Aim and subjects: The aim of our study was to describe the association of GS and PA in two unrelated patients and compare their clinical presentation with a group of patients with GS. Methods: Ten subjects suspected to have only GS were assigned to the control group. Saline infusion test was used to confirm the diagnosis of PA. GS was confirmed by sequencing of the causal genes (SLC12A3 and CLCNKB) and functional analyses in Xenopus laevis oocytes. Results: Confirmatory tests, gene analysis, and functional studies demonstrated the coexistence of GS and PA in both patients. In total, nine novel SLC12A3 gene variants, including seven missense mutations, one splice mutation, and one frameshift deletion, were found in 12 subjects. Four mutations (p.T60M, p.T304M, p.T465P,and p.N611T) harbored by the two patients with both PAand GS were revealed to be loss-of-function variants. Although both patients were normotensive, neither of them had normal nocturnal dip. Conclusions: Two rare diseases GS and PAmay occasionally coexist in one subject. In these patients, salt depletion and volume constriction might explain the absence of hypertension normally seen in PA patients. However, the protective mechanism against hypertension via down-regulation of renal sodium handling was probably not sufficient in those patients, since their normal circadian rhythm of blood pressure was disrupted. European Journal of Endocrinology 161 275–283 Introduction Theoretically, by chance only, the coexistence of PA and GS in one patient should be very rare Primary aldosteronism (PA)is the most common form of (w1/2 500 000), given the prevalence of hypertension secondary hypertension. Its prevalence among hyper- at about 17%. Indeed, according to our knowledge, the tensive patients may exceed 10%, as demonstrated by a coexistence has never been documented so far. Herein, large prospective survey (1). we report two cases with the coexistence of both Gitelman’s syndrome (GS; OMIM #263800), an diseases and attempt to explore the potential autosomal-recessively inherited renal salt-losing mechanism(s) under their special clinical features. disorder, is mainly caused by mutations in the SLC12A3 gene (MIM: 600968) (2), which encodes the thiazide-sensitive Na–Cl cotransporter (NCC) (3). Subjects and methods Additionally, a few patients with GS-like phenotype Patients carry mutations in CLCNKB gene (MIM: 602023) (4, 5). GS is the most common primary renal tubular A 39-year-old married male (patient 1) was admitted disease, with a prevalence of about 1 per 40 000 (6). for frequent muscle cramps that had occurred in the q 2009 European Society of Endocrinology DOI: 10.1530/EJE-09-0271 Online version via www.eje-online.org Downloaded from Bioscientifica.com at 09/28/2021 09:18:24PM via free access 276 Z Miao and others EUROPEAN JOURNAL OF ENDOCRINOLOGY (2009) 161 recent 4 months. Twelve years ago, he was once coexistence of PA (Table 2). No positive renal and referred to our outpatient clinic for an examination of adrenal gland image findings were detected. All her generalized muscle weakness associated with acral family members had normal levels of serum potassium paresthesia. At that time, his blood chemistry showed and BP. persistent hypokalemia (1.7–2.6 mmol/l), in associ- To make the diagnosis of these two patients clear, and ation with alkalosis (plasma bicarbonate, 29– compare their biochemical features with GS, we selected 32 mmol/l), inappropriate kaliuresis (fractional ten age- and body mass index-matched subjects (six excretion potassium (FEK): 31%), and salt losing (24 h males and four females) with only GS as controls. They urinary Na, 261 mmol, normal values, 137– came from nine unrelated families, and their age ranged 257 mmol). Plasma renin activity (PRA, 11.1 ng/ml from 34 to 46 years (mean 39G4 years). Their gross per h, normal values, 0.1–2.9 ng/ml per h) and plasma clinical features and biochemical data were shown in aldosterone concentration (PAC, 17.2 ng/dl, normal Tables 1 and 2. Criteria for GS diagnosis were: serum values, 2.9–16.1 ng/dl) were elevated. Renal ultra- magnesium level !0.65 mmol/l, serum potassium level sound findings were normal. Casual blood pressure (BP) lower than 3.5 mmol/l, and hypocalciuria (urinary averaged 105/70 mmHg. The association of hypoka- Ca/Cr ratio !0.1 mmol/mmol). lemic alkalosis, renal salt loss, and hyperreninemic All subjects had normal renal function, and claimed hyperaldosteronism associated with normotension led no laxatives or diuretics abuse. Informed consent was us to suspect a diagnosis of Bartter’s syndrome (BS). obtained from each subject and the study protocol was This patient did not comply with regular therapy except approved by the ethics committee of the affiliated for intermittent administration of potassium chloride. hospital, Qingdao University School of Medicine. After hospitalization this time, his physical and biochemical indices were revaluated (Tables 1 and 2). The laboratory findings of hypomagnesemia, with a Office BP and ambulatory blood pressure magnesium level of 0.31–0.44 mmol/l, and hypocal- monitoring ciuria (urine calcium/creatinine (Ca/Cr): 0.06– 0.1 mmol/mmol), suggested a diagnosis of GS. Repeated Office BP was measured with a mercury sphygmoman- examinations demonstrated his suppressed PRA and ometer after the patient had rested by sitting for at least elevated PAC. The PAC/PRA ratio was extremely high 5 min according to AHA guidelines (7) with the mean of (Table 2). Thus, the collective evidence of renal salt loss two readings used for analysis. All patients also and unexpectedly suppressed PRA led to the suspicion of underwent non-invasive ambulatory blood pressure coexistence of PA and GS in this patient. Computerized monitoring (ABPM; Spacelabs model 90207; Spacelabs tomography showed bilateral enlarged adrenal glands Inc., Richmond, WA, USA). The monitor recorded (data not shown). None of his family members had systolic and diastolic BP every 20 min during the hypokalemia and hypertension. daytime (0600–2200 h) and every 30 min at night Patient 2 was a 42-year-old woman who was (2200–0600 h). Nocturnal decline was defined as the hospitalized because of persistent muscle weakness for percentage difference in ambulatory day versus night 5 years. She was first diagnosed as GS according to BP levels. Dippers were defined as patients with R10% electrolytes analysis of her serum and urine. However, decline in both systolic and diastolic BP. the suppressed PRA, elevated level of PAC, and high PAC/PRA ratio also raised our suspicion of her Saline infusion test and adrenal venous sampling Table 1 Clinical characteristics of the two patients and control subjects. Sodium intake was unrestricted. After overnight recumbency, 2 l of 0.9% saline solution were adminis- Patients suspected tered intravenously in 4 h between 0800 h and noon. of PA and GS (nZ2) BP and heart rate were monitored closely during the Control test. PRA and PAC were measured before and after the subjects with test. Adrenal venous sampling (AVS) was carried to Clinical only GS identify the lateralization of aldosterone secretion. characteristics Patient 1 Patient 2 (nZ10) Male/female 1/1 6/4 Age (years) 39 42 39G4 Mutation analysis Body mass index (kg/m2) 26.5 21 23.6G2.2 Systolic office BP (mmHg) 135 130 112G10* Genomic DNA was extracted from peripheral blood of Diastolic office BP (mmHg) 85 80 71G9.1 these two patients, control subjects, their family Systolic 24-h BP (mmHg) 129 126 105G9* members, and 200 normal healthy controls by the Diastolic 24-h BP (mmHg) 79 76 65G6* GenElute blood genomic DNA kit (Sigma, NA2010). Dipper/non-dipper 0/2 9/1* SLC12A3 and CLCNKB genes were analyzed as *P!0.05. described (8, 9). To analyze transcriptional profiles for www.eje-online.org Downloaded from Bioscientifica.com at 09/28/2021 09:18:24PM via free access EUROPEAN JOURNAL OF ENDOCRINOLOGY (2009) 161 Renal salt-losing disease and adrenal hyperplasia 277 Table 2 Biochemical summary of the two patients and control of the CYP11B1/CYP11B2 chimeric gene was studied subjects. using the long PCR technique introduced by Jonsson et al. (12). Patients suspected of PA and GS (nZ2) Control Functional studies of SLC12A3 mutations subjects Biochemical with only Normal NCC-directed mutagenesis and in vitro human NCC Z data Patient 1 Patient 2 GS (n 10) range cRNA translation Four mutations identified in these Serum levels of electrolytes two patients were selected for functional analysis Na (mmol/l) 140 142 138G3.3 130–147 (T60M, T304M, T465P, and N611T).
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