Mutations in the Chloride Channel Gene CLCNKB As a Cause of Classic Bartter Syndrome
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J Am Soc Nephrol 11: 1449–1459, 2000 Mutations in the Chloride Channel Gene CLCNKB as a Cause of Classic Bartter Syndrome MARTIN KONRAD,* MARTIN VOLLMER,† HENNY H. LEMMINK,‡ LAMBERTUS P. W. J. VAN DEN HEUVEL,‡ NIKOLA JECK,* ROSA VARGAS-POUSSOU,§ ALICIA LAKINGS,ʈ RAINER RUF,† GEORGES DESCHENES,ˆ ¶ CORINNE ANTIGNAC,§ LISA GUAY-WOODFORD,ʈ NINE V. A. M. KNOERS,‡ HANNSJORG¨ W. SEYBERTH,* DELPHINE FELDMANN,¶ and FRIEDHELM HILDEBRANDT† *Department of Pediatrics, Philipps University, Marburg, Germany; †Department of Pediatrics, Albert Ludwigs University of Freiburg, Germany; ‡Departments of Pediatrics and Human Genetics, University Hospital Nijmegen, The Netherlands; §Institut National de la Sante´et de la Recherche Me´dicale U423, Necker Hospital, University of Paris, France; ʈDepartments of Medicine and Pediatrics, University of Alabama at Birmingham, Alabama; ¶Departments of Biochemistry and Pediatric Nephrology, Armand-Trousseau Hospital, Paris, France. Abstract. Inherited hypokalemic renal tubulopathies are differ- ROMK (KCNJ1). Recently, mutations in a basolateral chloride entiated into at least three clinical subtypes: (1) the Gitelman channel CLC-Kb (CLCNKB) have been described in a subset variant of Bartter syndrome (GS); (2) hyperprostaglandin E of patients with a Bartter-like phenotype typically lacking syndrome, the antenatal variant of Bartter syndrome (HPS/ nephrocalcinosis. In this study, the screening for CLCNKB aBS); and (3) the classic Bartter syndrome (cBS). Hypokale- mutations showed 20 different mutations in the affected mic metabolic alkalosis and renal salt wasting are the common children from 30 families. The clinical characterization re- characteristics of all three subtypes. Hypocalciuria and hypo- vealed a highly variable phenotype ranging from episodes of magnesemia are specific clinical features of Gitelman syn- severe volume depletion and hypokalemia during the neo- drome, while HPS/aBS is a life-threatening disorder of the natal period to almost asymptomatic patients diagnosed newborn with polyhydramnios, premature delivery, hyposthe- during adolescence. This study adds 16 novel mutations to nuria, and nephrocalcinosis. The Gitelman variant is uniformly the nine already described, providing further evidence that caused by mutations in the gene for the thiazide-sensitive mutations in the gene for the basolateral chloride channel NaCl-cotransporter NCCT (SLC12A3) of the distal tubule, CLC-Kb are the molecular basis of classic Bartter syn- while HPS/aBS is caused by mutations in the gene for either drome. Interestingly, the phenotype elicited by CLCNKB the furosemide-sensitive NaK-2Cl-cotransporter NKCC2 mutations occasionally includes HPS/aBS, as well as a (SLC12A1) or the inwardly rectifying potassium channel Gitelman-like phenotype. Inherited hypokalemic tubulopathies have previously been defects and extensive pathophysiologic studies have allowed a summarized under the term Bartter syndrome (BS). All disease more stringent molecular genetic classification. However, the variants follow autosomal recessive inheritance and share the correlation between molecular genetic defects and the clinical following characteristic clinical features: renal salt wasting, phenotype has not been clearly delineated as yet. From a hypokalemic metabolic alkalosis, normotensive hyperrenine- clinical perspective, the classification into three different vari- mic hyperaldosteronism, and hyperplasia of the juxtaglomeru- ants seems justified (1,2): lar apparatus. Recent identification of the primary genetic 1. In Gitelman syndrome (GS), the hypocalciuric-hypomag- nesemic variant (3), patients are often asymptomatic with the exception of transient muscular weakness, carpopedal Received October 18, 1999. Accepted January 18, 2000. Dr. Martin Konrad and Dr. Martin Vollmer contributed equally to this work. spasms, tetanic episodes, and abdominal pain. Therefore, Dr. Daniel G. Bichet served as Guest Editor and supervised the review and diagnosis is made as a rule after the age of 6 yr. In contrast final disposition of this manuscript. to the other variants, there is marked hypocalciuria and Correspondence to Dr. Hannsjo¨rg W. Seyberth, Department of Pediatrics, hypomagnesemia. Philipps University, Deutschhausstrasse 12, D-35037 Marburg, Germany. 2. Hyperprostaglandin E syndrome (HPS), also known as an- Phone: ϩ49 6421 2866226; Fax: ϩ49 6421 2868956; E-mail: seyberth@ mailer.uni-marburg.de tenatal Bartter syndrome (aBS) (1,2,4,5), is the most severe 1046-6673/1108-1449 form and leads to polyhydramnios and premature birth due Journal of the American Society of Nephrology to excessive polyuria in utero. Often there is a life-threat- Copyright © 2000 by the American Society of Nephrology ening clinical course in the perinatal period with severe salt 1450 Journal of the American Society of Nephrology J Am Soc Nephrol 11: 1449–1459, 2000 and water loss, hypokalemic alkalosis, and systemic mani- ROMK. Clinically, the cohort consisted of patients with GS festations such as fever, vomiting, diarrhea, and failure to (n ϭ 5), HPS/aBS (n ϭ 7), and cBS (n ϭ 38). In 36 patients thrive. Marked hypercalciuria and the development of from 30 families, 20 different mutations in CLCNKB were nephrocalcinosis ensue often within several weeks. Gener- detected, 16 of which are novel. These patients were carefully alized symptoms have been attributed to enhanced systemic reanalyzed clinically. We found that these patients presented prostaglandin formation, and treatment with indomethacin, with a highly variable phenotype, ranging from a severe peri- an inhibitor of prostaglandin synthesis, is the most effective natal course to patients who were almost symptom-free and therapeutic option (5). were diagnosed only by accidental detection of hypokalemia 3. Classic Bartter syndrome (cBS) presents with sequelae of with the majority fulfilling the criteria of cBS. A novel non- pronounced hypokalemia and marked salt loss resulting in homologous recombination event in the CLCNKB gene was muscle weakness and volume contraction during the first detected. years of life. Nephrocalcinosis is an uncommon finding, and investigation of renal concentrating ability is impaired to a Materials and Methods lesser extent than in HPS/aBS (2). Patients We analyzed by mutational analysis 50 patients from 43 families Recently, four distinct primary genetic defects have been diagnosed as having either GS (n ϭ 5), HPS/aBS (n ϭ 7), or cBS (n ϭ elucidated for different variants of BS: 38), in whom no linkage to or mutations in SLC12A3, SLC12A1, and KCNJ1 was detected in previous studies (7,10,11,14,15,17). Diagno- 1. GS (MIM 263800) is caused by mutations in the NaCl sis of GS and HPS/aBS was made following the criteria of Bettinelli cotransporter gene (SLC12A3), encoding a protein located et al. (18) and Seyberth et al. (4,5), respectively. Patients were in the apical membrane of the distal convoluted tubule, considered as having cBS when they presented with hypokalemic which is known to be inhibited by thiazides (6,7). There- alkalosis, renal salt wasting without antenatal manifestation, and no fore, the symptoms of GS mimic chronic administration of major disturbance of serum calcium or magnesium. This study was thiazides (8). In contrast to GS, HPS/aBS was found to be approved by the local ethics committee, and informed consent was caused by at least two different genes: obtained from the patients and/or their parents. 2. Mutations in the furosemide-sensitive luminal Na-K-2Cl cotransporter (SLC12A1), which is expressed in the thick Genotype Analysis and Haplotype Construction ascending limb of Henle’s loop, cause the genetic variant of Genomic DNA of all affected individuals and available family BS type 1 (MIM 600839) and lead to the clinical phenotype members was extracted from whole blood by standard methods (19) of HPS/aBS (9–11). This is in keeping with the observation or after Epstein-Barr virus transformation of peripheral blood lym- that there is an impaired response to furosemide in HPS/ phocytes (20). Haplotype analysis was performed as described previ- ously (14), using the following markers, which were linked to the aBS patients and that the clinical phenotype of HPS/aBS CLCNKA/CLCNKB loci: D1S2826, D1S2672, D1S2644, D1S507, and mimics the sequelae of chronic furosemide treatment (12). D1S436 (21). 3. Mutations in the gene for the inwardly rectifying potassium Microsatellite polymorphisms were amplified as described previ- channel ROMK (KCNJ1) cause the genetic variant of BS ously (14), and amplified products were separated on 0.5ϫ Tris- type 2 (MIM 600359) and lead to the clinical phenotype of borate-ethylenediaminetetra-acetic acid, 6% polyacrylamide gels run HPS/aBS (13–15). ROMK ensures functioning of the Na- under denaturing conditions (22). The gels were analyzed using Ge- K-2Cl cotransporter by recycling potassium back to the nescan 672 software, version 1.2 (Applied Biosystems), the Pharma- renal tubular lumen. cia Fragment Manager (Amersham Pharmacia), or autoradiography. 4. Mutations in the gene for the basolateral chloride channel Haplotypes were constructed from the genotype data. The most likely CLC-Kb (CLCNKB) cause the genetic variant of BS type 3 haplotypes were inferred by minimizing the number of crossover (MIM 602023), which is defined by a distinct subset of events in each sibship. patients in whom nephrocalcinosis is absent. Diagnosis in these patients is usually made during infancy or childhood Deletion Detection by PCR (16). No prenatal history