Pediatr Nephrol (2000) 14:1121–1136
INVITED REVIEW
Juan Rodríguez-Soriano
New insights into the pathogenesis of renal tubular acidosis –
from functional to molecular studies
Received: 10 February 2000 / Revised: 7 April 2000 / Accepted: 7 April 2000
Abstract The diagnosis and classification of renal tubu-
lar acidosis (RTA) have traditionally been made on the
basis of functional studies. On these grounds, RTA has
been separated into three main categories: (1) proximal
RTA, or type 2; (2) distal RTA, or type 1; and (3) hyper-
kalemic RTA, or type 4. In recent years significant ad-
vances have been made in our understanding of the sub-
cellular mechanisms involved in renal bicarbonate
(HCO3–) and H+ transport. Application of molecular bi-
ology techniques has also opened a completely new per-
spective to the understanding of the pathophysiology of
inherited cases of RTA. Mutations in the gene SLC4A4,
encoding Na+-HCO3– cotransporter (NBC-1), have been
found in proximal RTA with ocular abnormalities; in the
gene SLC4A1, encoding Cl–-HCO3– exchanger (AE1), in
autosomal dominant distal RTA; in the gene ATP6B1,
encoding B1 subunit of H+-ATPase, in autosomal reces-
sive distal RTA with sensorineural deafness; and in the
gene CA2, encoding carbonic anhydrase II, in autosomal
recessive osteopetrosis. Syndromes of aldosterone resis-
tance have been also characterized molecularly and mu-
tations in the gene MLR, encoding mineralocorticoid re-
ceptor, and in the genes SNCC1A, SNCC1B, and
SCNN1G, encoding subunits of the epithelial Na+ chan-
nel, have been found in dominant and recessive forms of
pseudohypoaldosteronism type 1, respectively. It can be
concluded that, although functional studies are still nec-
essary, a new molecular era in the understanding of dis-
orders of renal acidification has arrived.
J. Rodríguez-Soriano (✉)
Department of Pediatrics, Hospital de Cruces, Plaza de Cruces s/n,
Baracaldo, 48903 Vizcaya, Spain
e-mail: jrs00014@teleline.es
Tel.: +34-94-6006357, Fax: +34-94-6006044/+34-94-4850148
J. Rodríguez-Soriano
Division of Pediatric Nephrology, Department of Pediatrics,
Hospital de Cruces and Basque University School of Medicine,
Bilbao, País Vasco, Spain
© IPNA 2000
Key words Renal tubular acidosis ·
Pseudohypoaldosteronism · H+-ATPase · NBC-1 · AE1 ·
Carbonic anhydrase · Mineralocorticoid receptor ·
Epithelial Na+ channel
Introduction
To date classification of renal tubular acidosis (RTA) has
been exclusively based on clinical and functional stud-
ies. On these grounds RTA has been separated into three
main categories: (1) proximal RTA, or type 2; (2) distal
RTA, or type 1; and (3) hyperkalemic RTA, or type 4 [1,
2, 3]. In the past few years the rapidly expanding knowl-
edge about the molecular abnormalities involved in the
disturbed bicarbonate (HCO3–) and H+ transport in these
patients has opened a completely new perspective for the
understanding of the pathophysiology of this entity. Al-
though RTA may occur in a number of etiologies, both
inherited and acquired, in this review we shall limit com-
ments to the molecular biology of the primary forms of
RTA (Table 1).
Physiology of renal acidification
Renal acid-base homeostasis may be broadly divided in-
to two processes: (1) reabsorption of filtered HCO3–,
which occurs fundamentally in the proximal convoluted
tubule, and (2) excretion of fixed acids through the titra-
tion of urinary buffers and the excretion of ammonium,
which takes place primarily in the distal nephron.
Proximal HCO3– reabsorption
The mechanisms for proximal reabsorption of about
80%–90% of filtered HCO3– are shown in Fig. 1 [4]. The
foremost processes occurring in this segment are H+ se-
cretion at the luminal membrane via a specific Na+-H+
exchanger (NHE-3) and HCO3– transport at the basolat-
1122
Table 1 Genetics of primary renal tubular acidosis (RTA) (NBC-1 Na+-HCO3– cotransporter, NHE-3 Na+-H+ exchanger, AE1 Cl– –
HCO3– exchanger, ENaC epithelial Na+ channel)

Syndrome Gene localization Locus symbol Gene product

Primary proximal RTA (type 2)

Autosomal dominant ? ? ?
Autosomal recessive with ocular abnormalities 4q21 SLC4A4 NBC-1
Sporadic in infancy – – Immaturity of NHE-3?

Primary distal RTA (type 1)

Autosomal dominant 17q21–22 SLC4A1 AE1
Autosomal recessive with deafness (rdRTA1) 2p13 ATP6B1 B1 subunit of H+-ATPase
Autosomal recessive without deafness (rdRTA2) 7q33–34 ? ?

Combined proximal and distal RTA (type 3)

Autosomal recessive with osteopetrosis 8q22 CA2 Carbonic anhydrase II

Hyperkalemic distal RTA (type 4)

Pseudohypoaldosteronism type 1
Autosomal dominant renal form 4q31.1 MLR Mineralocorticoid receptor
Autosomal recessive multiple organ form 16p12 SNCC1B, SCNN1G β and γENaC
Autosomal recessive multiple organ form 12p13 SNCC1A αENaC
Early childhood hyperkalemia – – Immaturity of
mineralocorticoid receptor?
Pseudohypoaldosteronism type 2 (Gordon syndrome) 1q31–42,17p11-q21 ? ?

Both CA II and CA IV are markedly stimulated during

Fig. 1 Schematic model of bicarbonate (HCO3–) reabsorption in
proximal convoluted tubule. The processes occurring are H+ secre-
tion at the luminal membrane via a specific Na+-H+ exchanger
(NHE-3) and HCO3– transport at the basolateral membrane via a
1 Na+-3 HCO3– cotransporter (NBC-1). Cytoplasmic carbonic an-
hydrase II (CA II) and membrane-bound carbonic anhydrase IV
(CA IV) are necessary to reabsorb HCO3–
eral membrane via a Na+-HCO3– cotransporter (NBC-1).
In the proximal tubules, carbonic acid (H2CO3) is formed
within the cell by the hydration of CO2, a reaction cata-
lyzed by a soluble cytoplasmic carbonic anhydrase (CA
II). The H2CO3 ionizes and the H+ is secreted in ex-
change for luminal Na+. This mechanism is electroneu-
tral, driven by a lumen-to-cell Na+ gradient, stimulated
by intracellular acidosis and inhibited by high concentra-
tions of amiloride.
HCO3– generated within the cell leaves across the ba-
solateral membrane by passive 1 Na+-3 HCO3– cotrans-
port. The secreted H+ reacts with filtered HCO3– to form
luminal H2CO3, which quickly dissociates into CO2 and
water by the luminal action of membrane-bound carbon-
ic anhydrase (CA IV). Luminal CO2 can freely diffuse
back into the cell to complete the reabsorption cycle.
chronic metabolic acidosis.
A substantial fraction of proximal HCO3– reabsorption
is mediated by vacuolar H+-ATPase, thus mutations of
genes encoding the protein subunits of this transporter
might lead to proximal RTA. However, it is possible that
proximal HCO3– reabsorption through Na+-H+ exchange
may fully compensate for defective H+-mediated reab-
sorption. Also, about 20% of filtered HCO3– is reabsorbed
by passive back-diffusion along the paracellular pathway.
A second major function of the proximal tubule cell is
ammonia (NH3) formation from glutamine, a reaction
which is rate-limited by the enzymes glutaminase and
phosphoenolpyruvate carboxylase. Chronic acidosis up-
regulates the activity of both enzymes.
In recent years important advances have been made
concerning the molecular biology of these transporters
and enzymes . Na+-H+ exchangers (NHE) belong to a
common family of transport proteins and perform elec-
troneutral 1:1 exchange of Na+ and H+ [5]. To date, five
isoforms of NHE have been cloned in mammals [6, 7].
They share a similar predicted structure with approxi-
mately 800 amino acids and 12 transmembrane domains
and two cytoplasmic termini (Fig. 2). The carboxy-
terminal half of the protein is mainly regulatory in func-
tion and contains phosphorylation sites that are targets
for protein kinases, and domains that bind to various reg-
ulatory cofactors [8]. NHE-1 and NHE-3 are the princi-
pal isoforms involved in renal function. NHE-1 is ubiq-
uitous and is immunolocalized at the basolateral mem-
brane. NHE-3 is kidney specific and is apically localized
in proximal tubule and TALH cells. The human NHE-3
gene (SLC9A3) is encoded at 5p15.3 [9].
There are three Na+-HCO–3 cotransporters (NBC-1,
-2, and -3) belonging to a superfamily of HCO3– trans-

Fig. 2 Membrane topology of Na+-H+ exchangers (NHE). They
share a similar structure with 12 transmembrane domains and cy-
toplasmic amino- and carboxy-termini
Fig. 3 Membrane topology of Na+-HCO3– cotransporters (NBC).
NBC-1 is present in the kidney and contains 10 transmembrane
domains and cytoplasmic amino- and carboxy-termini
porters, which also includes Cl–-HCO3– exchangers and
K+-HCO3– cotransporters [10]. NBC-1 is formed by
1,035 amino acids, it contains ten transmembrane do-
mains and two cytoplasmic termini, and is present in
kidney, brain, eye, pancreas, heart, prostate, epididymis,
stomach, and intestine (Fig. 3) There are two isoforms:
kNBC-1 (from kidney) and p(h)NBC-1 (from pancreas
and heart). NBC-1 is expressed mainly at the basolateral
membrane of proximal tubule, with only traces found in
medullary thick ascending limb of Henle. In the kidney,
NBC-1 is up-regulated by metabolic acidosis, K+ deple-
tion and glucocorticoid excess and is down-regulated by
HCO3– loading or metabolic alkalosis. There are at least
two genes encoding the NBC proteins. The human NBC-
1 gene (SLC4A4) is located at 4p21 [11].
The carbonic anhydrases (CA) are a family of at least
14 zinc metalloenzymes (CA I-XIV) that catalyze the re-
versible hydration of CO2 in the reaction CO2+H2O=
HCO3–+H+. The isoenzymes vary in physicochemical
and enzymatic properties, in sensitivities to various in-
hibitors, and in subcellular localizations. Cytoplasmic
(CA I, II, III, and VII), extracellular (CA IV, VI, IX, XII,
and XIV), and mitochondrial (CA V) isoenzymes have
1123
been described [12, 13]. In the kidney more than 95% of
CA activity is located in the cytosol and is attributable to
CA II. It is primarily found in proximal tubular cells and
in intercalated cells of the cortical and outer medullary
collecting tubules [14]. Membrane-bound CA IV repre-
sents approximately 5% of total kidney CA activity and
although it is mainly localized at the apical side of proxi-
mal and medullary tubular cells, its presence in the baso-
lateral membrane has been also demonstrated. The hu-
man CA II gene (CA2) maps to 8q22, whereas the hu-
man CA IV gene (CA4) maps to 17q23 [15]. A low pH
is required for bone resorption, hence CA II is also ex-
pressed in osteoclasts, where it generates protons for a
specific vacuolar H+-ATPase [16].
Proximal HCO3– reabsorption is influenced by lumi-
nal HCO3– concentration and flow rate, extracellular flu-
id volume, peritubular HCO3– concentration and PCO2,
Cl–, K+, Ca2+, phosphate, parathyroid hormone, gluco-
corticoids, α-adrenergic tone, and angiotensin II [17].
Distal urinary acidification
Urinary acidification takes place in the distal nephron by
three related processes: (1) reclamation of the small frac-
tion of filtered HCO3– that escapes reabsorption proxi-
mally (10%–20%); (2) titration of divalent basic phos-
phate (HPO42–), which is converted to the monovalent
acid form (H2PO4–) or titrable acid; and (3) accumulation
of NH3 intraluminally, which buffers H+ to form non-dif-
fusible ammonium (NH4+).
The thick ascending limb of loop of Henle reabsorbs
about 15% of the filtered HCO3– load by a mechanism
similar to that present in the proximal tubule, i.e.,
through Na+-H+ apical exchange. It also participates in
NH3 transport. Absorption of NH4+ in the apical mem-
brane of the loop of Henle occurs by substitution for K+
both in the Na+ K+ 2Cl– cotransport system and in the
K+-H+ antiport system. The medullary thick ascending
limb has a low permeability to NH3, limiting back-diffu-
sion. A NH4+ medullary concentration gradient is gener-
ated and amplified by countercurrent multiplication
through NH4+ secretion into the proximal tubule and
possibly into the thin descending limb of the loop of
Henle. The accumulation of NH3 in the medullary inter-
stitium increases the driving force for diffusional entry
of NH3 into the collecting tubule, a process facilitated by
the high acidity of the tubular fluid at this level. Abnor-
malities in this complex process of NH3/NH4+ synthesis
and transport may lead to impaired distal urinary acidifi-
cation.
Distal urinary acidification occurs mainly in the col-
lecting tubules [18]. In the cortical collecting tubule, the
intercalated cells are involved in both H+ and HCO3– se-
cretion, while the principal cells are in charge of Na+ re-
absorption and K+ secretion. There are two populations
of intercalated cells that differ both functionally and
structurally. The α-cell is responsible for H+ secretion,
and the β-cell is responsible for HCO3– secretion. The
1124
Fig. 4 Schematic model of H+ secretion in cortical collecting tu-
bule. The main pump for luminal H+ secretion in the α-type inter-
calated cell is a vacuolar H+-ATPase. A H+, K+-ATPase is also in-
volved in H+ secretion. Intracellularly formed HCO3– leaves the
cell via Cl–-HCO–3 exchange, facilitated by an anion exchanger
(AE1). Cytoplasmic CA II is necessary to secrete H+
cellular mechanisms involved in distal acidification are
shown in Fig. 4. The main pump for luminal H+ secre-
tion in the α−type intercalated cell is a vacuolar H+-
ATPase, but it is also highly influenced by the luminal
electronegativity caused by active Na+ transport taking
place in the principal cells. A second ATPase, the H+,
K+-ATPase, is also involved in H+ secretion, but its
physiological role is probably more related to K+ than to
acid-base homeostasis. Intracellularly formed HCO3–
leaves the cell by an electroneutral mechanism involving
CI–-HCO3– exchange, facilitated by an anion exchanger
(AE1 or band 3 protein).
H+ secretion proceeds in the outer medullary collect-
ing tubule, which is a unique segment that does not reab-
sorb Na+ or secrete K+ and whose only function is the
transport of H+ [19]. The medullary collecting tubule is
lumen positive and H+ must be secreted against the elec-
trochemical gradient via an electrogenic, Na+-indepen-
dent process modulated by the vacuolar H+-ATPase. H+
secretion is not inhibited by agents that block Na+ trans-
port, but is influenced by aldosterone, through a mecha-
nism which is independent of Na+ delivery or reabsorp-
tion. The terminal part, the inner medullary collecting
duct, also plays an important role in distal acidification
[20]. The cellular process involved in mediating H+ se-
cretion appears to be similar to the process described in
α-intercalated cells, but its importance in overall renal
H+ secretion remains to be determined. All segments of
the collecting tubule are very rich in cytosolic carbonic
anhydrase II, but membrane-bound, luminal carbonic an-
hydrase IV is also present in both outer and inner seg-
ments of the medullary collecting duct. The luminal CA
IV seems to play an important role for HCO3– absorption
in this segment [21].
The vacuolar H+-ATPase (V-ATPase) is one of the
most-fundamental enzymes in nature [22]. It functions in
almost every eukaryotic cell and energizes a wide variety
of organelles and membranes. Its primary function is
ATP-dependent proton transfer. V-ATPases have similar
Fig. 5 Membrane topology of the vacuolar H+-ATPase. Vacuolar
H+-ATPase is a complex of different protein subunits organized in
two major domains, V0 and Vl. The intracellular, catalytic Vl seg-
ment is formed by three A subunits and three B subunits
structure and mechanism of action as F-ATPases, but
these latter enzymes are confined to mitochondria, and
the primary function is to form ATP at the expense of the
proton-motif force. The structure of vacuolar H+-ATP-
ases has been mainly elucidated in yeast [23, 24]. Genet-
ic screening has lead to the identification of 14 genes en-
coding subunits of the enzyme complex. Several addi-
tional genes have been identified that encode proteins
that are not part of the final V-ATPase complex yet are
required for its assembly. The complex is organized into
two major domains, V0 and V1 (Fig. 5). The intracellu-
lar, catalytic V1 segment is formed by three A subunits
and three B subunits. There are two isoforms (B1 and
B2), encoded by different genes (ATP6B1 and ATP6B2)
and showing different patterns of expression. The B2
isoform is widely distributed while the B1 isoform has
been exclusively detected in α-intercalated cells of the
distal nephron, placenta, and inner ear [25]. The human
ATP6B1 gene is located at 2p13 and contains 14 exons.
The H+, K+-ATPases comprise a group of integral
membrane proteins that belong to the P cation-transport-
ing ATPases [26]. The other important member of this
family is Na+, K+-ATPase. Both consist of two trans-
membrane subunits, the larger of which (catalytic α-sub-
unit) has ten domains and exchanges K+ against intracel-
lular Na+ or H+, at the expense of ATP hydrolysis. The
β-subunit seems to be necessary for the correct packing
and stable membrane insertion of the α-subunit [27]
(Fig. 6). Differences in the functional properties and
adaptability of the H+, K+-ATPases in different tissues
can partly be explained by the existence of isoforms of
the enzyme components. The isoforms of the α-subunit
(HKα) were initially specified according to their original
tissue origin, gastric or colonic. Recently, there is agree-
ment that the HKα subunits should be assigned accord-
ing to their order of discovery: HKα1 (gastric), HKα2
(colonic), HKα3, and HKα4. The ATP4A and ATP1AL1
genes code for HKα1 and HKα2, respectively. The hu-
man ATP1AL1 gene, formed by 23 exons, has been

Fig. 6 Membrane topology of the H+, K+-ATPase. It is formed by
two transmembrane subunits, the larger of which (catalytic subunit
α) has 10 domains and exchanges K+ against intracellular H+, at
the expense of ATP hydrolysis. The β-subunit seems to be neces-
sary for the correct packing and stable membrane insertion of the
α-subunit
cloned [28]. At least three different pumps containing
the HKα1, HKα2, and HKα3 subunits have been detect-
ed in rabbit kidney. The HKβ protein associates with
HKα1 in gastric tissue, but in the kidney the main role
seems to be played by HKα2-HKβ isoforms [29]. Future
work should elucidate the activity and pharmacological
properties of different H+, K+-ATPases, depending on the
presence of HKα2 variants and the interaction with dif-
ferent HKβ subunits.
Anion exchangers (AE) interchange Cl– and HCO3– at
cell membranes and belong to a superfamily of transporters
which also includes Na+-HCO3– and K+-HCO3– cotrans-
porters [30]. There are three isoforms: AE1, AE2, and
AE3. The red cell AE1, or band 3 protein, contributes to
cytoskeletal structure and is important for the respiratory
function by interchanging Cl– and HCO3– at red cell mem-
branes. In the kidney, AE1 interchanges anions at basolat-
eral membranes of α type intercalated cells of cortical and
medullary collecting ducts [31]. AE2 is also expressed in
the kidney, especially in medullary thick ascending limb
[32]. AE3 is mainly expressed in cardiac muscle and brain.
AE1 has 911 amino acids and it was formerly believed that
it was made up of 14 transmembrane domains and two cy-
toplasmic termini. Recent studies, however, have shown
that human AE1 of erythrocyte membranes is composed of
13 typical transmembrane segments, while the region
Asp807-His834 is membrane embedded but does not have
the usual α-helical conformation [33] (Fig. 7). The AE1
gene (SLC4A1) is located at 17q21–22 and the AE2 gene
(SLC4A2) has been localized to 7q35-36.
Distal urinary acidification is influenced by blood pH
and PCO2, distal Na+ transport and transepithelial poten-
tial difference, aldosterone, and K+. Aldosterone influ-
ences distal acidification through several mechanisms
(Fig. 8). Firstly it enhances Na+ transport in the late dis-
tal and cortical collecting tubules, and thereby increases
the lumen-negative potential difference across epitheli-
um, so favoring both H+ and K+ secretion. This action is
early mediated by activation of pre-existing epithelial
1125
Fig. 7 Membrane topology of the AE1 exchanger. It is formed by
13 membrane-spanning domains, an atypical intramembranous re-
gion (Asp807-His834), and intracellular amino- and carboxy-termini
Fig. 8 Schematic representation of aldosterone action in distal and
cortical collecting tubules. Once aldosterone is bound to the min-
eralocorticoid receptor, it penetrates into the nucleus and activates
specific genes. The result is stimulation of Na+ entry and both H+
and K+ exit at the luminal membrane, and of K+ entry and Na+ exit
at the basolateral membrane
Na+ channels (ENaC) and pumps (Na+, K+- ATPase), and
subsequently mediated by increasing the overall trans-
port capacity of the renal tubular cells [34]. Aldosterone
seems to be responsible for the specific localization of
the ENaC in the apical membrane of principal cells of
distal and cortical collecting tubules [35]. Both early reg-
ulatory and late anabolic-type actions depend on the
transcriptional regulation exerted by hormone-activated
mineralocorticoid receptors (MR). However, the regula-
tory pathways that link the transcriptional action of aldo-
sterone to these Na+ transport proteins are still largely
unknown [36]. In addition to the genomic action of aldo-
sterone, rapid effects involving second messengers, such
as calcium and cAMP, have been also observed in
knockout mice lacking the MR [37].
Aldosterone also enhances H+-ATPase activity in cor-
tical and medullary collecting tubules, an effect that is
independent of plasma K+ levels. However, the stimula-
tion of H+, K+-ATPase, which is also observed in aldo-
sterone excess, depends predominantly on the stimulus
exerted by accompanying hypokalemia [38]. 3) Aldo-
sterone also affects NH4+ excretion by increasing NH3
synthesis, both as a direct action and as a consequence of
simultaneous changes in K+ homeostasis [39].
1126
Fig. 9 Membrane topology of the epithelial Na+ channel. The pro-
posed model is a heterotetrameric structure formed by two α-sub-
units, one β-subunit, and one γ-subunit Each subunit is formed by
two membrane spanning-domains, a large extracellular loop, and
cytoplasmic amino- and carboxy-termini
The MR is a protein of 984 amino acids belonging to
the superfamily of steroid receptors. It contains an im-
munogenic domain, a zinc finger DNA-binding domain,
and a hormone-binding domain. Unlike the glucocorti-
coid receptor, which is almost ubiquitous, MR expres-
sion is restricted to specific cells of kidney distal and
collecting tubules, colonic epithelium, and sweat and sal-
ivary gland ducts. In all these epithelia aldosterone stim-
ulates Na+ reabsorption [40]. The structure of the gene
encoding the human MR (MLR) has been elucidated. It
is formed by nine exons and is located at 4q31.1
[41].Two different isoforms have been identified. Each
isoform is expressed at an approximately equivalent lev-
el in kidney, colon, and sweat glands [42].
The epithelial Na+ channel (ENaC) is formed by
three subunit proteins (α, β, and γ), having short cytosol-
ic termini, two transmembrane domains, and a large ex-
tracellular loop [43]. The α-subunit appears to be re-
quired for the assembly or function of the whole com-
plex. The three ENaC subunits are homologous to each
other and have about 35% amino acid identity. There is a
possible membrane topology of the heterotetrameric
complex formed by 2 α, 1 β, and 1 γ subunits, since this
complex maintains a high amiloride sensitivity and a
very Na+ selective pore [44] (Fig. 9 ). The ENaC is not
only present in the kidney but also in other organs such
as lung, colon, exocrine glands, skin, and hair follicle.
Both genes encoding the β− (SNCC1B) and γ-subunits
(SNCC1G) are located in 16p12, while the gene encod-
ing the α-subunit (SNCC1A) is located in 12p13 [45].
Ontogeny of renal acidification
lt is well known that during early postnatal life there is a
maturational increase in proximal tubular reabsorption of
HCO3– [46]. The immaturity of this process is still more
apparent in preterm newborn infants [47]. Classic func-
tional studies in puppies and rabbits have shown that the
rate of reabsorption in neonatal proximal tubules is ap-
proximately one-third of that observed in mature seg-
ments, and that normalization only occurs after a period
of several weeks [48, 49]. Recent investigations have
shown that several transporters and enzymes involved in
HCO3– transport are insufficiently expressed during the
early neonatal period. The functioning of apical NHE-3,
either studied as Na+-H+ antiporter activity in microvil-
lus membrane vesicles prepared from cortex of fetal and
newborn lambs [50] or as expression of NHE-3 mRNA
in cortex from neonatal rabbits [51, 52], is clearly im-
paired. NBC-1 activity at the basolateral membrane is
also decreased in neonatal rabbits, but this activity is rel-
atively more mature than the NHE-3 activity at the api-
cal membrane [53]. Maturation of CA II and CA IV ac-
tivities may also play an important role, since these en-
zymes are insufficiently expressed during the first 2
weeks of life in rat and rabbit kidneys, respectively [54,
55]. The maturational increase of proximal tubular reab-
sorption of HCO3– takes place pari passu with parallel
increases in proximal tubular basolateral surface area
and Na+, K+-ATPase activity [56, 57, 58].
lt is of great interest that administration of glucocor-
ticoids accelerates the maturation of both Na+-H+ anti-
porter activity [59] and expression of NHE-3 mRNA
[51, 52]. These experimental findings have an important
human correlate because administration of prenatal ste-
roids is also associated with earlier maturation of glom-
erular filtration rate and tubular Na+ reabsorption [60,
61].
The process of distal tubular acidification appears to
mature earlier than proximal tubular transport. In fact,
the ability to excrete an acid load is not different in in-
fancy than later in life [46]. Premature infants, however,
do present an inability to acidify the urine as a conse-
quence of insufficient ammoniagenesis [62, 63]. Gluta-
mine uptake, NH3 production, and excretion into the tu-
bular fluid are lower in neonatal rats after an acid load
[64].
There are few molecular biology studies related to on-
togeny of distal H+ transport. They show that the various
transporters involved are all expressed in post-S-shape
stages, suggesting that microanatomical differentiation
of the developing distal nephron to some degree pre-
cedes the tubular expression of specific transport-related
gene product [65]. It should be noted that intercalated
cells are fully developed in the fetal rat kidney and that
the entire population of these cells present in the medul-
lary collecting duct are eliminated, by programmed cell
death, during the development of the collecting duct
[66]. However, in the cortical collecting duct of the rab-
bit, intercalated cells are reduced in number and are also
functionally immature. They undergo postnatal prolifera-
tion and maturation to attain adult function several
weeks postnatally [67].
It is well known that, in contrast to term newborn in-
fants, preterm newborn infants born before 35 weeks of
gestational age present an obligatory Na+ loss despite

very elevated plasma levels of renin and aldosterone.
This situation is especially observed in the context of
high water intake and is caused by deficient proximal
and distal tubular Na+ reabsoption [68].
The various proteins implicated in the function of al-
dosterone target cells, such as MR and ENaC, are al-
ready fully expressed in the terminal part of the nephron
and the collecting duct [69]. The aldosterone unrespon-
siveness present during development may be therefore
related to a low density of mineralocorticoid receptors
and apical epithelial Na+ channels [70, 71].
Proximal RTA (type 2)
Proximal RTA (type 2) is caused by an impairment of
HCO3– reabsorption in the proximal tubule and is char-
acterized by a decreased renal HCO3– threshold. Distal
acidification mechanisms are intact and when plasma
HCO3– concentration diminishes to sufficiently low lev-
els these patients may lower urine pH below 5.5 and ex-
crete adequate amounts of NH4+. In children, proximal
RTA is most frequently observed in the Fanconi syn-
drome, but it may also occur as a primary or inherited
entity.
Autosomal dominant proximal RTA
This form has been exclusively described in nine mem-
bers of a Costa Rican family by Brenes et al. [72]. The
age of the patients varied between 2 and 27 years and
clinical signs were limited to the presence of growth re-
tardation. The presence of the disorder in several genera-
tions suggested an autosomal dominant transmission.
Molecular biology studies have not yet been reported in
this family, but one may speculate about a possible can-
didate gene, such as SLC9A3, encoding the NHE-3 trans-
porter.
A mouse model in which the gene SLC9A3 has been
abated using gene targeting strategies has been devel-
oped [73]. These knock-out mice lack NHE-3 activity
and have combined renal and intestinal absorptive de-
fects. Microperfusion and micropuncture studies show a
significant decrease in HCO3– reabsorption in the proxi-
mal tubule [74, 75]. However, the mice only exhibit a
mild degree of metabolic acidosis, due to a compensato-
ry increase in HCO3– reabsorption in more distal neph-
ron segments [76]. Kidney expression of renin and dif-
ferent transporters such as NBC1, AE1, and HKα2 is in-
creased [73]. It will be of interest to determine the clini-
cal findings of surviving animals and specifically wheth-
er they exhibit growth retardation.
1127
Autosomal recessive proximal RTA
with ocular abnormalities
Primary proximal RTA has also been reported as an auto-
somal recessive entity in association with other anoma-
lies, such as mental retardation and ocular abnormalities
[77, 78, 79]. Igarashi et al. [80] have reported molecular
biology studies in two unrelated girls, of 22 and 11 years
of age, presenting with short stature, mental retardation,
bilateral glaucoma, cataracts, band keratopathy, and per-
manent isolated proximal RTA. Both girls had homozy-
gous missense mutations (Arg298Ser in patient 1,
Arg510His in patient 2) in the gene SLC4A4, encoding
NBC-1. These findings are of great interest since they
are the first showing that loss-of-function mutations of
SLCA4A4 may cause permanent primary proximal RTA
with ocular abnormalities.
The involvement of the corneal epithelium may be
explained by the fact that it transports fluids, Na+, and
HCO3– out of the corneal stroma into the aqueous humor
to maintain corneal transparency. The function of NBC-1
in this process is of great importance and NBC1 is high-
ly expressed in corneal epithelium [81]. In mutated pa-
tients, the increase in HCO3– concentration in the corneal
stroma may facilitate calcium deposition and develop-
ment of band keratopathy.
Sporadic isolated proximal RTA
A non-familial and transient type of isolated proximal
RTA has been described in infancy [82, 83]. Affected in-
dividuals present with an isolated defect in renal and in-
testinal HCO3– absorption, without any identifiable
cause or evidence of other abnormality. The presenting
symptoms are growth retardation and persistent vomiting
in early infancy. Alkali therapy induces a rapid increase
in growth and can be discontinued after several years
without reappearance of symptoms. The transient nature
of this entity suggests the persistence beyond the neona-
tal period of a decreased HCO3– threshold, possibly as a
continued immaturity of NHE-3 function.
Distal RTA (type 1)
This type of RTA is caused by impaired distal acidificat-
ion and is characterized by the inability to lower urine
pH maximally (below 5.5) under the stimulus of system-
ic acidemia. The impaired excretion of NH4+ is second-
ary to this defect. Distal RTA is almost always observed
in children as a primary entity inherited in both autoso-
mal dominant and recessive patterns. In adults, distal
RTA is generally acquired and is often seen in the con-
text of an immune-mediated disease. Prominent clinical
features include impairment of growth, polyuria, hyper-
calciuria, nephrocalcinosis, lithiasis, and K+ depletion.
Progression of nephrocalcinosis may lead to the develop-
1128
ment of chronic renal failure. If detected early in life,
therapeutic correction of the acidosis by continuous alka-
li administration may induce resumption of normal
growth, arrest of nephrocalcinosis, and preservation of
renal function.
Autosomal dominant distal RTA
In a few reported families the presence of the disorder in
several generations suggests an autosomal dominant
transmission [84, 85]. Although clinical findings are not
different from those observed in autosomal recessive or
sporadic cases, in these patients the disease may be diag-
nosed later or manifest with milder symptomatology.
Autosomal dominant distal RTA has been found to be as-
sociated in several kindreds with mutations in the
SLC4A1 gene encoding the CI–/HCO3– exchanger AEI
[86, 87, 88]. Neither morphological abnormalities nor in-
creased fragility are present in the erythrocytes, in con-
trast with an autosomal recessive AEI nonsense mutation
found in cattle which is associated with systemic acido-
sis, severe anemia, and red cell fragility [89].
The abnormalities described in patients with autoso-
mal dominant distal RTA mostly include missense muta-
tions in codon Arg589 (Arg589His, Arg589Ser,
Arg589Cys) found in various unrelated families, the
Ser613Phe and Gly1766A1a mutations found in two
families, and an 11-amino acid deletion at the carboxy
terminus found in another family [86, 87, 88]. One of
our patients presented a de novo Arg589His mutation
[88]. The frequent involvement of codon Arg589 indi-
cates the critical importance of this residue in the normal
acidification process. Arg589 lies at the intracellular bor-
der of the sixth transmembrane domain of the protein,
adjacent to Lys590. These basic residues are conserved
in all the known vertebrate exchanger isoforms and may
form part of the site of intracellular anion binding.
The few mutations described in distal RTA contrast
with the great number of AE1 mutations present in red
cell diseases such as hereditary spherocytosis and South-
east Asian ovalocytosis, where more than 20 different
missense, nonsense, and frameshift mutations have been
described [90]. A remarkable fact is that these hereditary
red cell disorders are not generally associated with distal
RTA. Administration of an acid load to ten patients from
seven unrelated families with hereditary spherocytosis
and AE1 deficiency revealed that uniquely two patients
from one family had an acidification defect [91]. Also,
the presence of distal RTA in hereditary ovalocytosis
[92] or elliptocytosis [93, 94] has been only exceptional-
ly described.
How can one explain either the absence of red cell ab-
normalities in patients with distal RTA or the rarity of
defects in distal urinary acidification in patients with he-
matological disorders, when in both circumstances muta-
tions in the same SLC4A1 gene are present?. Functional
analysis of the Arg589His mutation has revealed only a
modest reduction in AE1-mediated 36C1– transport when
expressed in Xenopus oocytes or of sulfate transport in
patients' red cells [86]. It is therefore possible that this
and other AE1 mutations do not lead to defective distal
acidification through a loss-of-function of the protein but
through an intracellular misrouting. Lack of insertion of
AE1 exchanger into the basolateral membrane or errone-
ous insertion into the apical membrane would interfere
with H+ secretion. The finding of high urine PCO2 val-
ues in an adult patient with distal RTA and ovalocytosis
favors the possibility that α-type intercalated cells se-
crete HCO3– instead of H+ due to the erroneous presence
of AE1 in the apical membrane [92]. This hypothesis is
also supported by the findings in two affected siblings
with a homozygous, loss-of-function mutation,
Gly701Asp [95]. AE1-Gly701Asp loss-of-function was
accompanied by impaired trafficking to the Xenopus oo-
cyte surface. Glycophorin A rescued both AE1-mediated
Cl– transport and AE1 surface expression in oocytes. In
conclusion, normal erythroid anion transport may be
present when the AE1 mutation leads to disrupted intra-
cellular trafficking rather than to significant loss-of-func-
tion of AE1. Conversely, in hematological disorders due
to AE1 mutations, remaining function of the exchanger
in the heterozygous carriers may be insufficient to pre-
serve the integrity of red cell membranes but sufficient
to maintain, with a few exceptions, normal distal H+ se-
cretion.
Autosomal recessive distal RTA
with sensorineural deafness
An important fraction of cases of sporadic or autosomal
recessive distal RTA develop sensorineural deafness.
This association was first noted by Royer and Broyer in
1967 [96], and to date some 50 cases have been de-
scribed [97]. Clinical findings, other than deafness, are
identical to those present in patients with sporadic or au-
tosomal recessive distal RTA and normal hearing. There
is great variation in the presentation of deafness, from
birth to late childhood, it is progressive and does not
ameliorate after alkali therapy.
Karet et al. [98] have recently demonstrated that most
patients with distal RTA and nerve deafness have muta-
tions in the gene ATP6B1 encoding the B1-subunit of
H+-ATPase. These represent the first genetic abnormali-
ties described in autosomal recessive distal RTA
(rdRTA1). They found 15 different mutations in 20 pa-
tients belonging to 15 kindreds. The nonsense mutation,
Ala31Stop, was found in three unrelated patients, frame-
shift mutations were identified in 4 patients, and 7 differ-
ent missense mutations were identified in 9 patients. Fi-
nally, mutations altering the highly conserved splice do-
nor (GT) or splice acceptor (CAG) sequences were iden-
tified in 4 patients. The mutations were distributed
across the ATP6B1 gene and not clustered in the protein
structure, suggesting that alterations in many parts of this
highly conserved molecule may result in loss of func-
tion.

The absence of ATP6B1 mutations in nine kindreds
with distal RTA and deafness indicates at least one addi-
tional locus [98]. An unknown gene may be also in-
volved in the pathogenesis of a novel disorder described
in two siblings with progressive central nervous system
calcification, nerve deafness, microcytic anemia, and re-
nal tubular acidosis, and in whom carbonic anhydrase II
was normal [99].
The findings reported by Karet et al. [98] open new
insights into the pathogenesis of hearing impairment.
They demonstrated that ATP6B1 mRNA was expressed
in fetal and adult human cochlea. Also, immunohisto-
chemical studies using a polyclonal antibody specific
for the carboxy terminus of the B1-subunit showed
high-intensity staining in the interdental cell layer of the
cochlear spiral limbus and in the epithelial cells of the
endolymphatic sac of neonatal mice. The interdental and
endolymphatic sac cells have both H+-ATPase and Cl–-
HCO3– exchanger, and closely resemble the α-type in-
tercalated cell [100]. A normal acid-secreting capacity
of these cells is necessary to maintain a low endolymph
pH and a normal auditory function. Therefore, it is high-
ly probable that mutations leading to alkalinization of
the endolymph will also result in impaired hearing func-
tion.
Autosomal recessive distal RTA with normal hearing
Karet et al. [101] have reported the results of genetic
analysis of thirteen kindred with autosomal recessive
distal RTA and normal hearing. Other than the difference
in hearing status there was no significant differences in
clinical or biochemical findings related to distal RTA. In
all kindreds, the involvement of the ATP6B1 gene could
be excluded. In nine kindreds, the disease could be
linked to the segment 7q33-34 (rdRTA2). However, in
four kindreds there was no evidence for such linkage,
thus implying the existence of at least one additional dis-
tal RTA locus.
Karet et al. [101] speculate about the identity of this
new gene, given the fact that no candidate genes are cur-
rently known to lie in the linked interval. They believe
that the rdRTA2 gene encodes a subunit of H+-ATPase.
Considering the normality of hearing function, one could
anticipate that only genes encoding specific renal iso-
forms of H+-ATPase subunits would be implicated. Mu-
tations in the SLC4A2 gene, encoding AE2, were exclud-
ed. Although this gene is also present in chromosome 7,
its locus is telomeric to that of rdRTA2. A defective H+-
K+-ATPase function at the apical surface of α-type inter-
calated cells has been previously proposed as a potential
mechanism of disease [102], but this possibility remains
highly theoretical since this transporter is more implicat-
ed in K+ than in H+ homeostasis [103].
Nevertheless, deficient H+-K+-ATPase function sec-
ondary to vanadium toxicity may be the cause of the en-
vironmental hypokalemic distal RTA present in north-
eastern Thailand [104].
1129
Combined proximal and distal RTA (type 3)
In some patients the delineation between proximal and
distal RTA is difficult to establish because they share
features of both forms. In these cases there is a striking
reduction in tubular reclamation of filtered HCO3–, but
in contrast to a situation of pure proximal dRTA, there is
also an inability to acidify the urine maximally despite
severe degrees of systemic acidemia.
Primary distal RTA with HCO3– wasting
The pattern of combined proximal and distal RTA may
be observed as a transient phenomenon in infants and
young children with primary distal RTA, and does not re-
present a different genetic entity [105, 106, 107]. Most
cases were observed during the 1960s and 1970s, may be
in relation to some exogenous factor such as a high salt
intake. It should be noted that this pattern of hereditary
distal RTA has almost disappeared over the past 2 de-
cades.
CA II deficiency
CA II deficiency is the primary defect in the autosomal
recessive syndrome of osteopetrosis, renal tubular acido-
sis, cerebral calcification, and mental retardation [108].
To date more than 50 cases have been reported world-
wide. However, the majority of patients come from
North Africa and the Middle East, with nearly 75% be-
ing of Arabic descent.
Most of the Mediterranean and Arab patients are ho-
mozygous for the so-called Arabic mutation, i.e., a
unique splice junction mutation at the boundary of exon
2/intron 2 [109, 110, 111]. Despite the presence of the
same mutation there is a great inter-/intra-familial phe-
notypic variability. In Arab patients, severe mental retar-
dation and metabolic acidosis are prominent, while bone
fractures are less frequent. In patients of different ethnic
origin other mutations are important, including single-
base deletion [112], missense mutations [113, 114], and a
different splice junction mutation [115].
All clinical findings may be explained as secondary to
CA II deficiency in different organs and systems. Renal
functional studies show the presence of impaired renal
reabsorption of HCO3–, failure to achieve maximally low
urine pH, decreased NH4+ excretion, low urine-to-blood
PCO2 difference in alkaline urine, and a high urinary ci-
trate level, all indicative of the coexistence of proximal
and distal RTA [116]. Osteopetrosis may be readily ex-
plained by the failure of osteoclasts to secrete acid to
dissolve bone mineral [117]. In this process both normal
activities of CA II and a specific vacuolar H+-ATPase are
required [16, 118]. Mice with a targeted deletion of ex-
ons 2–5 of the Atp6i gene, encoding a specific bone H+-
ATPase, also exhibit severe osteopetrosis [119]. Howev-
1130
er, not all mutant animals with osteopetrosis evidence
abnormalities in osteoclastic acid secretion and there are
at least four osteopetrotic mutations in the rat showing
normal osteoclastic CA II and H+-ATPase functions
[120]. CA II is present in oligodendrocytes and astro-
cytes and its deficiency may delay brain maturation and
result in mental retardation and cerebral calcification
[121].
The development of mutant mice (CAR2n) exhibiting
a loss-of-function point mutation in the CA2 gene has
been of great help in studying the pathogenesis of CA II
deficiency. This mutant mouse is generated by exposure
to N-ethyl-nitrosourea and transmission of the mutation
to the progeny [122]. The most-interesting study per-
formed in this mouse has been the correction of the acid-
ification defect by gene therapy. Lai et al. [123] per-
formed retrograde injection into the intrarenal pelvicaly-
ceal system of cationic liposome-complexed plasmid
containing human CA II cDNA under the control of the
cytomegalovirus early promoter. Expression of CA2
mRNA was highest by day 3 after treatment, but re-
mained undetectable after 1 month. After gene therapy
CA II-deficient mice had restored ability to acidify the
urine, but this ability was progressively lost by 6 weeks.
This study represents the first successful gene therapy of
a genetic renal disease and opens a completely new way
for treating other hereditary renal tubular disorders.
Hyperkalemic RTA (type 4)
Hyperkalemic RTA (type 4) accompanies a large number
of hyperkalemic states: the acidification defect is mainly
caused by impaired renal ammoniagenesis. It is charac-
terized by a normal ability to acidify the urine after an
acid load, but net acid excretion remains subnormal due
to a very low rate of NH4+ excretion. Although the de-
crease in NH3 production is mainly caused by hyperkale-
mia itself, aldosterone deficiency or resistance may also
play important contributory roles [124]. Hyperkalemic
RTA of hereditary origin is most frequently observed in
children with primary pseudohypoaldosteronism.
Pseudohypoaldosteronism type 1
Pseudohypoaldosteronism type 1 (PHA1) is a hereditary
condition characterized by salt wasting, hyperkalemia,
and metabolic acidosis in the presence of markedly ele-
vated plasma renin activity and aldosterone concentra-
tion. Since its first description by Check and Perry in
1958 [125], many cases have been reported. In recent
years, it has become clear that PHA1 is a heterogeneous
syndrome that includes at least two clinically and geneti-
cally distinct entities with either renal or multiple target
organ defects [126].
The autosomal dominant renal form represents the
most frequently encountered form of PHA1. These pa-
tients present with salt wasting, metabolic acidosis, and
hyperkalemia, but do not have pulmonary, sweat glands,
or any other organ involvement. Clinical features are ex-
tremely variable, from severe neonatal sodium loss and
menacing hyperkalemia to lack of symptoms throughout
life [127]. Although the primary defect persists forever,
improvement may occur beyond 1 or 2 years of age, due
to maturation of proximal tubular transport, development
of salt appetite, and improvement in the renal tubular re-
sponse to mineralocorticoids [128].
The pathogenesis of renal PHA1 has been greatly
clarified with the identification of heterozygous muta-
tions in the mineralocorticoid receptor gene in one spo-
radic and four dominant kindreds with this disease [129].
The mutations found included two frameshift mutations,
which resulted in deletion of a single base pair in exon 2,
one premature stop codon in exon 2 at codon 537, and a
single pair deletion in the intron 5 splice donor site. In
two patients no mutations in the MRL gene could be
demonstrated, indicating either the existence of other
mutations in additional genes or the implication of non-
genetic factors.
The observation that many adult gene carriers have
elevated aldosterone levels but no history of clinical dis-
ease raises the possibility that only a fraction of such
carriers develop clinically evident disease [130]. The
reasons for the phenotype differences are unknown, but
may be related to intercurrent volume-depleting events
or to dietary habits of salt ingestion.
The coexistence of polymorphisms or mutations in
the gene encoding ENaC could also play a potential con-
tributory role. Polymorphisms and mutations which lead
to either loss-of-function or gain-of-function of the epi-
thelial Na+ channel may aggravate or attenuate, respec-
tively, the consequences of deficient mineralocorticoid
receptor function [131, 132, 133].
Mineralocorticoid receptor-deficient mice have been
generated by gene targeting technology [134]. These
MRL knock-out mice develop symptoms of pseudohypo-
aldosteronism soon after birth, which can be compensat-
ed by abundant sodium chloride administration [135].
The renin-angiotensin-aldosterone system is greatly
stimulated with maximal expression of renin mRNA in
kidney and adrenal gland [136].
A few kindreds have been reported with PHA1 due to
multiple target organ resistance (kidney, colon, sweat
and salivary glands) since its original description [137].
This variant is inherited as an autosomal recessive disor-
der, with uniform expression. The parents of affected
children are asymptomatic and evidence normal plasma
aldosterone levels. This autosomal recessive form
presents with more-severe salt wasting and has a poorer
outcome than the renal form. Patients manifest salt wast-
ing episodes early after birth, and death may ensue dur-
ing the neonatal period. Sweat and salivary electrolytes
are markedly elevated. The high incidence of lower res-
piratory tract involvement may contribute to the confu-
sion with cystic fibrosis [138, 139].
lt has recently been demonstrated that this entity is
caused by loss-of-function mutations of genes encoding

one of the three constitutive subunits (α, β, and γ) of the
ENaC. Conversely, Liddle syndrome is caused by gain-
of-function mutations of only the genes encoding the
subunits β and γ of the ENaC [140]. In the recessive
form, homozygous mutations have been identified in all
three ENaC subunits and include frameshift, missense,
and premature stop codons [141, 142, 143, 144]. Critical
hot spots for loss-of-function mutations seem to be the
cysteine-rich domains in the large extracellular loop of
the proteins [145].
Multiple target organ PHA1 is due to defective Na+
transport in many organs containing the ENaC: kidney,
lung, colon, and exocrine glands. Insights into pathogen-
esis have been facilitated by the development of trans-
genic mouse models in which expression of the α, β, or γ
subunits of ENaC has been abated. Interestingly, only the
αENaC-deficient mice have marked failure to clear the
fetal lung fluid that leads to early neonatal death [146]. lf
the mice are "rescued" from death by the engineered ex-
pression of the α-subunit gene in the lung, they develop
a full-blown picture of pseudohypoaldosteronism, with
salt wasting and hyperkalemia [147]. The βENaC- and
γENaC-deficient mice do not die of neonatal respiratory
failure and develop from birth a very severe picture of
neonatal salt wasting and hyperkalemia, similar to hu-
man PHA1 [148, 149, 150].
The neonatal lung findings present in αENaC-defi-
cient mice are only exceptionally observed in humans
[151], despite impressive truncations of the α-subunit in
some kindreds. Bonny et al. [143] tried to explain this
discrepancy by demonstrating that the tetrameric struc-
ture of ENaC (αβαγ), although formed in humans by
two mutated α-subunits, maintains a low but sufficient
Na+ transport activity to absorb the fetal pulmonary flu-
id. However, some impairment in Na+ transport across
airway epithelia may persist throughout life. In fact, pul-
monary symptoms in patients with autosomal recessive
PHA1 are not always related to infection and may be
secondary, especially in young patients, to failure to ab-
sorb liquid from airway surfaces [144, 152]. The defect
in Na+ transport can be demonstrated by measurement of
transepithelial voltage across the nasal epithelium [153].
Early childhood hyperkalemia
A transient syndrome of hyperkalemia and metabolic ac-
idosis, without clinical salt wasting, has been described
in infancy. Plasma renin activity and aldosterone excre-
tion were consistently normal or elevated [154, 155].
This entity has been called “early-childhood” hyperkale-
mia and represents a variant of the renal form of PHA1
probably due to a maturation disorder in the number or
function of mineralocorticoid receptors. This hypothesis,
however, remains highly speculative because it does not
explain the absence of salt wasting.
1131
Pseudohypoaldosteronism type 2
(Gordon syndrome)
An autosomal dominant syndrome of arterial hyperten-
sion, hyperkalemia, metabolic acidosis, and suppressed
plasma renin activity was characterized as a new clinical
entity by Gordon et al. in 1970 [156]. Less than 50 cases
with so-called Gordon syndrome have been reported in
the literature [157]. Hypertension represents a feature
limited to adolescent or adult individuals. A similar con-
dition has been reported in children with short stature,
hyperkalemia, and metabolic acidosis but with normal
blood pressure (Spitzer-Weinstein syndrome) [158, 159].
The name of “chloride-shunt” syndrome has been also
proposed, according to the hypothesis that the primary
abnormality is a tubular hyper-reabsorption of sodium
chloride in the thick ascending loop of Henle or early
distal tubule that leads to impaired K+ and H+ secretion
in cortical collecting duct as a consequence of a voltage-
shunting defect [160].
The genetic defect persists unknown. Linkage analy-
sis in eight affected families showing autosomal domi-
nant transmission demonstrated locus heterogeneity of
the trait with involvement of chromosomes 1q31–42 and
17p11-q21 [161]. Therefore, gain-of-function mutations
at the genes encoding bumetanide-sensitive Na-K-2Cl
cotransporter, thiazide-sensitive Na-Cl cotransporter and
chloride channel ClC-Kb can be readily excluded. An at-
tractive hypothesis is that the syndrome results from
gain-of-function mutations of a carrier protein governing
sodium chloride passage across the paracellular tight
junctions of the thick ascending loop of Henle. However,
the existence of such a carrier protein remains to be
proved.
Future perspectives
Molecular biology studies have opened completely new
insights into the pathogenesis of RTA. At present only a
few genes controlling renal H+, HCO3–, and Na+ trans-
port have been implicated, but soon other candidate
genes will surely join the spectrum of genetic causes of
primary RTA. However, “loss-of-function” resulting
from observed mutations has been experimentally dem-
onstrated in only a few cases. Over the next few years
functional studies with the mutant genes expressed in a
heterologous system such as the Xenopus oocyte will be
necessary to demonstrate the functional consequences of
specific mutations. Also, molecular studies will also help
to better understand cases of secondary RTA. Immuno-
histochemical techniques using mono- or polyclonal an-
tibodies against specific renal transporters have already
been used to clarify the pathogenesis of distal RTA asso-
ciated with immune-mediated diseases such as thyroidi-
tis, systemic lupus erythematosus nephritis, and Sjögren
syndrome [162, 163]. Direct study in renal tissue of gene
expression of such transporters will soon ensue. Unfortu-
nately, these molecular studies do not offer any obvious
1132
advantage with regard to therapy, since gene transfer in
the kidney is only expected to be clinically available in
the distant future, and be initially oriented to more-com-
mon renal disorders, such as transplantation, polycystic
disease or cancer [164]. Fortunately, the therapeutic
needs of most patients with primary RTA are easily cov-
ered with alkali therapy. Nevertheless, application of
gene therapy to generalized disorders such as CA II defi-
ciency or autosomal recessive pseudohypoaldosteronism
type 1 remains a prospect for the future.
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L I T E R AT U R E A B S T R A C T S
H. Kaul · M. Girndt · U. Sester · M. Sester · H. Kohler
Initiation of hemodialysis treatment leads
to improvement of T-cell activation in patients
with end-stage renal disease
Am J Kidney Dis (2000) 35:611–616
Patients with chronic renal failure show an immunodeficiency
characterized by frequent infectious complications and a low re-
sponse to vaccinations. This is paralleled in vitro by a low T-cell
proliferation on mitogenic stimuli because of an impaired costim-
ulation by accessory cells. Furthermore, alterations of the cytokine
profile are correlated with impaired immune function. The im-
mune system is influenced by both uremia and renal replacement
therapy. To evaluate the influence of hemodialysis on immune pa-
rameters, we studied patients before and after the initiation of
chronic hemodialysis therapy. Fourteen patients with end-stage re-
nal failure were tested before dialysis initiation and during the first
6 weeks of hemodialysis treatment. We determined the in vitro T-
cell proliferation, as well as plasma levels of interleukin-6 (IL-6)
and the release of IL-6 and IL-10 into culture supernatant post-
stimulation with lipopolysaccharide. After 6 weeks of intermittent
hemodialysis, in vitro T-cell proliferation on stimulation improved
significantly (stimulation index, 21.6 +/– 18.5 versus 58.1
+/– 45.5; P < 0.01). This improvement occurred regardless of
whether synthetic dialyzers or cellulosic membranes were used for
the initiation of dialysis. Plasma IL-6 levels, as well as IL-6 and
IL-10 secretion, did not change during the study period. In pa-
tients with end-stage renal disease, the initiation of hemodialysis
led to a significant improvement of in vitro T-cell proliferation.
This effect may have a role for an improvement of immune func-
tion in vivo. The expected normalization of IL-6 and IL-10 pro-
duction may be masked by cytokine induction through hemodialy-
sis membranes.
161. Mansfield TA, Simon DB, Farfel Z, Bia M, Tucci JTR,
Lebel M, Gutkin M, Vialettes B, Christofilis MA, Kaup-
pinen-Makelin R, Mayan H, Risch N, Lifton RP (1997)
Multilocus linkage of familial hyperkalaemia and hyperten-
sion, pseudohypoaldosteronism type II, to chromosomes
1q31–42 and 17p11–q21. Nat Genet 16:202–205
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Gluck S, Yang L (1996) Preservation of intercalated cell H+-
ATPase in two patients with lupus nephritis and hyper-
kalemic distal renal tubular acidosis. J Am Soc Nephrol
8:1109–1117
163. Jon KW, Jeon US, Han JS, Ahn C, Kim S, Lee JS, Kim GH,
Cho YS, Kim YH, Kim J (1998) Absence of H+-ATPase in
the intercalated cells of renal tissues in classic distal renal
tubular acidosis. Clin Nephrol 49:226–231
164. Kelley VR, Sukhatme VP (1999) Gene transfer in the kid-
ney. Am J Physiol 276:Fl–F9
D.K. Wilson · D.A. Sica · S.B. Miller
Effects of potassium on blood pressure
in salt-sensitive and salt-resistant black
adolescents
Hypertension (1999) 34:181–186
This study examined the effects of increasing dietary potassium on
ambulatory blood pressure nondipping status (<10% decrease in
blood pressure from awake to asleep) and cardiovascular reactivi-
ty in salt-sensitive and salt-resistant black adolescents. A sample
of 58 normotensive (blood pressure, 101/57+/–9/4 mm Hg) black
adolescents (aged 13 to 16 years) participated in a 5-day low sodi-
um diet (50 mmol/24 h) followed by a 10-day high sodium diet
(150 mmol/24 h NaCl supplement) to determine salt-sensitivity
status. Participants showed a significant increase in urinary sodi-
um excretion (24+/–19 to 224+/–65 mmol/24 h) and were identi-
fied as salt-sensitive if their mean blood pressure increase was
>/=5 mm Hg from the low to high sodium diet. Sixteen salt-sensi-
tive and 42 salt-resistant subjects were then randomly assigned to
either a 3-week high potassium diet (80 mmol/24 h) or usual diet
control group. Urinary potassium excretion significantly increased
in the treatment group (35+/–7 to 57+/–21 mmol/24 h). At base-
line, a significantly greater percentage of salt-sensitive (44%)
compared with salt-resistant (7%) subjects were nondippers on the
basis of diastolic blood pressure classifications (P<0.04). After the
dietary intervention, all of the salt-sensitive subjects in the high
potassium group achieved dipper status as a result of a drop in
nocturnal diastolic blood pressure (daytime, 69 versus 67 mm Hg;
nighttime, 69 versus 57 mm Hg). No significant group differences
in cardiovascular reactivity were observed. These results suggest
that a positive relationship between dietary potassium intake and
blood pressure modulation can still exist even when daytime blood
pressure is unchanged by a high potassium diet.