Clinical and diagnostic features of Bartter and Gitelman syndromes

Abstract

Background: Bartter and Gitelman syndromes are autosomal recessive disorders of renal tubular salt handling. Due to their rarity, limited long-term data are available to inform prognosis and management.

Methods: Long-term longitudinal data were analysed for 45 children with pathogenic variants in SLC12A1 (n = 8), KCNJ1 (n = 8), CLCNKB (n = 17), BSND (n = 2) and SLC12A3 (n = 10) seen at a single centre between 1984 and 2014. Median follow-up was 8.9 [interquartile range (IQR) 0.7-18.1] years.

Results: Polyhydramnios and prematurity were seen in children with SLC12A1 and KCNJ1 mutations. Patients with CLCNKB mutations had the lowest serum potassium and serum magnesium and the highest serum bicarbonate levels. Fractional excretion of chloride was >0.5% in all patients prior to supplementation. Nephrocalcinosis at presentation was present in the majority of patients with SLC12A1 and KCNJ1 mutations, while it was only present in one patient with CLCNKB and not in SLC12A3 or BSND mutations. Growth was impaired, but within the normal range (median height standard deviation score -1.2 at the last follow-up). Impaired estimated glomerular filtration rate (eGFR <90 mL/min/1.73 m²) at the last follow-up was seen predominantly with SLC12A1 [71 mL/min/1.73 m² (IQR 46-74)] and KCNJ1 [62 mL/min/1.73 m² (IQR 48-72)] mutations. Pathological albuminuria was detected in 31/45 children.

Conclusions: Patients with Bartter and Gitelman syndromes had a satisfactory prognosis during childhood. However, decreased eGFR and pathologic proteinuria was evident in a large number of these patients, highlighting the need to monitor glomerular as well as tubular function. Electrolyte abnormalities were most severe in CLCNKB mutations both at presentation and during follow-up. Fractional excretion of chloride prior to supplementation is a useful screening investigation in children with hypokalaemic alkalosis to establish renal salt wasting.

Keywords: Bartter syndrome; Gitelman syndrome; chronic kidney disease; hypokalaemic metabolic alkalosis; renal tubular disease.

Fig. 1.

Biochemical data at presentation and last follow-up. Dotted lines indicate upper and lower limits of reference range. (A) Potassium at presentation and (B) at last follow-up. (C) Bicarbonate at presentation and (D) at last follow-up. (E) Magnesium at presentation and (F) at last follow-up. (G) Urine calcium:creatinine ratio at presentation. (H) eGFR at last follow-up. *P < 0.05. ^#Bicarbonate as measured in the laboratory (initial bicarbonate calculated on blood gas analysis was 80 mmol/L, described in detail by Plumb et al. [10]).