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or by determining maximum urinary pCO<span class="elsevierStyleInf">2</span> &#40;UpCO<span class="elsevierStyleInf">2</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">4</span></a> Clinically&#44; distal RTA is characterised by the presence of polyuria&#44; polydipsia&#44; nephrocalcinosis&#44; hypokalaemia&#44; persistently alkaline urine&#44; hypercalciuria&#44; hypocitraturia&#44; and a defect in renal concentrating capacity&#44; with a tendency towards dehydration&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Secondary forms of distal RTA&#44; more common in adults&#44; are associated with the administration of drugs or toxins&#44; or with systemic or immunological diseases&#46; In children&#44; secondary causes are less common&#44; and have been described in cases of Sj&#246;gren&#39;s syndrome<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a> or systemic lupus erythematosus&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> or after oral intake of some medications&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Few cases of distal RTA associated with classic hypothyroidism or with autoimmune thyroid disease have been reported&#46; 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dry oral mucosa&#44; tachycardia&#44; signs of pulmonary consolidation in the right hemithorax&#44; and distended abdomen with decreased peristalsis&#46; A chest X-ray confirmed the diagnosis of pneumonia&#44; and an abdominal X-ray was compatible with metabolic ileus&#46; Laboratory test findings included metabolic acidosis&#44; hyperchloraemia and hypokalaemia&#44; which persisted despite restoration of the fluid balance &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; A urine test found hypercalciuria and hypocitraturia &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and the kidney ultrasound showed grade 2 nephrocalcinosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; An acetazolamide- and sodium bicarbonate-loading test was performed&#44; obtaining a maximum urinary pCO<span class="elsevierStyleInf">2</span> of 47<span class="elsevierStyleHsp" style=""></span>mmHg at 60<span class="elsevierStyleHsp" style=""></span>min &#40;urine-blood pCO<span class="elsevierStyleInf">2</span> gradient&#58; 15<span class="elsevierStyleHsp" style=""></span>mmHg&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The audiometry test was normal&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">After reaching a diagnosis of distal RTA&#44; treatment with potassium citrate solution was initiated &#40;4<span class="elsevierStyleHsp" style=""></span>mEq&#47;kg&#47;day&#41;&#44; with no improvement in weight and height&#44; and persistence of asthenia&#44; adynamia and somnolence&#46; The thyroid function test showed thyroid-stimulating hormone &#40;TSH&#41; levels of more than 150<span class="elsevierStyleHsp" style=""></span>mU&#47;l&#44; T3 levels of 0&#46;19<span class="elsevierStyleHsp" style=""></span>ng&#47;ml and undetectable T4&#46; Blood samples were positive for antithyroglobulin &#40;181&#46;6<span class="elsevierStyleHsp" style=""></span>IU&#47;ml&#41; and antiperoxidase &#40;373&#46;2<span class="elsevierStyleHsp" style=""></span>IU&#47;ml&#41; antibodies&#46; Levothyroxine was started&#44; and the patient&#39;s weight and height improved&#46; Now&#44; at 11 years of age&#44; her weight is 29<span class="elsevierStyleHsp" style=""></span>kg &#40;p8&#37;&#41; and her height 133<span class="elsevierStyleHsp" style=""></span>cm &#40;p6&#37;&#41;&#59; urinary acidification defect persists &#40;maximum urinary pCO<span class="elsevierStyleInf">2</span> of 49<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">No molecular alterations were observed in <span class="elsevierStyleItalic">ATP6V0A4</span>&#44; <span class="elsevierStyleItalic">ATP6V1B1</span> and <span class="elsevierStyleItalic">SLC4A1</span> genes analysed by targeted exon and exon-intron transition sequencing&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case 2</span><p id="par0040" class="elsevierStylePara elsevierViewall">This was a 13-year-old girl&#44; with no significant family history&#44; with arrested weight gain and growth from the age of 7&#46; Since then&#44; she had presented 4 episodes of limb paralysis and generalised weakness&#44; with craniocervical instability and bilateral genu valgum&#46; At age 11 she was diagnosed with hypothyroidism&#44; and started treatment with levothyroxine&#46; She was subsequently referred to the hospital for a hypokalaemia study&#46; The results of the blood and urine panels and acidification test are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46; Along with the distal acidification defect&#44; a bicarbonate leak in the proximal tubule&#44; compatible with type 3 RTA was observed &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Kidney ultrasound showed bilateral grade 2 nephrocalcinosis&#46; The audiometry assessment was normal&#46; Blood samples were positive for antithyroglobulin &#40;246&#46;8<span class="elsevierStyleHsp" style=""></span>IU&#47;ml&#41; and antiperoxidase &#40;92&#46;6<span class="elsevierStyleHsp" style=""></span>IU&#47;ml&#41; antibodies&#46; One year after the diagnosis of RTA&#44; the patient required higher doses of citrate&#44; and the urinary acidification defect &#40;maximum urinary pCO<span class="elsevierStyleInf">2</span> of 53<span class="elsevierStyleHsp" style=""></span>mmHg&#41; persists&#46; Now&#44; at 14 years of age&#44; she weighs 40<span class="elsevierStyleHsp" style=""></span>kg &#40;p5&#37;&#41; and her height is 138<span class="elsevierStyleHsp" style=""></span>cm &#40;p0&#37;&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Thyroid hormones influence kidney development&#44; kidney structure&#44; renal haemodynamics&#44; glomerular filtration rate&#44; the function of many transport systems along the nephron&#44; in particular those related to the management of sodium&#44; acid&#8211;base balance and renal concentrating capacity&#46; These effects of the thyroid hormone are in part due to direct renal actions&#44; and in part to cardiovascular and systemic haemodynamic effects that influence kidney function&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Thyroid hormones directly influence the expression and&#47;or activity of a number of ion channels and transporters&#46; Pioneering micropuncture studies in hypothyroid rats have shown a reduction in the renal glomerular filtration rate &#40;GFR&#41; and an increase in the urinary excretion of sodium and water&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> A subsequent study reported that the thyroid hormone regulates the activity of the proximal tubular type 3 Na<span class="elsevierStyleSup">&#43;</span>&#47;H<span class="elsevierStyleSup">&#43;</span> exchanger &#40;NHE3&#41;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; an effect that is due to direct binding of the hormone with the promoter region of the encoding gene&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">A study published in 2007 confirmed the activity of several transporters involved in sodium and acid&#8211;base balance in rats rendered hypothyroid by the administration of methimazole&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a> The results obtained are summarised in the footer of <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; Basically&#44; the activity of several proximal tubule transporters is reduced&#44; which results in a loss of sodium and a reduction in the elimination of hydrogen ions at this level&#44; while expression of the Cl<span class="elsevierStyleSup">&#8722;</span>&#47;HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> &#40;AE1&#41; exchanger specific to &#945;-intercalated cells of the connecting tubule and cortical collecting duct increases&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a> This shows&#44; therefore&#44; that thyroid hormone deficiency is associated with a defect in the renal handling of sodium and of the acid&#8211;base balance&#44; which is mainly located in the proximal tubule and is compensated by the distal nephron&#46; Consequently&#44; on a physiological level&#44; the thyroid hormone modulates the renal response to acid overload and alters the expression of several transporters that are key in the maintenance of the acid&#8211;base balance&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">This begs the question of why significant proximal sodium loss does not lead to reduced levels of sodium in hypothyroidism&#46; This was studied in transgenic mice deficient in the Na<span class="elsevierStyleSup">&#43;</span>&#47;H<span class="elsevierStyleSup">&#43;</span> &#40;NHE3&#41; exchanger<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a> and in adults with mutations in the encoding gene&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> In these cases&#44; loss of NHE3 was compensated by a reduction in GFR caused by adenosine-induced vasoconstriction of the afferent arteriole&#46; This is one of the reasons why GFR is reduced in hypothyroid patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A study published in the 1970s showed that 2 of 5 adults with primary hypothyroidism without metabolic acidosis and with no clinical evidence of autoimmune disease were unable to lower their urine pH appropriately after short duration acid-loading<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a>&#59; this is typical of incomplete distal RTA&#46; Subsequently&#44; various cases of type 1 RTA have been described in adults with non-autoimmune hypothyroidism&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">18&#44;19</span></a> One of these patients presented with hyperkalaemia &#40;type 4 RTA&#41; compatible with an increase in Na<span class="elsevierStyleSup">&#43;</span> levels in the tubular lumen of the collecting duct and impaired distal secretion due to an H<span class="elsevierStyleSup">&#43;</span> and K<span class="elsevierStyleSup">&#43;18</span> gradient defect&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">However&#44; most patients with both clinical conditions presented autoimmune hypothyroidism&#46; This combination has been described both in adults<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">20&#8211;22</span></a> and children<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">23&#44;24</span></a>&#59; in one of these cases of RTA&#44; serum levels of T3&#44; T4 and TSH were normal&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a> supporting the notion that&#44; as in other autoimmune diseases&#44; antithyroid antibodies can <span class="elsevierStyleItalic">per se</span> can have a negative effect on renal acidification capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;7</span></a> There are several references in the literature to the triple association of RTA&#44; hypothyroidism and another autoimmune disease such as diabetes mellitus<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a> or Sj&#246;gren&#39;s syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">26&#44;27</span></a> The fact that our second case was diagnosed with RTA 2 years after starting treatment with thyroid hormone supports the hypothesis that antithyroid antibodies have a negative effect on renal acidification capacity&#44; although poor compliance with replacement treatment cannot be entirely ruled out&#46; The pathophysiological mechanism of distal RTA associated with autoimmune disease is not well understood&#46; In patients with Sj&#246;gren&#39;s syndrome&#44; immunohistochemical studies have shown the absence of vacuolar H<span class="elsevierStyleSup">&#43;</span>-ATPase in collecting duct cells obtained from renal biopsies&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> More recently&#44; in the same disease&#44; autoantibodies against carbonic anhydrase II enzymes have been described &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The test used to determine maximum urinary pCO<span class="elsevierStyleInf">2</span> in both our patients is a variant of the one previously described by our Group&#46; In this challenge&#44; acetazolamide and sodium bicarbonate are administered simultaneously at lower doses than usual&#44; thus obtaining valid results &#40;urinary HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#41; while avoiding significant side effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">4&#44;30&#44;31</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The loss of proximal bicarbonate reported in case 2 must be associated with a reduction in the activity of both the Na<span class="elsevierStyleSup">&#43;</span>&#47;H<span class="elsevierStyleSup">&#43;</span> exchanger &#40;NHE3&#41; and the Na<span class="elsevierStyleSup">&#43;</span>&#47;HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> &#40;NBCe1&#41; cotransporter&#44; as described above &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a> However&#44; being a type 3 RTA &#40;proximal and distal&#41; the patient could&#44; theoretically&#44; be a carrier of autoantibodies against carbonic anhydrase II&#44; which is functional in both the proximal and distal portions of the nephron&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Renal tubular acidosis"
            1 => "Hypothyroidism"
            2 => "Autoimmunity"
            3 => "Maximum urinary pCO<span class="elsevierStyleInf">2</span>"
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            0 => "Acidosis tubular renal"
            1 => "Hipotiroidismo"
            2 => "Autoinmunidad"
            3 => "pCO<span class="elsevierStyleInf">2</span> urinaria m&#225;xima"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Two cases of children diagnosed with renal tubular acidosis &#40;RTA&#41; associated with autoimmune hypothyroidism are presented&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Case 1 developed an intestinal ileus at the age of five in the context of a respiratory problem&#46; The tests performed confirmed metabolic acidosis&#44; hyperchloraemia&#44; hypokalaemia and nephrocalcinosis&#46; Case 2 was diagnosed with hypothyroidism at the age of 11&#44; and with RTA two years later&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In both patients&#44; the diagnosis of RTA was verified when decreased maximum urinary pCO<span class="elsevierStyleInf">2</span> was found&#46; In case 2&#44; a proximal bicarbonate leak &#40;type 3 RTA&#41; was also confirmed&#46; This was the first case to be published on the topic&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The causes of RTA in patients with hypothyroidism are reviewed&#46; The deleterious effect on the kidneys may be due to the absence of thyroid hormone and&#47;or autoantibodies in the cases of autoimmune hypothyroidism&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se presentan dos casos en edad pedi&#225;trica diagnosticados de acidosis tubular renal &#40;ATR&#41; asociada a hipotiroidismo de causa autoinmune&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El caso 1 desarroll&#243; un &#237;leo intestinal a los 5 a&#241;os de edad en el seno de un problema respiratorio&#46; En los ex&#225;menes realizados se constat&#243; acidosis metab&#243;lica&#44; hipercloremia&#44; hipopotasemia y nefrocalcinosis&#46; El caso 2 fue diagnosticado de hipotiroidismo a los 11 a&#241;os de edad y 2 a&#241;os despu&#233;s&#44; de ATR&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En ambos pacientes&#44; se comprob&#243; el diagn&#243;stico de ATR al observarse una pCO<span class="elsevierStyleInf">2</span> urinaria m&#225;xima reducida&#46; En el caso 2 se constat&#243;&#44; adem&#225;s&#44; una fuga proximal de bicarbonato &#40;ATR tipo 3&#41;&#44; que constituye el primer caso publicado sobre el tema&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se revisan las causas de ATR en pacientes con hipotiroidismo&#46; El efecto delet&#233;reo sobre el ri&#241;&#243;n puede ser debido a la propia ausencia de hormona tiroidea y&#47;o a los autoanticuerpos en los casos de hipotiroidismo autoinmune&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guerra-Hern&#225;ndez NE&#44; Ordaz-L&#243;pez KV&#44; Vargas-Poussou R&#44; Escobar-P&#233;rez L&#44; Garc&#237;a-Nieto VM&#46; Acidosis tubular renal distal en dos ni&#241;as diagnosticadas de hipotiroidismo adquirido&#46; Nefrologia&#46; 2018&#59;38&#58;655&#8211;659&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The expression of the Na<span class="elsevierStyleSup">&#43;</span>&#47;H<span class="elsevierStyleSup">&#43;</span> exchanger &#40;NHE3&#41;&#44; the Na&#43;-phosphate cotransporter NaPi-IIa&#44; and the B2 subunit of the vacuolar H<span class="elsevierStyleSup">&#43;</span>-ATPase &#40;not shown here&#41; is reduced in the brush-border membrane of the proximal tubule in hypothyroid rats&#46; This is accompanied by a lower abundance of the Na<span class="elsevierStyleSup">&#43;</span>&#47;HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> cotransporter &#40;NBCe1&#41; and a higher expression of the acid-secretory type A intercalated cell-specific Cl<span class="elsevierStyleSup">&#8722;</span>&#47;HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> exchanger &#40;AE1&#41; in the connecting tubule and cortical collecting duct&#46; NBCe1 expression and the number of &#945;-intercalated cells increased in hypothyroid rats during metabolic acidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a> ACII&#58; carbonic anhydrase II&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Case 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Case 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Venous blood gas</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>pH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> &#40;mEq&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Serum chlorine &#40;mmol&#47;l&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Serum potassium &#40;mmol&#47;l&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Serum uric acid&#44; &#40;mg&#47;dl&#41;</span>&nbsp;\t\t\t\t\t\t\n
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Case report
Distal renal tubular acidosis in two children with acquired hypothyroidism
Acidosis tubular renal distal en dos niñas diagnosticadas de hipotiroidismo adquirido
Norma E. Guerra-Hernándeza,
Corresponding author
, Karen V. Ordaz-Lópeza, Rosa Vargas-Poussoub, Laura Escobar-Pérezc, Víctor M. García-Nietod
a Servicio de Nefrología Pediátrica, Hospital General del Centro Médico Nacional «La Raza», Instituto Mexicano del Seguro Social (IMSS), Ciudad de México, Mexico
b Departamento de Genética y Fisiología, Hospital Europeo Georges Pompidou, París, France
c Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de México, Ciudad de México, Mexico
d Sección de Nefrología Pediátrica, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
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or by determining maximum urinary pCO<span class="elsevierStyleInf">2</span> &#40;UpCO<span class="elsevierStyleInf">2</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">4</span></a> Clinically&#44; distal RTA is characterised by the presence of polyuria&#44; polydipsia&#44; nephrocalcinosis&#44; hypokalaemia&#44; persistently alkaline urine&#44; hypercalciuria&#44; hypocitraturia&#44; and a defect in renal concentrating capacity&#44; with a tendency towards dehydration&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Secondary forms of distal RTA&#44; more common in adults&#44; are associated with the administration of drugs or toxins&#44; or with systemic or immunological diseases&#46; In children&#44; secondary causes are less common&#44; and have been described in cases of Sj&#246;gren&#39;s syndrome<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">6</span></a> or systemic lupus erythematosus&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">7</span></a> or after oral intake of some medications&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Few cases of distal RTA associated with classic hypothyroidism or with autoimmune thyroid disease have been reported&#46; Even fewer cases have been reported in children&#46; We report the cases of two girls with acquired hypothyroidism associated with secondary distal RTA&#46; The association between hypothyroidism and type 3 RTA in one of the patients is the first case reported in the literature&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case 1</span><p id="par0025" class="elsevierStylePara elsevierViewall">A girl aged 5 years and 7 months&#44; with a history of abdominal distension from the first months of life&#44; together with arrested weight gain and growth from the age of 2 &#40;below the 3rd percentile&#41;&#46; She was admitted due to a 3-day history of fever of 39<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; greenish rhinorrhoea&#44; productive cough and pharyngeal pain&#44; accompanied by progressive respiratory difficulty&#44; polypnoea and abdominal distension&#46; On admission&#44; the physical examination found severe dehydration&#44; dry oral mucosa&#44; tachycardia&#44; signs of pulmonary consolidation in the right hemithorax&#44; and distended abdomen with decreased peristalsis&#46; A chest X-ray confirmed the diagnosis of pneumonia&#44; and an abdominal X-ray was compatible with metabolic ileus&#46; Laboratory test findings included metabolic acidosis&#44; hyperchloraemia and hypokalaemia&#44; which persisted despite restoration of the fluid balance &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; A urine test found hypercalciuria and hypocitraturia &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; and the kidney ultrasound showed grade 2 nephrocalcinosis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; An acetazolamide- and sodium bicarbonate-loading test was performed&#44; obtaining a maximum urinary pCO<span class="elsevierStyleInf">2</span> of 47<span class="elsevierStyleHsp" style=""></span>mmHg at 60<span class="elsevierStyleHsp" style=""></span>min &#40;urine-blood pCO<span class="elsevierStyleInf">2</span> gradient&#58; 15<span class="elsevierStyleHsp" style=""></span>mmHg&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; The audiometry test was normal&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">After reaching a diagnosis of distal RTA&#44; treatment with potassium citrate solution was initiated &#40;4<span class="elsevierStyleHsp" style=""></span>mEq&#47;kg&#47;day&#41;&#44; with no improvement in weight and height&#44; and persistence of asthenia&#44; adynamia and somnolence&#46; The thyroid function test showed thyroid-stimulating hormone &#40;TSH&#41; levels of more than 150<span class="elsevierStyleHsp" style=""></span>mU&#47;l&#44; T3 levels of 0&#46;19<span class="elsevierStyleHsp" style=""></span>ng&#47;ml and undetectable T4&#46; Blood samples were positive for antithyroglobulin &#40;181&#46;6<span class="elsevierStyleHsp" style=""></span>IU&#47;ml&#41; and antiperoxidase &#40;373&#46;2<span class="elsevierStyleHsp" style=""></span>IU&#47;ml&#41; antibodies&#46; Levothyroxine was started&#44; and the patient&#39;s weight and height improved&#46; Now&#44; at 11 years of age&#44; her weight is 29<span class="elsevierStyleHsp" style=""></span>kg &#40;p8&#37;&#41; and her height 133<span class="elsevierStyleHsp" style=""></span>cm &#40;p6&#37;&#41;&#59; urinary acidification defect persists &#40;maximum urinary pCO<span class="elsevierStyleInf">2</span> of 49<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">No molecular alterations were observed in <span class="elsevierStyleItalic">ATP6V0A4</span>&#44; <span class="elsevierStyleItalic">ATP6V1B1</span> and <span class="elsevierStyleItalic">SLC4A1</span> genes analysed by targeted exon and exon-intron transition sequencing&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case 2</span><p id="par0040" class="elsevierStylePara elsevierViewall">This was a 13-year-old girl&#44; with no significant family history&#44; with arrested weight gain and growth from the age of 7&#46; Since then&#44; she had presented 4 episodes of limb paralysis and generalised weakness&#44; with craniocervical instability and bilateral genu valgum&#46; At age 11 she was diagnosed with hypothyroidism&#44; and started treatment with levothyroxine&#46; She was subsequently referred to the hospital for a hypokalaemia study&#46; The results of the blood and urine panels and acidification test are shown in <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a>&#46; Along with the distal acidification defect&#44; a bicarbonate leak in the proximal tubule&#44; compatible with type 3 RTA was observed &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Kidney ultrasound showed bilateral grade 2 nephrocalcinosis&#46; The audiometry assessment was normal&#46; Blood samples were positive for antithyroglobulin &#40;246&#46;8<span class="elsevierStyleHsp" style=""></span>IU&#47;ml&#41; and antiperoxidase &#40;92&#46;6<span class="elsevierStyleHsp" style=""></span>IU&#47;ml&#41; antibodies&#46; One year after the diagnosis of RTA&#44; the patient required higher doses of citrate&#44; and the urinary acidification defect &#40;maximum urinary pCO<span class="elsevierStyleInf">2</span> of 53<span class="elsevierStyleHsp" style=""></span>mmHg&#41; persists&#46; Now&#44; at 14 years of age&#44; she weighs 40<span class="elsevierStyleHsp" style=""></span>kg &#40;p5&#37;&#41; and her height is 138<span class="elsevierStyleHsp" style=""></span>cm &#40;p0&#37;&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Thyroid hormones influence kidney development&#44; kidney structure&#44; renal haemodynamics&#44; glomerular filtration rate&#44; the function of many transport systems along the nephron&#44; in particular those related to the management of sodium&#44; acid&#8211;base balance and renal concentrating capacity&#46; These effects of the thyroid hormone are in part due to direct renal actions&#44; and in part to cardiovascular and systemic haemodynamic effects that influence kidney function&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Thyroid hormones directly influence the expression and&#47;or activity of a number of ion channels and transporters&#46; Pioneering micropuncture studies in hypothyroid rats have shown a reduction in the renal glomerular filtration rate &#40;GFR&#41; and an increase in the urinary excretion of sodium and water&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a> A subsequent study reported that the thyroid hormone regulates the activity of the proximal tubular type 3 Na<span class="elsevierStyleSup">&#43;</span>&#47;H<span class="elsevierStyleSup">&#43;</span> exchanger &#40;NHE3&#41;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">10</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; an effect that is due to direct binding of the hormone with the promoter region of the encoding gene&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">11</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">A study published in 2007 confirmed the activity of several transporters involved in sodium and acid&#8211;base balance in rats rendered hypothyroid by the administration of methimazole&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a> The results obtained are summarised in the footer of <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; Basically&#44; the activity of several proximal tubule transporters is reduced&#44; which results in a loss of sodium and a reduction in the elimination of hydrogen ions at this level&#44; while expression of the Cl<span class="elsevierStyleSup">&#8722;</span>&#47;HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> &#40;AE1&#41; exchanger specific to &#945;-intercalated cells of the connecting tubule and cortical collecting duct increases&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a> This shows&#44; therefore&#44; that thyroid hormone deficiency is associated with a defect in the renal handling of sodium and of the acid&#8211;base balance&#44; which is mainly located in the proximal tubule and is compensated by the distal nephron&#46; Consequently&#44; on a physiological level&#44; the thyroid hormone modulates the renal response to acid overload and alters the expression of several transporters that are key in the maintenance of the acid&#8211;base balance&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">This begs the question of why significant proximal sodium loss does not lead to reduced levels of sodium in hypothyroidism&#46; This was studied in transgenic mice deficient in the Na<span class="elsevierStyleSup">&#43;</span>&#47;H<span class="elsevierStyleSup">&#43;</span> &#40;NHE3&#41; exchanger<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">13</span></a> and in adults with mutations in the encoding gene&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">14</span></a> In these cases&#44; loss of NHE3 was compensated by a reduction in GFR caused by adenosine-induced vasoconstriction of the afferent arteriole&#46; This is one of the reasons why GFR is reduced in hypothyroid patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A study published in the 1970s showed that 2 of 5 adults with primary hypothyroidism without metabolic acidosis and with no clinical evidence of autoimmune disease were unable to lower their urine pH appropriately after short duration acid-loading<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">17</span></a>&#59; this is typical of incomplete distal RTA&#46; Subsequently&#44; various cases of type 1 RTA have been described in adults with non-autoimmune hypothyroidism&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">18&#44;19</span></a> One of these patients presented with hyperkalaemia &#40;type 4 RTA&#41; compatible with an increase in Na<span class="elsevierStyleSup">&#43;</span> levels in the tubular lumen of the collecting duct and impaired distal secretion due to an H<span class="elsevierStyleSup">&#43;</span> and K<span class="elsevierStyleSup">&#43;18</span> gradient defect&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">However&#44; most patients with both clinical conditions presented autoimmune hypothyroidism&#46; This combination has been described both in adults<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">20&#8211;22</span></a> and children<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">23&#44;24</span></a>&#59; in one of these cases of RTA&#44; serum levels of T3&#44; T4 and TSH were normal&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">22</span></a> supporting the notion that&#44; as in other autoimmune diseases&#44; antithyroid antibodies can <span class="elsevierStyleItalic">per se</span> can have a negative effect on renal acidification capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6&#44;7</span></a> There are several references in the literature to the triple association of RTA&#44; hypothyroidism and another autoimmune disease such as diabetes mellitus<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">25</span></a> or Sj&#246;gren&#39;s syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">26&#44;27</span></a> The fact that our second case was diagnosed with RTA 2 years after starting treatment with thyroid hormone supports the hypothesis that antithyroid antibodies have a negative effect on renal acidification capacity&#44; although poor compliance with replacement treatment cannot be entirely ruled out&#46; The pathophysiological mechanism of distal RTA associated with autoimmune disease is not well understood&#46; In patients with Sj&#246;gren&#39;s syndrome&#44; immunohistochemical studies have shown the absence of vacuolar H<span class="elsevierStyleSup">&#43;</span>-ATPase in collecting duct cells obtained from renal biopsies&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">28</span></a> More recently&#44; in the same disease&#44; autoantibodies against carbonic anhydrase II enzymes have been described &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">29</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The test used to determine maximum urinary pCO<span class="elsevierStyleInf">2</span> in both our patients is a variant of the one previously described by our Group&#46; In this challenge&#44; acetazolamide and sodium bicarbonate are administered simultaneously at lower doses than usual&#44; thus obtaining valid results &#40;urinary HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>80<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#41; while avoiding significant side effects&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">4&#44;30&#44;31</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The loss of proximal bicarbonate reported in case 2 must be associated with a reduction in the activity of both the Na<span class="elsevierStyleSup">&#43;</span>&#47;H<span class="elsevierStyleSup">&#43;</span> exchanger &#40;NHE3&#41; and the Na<span class="elsevierStyleSup">&#43;</span>&#47;HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> &#40;NBCe1&#41; cotransporter&#44; as described above &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a> However&#44; being a type 3 RTA &#40;proximal and distal&#41; the patient could&#44; theoretically&#44; be a carrier of autoantibodies against carbonic anhydrase II&#44; which is functional in both the proximal and distal portions of the nephron&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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            0 => "Renal tubular acidosis"
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            2 => "Autoimmunity"
            3 => "Maximum urinary pCO<span class="elsevierStyleInf">2</span>"
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            0 => "Acidosis tubular renal"
            1 => "Hipotiroidismo"
            2 => "Autoinmunidad"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Two cases of children diagnosed with renal tubular acidosis &#40;RTA&#41; associated with autoimmune hypothyroidism are presented&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Case 1 developed an intestinal ileus at the age of five in the context of a respiratory problem&#46; The tests performed confirmed metabolic acidosis&#44; hyperchloraemia&#44; hypokalaemia and nephrocalcinosis&#46; Case 2 was diagnosed with hypothyroidism at the age of 11&#44; and with RTA two years later&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In both patients&#44; the diagnosis of RTA was verified when decreased maximum urinary pCO<span class="elsevierStyleInf">2</span> was found&#46; In case 2&#44; a proximal bicarbonate leak &#40;type 3 RTA&#41; was also confirmed&#46; This was the first case to be published on the topic&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The causes of RTA in patients with hypothyroidism are reviewed&#46; The deleterious effect on the kidneys may be due to the absence of thyroid hormone and&#47;or autoantibodies in the cases of autoimmune hypothyroidism&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Se presentan dos casos en edad pedi&#225;trica diagnosticados de acidosis tubular renal &#40;ATR&#41; asociada a hipotiroidismo de causa autoinmune&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">El caso 1 desarroll&#243; un &#237;leo intestinal a los 5 a&#241;os de edad en el seno de un problema respiratorio&#46; En los ex&#225;menes realizados se constat&#243; acidosis metab&#243;lica&#44; hipercloremia&#44; hipopotasemia y nefrocalcinosis&#46; El caso 2 fue diagnosticado de hipotiroidismo a los 11 a&#241;os de edad y 2 a&#241;os despu&#233;s&#44; de ATR&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En ambos pacientes&#44; se comprob&#243; el diagn&#243;stico de ATR al observarse una pCO<span class="elsevierStyleInf">2</span> urinaria m&#225;xima reducida&#46; En el caso 2 se constat&#243;&#44; adem&#225;s&#44; una fuga proximal de bicarbonato &#40;ATR tipo 3&#41;&#44; que constituye el primer caso publicado sobre el tema&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se revisan las causas de ATR en pacientes con hipotiroidismo&#46; El efecto delet&#233;reo sobre el ri&#241;&#243;n puede ser debido a la propia ausencia de hormona tiroidea y&#47;o a los autoanticuerpos en los casos de hipotiroidismo autoinmune&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guerra-Hern&#225;ndez NE&#44; Ordaz-L&#243;pez KV&#44; Vargas-Poussou R&#44; Escobar-P&#233;rez L&#44; Garc&#237;a-Nieto VM&#46; Acidosis tubular renal distal en dos ni&#241;as diagnosticadas de hipotiroidismo adquirido&#46; Nefrologia&#46; 2018&#59;38&#58;655&#8211;659&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The expression of the Na<span class="elsevierStyleSup">&#43;</span>&#47;H<span class="elsevierStyleSup">&#43;</span> exchanger &#40;NHE3&#41;&#44; the Na&#43;-phosphate cotransporter NaPi-IIa&#44; and the B2 subunit of the vacuolar H<span class="elsevierStyleSup">&#43;</span>-ATPase &#40;not shown here&#41; is reduced in the brush-border membrane of the proximal tubule in hypothyroid rats&#46; This is accompanied by a lower abundance of the Na<span class="elsevierStyleSup">&#43;</span>&#47;HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> cotransporter &#40;NBCe1&#41; and a higher expression of the acid-secretory type A intercalated cell-specific Cl<span class="elsevierStyleSup">&#8722;</span>&#47;HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> exchanger &#40;AE1&#41; in the connecting tubule and cortical collecting duct&#46; NBCe1 expression and the number of &#945;-intercalated cells increased in hypothyroid rats during metabolic acidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a> ACII&#58; carbonic anhydrase II&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Case 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Case 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Venous blood gas</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>pH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> &#40;mEq&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Serum chlorine &#40;mmol&#47;l&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">116&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Serum potassium &#40;mmol&#47;l&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;47&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Serum uric acid&#44; &#40;mg&#47;dl&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Calcium&#47;creatinine ratio &#40;mg&#47;mg&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">24-Hour urine calcium</span> &#40;mg&#47;kg&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Citrate&#47;creatinine ratio &#40;mg&#47;mg&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">24-Hour urine citrate</span> &#40;mg&#47;kg&#47;day&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Oxaluria &#40;mmol&#47;mol&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Fractional excretion of bicarbonate</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;75&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Case 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Case 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary pH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">&#8722;</span> &#40;mEq&#47;l&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&#46;22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urine-blood pCO<span class="elsevierStyleInf">2</span> gradient &#40;mmHg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
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ISSN: 20132514
Original language: English
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