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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acid&#8211;base transporters involved in the secretion of H<span class="elsevierStyleSup">&#43;</span> and reabsorption of HCO<span class="elsevierStyleInf">3</span>&#8211; in the intercalated alpha cells of the collecting duct&#46; Transport of H<span class="elsevierStyleSup">&#43;</span> to the tnbular lumen is mediated by the vacuolar H<span class="elsevierStyleSup">&#43;</span>-ATPase&#44; which actively transfers this proton across the luminal membrane&#46; H<span class="elsevierStyleSup">&#43;</span> can also be secreted thanks to a second ATPase&#44; the H<span class="elsevierStyleSup">&#43;</span>&#47;K&#43;-ATPase&#44; which exchanges H<span class="elsevierStyleSup">&#43;</span> for K&#46; Bicarbonate&#44; formed intracellularly by the action of CAII&#44; leaves the cell through the basolateral membrane&#44; via the transport Anion exchange protein &#40;AE&#41;1 or band 3 protein&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Key concepts</span><p id="par0005" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0010" class="elsevierStylePara elsevierViewall">Hereditary dRTA is caused by mutations in genes that encode transporters that regulate acid-base balance at the distal tubular level&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0015" class="elsevierStylePara elsevierViewall">Mutations in the <span class="elsevierStyleItalic">ATP6V0A4</span> and <span class="elsevierStyleItalic">ATV6V1B1</span> genes are associated with earlier forms of dRTA&#44; and it is frequently accompanied by the development of sensorineural deafness since childhood&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0020" class="elsevierStylePara elsevierViewall">The evolution to chronic kidney disease is common in all hereditary forms of dRTA and this is due to various factors&#44; nephrocalcinosis&#47;kidney stones&#44; chronic hypokalemia and the frequent occurrence of acute pyelonephritis&#46; In addition&#44; poor metabolic control may worsen the evolution of kidney function&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Traditional treatment with bicarbonate or citrate salts does not achieve optimal metabolic control in all cases&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0030" class="elsevierStylePara elsevierViewall">Distal renal tubular acidosis &#40;dRTA&#41; is a rare disease with an estimated incidence &#60;1&#58; 100&#44;000&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Also known as type 1 RTA or classic RTA&#44; it is characterized by persistent hyperchloremic metabolic acidosis&#44; with a normal anion gap in plasma&#44; in the presence of high urinary pH and low urinary ammonium excretion&#46; dRTA is due to the failure of the type A renal intercalated cells of the collecting duct to produce a normal acidification of the urine&#44; which is due to a dysfunction in any of the transporters involved in this process&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Etiology</span><p id="par0035" class="elsevierStylePara elsevierViewall">DTRA can be acquired or inherited&#46; Acquired forms usually occur in adults and may be caused by drugs &#40;especially antimicrobial&#44; anti-inflammatory&#44; diuretics and antivirals&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> autoimmune diseases syndrome &#40;Sj&#246;gren&#44; systemic lupus erythematosus&#44; primary biliary cholangitis&#44; cholangitis sclerosing primary&#44; autoimmune hepatitis and autoimmune thyroiditis&#41;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> or may be secondary to uropathies or kidney transplantation&#46; It is not known with detail the mechanisms leading to these acquired forms&#46; It may be caused by to alterations that are voltage dependent&#44; lack of negative transepithelial difference in the distal lumen or defects of gradient&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Hereditary forms are most frequent in pediatric patients&#44; and is due to alterations in the genes that encode or control the encoding of the channels involved in urinary acidification in the distal and collecting tubules levels &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;7</span></a> Currently&#44; there are 5 recognized genes whose mutations can give rise to dRTA&#58; <span class="elsevierStyleItalic">ATP6V0A4</span>&#44; <span class="elsevierStyleItalic">ATP6V1B1</span>&#44; <span class="elsevierStyleItalic">SLC4A1</span>&#44; <span class="elsevierStyleItalic">FOXI1</span> and <span class="elsevierStyleItalic">WDR7</span>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Mutations in the <span class="elsevierStyleItalic">ATP6V1B1</span> and <span class="elsevierStyleItalic">ATP6V0A4</span> genes</span><p id="par0045" class="elsevierStylePara elsevierViewall">Defects in the activity of the H<span class="elsevierStyleSup">&#43;</span> ATPase &#40;V-ATPase &#41; pump cause most primary cases of dRTA&#46; H<span class="elsevierStyleSup">&#43;</span> -ATPase is a highly conserved proton pump that is expressed in intercalated alpha cells and is made up of 2 domains&#44; V1 and V0&#46; The B1 subunit&#44; encoded by the <span class="elsevierStyleItalic">ATP6V1B1</span> gene&#44; is part of the V1 domain that captures protons from the cell cytoplasm&#46; This subunit is also expressed in the cells of the inner ear and the endolymphatic sac&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> The A4 subunit&#44; encoded by the <span class="elsevierStyleItalic">ATP6V0A4</span> gene&#44; is part of the V0 transmembrane domain involved in the translocation of protons through the cell membrane and is expressed in the kidney&#44; inner ear and epididymis&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This type of dRTA follows an autosomal recessive pattern of inheritance&#46; Among the most frequent mutations in these genes are <span class="elsevierStyleItalic">nonsense</span>&#44; <span class="elsevierStyleItalic">frameshift</span> or <span class="elsevierStyleItalic">splice-site</span> mutations&#44; which are expected to alter the encoded protein&#44; whereas <span class="elsevierStyleItalic">missense</span> mutations have only been described in a few patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11&#8211;13</span></a> Experiments in cell culture models have shown that most of the mutations identified in this B1 subunit cause a dysfunction or alteration in the assembly of the protein complex that forms the V-ATPase pump&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Mutations in the A4 subunit can affect the binding of these 2 subunits&#44; leading to an incorrect assembly of the V1 and V0 domains&#44; forming a structurally and functionally defective V-ATPase&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In Europe&#44; the most frequent mutations are in the <span class="elsevierStyleItalic">ATP6V1B1</span> and <span class="elsevierStyleItalic">ATP6V0A4</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In our experience&#44; most patients in northern Spain have mutations in the <span class="elsevierStyleItalic">ATP6V0A4</span> gene&#46; This is consistent with previous studies that report a higher frequency of mutations in this gene compared to the <span class="elsevierStyleItalic">ATP6V1B1</span> gene in the Spanish and European population&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;17</span></a> Among them&#44; the presence of the c&#46;1691&#8239;&#43;&#8239;2dup variant in different patients in our cohort is particularly noteworthy&#44; as a reflection of a possible founder effect in this geographic region &#40;data pending publication&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Mutations in the <span class="elsevierStyleItalic">SLC4A1</span> gene</span><p id="par0060" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">SLC4A1</span> gene <span class="elsevierStyleItalic">plays</span> a crucial role in acid-base homeostasis since it encodes a chloride-bicarbonate exchanger&#44; also known as AE1 or band 3 protein&#44; responsible for the reabsorption of HCO3<span class="elsevierStyleSup">&#8722;</span> together with the excretion of chloride&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> This protein is expressed in the plasma membrane of erythrocytes and the basolateral membrane of the renal intercalated alpha cells of the collecting tubules&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The inheritance of this type of dRTA is complex&#44; with forms of transmission both autosomal dominant&#44; especially in Caucasians&#44; and recessive&#44; more common in Asians&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> The clinical manifestations are more severe in patients with recessive inheritance dRTA&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Different types of mutations have been described&#44; which in experimental studies cause intracellular retention of the mutated protein&#44; reduction of its transport activity&#44; misfolding and degradation&#44; or even misdirection towards the lumen membrane&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> The most common recessive inherited mutation&#44; G701D&#44; causes dRTA that in some cases is associated with hemolytic anemia&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Among Caucasian patients&#44; the most common autosomal dominant inheritance mutation is R589H&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The introduction of this mutation in mice leads to intercalated cell dysfunction with reduced expression of proton pumps&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;25</span></a> In mice&#44; it has been observed that the complete absence of the AE1 exchanger causes severe metabolic acidosis&#44; while the heterozygotes did not show any apparent defect&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In our population there are few cases described of dRTA with defects in this channel and they usually have a milder phenotype with a late onset with respect to mutations in previously described genes&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;26&#44;27</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Other genes associated with distal renal tubular acidosis</span><p id="par0080" class="elsevierStylePara elsevierViewall">The genes previously described only explain 70&#8211;80&#37; of the cases of primary dRTA&#44; which proves the existence of other candidate genes responsible for a significant number of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;28</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Pathogenic variants have been described recently in homozygous in gene <span class="elsevierStyleItalic">FOXI1</span> as responsible for early onset of sensorineural hearing loss and autosomal recessive dRTA&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> FOXI1 is a key transcription factor for the regulation of various membrane transporters&#44; including those necessary for normal acidification at the distal tubule and innerear &#40;AE1&#44; AE4 and various V-ATPase subunits &#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Enerb&#228;ck et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> demonstrated that in patients with homozygous mutations with loss of function in this factor&#44; there is a very limited DNA-binding activity of FOXI1&#44; which probably results in an inability for the transactivation of some of these transporter proteins&#44; which causes a syndrome severe deafness and acidosis&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Likewise&#44; homozygous pathogenic variants in the <span class="elsevierStyleItalic">WDR72</span> gene have recently been described as a cause of hereditary dRTA&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> It is believed that this gene could be involved in intracellular trafficking&#44; affecting the direction of acid-base regulating proteins&#44; such as the AE1 transporter isoform or V- ATPase&#44; causing intracellular retention or misdirection&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Mutations in <span class="elsevierStyleItalic">WDR72</span> have been associated to amelogenesis imperfecta&#44; which includes a large group of inherited diseases that affect the formation of dental enamel&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Different studies in animal models have revealed new genes that could be involved in DRTA&#46; Some have been identified in mice&#44; but there is no evidence that they cause dRTA in humans&#46; Recently&#44; whole exome sequencing studies in patients with dRTA have revealed the <span class="elsevierStyleItalic">ATP6V1C2</span> gene as a new gene responsible for recessive dRTA&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> This gene encodes the C subunit of V- ATPase and is mostly expressed in intercalated collecting duct cells&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Clinical manifestations and genotype-phenotype correlation</span><p id="par0100" class="elsevierStylePara elsevierViewall">The clinical manifestations of these genetic groups are common&#44; although they present some peculiarity depending on the underlying causal gene &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Clinical features at presentation</span>&#46; Clinical presentation in patients with hereditary dRTA usually begin in childhood with failure to thrive&#44; repeated vomiting&#44; polyuria&#44; and episodes of acute decompensation generally coinciding with infectious pictures&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;28</span></a> Biochemical findings include a marked metabolic acidosis with a normal anion gap due to the absence of acids would count as anions&#44; and a urine&#44; with a pH generally greater than 6&#46; The urinary anion gap is positive which reflects a of low urinary excretion of ammonium&#46; The hypokalemia is common in these patients&#44; it is present in a 30&#8211;50&#37; of the patients&#59; it is due to secondary hyperaldosteronism and to the defect of gradient in the distal tubule&#44; and produces muscle weakness&#44; constipation&#44; inability to concentrate urine and&#44; in extreme cases&#44; paralysis and arrhythmias which can be fatal&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;34&#44;35</span></a> In general&#44; people with recessive DTRA &#40;<span class="elsevierStyleItalic">ATP6V0A4</span> and <span class="elsevierStyleItalic">ATP6V1B1</span>&#41; have a more severe degree of metabolic acidosis and hypokalemia than those with dominant inheritance&#44; who usually present a milder form of acidosis partially compensated&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a> Polyuria secondary to a deficit in urinary concentration is very common in these patients and&#44; although the underlying mechanisms have not been fully elucidated&#44; probably it is caused by biochemical abnormalities associated&#44; mainly to hypokalemia and hypercalciuria&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> In some patients&#44; an associated transient proximal tubule dysfunction is observed at diagnosis&#44; which may be confused with Fanconi syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;40</span></a> Occasionally&#44; they can also present with hyperammonemia&#44; which tends to resolve when acidosis is corrected&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;41</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Regarding the age of onset&#44; cases of recessive dRTA &#40;<span class="elsevierStyleItalic">ATP6V0A4 and ATP6V1B1</span>&#41; are associated with an earlier presentation of symptoms&#44; generally at 6 and 24 months after birth&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28</span></a> However&#44; patients with a dominant dRTA &#40;<span class="elsevierStyleItalic">SLC4A1</span>&#41; have a later clinical onset&#44; with a mean age at diagnosis between 4 and 13 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;9&#44;28&#44;36</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Growth&#46;</span> dRTA is frequently diagnosed during the evaluation of growth defects in childhood&#44; mainly with poor linear growth with normal weight&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> This is primarily attributed to the inhibitory effect of metabolic acidosis on growth hormone metabolism&#46; Cases with mutations in the <span class="elsevierStyleItalic">SLC4A1</span> gene tend to have less degree of growth retardation than recessive forms due to later presentation and milder metabolic acidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> An adequate alkaline therapy tend to improve the growth&#44; although some recent series show that the final height is frequently below the mean&#44; regardless of the genetic group&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;17&#44;42</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hearing loss</span>&#46; Due to the importance of proton secretion in endolymph for inner ear function&#44; dRTA is also associated with sensorineural deafness&#46; This occurs in individuals with mutations in <span class="elsevierStyleItalic">ATP6V0A4 and ATP6V1B1</span>&#44; due to the simultaneous expression of V-ATPase in the kidney and ear&#44; and in <span class="elsevierStyleItalic">FOXI1</span>&#46; However&#44; the frequency of deafness associated with mutations in <span class="elsevierStyleItalic">ATP6V1B1</span> is much higher&#44; being observed in around 90&#37; of patients&#44; compared to 35&#8211;50&#37; of those with mutations in <span class="elsevierStyleItalic">ATP6V0A4</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28</span></a> Furthermore&#44; there is a significant difference in the age of onset of deafness between these 2 groups&#46; The detection of deafness in the first years of life is highly indicative of an underlying mutation in the <span class="elsevierStyleItalic">ATP6V1B1</span> gene&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;36</span></a> Some patients also present other abnormalities of the auditory system&#44; such as dilation of the vestibular aqueducts&#44; which is generally bilateral&#44; and they may suffer from dizziness&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;44</span></a> The cases described with pathogenic variants biallelic the gene <span class="elsevierStyleItalic">FOXI1</span> present dRTA deafness and the dilated vestibular aqueduct&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Skeletal manifestations</span>&#46; Metabolic acidosis causes the release of bicarbonate and phosphate from the bone&#44; which act as alkaline buffers to restore physiological blood pH&#46; This results in bone demineralization that can cause rickets in children and osteomalacia in adults&#46; These abnormalities have been described&#44; especially at diagnosis and in a variable manner&#44; in some patients with dRTA&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;42&#44;45</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hemolytic anemia</span>&#46; There are some cases reported&#44; mostly in Southeast Asia&#44; in pathogenic variants in the <span class="elsevierStyleItalic">SLC4A1</span> gene&#44; of recessive inheritance&#44; that can give rise to dRTA and hemolytic anemia&#44; generally in children&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> The importance of this fact is that these biallelic variants can produce morphological changes in erythrocytes and these&#44; under conditions of metabolic acidosis&#44; may undergo hemolysis&#46; Alkaline therapy corrects anemia and reticulocytosis&#46; These patients also respond to transfusions and ion therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Renal manifestations</span>&#46; Patients with dRTA very frequently and early develop nephrocalcinosis or lithiasis&#44; due to the combination of hypercalciuria&#44; hypocitraturia and a high urinary pH that favors the deposit of oxalate and calcium phosphate crystals&#46; The hypocitraturia is virtually universal in these patients and is due to increased citrate reabsorption in the proximal tubule in response to systemic acidosis&#46; The probability of developing nephrocalcinosis&#47;lithiasis increases with the age of the patient and with the delay in the initiation of alkalizing treatment&#44; that is&#44; with a late diagnosis&#46; Nephrocalcinosis is observed in 90&#8211;95&#37; of patients&#44; of any genetic group&#44; and persists in most cases despite adequate therapeutic control&#46; Adequate alkaline therapy usually prevents its progression&#44; but does not reverse it&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28&#44;36</span></a> The frequency of calculi in patients with mutations in the <span class="elsevierStyleItalic">SLC4A1</span> may be greater&#44; possibly due to a delay in diagnosis caused by milder phenotype expression&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Furthermore&#44; patients with dRTA frequently present with recurrent acute pyelonephritis&#44; associated with the presence of potentially obstructive stones and possibly hypercalciuria&#46; Finally&#44; many individuals develop spinal cysts in childhood or adulthood&#44; which has been attributed to some extent to chronic hypokalemia&#46; However&#44; other tubulopathies with sustained hypokalaemia&#44; such as Bartter syndrome&#44; rarely present medullary cysts during its the evolution&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;47</span></a> The clinical relevance of these cysts is unknown as it was not found a correlation between the development of medullary cysts and the degree of nephrocalcinosis or the long - term deterioration of renal function&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Incomplete distal renal tubular acidosis</span><p id="par0140" class="elsevierStylePara elsevierViewall">Incomplete dRTA cases have been described in patients who are heterozygous carriers of pathogenic variants in the <span class="elsevierStyleItalic">ATP6V1B1</span> gene&#46; These present mild renal acidification defects that do not lead to reduction in blood pH&#44; but fail to adequately acidify the urine if stimulated&#46; In these cases&#44; functional tests to assess maximum urinary acidification capacity may be useful&#46; These individuals frequently have associated hypercalciuria and hypocitraturia&#44; and an elevated risk of kidney stones&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;48&#44;49</span></a> Similarly&#44; some dominant mutations in the AE1 transporter can give rise to incomplete dRTA&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pregnancy</span><p id="par0145" class="elsevierStylePara elsevierViewall">Women with dRTA do not present a priori fertility disorders associated with their disease&#46; However&#44; during pregnancy they may present metabolic complications associated with dRTA mainly hypokalemia and severe metabolic acidosis&#46; In addition&#44; hyperemesis gravidarum may cause electrolyte imbalances by increasing electrolyte losses and making oral supplementation difficult&#46; Other complications to take into account are recurrent episodes of acute pyelonephritis&#44; already common in patients with dRTA&#44; and ureteral obstruction due to pre-existing kidney stones&#46; The worsening of kidney function or proteinuria are not complications usually observed in pregnant women with dRTA&#44; except in those cases with previous chronic kidney disease &#40;CKD&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;35</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Long-term evolution of kidney function</span><p id="par0150" class="elsevierStylePara elsevierViewall">In recent years&#44; there have been published large series of patients with dRTA with confirmed molecular diagnosis evaluating the risk of CKD at the long term&#44; describing CKD grade &#8805;2 in 30&#8211;80&#37; of patients&#44; without significant differences between the patients&#46; 3 main genes involved in dRTA&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;17&#44;28</span></a> Factors potentially involved in this progression are late diagnosis&#44; with a greater number of episodes of decompensation and acute renal failure&#44; nephrocalcinosis or nephrolithiasis particularly obstructive&#44; repeated episodes of pyelonephritis&#44; medullary cysts and persistent hypokalemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;28</span></a> Despite the fact that&#44; as expected&#44; the degree of CKD worsens with a longer evolution time&#44; many patients already have mild CKD since adolescence&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Despite the trend to CKD&#44; the clinical evolution of patients with dRTA is not critical&#44; particularly if the diagnosis is established early with the consequent correction of acidosis&#46; Although CKD is common&#44; end-stage kidney disease is rare&#46; In many patients&#44; adequate correction of acidosis and electrolyte disturbances is not achieved&#44; reflecting the difficulties with the usual forms of treatment with supplements&#44; both in tolerance and in maintaining therapeutic compliance&#46; Adequate metabolic control can reduce the risk of developing CKD at the long term&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Management of distal renal tubular acidosis&#46; New treatments</span><p id="par0160" class="elsevierStylePara elsevierViewall">The main objective in the management of dRTA is the correction of metabolic acidosis and the secondary and associated alterations&#44; mainly hypokalemia&#44; hypercalciuria and hypocitraturia&#46; This is to ensure normal growth and development in childhood&#44; avoid bone demineralization and associated rickets&#44; and avoid CKD development factors in the medium-long term&#46; The alkalizing treatment&#44; however&#44; does not succeed in modifying the onset or evolution of sensorineural deafness&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Correction of acidosis is carried out with bicarbonate or citrate salts&#44; and the dose usually required for this is higher in the young child and decreases with the end of growth&#46; Thus&#44; in infants&#44; alkali doses of up to 8&#8239;mEq&#47;kg&#47;day are required&#44; later in children&#44; doses of 3&#8211;4&#8239;mEq&#47;kg&#47;day are usually sufficient&#44; and in adults&#44; doses greater than 2&#8211;3&#8239;mEq&#47;kg&#47;day are generally not required&#46; The use of citrate as an alkalinizing agent has the advantage of correcting the hypocitraturia associated with acidosis and of avoiding to some extent the development of associated nephrocalcinosis&#46; The alkalizing agent is used in combination with sodium or potassium&#46; The use of sodium makes sense especially in patients with polyuria and extravascular volume depletion&#44; but it has the disadvantage of increasing calcium excretion and decreasing proximal bicarbonate reabsorption due to the volume overload that it may entail&#46; The use of potassium also attempts to correct the associated hypokalemia&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The most important drawback of the use of alkalizing salts&#44; especially citrate&#44; is poor gastrointestinal tolerance&#46; In addition&#44; it is necessary to divide the treatment into several doses per day to maintain a constant acid-base homeostasis&#46; On many occasions&#44; adequate metabolic control is not achieved&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Recently&#44; the ADV7103 molecule&#44; based on prolonged-release citrate and potassium bicarbonate &#40;2 daily administrations&#41;&#44; has been commercialized in order to improve therapeutic adherence and metabolic control in patients with dRTA&#46; A phase 3 study has shown its efficacy in improving metabolic control and its safety with good gastrointestinal tolerance&#46; This treatment has obtained in Europe the designation of orphan drug for the treatment of dRTA&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Some groups use amiloride as a potassium-sparing diuretic to optimize the treatment of hypokalaemia and to allow a reduction in potassium supplementation doses&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Sometimes they have been used thiazides as hypercalciuria treatment&#44; in order to prevent progression and nephrocalcinosis ERC&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However&#44; this treatment is not generally recommended as it potentially worsens potassium loss and there is no evidence that it improves kidney function in the long term&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">To evaluate sensorineural hearing abnormalities&#44; a standard audiogram should be performed to explore masked and unmasked air and bone conduction at different frequencies&#46; Both magnetic resonance imaging and computed tomography can be used to diagnose dilatation of the vestibular aqueduct&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;43</span></a> Hearing devices &#40;hearing aids or cochlear implants&#41; and language teaching are essential to guarantee the normal intellectual development and social integration of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Financial support</span><p id="par0185" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleGrantSponsor" id="gs0005">pharmaceutical company Advicenne &#40;France&#41;</span> has provided funding for the study of patients with distal renal tubular acidosis&#44; but has not participated in the preparation of this article &#40;grant <span class="elsevierStyleGrantNumber" refid="gs0005">BC&#47;A&#47;19&#47;039</span>&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">No conflict of interest to declare</p></span></span>"
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              "titulo" => "Mutations in the ATP6V1B1 and ATP6V0A4 genes"
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              "titulo" => "Mutations in the SLC4A1 gene"
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              "titulo" => "Other genes associated with distal renal tubular acidosis"
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          "titulo" => "Clinical manifestations and genotype-phenotype correlation"
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          "titulo" => "Incomplete distal renal tubular acidosis"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Distal renal tubular acidosis &#40;DRTA&#41; is a rare disease resulting from a failure in the normal urine acidification process at the distal tubule and collecting duct level&#46; It is characterised by persistent hyperchloremic metabolic acidosis&#44; with a normal anion gap in plasma&#44; in the presence of high urinary pH and low urinary excretion of ammonium&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To date&#44; 5 genes whose mutations give rise to primary DRTA have been described&#46; Alterations in the <span class="elsevierStyleItalic">ATP6V1B1</span> and <span class="elsevierStyleItalic">ATP6V0A4</span> genes are inherited recessively and are associated with forms of early onset and&#44; in many cases&#44; with neurosensorial deafness&#46; Pathogenic variants in the <span class="elsevierStyleItalic">SLC4A1</span> gene are habitually inherited dominantly and give rise to milder symptoms&#44; with a later diagnosis and milder electrolytic alterations&#46; Nonetheless&#44; evolution to nephrocalcinosis and lithiasis&#44; and the development of chronic kidney disease in the medium to long term has been described in a similar manner in all 3&#8239;groups&#46; Lastly&#44; recessive forms of DTRA associated to mutations in the <span class="elsevierStyleItalic">FOXI1</span> and <span class="elsevierStyleItalic">WDR72</span> genes have also been described&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The clinical management of DTRA is based on bicarbonate or citrate salts&#44; which do not succeed in correcting all cases of the metabolic alterations described and&#44; thus&#44; the consequences associated with them&#46; Recently&#44; a new treatment based on slow-release bicarbonate and citrate salts has received the designation of orphan drug in Europe for the treatment of DTRA&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La acidosis tubular renal distal &#40;ATRD&#41; es una enfermedad rara que se debe al fallo del proceso normal de acidificaci&#243;n de la orina a nivel tubular distal y colector&#46; Se caracteriza por una acidosis metab&#243;lica hiperclor&#233;mica persistente&#44; con ani&#243;n gap normal en plasma&#44; en presencia de un pH urinario elevado y baja excreci&#243;n urinaria de amonio&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se han descrito hasta el momento 5 genes cuyas mutaciones dan lugar a ATRD primaria&#46; Las alteraciones de los genes <span class="elsevierStyleItalic">ATP6V1B1</span> y <span class="elsevierStyleItalic">ATP6V0A4</span> se heredan de forma recesiva y est&#225;n asociadas a formas de inicio m&#225;s precoces y con sordera neurosensorial en muchos casos&#46; Las variantes patog&#233;nicas en el gen <span class="elsevierStyleItalic">SLC4A1</span> se heredan habitualmente de forma dominante y dan lugar a cuadros m&#225;s leves&#44; con un diagn&#243;stico m&#225;s tard&#237;o y alteraciones electrol&#237;ticas menores&#46; Sin embargo&#44; la evoluci&#243;n a nefrocalcinosis y litiasis&#44; y el desarrollo de enfermedad renal cr&#243;nica a medio-largo plazo se ha descrito de forma similar en estos 3&#8239;grupos&#46; Por &#250;ltimo&#44; se han descrito tambi&#233;n formas recesivas de ATRD asociadas a mutaciones en los genes <span class="elsevierStyleItalic">FOXI1</span> y <span class="elsevierStyleItalic">WDR72</span>&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El manejo cl&#237;nico de la ATRD se basa en sales de bicarbonato o citrato&#44; que no logran corregir en todos los casos las alteraciones metab&#243;licas descritas y&#44; por lo tanto&#44; las consecuencias asociadas a ellas&#46; Recientemente&#44; un nuevo tratamiento basado en sales de bicarbonato y citrato de liberaci&#243;n prolongada ha recibido la denominaci&#243;n de medicamento hu&#233;rfano en Europa para el tratamiento de la ATRD&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez-Conde S&#44; Garc&#237;a-Casta&#241;o A&#44; Aguirre M&#44; Herrero M&#44; Gondra L&#44; Casta&#241;o L&#44; et al&#46; Acidosis tubular renal distal hereditaria&#58; correlaci&#243;n genot&#237;pica&#44; evoluci&#243;n a largo plazo y nuevas perspectivas terap&#233;uticas&#46; Nefrologia&#46; 2021&#59;41&#58;383&#8211;390&#46;</p>"
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          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AI&#58; amelogenesis imperfecta&#59; ATRD&#58; distal renal tubular acidosis&#59; AV dilation&#58; dilation of the vestibular aqueduct&#46;</p>"
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                  \t\t\t\t">Age of onset&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4&#8722;13 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">6&#8722;14 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">2&#8722;24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">severity of dRTA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hypokalemia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Mild&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Mild&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">plasma HCO3<span class="elsevierStyleSup">&#8722;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">low&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#62;6&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#62;6&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#62;6&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">&#62;6&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Common and late&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Common and early&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Common and early&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Sensorineural hearing loss&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Common and early&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Common and late&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">VA dilation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">VA dilation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">VA dilation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">AI&nbsp;\t\t\t\t\t\t\n
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Differences in clinical characteristics between the main genetic groups causing dRTA&#46;</p>"
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Review
Hereditary distal renal tubular acidosis: Genotypic correlation, evolution to long term, and new therapeutic perspectives
Acidosis tubular renal distal hereditaria: correlación genotípica, evolución a largo plazo y nuevas perspectivas terapéuticas
Sara Gómez-Condea, Alejandro García-Castañoa,b, Mireia Aguirrea,d, María Herreroa,d, Leire Gondraa,d,e, Luis Castañoa,b,c,e, Leire Madariagaa,b,d,e,
Corresponding author
a Instituto de Investigación Sanitaria Biocruces Bizkaia, Barakaldo, Bizkaia, Spain
b CIBERDEM, CIBERER, Endo-ERN
c Sección de Endocrinología Pediátrica, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain
d Sección de Nefrología Pediátrica, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain
e Departamento de Pediatría, Universidad del País Vasco UPV/EHU, Barakaldo, Bizkaia, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Key concepts</span><p id="par0005" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0010" class="elsevierStylePara elsevierViewall">Hereditary dRTA is caused by mutations in genes that encode transporters that regulate acid-base balance at the distal tubular level&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0015" class="elsevierStylePara elsevierViewall">Mutations in the <span class="elsevierStyleItalic">ATP6V0A4</span> and <span class="elsevierStyleItalic">ATV6V1B1</span> genes are associated with earlier forms of dRTA&#44; and it is frequently accompanied by the development of sensorineural deafness since childhood&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0020" class="elsevierStylePara elsevierViewall">The evolution to chronic kidney disease is common in all hereditary forms of dRTA and this is due to various factors&#44; nephrocalcinosis&#47;kidney stones&#44; chronic hypokalemia and the frequent occurrence of acute pyelonephritis&#46; In addition&#44; poor metabolic control may worsen the evolution of kidney function&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">Traditional treatment with bicarbonate or citrate salts does not achieve optimal metabolic control in all cases&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0030" class="elsevierStylePara elsevierViewall">Distal renal tubular acidosis &#40;dRTA&#41; is a rare disease with an estimated incidence &#60;1&#58; 100&#44;000&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Also known as type 1 RTA or classic RTA&#44; it is characterized by persistent hyperchloremic metabolic acidosis&#44; with a normal anion gap in plasma&#44; in the presence of high urinary pH and low urinary ammonium excretion&#46; dRTA is due to the failure of the type A renal intercalated cells of the collecting duct to produce a normal acidification of the urine&#44; which is due to a dysfunction in any of the transporters involved in this process&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Etiology</span><p id="par0035" class="elsevierStylePara elsevierViewall">DTRA can be acquired or inherited&#46; Acquired forms usually occur in adults and may be caused by drugs &#40;especially antimicrobial&#44; anti-inflammatory&#44; diuretics and antivirals&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> autoimmune diseases syndrome &#40;Sj&#246;gren&#44; systemic lupus erythematosus&#44; primary biliary cholangitis&#44; cholangitis sclerosing primary&#44; autoimmune hepatitis and autoimmune thyroiditis&#41;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a> or may be secondary to uropathies or kidney transplantation&#46; It is not known with detail the mechanisms leading to these acquired forms&#46; It may be caused by to alterations that are voltage dependent&#44; lack of negative transepithelial difference in the distal lumen or defects of gradient&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Hereditary forms are most frequent in pediatric patients&#44; and is due to alterations in the genes that encode or control the encoding of the channels involved in urinary acidification in the distal and collecting tubules levels &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#44;7</span></a> Currently&#44; there are 5 recognized genes whose mutations can give rise to dRTA&#58; <span class="elsevierStyleItalic">ATP6V0A4</span>&#44; <span class="elsevierStyleItalic">ATP6V1B1</span>&#44; <span class="elsevierStyleItalic">SLC4A1</span>&#44; <span class="elsevierStyleItalic">FOXI1</span> and <span class="elsevierStyleItalic">WDR7</span>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Mutations in the <span class="elsevierStyleItalic">ATP6V1B1</span> and <span class="elsevierStyleItalic">ATP6V0A4</span> genes</span><p id="par0045" class="elsevierStylePara elsevierViewall">Defects in the activity of the H<span class="elsevierStyleSup">&#43;</span> ATPase &#40;V-ATPase &#41; pump cause most primary cases of dRTA&#46; H<span class="elsevierStyleSup">&#43;</span> -ATPase is a highly conserved proton pump that is expressed in intercalated alpha cells and is made up of 2 domains&#44; V1 and V0&#46; The B1 subunit&#44; encoded by the <span class="elsevierStyleItalic">ATP6V1B1</span> gene&#44; is part of the V1 domain that captures protons from the cell cytoplasm&#46; This subunit is also expressed in the cells of the inner ear and the endolymphatic sac&#44; among others&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> The A4 subunit&#44; encoded by the <span class="elsevierStyleItalic">ATP6V0A4</span> gene&#44; is part of the V0 transmembrane domain involved in the translocation of protons through the cell membrane and is expressed in the kidney&#44; inner ear and epididymis&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">This type of dRTA follows an autosomal recessive pattern of inheritance&#46; Among the most frequent mutations in these genes are <span class="elsevierStyleItalic">nonsense</span>&#44; <span class="elsevierStyleItalic">frameshift</span> or <span class="elsevierStyleItalic">splice-site</span> mutations&#44; which are expected to alter the encoded protein&#44; whereas <span class="elsevierStyleItalic">missense</span> mutations have only been described in a few patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11&#8211;13</span></a> Experiments in cell culture models have shown that most of the mutations identified in this B1 subunit cause a dysfunction or alteration in the assembly of the protein complex that forms the V-ATPase pump&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Mutations in the A4 subunit can affect the binding of these 2 subunits&#44; leading to an incorrect assembly of the V1 and V0 domains&#44; forming a structurally and functionally defective V-ATPase&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">In Europe&#44; the most frequent mutations are in the <span class="elsevierStyleItalic">ATP6V1B1</span> and <span class="elsevierStyleItalic">ATP6V0A4</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In our experience&#44; most patients in northern Spain have mutations in the <span class="elsevierStyleItalic">ATP6V0A4</span> gene&#46; This is consistent with previous studies that report a higher frequency of mutations in this gene compared to the <span class="elsevierStyleItalic">ATP6V1B1</span> gene in the Spanish and European population&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;17</span></a> Among them&#44; the presence of the c&#46;1691&#8239;&#43;&#8239;2dup variant in different patients in our cohort is particularly noteworthy&#44; as a reflection of a possible founder effect in this geographic region &#40;data pending publication&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Mutations in the <span class="elsevierStyleItalic">SLC4A1</span> gene</span><p id="par0060" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">SLC4A1</span> gene <span class="elsevierStyleItalic">plays</span> a crucial role in acid-base homeostasis since it encodes a chloride-bicarbonate exchanger&#44; also known as AE1 or band 3 protein&#44; responsible for the reabsorption of HCO3<span class="elsevierStyleSup">&#8722;</span> together with the excretion of chloride&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> This protein is expressed in the plasma membrane of erythrocytes and the basolateral membrane of the renal intercalated alpha cells of the collecting tubules&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The inheritance of this type of dRTA is complex&#44; with forms of transmission both autosomal dominant&#44; especially in Caucasians&#44; and recessive&#44; more common in Asians&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a> The clinical manifestations are more severe in patients with recessive inheritance dRTA&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Different types of mutations have been described&#44; which in experimental studies cause intracellular retention of the mutated protein&#44; reduction of its transport activity&#44; misfolding and degradation&#44; or even misdirection towards the lumen membrane&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> The most common recessive inherited mutation&#44; G701D&#44; causes dRTA that in some cases is associated with hemolytic anemia&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Among Caucasian patients&#44; the most common autosomal dominant inheritance mutation is R589H&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The introduction of this mutation in mice leads to intercalated cell dysfunction with reduced expression of proton pumps&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;25</span></a> In mice&#44; it has been observed that the complete absence of the AE1 exchanger causes severe metabolic acidosis&#44; while the heterozygotes did not show any apparent defect&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In our population there are few cases described of dRTA with defects in this channel and they usually have a milder phenotype with a late onset with respect to mutations in previously described genes&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;26&#44;27</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Other genes associated with distal renal tubular acidosis</span><p id="par0080" class="elsevierStylePara elsevierViewall">The genes previously described only explain 70&#8211;80&#37; of the cases of primary dRTA&#44; which proves the existence of other candidate genes responsible for a significant number of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;28</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Pathogenic variants have been described recently in homozygous in gene <span class="elsevierStyleItalic">FOXI1</span> as responsible for early onset of sensorineural hearing loss and autosomal recessive dRTA&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> FOXI1 is a key transcription factor for the regulation of various membrane transporters&#44; including those necessary for normal acidification at the distal tubule and innerear &#40;AE1&#44; AE4 and various V-ATPase subunits &#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Enerb&#228;ck et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> demonstrated that in patients with homozygous mutations with loss of function in this factor&#44; there is a very limited DNA-binding activity of FOXI1&#44; which probably results in an inability for the transactivation of some of these transporter proteins&#44; which causes a syndrome severe deafness and acidosis&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Likewise&#44; homozygous pathogenic variants in the <span class="elsevierStyleItalic">WDR72</span> gene have recently been described as a cause of hereditary dRTA&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> It is believed that this gene could be involved in intracellular trafficking&#44; affecting the direction of acid-base regulating proteins&#44; such as the AE1 transporter isoform or V- ATPase&#44; causing intracellular retention or misdirection&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> Mutations in <span class="elsevierStyleItalic">WDR72</span> have been associated to amelogenesis imperfecta&#44; which includes a large group of inherited diseases that affect the formation of dental enamel&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Different studies in animal models have revealed new genes that could be involved in DRTA&#46; Some have been identified in mice&#44; but there is no evidence that they cause dRTA in humans&#46; Recently&#44; whole exome sequencing studies in patients with dRTA have revealed the <span class="elsevierStyleItalic">ATP6V1C2</span> gene as a new gene responsible for recessive dRTA&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> This gene encodes the C subunit of V- ATPase and is mostly expressed in intercalated collecting duct cells&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Clinical manifestations and genotype-phenotype correlation</span><p id="par0100" class="elsevierStylePara elsevierViewall">The clinical manifestations of these genetic groups are common&#44; although they present some peculiarity depending on the underlying causal gene &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Clinical features at presentation</span>&#46; Clinical presentation in patients with hereditary dRTA usually begin in childhood with failure to thrive&#44; repeated vomiting&#44; polyuria&#44; and episodes of acute decompensation generally coinciding with infectious pictures&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;28</span></a> Biochemical findings include a marked metabolic acidosis with a normal anion gap due to the absence of acids would count as anions&#44; and a urine&#44; with a pH generally greater than 6&#46; The urinary anion gap is positive which reflects a of low urinary excretion of ammonium&#46; The hypokalemia is common in these patients&#44; it is present in a 30&#8211;50&#37; of the patients&#59; it is due to secondary hyperaldosteronism and to the defect of gradient in the distal tubule&#44; and produces muscle weakness&#44; constipation&#44; inability to concentrate urine and&#44; in extreme cases&#44; paralysis and arrhythmias which can be fatal&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;34&#44;35</span></a> In general&#44; people with recessive DTRA &#40;<span class="elsevierStyleItalic">ATP6V0A4</span> and <span class="elsevierStyleItalic">ATP6V1B1</span>&#41; have a more severe degree of metabolic acidosis and hypokalemia than those with dominant inheritance&#44; who usually present a milder form of acidosis partially compensated&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a> Polyuria secondary to a deficit in urinary concentration is very common in these patients and&#44; although the underlying mechanisms have not been fully elucidated&#44; probably it is caused by biochemical abnormalities associated&#44; mainly to hypokalemia and hypercalciuria&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> In some patients&#44; an associated transient proximal tubule dysfunction is observed at diagnosis&#44; which may be confused with Fanconi syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">39&#44;40</span></a> Occasionally&#44; they can also present with hyperammonemia&#44; which tends to resolve when acidosis is corrected&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;41</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Regarding the age of onset&#44; cases of recessive dRTA &#40;<span class="elsevierStyleItalic">ATP6V0A4 and ATP6V1B1</span>&#41; are associated with an earlier presentation of symptoms&#44; generally at 6 and 24 months after birth&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28</span></a> However&#44; patients with a dominant dRTA &#40;<span class="elsevierStyleItalic">SLC4A1</span>&#41; have a later clinical onset&#44; with a mean age at diagnosis between 4 and 13 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;9&#44;28&#44;36</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Growth&#46;</span> dRTA is frequently diagnosed during the evaluation of growth defects in childhood&#44; mainly with poor linear growth with normal weight&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> This is primarily attributed to the inhibitory effect of metabolic acidosis on growth hormone metabolism&#46; Cases with mutations in the <span class="elsevierStyleItalic">SLC4A1</span> gene tend to have less degree of growth retardation than recessive forms due to later presentation and milder metabolic acidosis&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> An adequate alkaline therapy tend to improve the growth&#44; although some recent series show that the final height is frequently below the mean&#44; regardless of the genetic group&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;17&#44;42</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hearing loss</span>&#46; Due to the importance of proton secretion in endolymph for inner ear function&#44; dRTA is also associated with sensorineural deafness&#46; This occurs in individuals with mutations in <span class="elsevierStyleItalic">ATP6V0A4 and ATP6V1B1</span>&#44; due to the simultaneous expression of V-ATPase in the kidney and ear&#44; and in <span class="elsevierStyleItalic">FOXI1</span>&#46; However&#44; the frequency of deafness associated with mutations in <span class="elsevierStyleItalic">ATP6V1B1</span> is much higher&#44; being observed in around 90&#37; of patients&#44; compared to 35&#8211;50&#37; of those with mutations in <span class="elsevierStyleItalic">ATP6V0A4</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28</span></a> Furthermore&#44; there is a significant difference in the age of onset of deafness between these 2 groups&#46; The detection of deafness in the first years of life is highly indicative of an underlying mutation in the <span class="elsevierStyleItalic">ATP6V1B1</span> gene&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;36</span></a> Some patients also present other abnormalities of the auditory system&#44; such as dilation of the vestibular aqueducts&#44; which is generally bilateral&#44; and they may suffer from dizziness&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;44</span></a> The cases described with pathogenic variants biallelic the gene <span class="elsevierStyleItalic">FOXI1</span> present dRTA deafness and the dilated vestibular aqueduct&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Skeletal manifestations</span>&#46; Metabolic acidosis causes the release of bicarbonate and phosphate from the bone&#44; which act as alkaline buffers to restore physiological blood pH&#46; This results in bone demineralization that can cause rickets in children and osteomalacia in adults&#46; These abnormalities have been described&#44; especially at diagnosis and in a variable manner&#44; in some patients with dRTA&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;42&#44;45</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Hemolytic anemia</span>&#46; There are some cases reported&#44; mostly in Southeast Asia&#44; in pathogenic variants in the <span class="elsevierStyleItalic">SLC4A1</span> gene&#44; of recessive inheritance&#44; that can give rise to dRTA and hemolytic anemia&#44; generally in children&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> The importance of this fact is that these biallelic variants can produce morphological changes in erythrocytes and these&#44; under conditions of metabolic acidosis&#44; may undergo hemolysis&#46; Alkaline therapy corrects anemia and reticulocytosis&#46; These patients also respond to transfusions and ion therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Renal manifestations</span>&#46; Patients with dRTA very frequently and early develop nephrocalcinosis or lithiasis&#44; due to the combination of hypercalciuria&#44; hypocitraturia and a high urinary pH that favors the deposit of oxalate and calcium phosphate crystals&#46; The hypocitraturia is virtually universal in these patients and is due to increased citrate reabsorption in the proximal tubule in response to systemic acidosis&#46; The probability of developing nephrocalcinosis&#47;lithiasis increases with the age of the patient and with the delay in the initiation of alkalizing treatment&#44; that is&#44; with a late diagnosis&#46; Nephrocalcinosis is observed in 90&#8211;95&#37; of patients&#44; of any genetic group&#44; and persists in most cases despite adequate therapeutic control&#46; Adequate alkaline therapy usually prevents its progression&#44; but does not reverse it&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28&#44;36</span></a> The frequency of calculi in patients with mutations in the <span class="elsevierStyleItalic">SLC4A1</span> may be greater&#44; possibly due to a delay in diagnosis caused by milder phenotype expression&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Furthermore&#44; patients with dRTA frequently present with recurrent acute pyelonephritis&#44; associated with the presence of potentially obstructive stones and possibly hypercalciuria&#46; Finally&#44; many individuals develop spinal cysts in childhood or adulthood&#44; which has been attributed to some extent to chronic hypokalemia&#46; However&#44; other tubulopathies with sustained hypokalaemia&#44; such as Bartter syndrome&#44; rarely present medullary cysts during its the evolution&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;47</span></a> The clinical relevance of these cysts is unknown as it was not found a correlation between the development of medullary cysts and the degree of nephrocalcinosis or the long - term deterioration of renal function&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Incomplete distal renal tubular acidosis</span><p id="par0140" class="elsevierStylePara elsevierViewall">Incomplete dRTA cases have been described in patients who are heterozygous carriers of pathogenic variants in the <span class="elsevierStyleItalic">ATP6V1B1</span> gene&#46; These present mild renal acidification defects that do not lead to reduction in blood pH&#44; but fail to adequately acidify the urine if stimulated&#46; In these cases&#44; functional tests to assess maximum urinary acidification capacity may be useful&#46; These individuals frequently have associated hypercalciuria and hypocitraturia&#44; and an elevated risk of kidney stones&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#44;48&#44;49</span></a> Similarly&#44; some dominant mutations in the AE1 transporter can give rise to incomplete dRTA&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Pregnancy</span><p id="par0145" class="elsevierStylePara elsevierViewall">Women with dRTA do not present a priori fertility disorders associated with their disease&#46; However&#44; during pregnancy they may present metabolic complications associated with dRTA mainly hypokalemia and severe metabolic acidosis&#46; In addition&#44; hyperemesis gravidarum may cause electrolyte imbalances by increasing electrolyte losses and making oral supplementation difficult&#46; Other complications to take into account are recurrent episodes of acute pyelonephritis&#44; already common in patients with dRTA&#44; and ureteral obstruction due to pre-existing kidney stones&#46; The worsening of kidney function or proteinuria are not complications usually observed in pregnant women with dRTA&#44; except in those cases with previous chronic kidney disease &#40;CKD&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;35</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Long-term evolution of kidney function</span><p id="par0150" class="elsevierStylePara elsevierViewall">In recent years&#44; there have been published large series of patients with dRTA with confirmed molecular diagnosis evaluating the risk of CKD at the long term&#44; describing CKD grade &#8805;2 in 30&#8211;80&#37; of patients&#44; without significant differences between the patients&#46; 3 main genes involved in dRTA&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;17&#44;28</span></a> Factors potentially involved in this progression are late diagnosis&#44; with a greater number of episodes of decompensation and acute renal failure&#44; nephrocalcinosis or nephrolithiasis particularly obstructive&#44; repeated episodes of pyelonephritis&#44; medullary cysts and persistent hypokalemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;28</span></a> Despite the fact that&#44; as expected&#44; the degree of CKD worsens with a longer evolution time&#44; many patients already have mild CKD since adolescence&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;28</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Despite the trend to CKD&#44; the clinical evolution of patients with dRTA is not critical&#44; particularly if the diagnosis is established early with the consequent correction of acidosis&#46; Although CKD is common&#44; end-stage kidney disease is rare&#46; In many patients&#44; adequate correction of acidosis and electrolyte disturbances is not achieved&#44; reflecting the difficulties with the usual forms of treatment with supplements&#44; both in tolerance and in maintaining therapeutic compliance&#46; Adequate metabolic control can reduce the risk of developing CKD at the long term&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Management of distal renal tubular acidosis&#46; New treatments</span><p id="par0160" class="elsevierStylePara elsevierViewall">The main objective in the management of dRTA is the correction of metabolic acidosis and the secondary and associated alterations&#44; mainly hypokalemia&#44; hypercalciuria and hypocitraturia&#46; This is to ensure normal growth and development in childhood&#44; avoid bone demineralization and associated rickets&#44; and avoid CKD development factors in the medium-long term&#46; The alkalizing treatment&#44; however&#44; does not succeed in modifying the onset or evolution of sensorineural deafness&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Correction of acidosis is carried out with bicarbonate or citrate salts&#44; and the dose usually required for this is higher in the young child and decreases with the end of growth&#46; Thus&#44; in infants&#44; alkali doses of up to 8&#8239;mEq&#47;kg&#47;day are required&#44; later in children&#44; doses of 3&#8211;4&#8239;mEq&#47;kg&#47;day are usually sufficient&#44; and in adults&#44; doses greater than 2&#8211;3&#8239;mEq&#47;kg&#47;day are generally not required&#46; The use of citrate as an alkalinizing agent has the advantage of correcting the hypocitraturia associated with acidosis and of avoiding to some extent the development of associated nephrocalcinosis&#46; The alkalizing agent is used in combination with sodium or potassium&#46; The use of sodium makes sense especially in patients with polyuria and extravascular volume depletion&#44; but it has the disadvantage of increasing calcium excretion and decreasing proximal bicarbonate reabsorption due to the volume overload that it may entail&#46; The use of potassium also attempts to correct the associated hypokalemia&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The most important drawback of the use of alkalizing salts&#44; especially citrate&#44; is poor gastrointestinal tolerance&#46; In addition&#44; it is necessary to divide the treatment into several doses per day to maintain a constant acid-base homeostasis&#46; On many occasions&#44; adequate metabolic control is not achieved&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Recently&#44; the ADV7103 molecule&#44; based on prolonged-release citrate and potassium bicarbonate &#40;2 daily administrations&#41;&#44; has been commercialized in order to improve therapeutic adherence and metabolic control in patients with dRTA&#46; A phase 3 study has shown its efficacy in improving metabolic control and its safety with good gastrointestinal tolerance&#46; This treatment has obtained in Europe the designation of orphan drug for the treatment of dRTA&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Some groups use amiloride as a potassium-sparing diuretic to optimize the treatment of hypokalaemia and to allow a reduction in potassium supplementation doses&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Sometimes they have been used thiazides as hypercalciuria treatment&#44; in order to prevent progression and nephrocalcinosis ERC&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However&#44; this treatment is not generally recommended as it potentially worsens potassium loss and there is no evidence that it improves kidney function in the long term&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">To evaluate sensorineural hearing abnormalities&#44; a standard audiogram should be performed to explore masked and unmasked air and bone conduction at different frequencies&#46; Both magnetic resonance imaging and computed tomography can be used to diagnose dilatation of the vestibular aqueduct&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;43</span></a> Hearing devices &#40;hearing aids or cochlear implants&#41; and language teaching are essential to guarantee the normal intellectual development and social integration of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Financial support</span><p id="par0185" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleGrantSponsor" id="gs0005">pharmaceutical company Advicenne &#40;France&#41;</span> has provided funding for the study of patients with distal renal tubular acidosis&#44; but has not participated in the preparation of this article &#40;grant <span class="elsevierStyleGrantNumber" refid="gs0005">BC&#47;A&#47;19&#47;039</span>&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">No conflict of interest to declare</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Distal renal tubular acidosis &#40;DRTA&#41; is a rare disease resulting from a failure in the normal urine acidification process at the distal tubule and collecting duct level&#46; It is characterised by persistent hyperchloremic metabolic acidosis&#44; with a normal anion gap in plasma&#44; in the presence of high urinary pH and low urinary excretion of ammonium&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To date&#44; 5 genes whose mutations give rise to primary DRTA have been described&#46; Alterations in the <span class="elsevierStyleItalic">ATP6V1B1</span> and <span class="elsevierStyleItalic">ATP6V0A4</span> genes are inherited recessively and are associated with forms of early onset and&#44; in many cases&#44; with neurosensorial deafness&#46; Pathogenic variants in the <span class="elsevierStyleItalic">SLC4A1</span> gene are habitually inherited dominantly and give rise to milder symptoms&#44; with a later diagnosis and milder electrolytic alterations&#46; Nonetheless&#44; evolution to nephrocalcinosis and lithiasis&#44; and the development of chronic kidney disease in the medium to long term has been described in a similar manner in all 3&#8239;groups&#46; Lastly&#44; recessive forms of DTRA associated to mutations in the <span class="elsevierStyleItalic">FOXI1</span> and <span class="elsevierStyleItalic">WDR72</span> genes have also been described&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The clinical management of DTRA is based on bicarbonate or citrate salts&#44; which do not succeed in correcting all cases of the metabolic alterations described and&#44; thus&#44; the consequences associated with them&#46; Recently&#44; a new treatment based on slow-release bicarbonate and citrate salts has received the designation of orphan drug in Europe for the treatment of DTRA&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La acidosis tubular renal distal &#40;ATRD&#41; es una enfermedad rara que se debe al fallo del proceso normal de acidificaci&#243;n de la orina a nivel tubular distal y colector&#46; Se caracteriza por una acidosis metab&#243;lica hiperclor&#233;mica persistente&#44; con ani&#243;n gap normal en plasma&#44; en presencia de un pH urinario elevado y baja excreci&#243;n urinaria de amonio&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se han descrito hasta el momento 5 genes cuyas mutaciones dan lugar a ATRD primaria&#46; Las alteraciones de los genes <span class="elsevierStyleItalic">ATP6V1B1</span> y <span class="elsevierStyleItalic">ATP6V0A4</span> se heredan de forma recesiva y est&#225;n asociadas a formas de inicio m&#225;s precoces y con sordera neurosensorial en muchos casos&#46; Las variantes patog&#233;nicas en el gen <span class="elsevierStyleItalic">SLC4A1</span> se heredan habitualmente de forma dominante y dan lugar a cuadros m&#225;s leves&#44; con un diagn&#243;stico m&#225;s tard&#237;o y alteraciones electrol&#237;ticas menores&#46; Sin embargo&#44; la evoluci&#243;n a nefrocalcinosis y litiasis&#44; y el desarrollo de enfermedad renal cr&#243;nica a medio-largo plazo se ha descrito de forma similar en estos 3&#8239;grupos&#46; Por &#250;ltimo&#44; se han descrito tambi&#233;n formas recesivas de ATRD asociadas a mutaciones en los genes <span class="elsevierStyleItalic">FOXI1</span> y <span class="elsevierStyleItalic">WDR72</span>&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El manejo cl&#237;nico de la ATRD se basa en sales de bicarbonato o citrato&#44; que no logran corregir en todos los casos las alteraciones metab&#243;licas descritas y&#44; por lo tanto&#44; las consecuencias asociadas a ellas&#46; Recientemente&#44; un nuevo tratamiento basado en sales de bicarbonato y citrato de liberaci&#243;n prolongada ha recibido la denominaci&#243;n de medicamento hu&#233;rfano en Europa para el tratamiento de la ATRD&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#8902;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; G&#243;mez-Conde S&#44; Garc&#237;a-Casta&#241;o A&#44; Aguirre M&#44; Herrero M&#44; Gondra L&#44; Casta&#241;o L&#44; et al&#46; Acidosis tubular renal distal hereditaria&#58; correlaci&#243;n genot&#237;pica&#44; evoluci&#243;n a largo plazo y nuevas perspectivas terap&#233;uticas&#46; Nefrologia&#46; 2021&#59;41&#58;383&#8211;390&#46;</p>"
      ]
    ]
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      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2063
            "Ancho" => 2333
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Fig&#46; "
            "rol" => "short"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Acid&#8211;base transporters involved in the secretion of H<span class="elsevierStyleSup">&#43;</span> and reabsorption of HCO<span class="elsevierStyleInf">3</span>&#8211; in the intercalated alpha cells of the collecting duct&#46; Transport of H<span class="elsevierStyleSup">&#43;</span> to the tnbular lumen is mediated by the vacuolar H<span class="elsevierStyleSup">&#43;</span>-ATPase&#44; which actively transfers this proton across the luminal membrane&#46; H<span class="elsevierStyleSup">&#43;</span> can also be secreted thanks to a second ATPase&#44; the H<span class="elsevierStyleSup">&#43;</span>&#47;K&#43;-ATPase&#44; which exchanges H<span class="elsevierStyleSup">&#43;</span> for K&#46; Bicarbonate&#44; formed intracellularly by the action of CAII&#44; leaves the cell through the basolateral membrane&#44; via the transport Anion exchange protein &#40;AE&#41;1 or band 3 protein&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AI&#58; amelogenesis imperfecta&#59; ATRD&#58; distal renal tubular acidosis&#59; AV dilation&#58; dilation of the vestibular aqueduct&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Clinical features&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AE1 &#40;dominant&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AE1 &#40;recessive&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">ATP6V1B1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">ATP6V0A4</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">FOXI1</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">WDR72</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age of onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8722;13 years&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#8722;14 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#8722;24 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">severity of dRTA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypokalemia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mild&#47;moderate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">plasma HCO3<span class="elsevierStyleSup">&#8722;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Close to normal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;6&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;6&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nephrocalcinosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Common and late&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Common and early&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Common and early&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Common and early&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unknown&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sensorineural hearing loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Absent&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Other features&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 20132514
Original language: English
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