Renal aminoaciduria

NS (acute) (general population) Renal Aminoaciduria Fanconi syndrome >80 (children) Chisolm 1962 Pueschel et al. 1972... 

B5. Baron, D. N., Dent, C. E., Harris, H., Hart, E. W., and Jepson, J. B., Hereditary pellagra-like skin rash with temporary cerebellar ataxia, constant renal aminoaciduria, and other bizarre biochemical features. Lancet ii, 421-428 (1956). 

Hartnup disease is a rare genetic condition in which there is a defect of the membrane transport mechanism for tryptophan and other large neutral amino acids. The result is that the intestinal absorption of free tryptophan is impaired, although dipeptide absorption is normal. There is a considerable urinary loss of tryptophan (and other amino acids) as a result of the failure of the normal reabsorption mechanism in the renal tubules - renal aminoaciduria. In addition to neurological signs that can be attributed to a deficit of tryptophan for the synthesis of serotonin in the central nervous system, the patients show clinical signs of pellagra, which respond to the administration of niacin. 

Metabolic studies by Milne et al. (M8) showed that in Hartnup disease the renal aminoaciduria is more constant than the excessive excretion of indican and indolic acids (indoleacetic acid, indolelactic acid, and indoleacetylglutamine). After ingestion of L-tryptophan in this disease there is usually delayed and incomplete absorption from the gut of the amino acid which is partly converted, by intestinal bacteria, to indole... 

The Hartnup disease described in 1956 (B2) under the title hereditary pellagra-like skin rash with temporary cerebellar ataxia, constant renal aminoaciduria, and other bizarre biochemical features evidently belongs to the diseases related to inborn errors of metabolism due to inherited differences. As was pointed out by Harris (H3), very often the detection of urinary amino acid metabolites has represented the starting point of the investigation of different genetic biochemical disorders. A recent study (A8) showed that the excess production of indole by colon bacteria in 15 cases of Hartnup disease was due entirely to an increased amount of tryptophan contained in the large bowel, and not to an abnormality of the bacteria themselves. 

Much that is known about renal reabsorption mechanisms has been learned from the study of various forms of aminoaciduria. Three types of aminoaciduria have been identified (1) overflow aminoaciduria occurs when the plasma level of one or more amino acids exceeds the renal threshold (tubular capacity for reabsorption) (2) renal aminoaciduria occurs when plasma levels are normal but the renal transport system has a congenital or acquired defect and (3) no-threshold aminoaciduria occurs when excessive amounts of an amino acid, arising from an inherited metabolic block, are present in urine, but plasma levels are essentially normal because ah the amino acid is excreted. The no-threshold aminoacidurias, such as homocystinuria, are not due to congenital or acquired kidney defects but solely to saturation of the normal renal tubular reabsorption mechanisms. 

Amino acid excretion in urine varies with maturation of renal tubular function. Premature infants, especially during the first week, have a generalized physiological renal aminoaciduria (see Figure 20-2) even at full term, aminoaciduria is more pronounced than in normal adults. In the urine of normal adults, glycine is usually the dominant fraction, with alanine, serine, glutamine, and— in indulgent meat eaters— histidine and 1-methylhistidine present in smaller quantities. In some normal urine, taurine is prominent in others, (3-aminoisobutyric acid is seen. 

Conservation of amino acids filtered at the glomerulus is made possible by the existence of four main transport systems for specific amino acids that facilitate active reabsorption of these amino acids from the proximal tubule. A lack or deficiency of the transport system responsible for the absorption of valine, alanine, cystine, and tryptophan, and of the transport system for arginine, lysine, cystine, and ornithine, leads to excretion of these specific amino acids in urine, which is characterized as renal aminoaciduria to distinguish it from overflow aminoaciduria. In the latter situation, the production of amino acids far exceeds the proximal tubular reabsorption capacity, thus leading to overflow of amino acids into urine. This can occur due to defective metabolism of amino acids, as is the case when phenylalanine cannot be metabolized due to the deficiency of the enzyme phenylalanine hydroxylase, or to the inability to deaminate amino acids in liver disease. 

Renal Effects. The characteristics of early or acute lead-induced nephropathy in humans include nuclear inclusion bodies, mitochondrial changes, and cytomegaly of the proximal tubular epithelial cells dysfunction of the proximal tubules (Fanconi s syndrome) manifested as aminoaciduria, glucosuria, and phosphaturia with hypophosphatemia and increased sodium and decreased uric acid excretion. These effects appear to be reversible. Characteristics of chronic lead nephropathy include progressive interstitial fibrosis, dilation of tubules and atrophy or hyperplasia of the tubular epithelial cells, and few or no nuclear inclusion bodies, reduction in glomerular filtration rate, and azotemia. These effects are irreversible. The acute form is reported in lead-intoxicated children, whose primary exposure is via the oral route, and sometimes in lead workers. The chronic form is reported mainly in lead workers, whose primary exposure is via inhalation. Animal studies provide evidence of nephropathy similar to that which occurs in humans, particularly the acute form (see Section 2.2.3.2). 

Information is available on the renal toxicity of ingested lead in several species, including rats, dogs, monkeys, and rabbits. The results indicate that histopathological changes in the kidneys of lead-treated animals are similar to those in humans (see Section 2.2.1.2). Reduced glomerular filtration rates and aminoaciduria were reported in some of the animal studies. Key animal studies on lead-induced renal toxicity will be discussed below. 

Chisolm JJ Jr. 1962. Aminoaciduria as a manifestation of renal tubular injury in lead intoxication and a comparison with patterns of aminoaciduria seen in other diseases. J Pediatr 60 1-17. 

Defects of complex IV. These disorders, also termed COX deficiency, have clinical phenotypes that fall into two main groups one in which myopathy is the predominant or exclusive manifestation and another in which brain dysfunction predominates (Fig. 42-3). In the first group, the most common disorder is fatal infantile myopathy, causing generalized weakness, respiratory insufficiency and death before age 1 year. There is lactic acidosis and renal dysfunction, with glycosuria, phosphaturia and aminoaciduria, also termed DeToni-Fanconi-Debre syndrome. The association of myopathy and cardiopathy in the same patient and myopathy and liver disease in the same family has also been described [14]. 

The urine frequently contains casts and amorphous debris, but rarely any considerable number of red blood corpuscles. Proteinuria and aminoaciduria are found in nearly all untreated patients from a very early age. The proteinuria is usually reported as albuminuria in the literature, but in some cases the urinary protein has been shown by electrophoresis to consist largely of a-globulin and other relatively low-molecular-weight proteins (B21). A similar urinary pattern occurs in a number of diseases of the renal tubule. The proteinuria is often only moderate in degree, e.g., < 50 to 150 mg protein per 100 ml of urine, but is easily detected by the conventional tests for protein, such as salicylsulfonic acid. Excretion of protein can rise to nearly 1 g/100 ml in some cases (H8, L7). 

In some cases, the amino acid pattern on a paper chromatogram is very similar to that found in diseases of the renal tubules, such as cystinosis, where there is a failure to reabsorb all amino acids from the glomerular filtrate and, in consequence, the urinary amino acid pattern resembles that of plasma (W6, W9). In other cases the aminoaciduria is less marked and the amino acids found in greatest excess are glycine, alanine, serine, threonine, and glutamine. In some cases no aminoaciduria has been detected. 

The proteinuria and aminoaciduria, and acidosis and glucosuria where they occur, are probably caused by reversible inhibition of some functions of the renal tubule. There would appear to be no structural damage to the kidney. However, 2 children developed nephrolithiasis while being treated with a low-lactose diet (B7, C5), The time course of events, when galactose is withdrawn from and returned to the diet, suggests that some metabolite of galactose accumulates in the cells of the renal tubules and has an inhibitory effect on the reabsorption of a number of substances. 

In those patients who survive more than a few weeks, the effects of renal tubular dysfunction become more severe. Acidosis and hypo-phosphatemic rickets are prominent features. The urine is alkaline and gives a strong Rothera reaction. However, the ability to concentrate the urine is never lost and there is neither polydipsia nor polyuria. Aminoaciduria, hydroxyphenyluria, glucosuria, fructosuria, and proteinuria continue. The liver remains large and cirrhotic. Death finally occurs in liver failure, sometimes after several years. There is evidence that some children recover with no residual signs other than a large firm liver. 

Renal calcinosis can develop as a result of hypercalciuria and is a major concern in the treatment of infantile spasms with corticotropin. In 16 infants, corticotropin, often associated with anticonvulsants, results in increased urinary excretion of calcium and phosphate, with increased parathormone serum concentrations and in some cases generalized aminoaciduria (26). This makes it imperative that the dose of corticotropin and the duration of treatment be kept to the minimum required to ensure efficacy. In one case in which calcified stones were removed surgically, recurrence was apparently prevented, despite the presence of a Cushingoid state, by long-term chlorothiazide (27). 

H9. Harrison, H. E., and Harrison, H. C., Experimental production of renal glycosuria, phosphaturia, and aminoaciduria by injection of maleic acid. Science 120, 606-608 (1954). 

Several heavy metals, particularly lead, are known to cause major adverse effects to the mammalian kidney, resulting in kidney function impairment. Adverse effects to the mammalian kidney caused by lead include lesions on the proximal tubule and Henle s loop, and the presence of lead inclusion bodies. The metal also is known to cause aminoaciduria, phosphaturia, glycosuria, and renal tubular acidosis. Workers associated with lead-smelting industries also have shown kidney cancer. 

A number of inherited conditions are now known in which some degree of renal aciduria has been found. These include diseases as diverse as cystinuria, galactosemia, and Wilson s disease. In the last of these the aminoaciduria is probably a consequence of renal tubular damage secondary to excessive copper deposition (H2). 

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