Renal Tubular Acidosis

Helena Gil-Pe~na, PhD1,2, Natalia Meja, MD3,*, and Fernando Santos, MD, PhD1,2

n this article, we discuss the current views on the renal

regulation of acid-base metabolism and the diagnostic
approach to children with metabolic acidosis, including
the major characteristics of the different types of renal
tubular acidosis (RTA), focusing on distal RTA (dRTA).
We update progress in identifying the underlying defective
transporters and gene mutations responsible for the primary
forms, suggest candidate genes possibly involved in some
cases, discuss the mechanisms causing growth retardation
and disordered mineral metabolism, and provide the basis
for differential diagnosis with other types of primary RTA.

Physiology of Renal Acid-Base Homeostasis

The majority of acid produced in the body is excreted as CO2
by the lungs. The kidneys regulate acid-base balance by reabsorbing filtered HCO3
and excreting nonvolatile acids, a
process linked to regeneration of the HCO3
consumed in
buffering these fixed acids. In the most distal segments of
the nephron, urinary acidification is accomplished by reclamation of 10%-15% of the filtered HCO3
that is not reabsorbed in proximal tubule and by secretion of H+. Secreted
H+ is eliminated as titratable acid and NH4+, as well as free
ions that determine the urine pH.
The intercalated cells of the collecting duct modify urine
pH according to the acid-base status. The a-intercalated cells
(AICs), identified by a vacuolar H+ATPase (adenosine triphosphatase) located on the luminal membrane and a basolateral anion exchanger (anion exchanger type 1 [AE1]), are
the largest contributors to net acid excretion (Figure 1;
available at www.jpeds.com).1
AICs are dispersed from the late distal convoluted tubule
to the initial inner medullary collecting duct.2 b-intercalated
cells have a H+ATPase in either cytoplasmic or basolateral
distribution and a Cl
/HCO3
exchanger, pendrin, in the
apical membrane responsible for the secretion of net base.3
A controversial subtype, non-a, non-b or C-intercalated
cells, express pendrin, H+ATPase, the ammonia transporter
Rhcg in the apical pole, and glycoprotein Rhbg in the baso-

AE1
AG
AIC
ATPase
CA
dRTA
GFR
GH
IGF-1
kAE1
RTA

Anion exchanger type 1

Anion gap
a-intercalated cell
Adenosine triphosphatase
Carbonic anhydrase
Distal renal tubular acidosis
Glomerular filtration rate
Growth hormone
Insulin-like growth factor 1
Kidney anion exchanger type 1
Renal tubular acidosis

lateral membrane.4,5 Simultaneous luminal expression of

H+ATPase and pendrin in b- and non-a, non-b intercalated
cells might cause the parallel secretion of H+ and HCO3

without affecting acid-base homeostasis.
Diagnostic Approach to the Child with Metabolic
Acidosis
Metabolic acidosis, identified by low plasma HCO3
concentration (<22-24 mEq/L in children and <20-22 mEq/L
in infants) and low blood pCO2 (<40 mm Hg in children
and <35 mm in infants), is usually classified according to
the plasma or serum anion gap (AG; in mEq/L). AG is
calculated in the clinical setting as (Na+ + K+)
(Cl

+ HCO3
). Elevated AG metabolic acidosis results from
the retention of acid containing an anion other than
Cl
in such conditions as advanced renal failure, intoxication, ketoacidosis, lactic acidosis, and inborn errors of
metabolism. Normal AG metabolic acidosis is hyperchloremic, because the drop in serum HCO3
is matched
by an equivalent increment in serum Cl
. Hyperchloremia
results from gastrointestinal loss of HCO3
(eg, diarrhea),
decreased renal reabsorption of HCO3
, and/or reduced
urinary NH4+ excretion (eg, RTA).
Although calculating serum AG is useful for the differential diagnosis of metabolic acidosis (Figure 2), there may
be overlap between the causes of normal and high AG
metabolic acidosis. Thus, 20%-30% of patients with
diabetic ketoacidosis have normal AG acidosis at
presentation or develop it during recovery. This normal AG
acidosis may be explained by the high urinary loss of
ketone anions when the glomerular filtration rate (GFR) is
normal, the administration of sodium chloridecontaining
solutions, cellular phosphate depletion, and insulininduced hypophosphatemia.
Proper assessment of AG requires that each laboratory
determine its own normal range, because the values of
Na+ and Cl
concentrations may vary according to measurement technique. Moreover, whenever possible, for a
more accurate interpretation of the AG change in a given individual, baseline AG should be used rather than the average
normal value.6 It is also important to note that the venous

From the 1Division of Pediatric Nephrology, Hospital Universitario Central de

Asturias; 2Department of Medicine, University of Oviedo, Oviedo, Spain; and
3
, Colombia
Department of Pediatrics, University of Los Andes, Bogota
*Completed during N.M.s sabbatical at the Department of Pediatrics, Hospital
Universitario Central de Asturias and University of Oviedo.
Partly financed by Instituto de Salud Carlos III (FIS PI 09/90758 and 09/02354),
 n Nutricio
 n y Crecimiento. The authors declare no
Fondos FEDER, and Fundacio
conflicts of interest.
0022-3476/$ - see front matter. Copyright 2014 Mosby Inc.
All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2013.10.085

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Figure 2. Diagnostic approach to metabolic acidosis and RTA. CRF, chronic renal failure.

HCO3
concentration must be measured using a blood gas

analyzer. Assessing serum HCO3
with a typical biochemical analyzer is less accurate and has been shown to yield
values up to 5.6 mEq/L lower than those measured by a
blood gas analyzer.7
Some clinicians do not include K+ in the calculation of AG;
however, the measurement of serum K+ is usually available,
and there may be significant differences in concentration in
patients with kidney disease, and thus its determination
seems justified. Because the AG reflects the difference between unmeasured anions and cations other than Na+ and
K+, modifications in the circulating concentrations of albumin and phosphate, which account for the majority of unmeasured anions, as well as in concentrations of calcium
and magnesium, affect the AG value. The AG drops approximately 0.5 mEq/L for every 1 mg/dL reduction in serum
phosphate8 and 2.3 mEq/L for every 1 g/dL reduction in
serum albumin.9 Without the correction for hypoalbumine692

mia, high AG acidosis may be overlooked in malnourished or

critically ill children.

Types of RTA
RTA is biochemically characterized by persistent, normal AG
metabolic acidosis. Four types of RTA can be distinguished
on the basis of clinical, pathophysiological, and molecular
criteria (Figure 2). Primary RTA results from specific
genetic defects in transporters or enzymes involved in renal
HCO3
reabsorption or H+ secretion. Primary RTA usually
presents in infancy or early childhood. Forms of RTA
secondary to exposure to drugs or toxins or as an aspect of
systemic disease are more common in adults.
Type 1 dRTA is caused by impaired distal tubular acidification. Most pediatric cases are primary. In the secondary
forms, the mechanism responsible for the defective urinary
acidification is usually not well understood, although cases
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April 2014
have been associated with the back-leak of secreted H+
(gradient defect), absence of a distal lumen-negative transepithelial difference (voltage-dependent defect), or reduced
urinary NH4+. Patients with obstructive uropathy and an
inability to maximally acidify the urine because of voltagedependent defects have impaired K+ secretion and develop
hyperkalemic type 1 dRTA.10
Proximal, type 2 RTA results from impaired HCO3
reabsorption in the proximal tubule. It most often occurs as a
component of Fanconi syndrome (ie, cystinosis) or secondary to the use of carbonic anhydrase (CA) inhibitors.11 Isolated primary type 2 RTA is extremely rare.
Type 3 RTA is a hybrid of type 1 and type 2 RTA. Autosomal recessive type 3 RTA occurs in association with osteopetrosis, cerebral calcification, and intellectual disability in
patients mostly from North Africa and the Middle East,
with loss-of-function mutations in the gene encoding CA
II.12 The classification of type 3 RTA was also applied to infants and young children with type 1 dRTA and transiently
impaired proximal reabsorption of HCO3
.13
Type 4 RTA is caused mainly by impaired ammoniagenesis
resulting from sustained hyperkalemia produced by drugs or
by either aldosterone deficiency or resistance.14 Type 4 RTA
in patients with chronic interstitial nephropathies (aldosterone resistance) is often associated with renal failure.

Primary Distal Type 1 RTA

Genetic and Molecular Basis

MEDICAL PROGRESS

Figure 3. Vacuolar H+-ATPase consists of 2 domains. The V1

cytosolic domain is responsible for ATP hydrolysis, whereas
the V0 membrane domain is responsible for proton translocation. The V0 subunits are in lowercase letters, and the V1
subunits are in uppercase letters. ADP, adenosine diphosphate; ATP, adenosine triphosphate.

Mutations of H+ATPase Subunits. The majority of primary dRTA cases are caused by an autosomal recessive defect
in H+ATPase. H+ATPase is a highly conserved macromolecule
containing 2 stalk-linked structural domains, V1 and V0. The
V1 domain, located in the cytoplasm, consists of 8 subunits
(A-H) that provide energy by ATP hydrolysis for proton transfer. V0 is formed by 6 subunits with an anchoring position that
likely allows H+ translocation across the cellular membrane15
(Figure 3). Variant a4 of the V0 domain (ATP6V0A4) is the
most abundant a-subunit in the kidney.16 The B1 isoform of
the V1 domain (ATP6V1B1) is expressed in intercalated cells
of the late distal tubule, connecting segment, and cortical
and medullary collecting duct,17 as well as in cells of the
inner ear and the endolymphatic sac.18

Autosomal Recessive dRTA-ATP6V1B1. To date, 2

genes encoding specific subunits of vacuolar H+ATPase

have been linked to recessive dRTA. The ATP6V1B1 gene
(formerly ATP6B1), located at 2p13.3, contains 14 exons
and encodes 1 of the 2 B-subunit isoforms in the V1 domain.
Mutations in this gene are responsible for autosomal recessive dRTA with early-onset sensorineural deafness. These
mutations were recognized in 19 of 31 unrelated dRTA families whose recessive transmission was supported by the
absence of disease in the parents, the occurrence of dRTA
in 2 or more siblings in 4 kindreds, and parental consanguinity in 27 kindreds. Impaired hearing, varying in severity from
mild to profound, was demonstrated in 15 affected subjects.

Renal Tubular Acidosis

ATP6V1B1 messenger RNA was detected in mouse cochlea as

well, supporting the role of the B1 subunit in maintaining inner ear endolymphatic pH and homeostasis.18

Autosomal Recessive dRTA-ATP6V0A4. Through a

similar linkage approach in dRTA kindreds with normal
hearing, new locus heterogeneity to a segment of 7q33-34
was identified.19 Eight of 9 kindreds had homozygous mutations in the ATP6V0A4 gene (formerly ATP6N1B). This gene
contains 23 exons and encodes the a4 subunit of the V0
domain. Mutations are responsible for autosomal recessive
dRTA with late-onset sensorineural deafness or without deafness. In addition to the renal AIC and inner ear, a4 has been
shown to express in bone, nose, eyes, and skin.20 The considerable phenotypic overlap in these 2 forms of recessive dRTA
means that the age of onset and severity of deafness cannot
serve as reliable markers of the underlying gene defect.21

Mutations of AE1. Human AE1 is mostly expressed in

erythrocyte membrane. AE1 has 911 amino acids with 1214 transmembrane spans and N and C termini cytoplasmic
domains. In human AIC, the N-terminally truncated isoform
kidney AE1 (kAE1) exchanges HCO3
for Cl
2 (Figure 1).
kAE1 has a cytoplasmic C-terminal tail that contains
binding sites for CA II, whereas CA IV is anchored to the
extracellular surface of cells.
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Table I. Potential candidate genes for primary dRTA37-43

Gene
Slc26a7
KCC4
HKa1
HKa2
Rhbg
Rhcg
NHE4
Foxi1
DMBT1

Protein

KO model

Phenotype of KO model

Cl /HCO3 exchanger
K-Cl co-transporter
H-K-ATPases

Yes
Yes
No

Complete dRTA
Retarded growth; progressive deafness; alkaline urine; compensated metabolic acidosis
Normal phenotype

Rh B glycoprotein
Rh C glycoprotein
Na+/H+ exchanger
Forkhead transcription factor 1
Hensin

Yes

Rhbg
/
, normal phenotype; Rhcg
/
, impaired urinary ammonium excretion

Yes
Yes
Yes

Compensated metabolic acidosis; inappropriate net acid excretion

Complete dRTA; deafness
Complete dRTA

KO, knockout.

The AE1 gene located at chromosome 17 (17q21.31) has

been named SLC4A1, because it belongs to the solute carrier
gene family 4. Both erythrocyteAE1 and kAE1 isoforms are
encoded by SLC4A1 using different promoter regions and
alternative splicing. Thus, mutations in the same gene result
in 2 unrelated diseases, hemolytic anemia with red cell
morphology anomalies and dRTA. Moreover, dRTA caused
by mutations in this gene can occur with either an autosomal
dominant22-24 or an autosomal recessive25,26 mode of inheritance. Misarrangements in protein structure influence intracellular traffic of mutated kAE1 from endoplasmic reticulum
and Golgi apparatus to the plasma membrane.27

Autosomal Dominant dRTA-SLC4A1. Few cases of

dominant dRTA have been reported. Bruce et al22 studied 4
families from southeast England with affected members heterozygous for mutations in the SLC4A1 gene. Three unrelated
families with autosomal dominant dRTA and normal red
blood cells were subsequently reported by Jarolim et al.23
Karet et al24 screened kindreds with primary dRTA without
anemia for mutations in AE1 and found no AE1 mutations
in 17 kindreds with autosomal recessive dRTA, but mutations
in 1 autosomal dominant dRTA kindred. Additional families
with autosomal dominant dRTA caused by SLC4A1 mutations have been described.28 Nearly all reported patients
with autosomal dominant dRTA are of occidental origin.

bolic acidosis, low net acid excretion, and inability to acidify

the urine.31 Homozygous mice had nephrocalcinosis, hypercalciuria, hyperphosphaturia, and hypocitraturia. Unlike humans lacking AE1, slc4a1
/
mice developed albuminuria
and mesangial fibrosis, suggesting that kAE1 protein interacts
with nephrin to maintain the structure of glomerular basement membrane.32
Atpv1b1
/
mice lacking the b1 subunit of H+ATPase did
not develop spontaneous metabolic acidosis, but nonetheless did not exhibit appropriate urine acidification after an
acid challenge, resembling incomplete dRTA.33 Differences
from the human phenotype included an absence of hypercalciuria and nephrocalcinosis, normal bone density, and
preserved hearing.34 Overexpression of the b2 subunit in
AIC of mouse kidney likely compensates for the absence
of b1 expression.35
Atp6v0a4 knockout mice lacking the a4 subunit of the V0
domain were reported recently.20 Severe metabolic acidosis,
hypokalemia, and early nephrocalcinosis were noted at the
time of weaning. The mice were hypocitraturic but not hypercalciuric, were deaf, and had an impaired sense of smell.
They died quickly without alkali treatment. Heterozygous
mice were biochemically normal but became more acidotic
than wild-type Atp6v0a4+/+ mice after an acid challenge.
Atp6v0a4 deficiency was also associated with proximal tubule
dysfunction with defective endocytic trafficking, proteinuria,
phosphaturia, and accumulation of lysosomal material.36

Autosomal Recessive dRTA-SLC4A1. Mutations of

SLC4A1 causing autosomal recessive dRTA have been

detected mainly in association with Southeast Asian ovalocytosis. Tanphaichitir et al25 reported Thai brothers with lossof-function mutation G701D and normal erythroid anion
transport; this was explained by glycophorin A acting as a
chaperone, rescuing the mutant protein traffic to erythrocyte
membrane. Homozygosity for the G701D mutation was
found in other Thai patients with autosomal recessive
dRTA, and a high allele frequency of this mutation was
confirmed in this population.29

Experimental Models
Knockout mouse models of dRTA have been developed. Mice
lacking AE1 (slc4a1
/
) exhibited retarded growth, hemolytic anemia, thrombotic disorder, and a high mortality rate.30
Heterozygous mice had spontaneous hyperchloremic meta694

Candidate Genes for dRTA

In approximately 20% of patients with a clinical diagnosis of
primary dRTA, no mutations in genes known to cause the
disease can be identified. Various plausible candidate genes
for human dRTA can be proposed, including genes of known
subunits of the proton pump, genes of potential but as-yet
undetected kidney-specific isoforms of involved transporters,
genes of products required for trafficking in AIC, and genes
of molecules essential for maintaining the electrochemical
gradient of cell membranes (Table I). Some of these have
been identified in mice, but there is no evidence that these
genes cause dRTA in humans.
Biochemical and Clinical Features
Typical findings of type 1 dRTA include low serum HCO3
,
normal serum AG, hyperchloremia, hypokalemia, low NH4+
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April 2014
excretion, hypercalciuria, and hypocitraturia. Serum calcium
and phosphate levels are usually normal, as is the GFR.
Hereditary autosomal recessive dRTA begins in the first
years of life with failure to thrive, poor feeding, and vomiting.
Autosomal dominant forms usually develop in adolescence
or adulthood, with less severe symptoms. Growth delay has
been attributed to the effects of metabolic acidosis on mineral
balance and growth hormone (GH)/insulin-like growth factor 1 (IGF-1) axis. Diminished GH secretion, low serum IGF1, and low hepatic IGF-1 and GH receptor messenger RNAs,
as well as suppressed gene expression of IGF-1 at the long
bone growth plates, have been identified in animal models
of metabolic acidosis.44 In young acidotic rats, growth retardation was associated with marked shortening of the growth
cartilage and slow chondrocyte turnover.45
Nerve deafness is present in both autosomal recessive
forms of dRTA caused by defective H+ATPase, but not in patients with an AE1 mutation. The age at which hearing
impairment begins ranges from the first months of life to
age 15 years, although most patients experience hearing
impairment before age 12 years.21,46-49 Bilateral enlargement
of the vestibular aqueduct has been reported in some deaf patients with dRTA.50
The combination of hypercalciuria, hypocitraturia, and
high urine pH leads to nephrocalcinosis and/or nephrolithiasis. Nephrocalcinosis can be identified by ultrasonography during the first weeks of life and is irreversible. Severe
interstitial nephropathy secondary to progressive nephrocalcinosis can lead to polyuric chronic renal failure, a rare
complication seen in only 1 of 18 patients with primary
dRTA diagnosed during childhood after 2-18.5 years of
follow-up.51 Renal calculi are not usually detected until
later in life and can be prevented by adequate alkali therapy.
In chronic metabolic acidosis, buffering of retained fixed
acids promotes the release of hydroxyapatite from the skeleton in exchange for H+. This mechanism is commonly
invoked to explain the hypercalciuria seen in patients
with dRTA.
An inverse lineal relationship between plasma HCO3

concentration and urinary calcium excretion has been found
in pediatric patients with dRTA, prompting a suggestion that
the absence of hypercalciuria may indicate good control of
metabolic acidosis in these patients.13 However, primary
dRTA is usually diagnosed in infancy or early childhood,
when urine calcium levels are high, and calciuria is expected
to decrease with age irrespective of the correction of acidosis.
Moreover, some infants with dRTA with confirmed
ATP6V1B1 mutations do not exhibit hypercalciuria at diagnosis.47,52 Low sodium intake and volume contraction may
cause increased calcium reabsorption and thus may be partly
responsible for the lack of hypercalciuria.
Studies in mice also have shown that chronic metabolic
acidosis down-regulates tubular calcium transporters, such
as TRPV5 and calbindin-D28K,53 suggesting that a direct effect of acidosis on renal calcium reabsorption may contribute
to the hypercalciuria seen in patients with dRTA. The loss of
bone mass supports an osseous origin of the increased calRenal Tubular Acidosis

MEDICAL PROGRESS
cium excretion in patients with dRTA. To our knowledge,
there are no published data on bone structure in children
with dRTA, but Thai patients diagnosed with dRTA as adults
had normal bone mineral density at the L2-L4 vertebrae, total
femur, and femoral neck; no acidotic patient had hypercalciuria.54 Hypocitraturia results from the affects of acidosis
on reducing renal citrate excretion. Even small decreases in
tubular pH increase proximal tubular reabsorption of citrate
via the sodium citrate cotransporter, which has been shown
to be up-regulated in the luminal membrane under conditions of acidosis.55 Hypocitraturia facilitates calcium deposition because citrate acts as a chelating agent that increases the
solubility of calcium in urine.
Constipation, muscle weakness, and an inability to concentrate urine, resulting in polyuria and dehydration, can
be attributed in part to hypokalemia. The mechanism of hypokalemia in dRTA is unclear and likely of multifactorial
origin. Intravascular volume contraction activates the
renin-angiotensin-aldosterone axis, promoting potassium
tubular secretion. Intracellular acidity enhances BK MaxiK+ channel activity, whereas alkaline urine prevents normal
inhibition of voltage-gated K+ channel Kv1.3 in intercalated
cells.56,57 Potassium also could be shifted into intracellular
compartments or lost with feces.
Laboratory Diagnosis of dRTA
Sustained metabolic acidosis accompanied by hyperchloremia or normal plasma AG is common to all types of RTA.
In children, normal plasma AG metabolic acidosis is usually
secondary to diarrhea. The diagnosis of RTA requires
demonstration of the renal origin of the acidosis. The
biochemical determinations and tests useful in the diagnosis
of dRTA are summarized in Table II. In acute significant
metabolic acidosis (ie, serum HCO3 <18 mEq/L) with
normal distal tubule function, urine pH should be <5.5 at
all ages. Correct interpretation of pH in a fresh urine
sample requires the simultaneous measurement of urine:
(1) osmolality, because pH is a measurement of H+
concentration and can be inappropriately high in diluted
urine; (2) sodium, because a low sodium concentration
causes a voltage-dependent acidification defect; and (3)
NH4+, because, given that urine pH reflects the
concentration of free H+, low NH4+ concentrations may
coexist with defective H+ secretion and normal minimum
urine pH. Conversely, chronic metabolic acidosis causes a
marked increase in the renal production of NH4+, and
urine pH might not drop to <5.5 because of the buffering
capacity of urinary NH4+. Thus, the assessment of urine
NH4+ instead of urine pH is critical for the diagnosis of a
renal cause of acidosis.
Measurement of NH4+ in urine by traditional methods,
such as the formaldehyde titration method, is cumbersome
and expensive. Urine AG has been proposed as an indirect index of urinary NH4+ excretion in the presence of acidosis.58
dRTA is characterized by a positive urine AG. When urine
pH exceeds 6.5 or when other anions (eg, ketones) are present in the urine, measurement of urinary AG is not a reliable
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Table II. Differential diagnosis of RTA according to biochemical findings in the presence of metabolic acidosis and
response to functional tests
Normal individuals

Type 1 RTA

In the presence of spontaneous

and sustained metabolic acidosis
Serum chloride
98-102 mEq/L

Serum AG

Traditional values: 12  4 mEq/L;

lower values using autonalyzers.

Serum potassium

3.7-5.2 mEq/L

Urine ammonium

57.0  4.3 mEq/min/1.73 m2 (age 1-16

mo); 80.0  3.7 mEq/min/1.73 m2
(age 7-12 y)

Urine AG

Negative

Urine citrate
Response to functional tests
Fractional excretion of HCO3

Type 2 RTA

Type 4 RTA

High

High

High

Low/normal

Low

High

Low

Normal

Low

Positive

Negative

Positive

Low

Normal

Normal

High

High

>8 mg/kg/d; citrate/Cr >400 mg/g

<5%

Normal

Urine PCO2
Urineblood PCO2

>60-70 mm Hg
>20-30 mm Hg

Low
Low

Normal
Normal

Normal
Normal

Urine pH

<5.3-5.5

High

Normal

Normal

Comments

Normal values depend on the

measurement method. The use of ionspecific electrode yields higher
concentrations.
Methodologic issues related to Cldetermination and changes in serum
albumin and other serum anions and
cations must be considered for a
correct interpretation.
In type 1 RTA, correction of acidosis with
NaHCO3 may aggravate hypokalemia,
particularly if dose is too high.
Urine NH4+ levels depend on aldosterone
stimulus, acidosis, and proximal
production of NH3. Low in forms of
type 2 RTA associated with general
proximal tubular dysfunction.
Indirect index of NH4+ excretion.
Limitations for interpretation in the
clinical setting.
Calculated when serum HCO3
is
normal, after oral or intravenous
HCO3
administration.
In the presence of normal serum HCO3and alkaline urine, that is, after oral
HCO3
load (3-4 mEq/kg) or
acetazolamide administration (15-20
mg/kg). Sensitive index of distal urinary
acidification.
Measured after administration of an
acidifying agent (ie, NH4Cl) or
furosemide.

Cr, creatine.
Serum AG: ([Na+ + K+]
[Cl
+ HCO3
]); urine AG: Na+ + K+
Cl
. Fractional excretion of bicarbonate: ([urine HCO3
/ serum HCO3
]  [serum Cr  100 / urine Cr]).

indicator of NH4+ elimination. Likewise, the correlation between urinary NH4+ and urinary AG in infants during the
first weeks of life is absent or very weak, although the
increased urinary NH4+ concentration resulting from
acidosis was associated with some decrease in urinary
AG.59 Reliable measurements of urinary NH4+ have been reported using an autoanalyzer, prediluted urine samples, and
the same enzymatic assay used to measure NH4+ in serum.60
This method allows the routine determination of NH4+ in
urine.
The calculation of urine osmolal gap has been proposed to
overcome some of the limitations of the urine AG.61
Urine osmolal gap Measured urine osmolality



2 Na K
urea nitrogen mg=dL=2:8
glucose mg=dL=18:
This method is valuable for bedside screening for gross
changes in urinary NH4+ concentration.62 A urine osmolal
gap <100 mOsm/kg H2O suggests a defect in distal urinary
696

acidification. The measurement of PCO2 in alkaline urine reflects the function of the proton pump in conditions that
favor H+ secretion.63 Additional functional tests, such as
phosphate or sulphate load and furosemide administration,64
have been applied to characterize the underlying mechanism
responsible for urinary acidification defects resulting from a
reversible inability to overcome an electric or chemical
gradient or from increased permeability of tubular cell membranes. These studies are not usually needed in children with
primary dRTA. The inability to achieve a minimum urinary
pH after the simultaneous administration of oral furosemide
and fludrocortisone,64 or after a dose of intravenous furosemide (1 mg/kg),14 may be useful for diagnosing primary
dRTA in the clinical setting. This test and the measurement
of urineblood PCO2 after an alkali load or acetazolamide
administration65 also have been proposed as practical tools
for detecting incomplete forms of dRTA in individuals with
renal acidification defects who do not develop spontaneous
metabolic acidosis. The diagnostic workup should include
renal ultrasonography to rule out nephrocalcinosis and/or
lithiasis as well as hydronephrosis, along with measurements
of urinary excretion of calcium and citrate. Audiometry or
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April 2014
auditory evoked potentials are necessary to detect deafness.
Mutational analysis of involved genes should be performed
to identify the underlying molecular defect.
Treatment and Prognosis
The mainstay of dRTA treatment is the chronic administration of alkali to balance net acid production and avoid
disease-related complications. Alkali supplementation as sodium and/or potassium bicarbonate or citrate salts must be
provided to maintain a normal serum HCO3
concentration
of >20 mEq/L in infants and >22 mEq/L in children. Of note,
excessive intake of sodium bicarbonate will expand extracellular volume and decrease proximal tubular reabsorption of
HCO3
, thereby increasing the need for alkali. The amount
of alkali required typically decreases with age, from 5-8
mEq/kg/day in infants to 3-4 mEq/kg/day in children and
then to 1-2 mEq/kg/day in adults,13 likely related to the
high retention of alkali in bone during growth. The bitter
taste of the citrate solution and the need for repeated doses
hinder compliance. Palatability can be improved by mixing
the solution with water or juice.
Normalization of serum HCO3
concentration and
growth are good indicators of appropriate treatment.
Abdominal ultrasonography may be performed annually to
monitor nephrocalcinosis and urolithiasis. Early and sustained correction of acidosis reverses growth retardation,
stops nephrocalcinosis progression, and minimizes the risk
of stone formation and GFR deterioration, but does not
modify the course of deafness.
Although our knowledge of dRTA has increased greatly
over the last 3 decades, clinical and basic researchers should
join in the effort to fully define the underlying molecular defects and to better characterize the pathophysiological mechanisms responsible for the manifestations of the disease, along
with the reliable use of biochemical diagnostic indices. n
Submitted for publication Jun 13, 2013; last revision received Sep 10, 2013;
accepted Oct 30, 2013.
Reprint requests: Fernando Santos, MD, PhD, Pediatra. Quinta planta,
Facultad de Medicina, c/ Julian Claveria 6, 33006 Oviedo, Spain. E-mail:
fsantos@uniovi.es

References
1. Alper SL, Natale J, Gluck S, Lodish HF, Brown D. Subtypes of intercalated cells in rat kidney collecting duct defined by antibodies against
erythroid band 3 and renal vacuolar H+-ATPase. Proc Natl Acad Sci
USA 1989;86:5429-33.
2. Kovacikova J, Winter C, Loffing-Cueni D, Loffing J, Finberg KE,
Lifton RP, et al. The connecting tubule is the main site of the
furosemide-induced urinary acidification by the vacuolar H+-ATPase.
Kidney Int 2006;70:1706-16.
3. Brown D, Hirsch S, Gluck S. An H+-ATPase in opposite plasma membrane
domains in kidney epithelial cell subpopulations. Nature 1988;331:622-4.
4. Wall SM, Hassell KA, Royaux IE, Green ED, Chang JY, Shipley GL, et al.
Localization of pendrin in mouse kidney. Am J Physiol Renal Physiol
2003;284:F229-41.
5. Weiner ID, Verlander JW. Role of NH3 and NH4+ transporters in
renal acid-base transport. Am J Physiol Renal Physiol 2011;300:
F11-23.

Renal Tubular Acidosis

MEDICAL PROGRESS
6. Kraut JA, Madias NE. Serum anion gap: its uses and limitations in clinical medicine. Clin J Am Soc Nephrol 2007;2:162-74.
7. Adedoyin O, Gottlieb B, Frank R, Vento S, Vergara M, Gauthier B, et al.
Evaluation of failure to thrive: diagnostic yield of testing for renal
tubular acidosis. Pediatrics 2003;112:e463-6.
8. Kellum JA. Clinical review: reunification of acid-base physiology. Crit
Care 2005;9:500-7.
9. Feldman M, Soni N, Dickson B. Influence of hypoalbuminemia or hyperalbuminemia on the serum anion gap. J Lab Clin Med 2005;146:
317-20.
10. Batlle DC, Arruda JA, Kurtzman NA. Hyperkalemic distal renal tubular
acidosis associated with obstructive uropathy. N Engl J Med 1981;304:
373-80.
11. Haque SK, Ariceta G, Batlle D. Proximal renal tubular acidosis: a not so
rare disorder of multiple etiologies. Nephrol Dial Transplant 2012;27:
4273-87.
12. Hu PY, Roth DE, Skaggs LA, Venta PJ, Tashian RE, Guibaud P, et al. A splice
junction mutation in intron 2 of the carbonic anhydrase II gene of osteopetrosis patients from Arabic countries. Hum Mutat 1992;1:288-92.
13. Rodrguez Soriano J, Vallo A, Castillo G, Oliveros R. Natural history of
primary distal renal tubular acidosis treated since infancy. J Pediatr 1982;
101:669-76.
14. Rodrguez Soriano J. Renal tubular acidosis: the clinical entity. J Am Soc
Nephrol 2002;13:2160-70.
15. Toei M, Toei S, Forgac M. Definition of membrane topology and identification of residues important for transport in subunit a of the vacuolar
ATPase. J Biol Chem 2011;286:35176-86.
16. Smith AN, Finberg KE, Wagner CA, Lifton RP, Devonald MA, Su Y, et al.
Molecular cloning and characterization of Atp6n1b: a novel fourth murine vacuolar H+-ATPase a-subunit gene. J Biol Chem 2001;276:42382-8.
17. Smith AN, Jouret F, Bord S, Borthwick KJ, Al-Lamki RS, Wagner CA,
et al. Vacuolar H+-ATPase d2 subunit: molecular characterization,
developmental regulation, and localization to specialized proton pumps
in kidney and bone. J Am Soc Nephrol 2005;16:1245-56.
18. Karet FE, Finberg KE, Nelson RD, Nayir A, Mocan H, Sanjad SA, et al.
Mutations in the gene encoding B1 subunit of H+-ATPase cause renal
tubular acidosis with sensorineural deafness. Nat Genet 1999;21:84-90.
19. Smith AN, Skaug J, Choate KA, Nayir A, Bakkaloglu A, Ozen S, et al. Mutations in ATP6N1B, encoding a new kidney vacuolar proton pump 116kD subunit, cause recessive distal renal tubular acidosis with preserved
hearing. Nat Genet 2000;26:71-5.
20. Norgett EE, Golder ZJ, Lorente-Canovas B, Ingham N, Steel KP, KaretFrankl FE. Atp6v0a4 knockout mouse is a model of distal renal tubular
acidosis with hearing loss, with additional extrarenal phenotype. Proc
Natl Acad Sci USA 2012;109:13775-80.
21. Vargas-Poussou R, Houillier P, Le Pottier N, Strompf L, Loirat C,
Baudouin V, et al. Genetic investigation of autosomal recessive distal
renal tubular acidosis: evidence for early sensorineural hearing loss associated with mutations in the ATP6V0A4 gene. J Am Soc Nephrol 2006;
17:1437-43.
22. Bruce LJ, Cope DL, Jones GK, Schofield AE, Burley M, Povey S, et al.
Familial distal renal tubular acidosis is associated with mutations in the
red cell anion exchanger (band 3, AE1) gene. J Clin Invest 1997;100:
1693-707.
23. Jarolim P, Shayakul C, Prabakaran D, Jiang L, Stuart-Tilley A, Rubin HL,
et al. Autosomal dominant distal renal tubular acidosis is associated in
three families with heterozygosity for the R589H mutation in the AE1
(band 3) Cl-/HCO3- exchanger. J Biol Chem 1998;273:6380-8.
24. Karet FE, Gainza FJ, Gy
ory AZ, Unwin RJ, Wrong O, Tanner MJ, et al.
Mutations in the chloride-bicarbonate exchanger gene AE1 cause autosomal dominant but not autosomal recessive distal renal tubular
acidosis. Proc Nat Acad Sci USA 1998;95:6337-42.
25. Tanphaichitir VS, Sumboonnanonda A, Ideguchi H, Shayakul C,
Brugnara C, Takao M, et al. Novel AE1 mutations in recessive distal renal
tubular acidosis: loss-of-function is rescued by glycophorin A. J Clin
Invest 1998;102:2173-9.
26. Vasuvattakul S, Yenchitsomanus PT, Vachuanichsanong P, Thuwajit P,
Kaitwatcharachai C, Laosombat V, et al. Autosomal recessive distal renal
697

THE JOURNAL OF PEDIATRICS

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

698

www.jpeds.com

tubular acidosis associated with Southeast Asian ovalocytosis. Kidney Int

1999;56:1674-82.
Devonald MAJ, Smith AN, Poon JP, Ihrke G, Karet FE. Non-polarized
targeting of AE1 causes autosomal dominant distal renal tubular
acidosis. Nat Genet 2003;33:125-7.
Fry AC, Su Y, Yiu V, Cuthbert AW, Trachtman H, Karet Frankl FE. Mutation conferring apical-targeting motif on AE1 exchanger causes autosomal dominant distal RTA. J Am Soc Nephrol 2012;23:1238-49.
Yenchitsomanus PT, Sawasdee N, Paemanee A, Keskanokwong T,
Vasuvattakul S, Bejrachandra S, et al. Anion exchanger 1 mutations associated with distal renal tubular acidosis in the Thai population. J Hum
Genet 2003;48:451-6.
Southgate CD, Chishti AH, Mitchell B, Yi SJ, Palek J. Targeted disruption of the murine erythroid band 3 gene results in spherocytosis and severe haemolytic anaemia despite a normal membrane skeleton. Nat
Genet 1996;14:227-30.
Stehberger PA, Shmukler BE, Stuart-Tilley AK, Peters LL, Alper SL,
Wagner CA. Distal renal tubular acidosis in mice lacking the AE1
(band3) Cl/HCO3 exchanger (slc4a1). J Am Soc Nephrol 2007;18:1408-18.
Wu F, Saleem MA, Kampik NB, Satchwell TJ, Williamson RC,
Blattner SM, et al. Anion exchanger 1 interacts with nephrin in podocytes. J Am Soc Nephrol 2010;21:1456-67.
Finberg KE, Wagner CA, Bailey MA, Paunescu TG, Breton S, Brown D,
et al. The B1-subunit of the H(+) ATPase is required for maximal urinary acidification. Proc Natl Acad Sci USA 2005;102:13616-21.
Dou H, Finberg K, Cardell EL, Lifton R, Choo D. Mice lacking the
B1 subunit of H+-ATPase have normal hearing. Hear Res 2003;180:
76-84.
Paunescu TG, Da Silva N, Marshansky V, McKee M, Breton S, Brown D.
Expression of the 56-kDa B2 subunit isoform of the vacuolar H(+)ATPase in proton-secreting cells of the kidney and epididymis. Am J
Physiol Cell Physiol 2004;287:C149-62.
Hennings JC, Picard N, Huebner AK, Stauber T, Maier H, Brown D, et al.
A mouse model for distal renal tubular acidosis reveals a previously unrecognized role of the V-ATPase a4 subunit in the proximal tubule.
EMBO Mol Med 2012;4:1057-71.
Xu J, Song P, Nakamura S, Miller M, Barone S, Alper SL, et al. Deletion
of the chloride transporter Slc26a7 causes distal renal tubular acidosis
and impairs gastric acid secretion. J Biol Chem 2009;284:29470-9.
Boettger T, Hubner CA, Maler H, Rust MB, Beck FX, Jentsch TJ. Deafness and renal tubular acidosis in mice lacking the K-CI co-transporter
Kcc4. Nature 2002;416:874-8.
Chambrey R, Goossens D, Bourgeois S, Picard N, Bloch-Faure M, Leviel F,
et al. Genetic ablation of Rhbg in the mouse does not impair renal ammonium excretion. Am J Physiol Renal Physiol 2005;289:F1281-90.
Biver S, Belge H, Bourgeois S, Van Vooren P, Nowik M, Scohy S, et al. A
role for Rhesus factor Rhcg in renal ammonium excretion and male
fertility. Nature 2008;456:339-43.
Bourgeois S, Meer LV, Wootla B, Bloch-Faure M, Chambrey R, Shull GE,
et al. NHE4 is critical for the renal handling of ammonia in rodents. J
Clin Invest 2010;120:1895-904.
Blomqvist SR, Vidarsson H, Fitzgerald S, Johansson BR,
Ollerstam A, Brown R, et al. Distal renal tubular acidosis in
mice that lack the forkhead transcription factor Foxi1. J Clin Invest
2004;113:1560-70.
Gao X, Eladari D, Leviel F, Tew BY, Mir
o-Julia C, Cheema FH, et al.
Deletion of hensin/DMBT1 blocks conversion of beta- to alphaintercalated cells and induces distal renal tubular acidosis. Proc Natl
Acad Sci USA 2010;107:21872-7.
Kuemmerle N, Krieg RJ Jr, Latta K, Challa A, Hanna JD, Chan JC.
Growth hormone and insulin-like growth factor in non-uremic acidosis
and uremic acidosis. Kidney Int 1997;58:S102-5.

Vol. 164, No. 4

~ez FA, Ni~
45. Carbajo E, L
opez JM, Santos F, Ord
on
no P, Rodrguez J. Histologic and dynamic changes induced by chronic metabolic acidosis in
the rat growth plate. J Am Soc Nephrol 2001;12:1228-34.
46. Stover EH, Borthwick KJ, Bavalia C, Eady N, Fritz DM, Rungroj N, et al.
Novel ATP6V1B1 and ATP6V0A4 mutations in autosomal recessive
distal renal tubular acidosis with new evidence for hearing loss. J Med
Genet 2002;39:796-803.
~ez FA, Malaga S, et al.
47. Gil H, Santos F, Garca E, Alvarez MV, Ord
on
Distal RTA with nerve deafness: clinical spectrum and mutational analysis in five children. Pediatr Nephrol 2007;22:825-8.
48. Karet FE. Inherited distal renal tubular acidosis. J Am Soc Nephrol 2002;
13:2178-84.
49. Hahn H, Kang HG, Ha IS, Cheong HI, Choi Y. ATP6B1 gene mutations
associated with distal renal tubular acidosis and deafness in a child. Am J
Kidney Dis 2003;41:238-43.
50. Joshua B, Kaplan DM, Raveh E, Lotan D, Anikster Y. Audiometric and
imaging characteristics of distal renal tubular acidosis and deafness. J
Laryngol Otol 2008;122:193-8.
51. Bajpai A, Bagga A, Hari P, Bardia A, Mantan M. Long-term outcome in
children with primary distal renal tubular acidosis. Indian Pediatr 2005;
42:321-8.
52. Tsai HY, Lin SH, Lin CC, Huang FY, Lee MD, Tsai JD. Why is hypercalciuria absent at diagnosis in some children with ATP6V1B1 mutation?
Pediatr Nephrol 2011;26:1903-7.
53. Nijenhuis T, Renkema KY, Hoenderop JG, Bindels RJ. Acid-base status
determines the renal expression of Ca2+ and Mg2+ transport proteins. J
Am Soc Nephrol 2006;17:617-26.
54. Domrongkitchaiporn S, Pongsakul C, Stitchantrakul W,
Sirikulchayanonta V, Ongphiphadhanakul B, Radinahamed P, et al.
Bone mineral density and histology in distal renal tubular acidosis. Kidney Int 2001;59:1086-93.
55. Aruga S, Wehrli S, Kaissling B, Moe OW, Preisig PA, Pajor AM, et al.
Chronic metabolic acidosis increases NaDC-1 mRNA and protein abundance in rat kidney. Kidney Int 2000;58:206-15.
56. Pluznick JL, Sansom SC. BK channels in the kidney: role in K(+) secretion and localization of molecular components. Am J Physiol Renal
Physiol 2006;291:F517-29.
57. Carrisoza-Gaytan R, Salvador C, Satlin LM, Liu W, Zavilowitz B,
Bobadilla NA, et al. Potassium secretion by voltage-gated potassium
channel Kv1.3 in the rat kidney. Am J Physiol Renal Physiol 2010;299:
F255-64.
58. Goldstein MB, Bear R, Richardson RM, Marsden PA, Halperin ML. The
urine anion gap: a clinically useful index of ammonium excretion. Am J
Med Sci 1986;292:198-202.
59. Sulyok E, Guignard JP. Relationship of urinary anion gap to urinary
ammonium excretion in the neonate. Biol Neonate 1990;57:98-106.
60. Szmidt-Adjide V, Vanhille P. Ammoniuries: validation dune technique
de dosage enzymatique et evaluation par rapport a une estimation par le
calcul. Ann Biol Clin 2008;66:393-9.
61. Kim GH, Han JS, Kim YS, Joo KW, Kim S, Lee JS. Evaluation of urine
acidification by urine anion gap and urine osmolal gap in chronic metabolic acidosis. Am J Kidney Dis 1996;27:42-7.
62. Kraut JA, Madias NE. Differential diagnosis of nongap metabolic acidosis:
value of a systematic approach. Clin J Am Soc Nephrol 2012;7:671-9.
63. Kim S, Lee JW, Park J, Na KY, Joo KW, Ahn C, et al. The urine-blood
PCO gradient as a diagnostic index of H+-ATPase defect distal renal
tubular acidosis. Kidney Int 2004;66:761-7.
64. Walsh SB, Shirley DG, Wrong OM, Unwin RJ. Urinary acidification assessed by simultaneous furosemide and fludrocortisone treatment: an
alternative to ammonium chloride. Kidney Int 2007;71:1310-6.
65. Alon U, Hellerstein S, Warady BA. Oral acetazolamide in the assessment
of (urineblood) pCO2. Pediatr Nephrol 1991;5:307-11.

~a, Meja, and Santos

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Figure 1. Regulation of acid-base in intercalated cells. A, AIC. H+ are actively secreted to the lumen by a proton pump or
H+ATPase and new HCO3- passively returns to the systemic circulation through the basolateral Cl-/HCO3- exchanger or kAE1. Clis reabsorbed through K+/Cl- cotransporters (Kcc) and ClC chloride channels. The luminal membrane H+/K+ ATPase plays a role
in potassium preservation during deficiency. Transporters responsible for primary dRTA (see text for details) are highlighted and
marked with asterisks. B, b-intercalated cell. Bicarbonate is secreted to the tubular lumen and Cl- is reabsorbed, using the apical
anion exchanger pendrin. A H+-ATPase and a Cl- channel locate at the basolateral membrane whereas a H+/K+ ATPase exchanges H+ by K+ at the luminal membrane.

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