Bartter Syndrome 

Updated: Jun 02, 2021
Author: Lynda A Frassetto, MD; Chief Editor: Vecihi Batuman, MD, FASN 

Overview

Practice Essentials

Bartter syndrome, originally described by Bartter and colleagues in 1962,[1] represents a set of closely related, autosomal recessive renal tubular disorders characterized by hypokalemia, hypochloremia, metabolic alkalosis, and hyperreninemia with normal blood pressure.[2, 3] The underlying kidney abnormality results in excessive urinary losses of sodium, chloride, and potassium.

Bartter syndrome has traditionally been classified into three main clinical variants, as follows:

  • Neonatal (or antenatal) Bartter syndrome
  • Classic Bartter syndrome
  • Gitelman syndrome

Advances in molecular diagnostics have revealed that Bartter syndrome results from mutations in numerous genes that affect the function of ion channels and transporters that normally mediate transepithelial salt reabsorption in the distal nephron segments (see the image below). Hundreds of mutations have been identified to date. Such advances may result in the development of new therapies.[4] (See Pathophysiology and Etiology.)

Normal transport mechanisms in the thick ascending Normal transport mechanisms in the thick ascending limb of the loop of Henle. Reabsorption of sodium chloride is achieved with the sodium chloride/potassium chloride cotransporter, which is driven by the low intracellular concentrations of sodium, chloride, and potassium. Low concentrations are maintained by the basolateral sodium pump (sodium-potassium adenosine triphosphatase), the basolateral chloride channel (ClC-kb), and the apical potassium channel (ROMK).

More recently, other classification systems for Bartter syndrome have been developed. Seyberth proposed a classification of Bartter syndrome that takes into account the three main anatomic and pathophysiologic disturbances that lead to the salt-losing tubulopathy. The classification is as follows (see Etiology, Presentation, and Workup)[5] :

  • Classic Bartter syndrome and Gitelman syndrome - The first type involves dysfunction in the thick ascending limb of the loop of Henle (TALH) or distal convoluted tubule (DCT) that leads to hypokalemia; this condition takes the form of either classic Bartter syndrome (caused by mutations in the CLCNKB gene) or Gitelman syndrome (caused by mutations in the NCCT gene). In addition, a mutation in the basolateral calcium sensing receptor has been identified as causing milder symptoms of classic Bartter syndrome.[6]

  • Neonatal (or antenatal) Bartter syndrome - The second type involves polyuric loop dysfunction that is more severe; this form of Bartter syndrome is characterized by defects in the NKCC2 and ROMK genes

  • Neonatal (or antenatal) Bartter syndrome with sensorineural deafness - The third type involves the most severe combined loop and distal convoluted tubule dysfunction; it is caused by defects in the chloride channel genes CLCNKB and CLCNKA or their beta subunit BSND.

A widely used system classifies Bartter syndrome on the basis of the underlying genetics, as follows[7] :

  • Type 1 – Antenatal Bartter syndrome: Results from mutations in SLC12A1, the sodium-chloride-potassium cotransporter gene
  • Type 2  – Antenatal/neonatal Bartter syndrome: Results from mutations in the ROMK gene 
  • Type 3 – Classic Bartter syndrome: caused by mutations of the chloride voltage-gated channel Kb gene ( CLCNKB), which encodes the kidney-specific basolateral chloride channel (ClC-Kb) involved in sodium chloride reabsorption in the renal tubule [8]
  • Type 4 – Bartter syndrome with sensorineural deafness: Results from loss-of-function mutations in BSND, which encodes an essential beta subunit for chloride channels
  • Type 5 – Gitelman syndrome: Results from mutations in SLC12A3, the sodium-chloride cotransporter

Most recently, an international team of researchers has identified an X-linked disorder characterized by polyhydramnios with prematurity and a severe but transient form of antenatal Bartter syndrome. The disorder results from mutations in MAGED2, a gene on the X chromosome that encodes melanoma-associated antigen D2 (MAGE-D2), which is essential for fetal renal salt reabsorption, amniotic fluid homeostasis, and the maintenance of pregnancy. In their study of 13 infants, four died perinatally and 11 survived; in the survivors, all symptoms disappeared spontaneously during follow-up.[9] In a recent French cohort, MAGED2 mutations accounted for 9% of antenatal Bartter syndrome and 38% of patients without other characterized mutations.[10]

Pathophysiology

Bartter and Gitelman syndromes are renal tubular salt-wasting disorders in which the kidneys cannot reabsorb chloride in the loop of Henle (TALH) or distal convoluted tubule (DCT), depending on the mutation.

Chloride is passively absorbed along most of the proximal tubule but is actively transported in the TALH and the DCT. Failure to reabsorb chloride results in a failure to reabsorb sodium and leads to excessive sodium and chloride (salt) delivery to the distal tubules, with consequent excessive salt and water loss from the body.

Other pathophysiologic abnormalities result from excessive salt and water loss. The renin-angiotensin-aldosterone system (RAAS) is a feedback system activated with volume depletion. Long-term stimulation may lead to hyperplasia of the juxtaglomerular complex.

Angiotensin II (ANG II) is directly vasoconstrictive, increasing systemic and renal arteriolar constriction, which helps to prevent systemic hypotension. It directly increases proximal tubular sodium reabsorption.

ANG II–induced renal vasoconstriction, along with potassium deficiency, produces a counterregulatory rise in vasodilating prostaglandin E (PGE) levels. High PGE levels are associated with growth inhibition in children.

High levels of aldosterone also enhance potassium and hydrogen exchange for sodium. Excessive intracellular hydrogen ion accumulation is associated with hypokalemia and intracellular renal tubule potassium depletion. This is because hydrogen is exchanged for potassium to maintain electrical neutrality. It may lead to intracellular citrate depletion, because the alkali salt is used to buffer the intracellular acid and then lowers urinary citrate excretion. Hypocitraturia is an independent risk factor for renal stone formation.

Excessive distal sodium delivery increases distal tubular sodium reabsorption and exchange with the electrically equivalent potassium or hydrogen ion. This, in turn, promotes hypokalemia, while lack of chloride reabsorption promotes inadequate exchange of bicarbonate for chloride, and the combined hypokalemia and excessive bicarbonate retention lead to metabolic alkalosis.

Persons with Bartter syndrome often have hypercalciuria. Normally, reabsorption of the negative chloride ions promotes a lumen-positive voltage, driving paracellular positive calcium and magnesium absorption. Continued reabsorption and secretion of the positive potassium ions into the lumen of the TALH also promotes reabsorption of the positive calcium ions through paracellular tight junctions. Dysfunction of the TALH chloride transporters prevents urine calcium reabsorption in the TALH. Excessive urine calcium excretion may be one factor in the nephrocalcinosis observed in these patients.

Calcium is usually reabsorbed in the DCT. Theoretically, chloride is reabsorbed through the thiazide-sensitive sodium chloride cotransporter and transported from the cell through a basolateral chloride channel, reducing intracellular chloride concentration. The net effect is increased activity of the voltage-dependent calcium channels and enhanced electrical gradient for calcium reabsorption from the lumen.

In Gitelman syndrome, dysfunction of the sodium chloride cotransporter (NCCT) leads to hypocalciuria and hypomagnesemia. In the last several years, the understanding of magnesium handling by the kidney has improved and advances in genetics have allowed the differentiation of a variety of magnesium-handling mutations.

While patients with the variants that make up Bartter syndrome may or may not have hypomagnesemia, this condition is pathognomonic for Gitelman syndrome. The mechanism of the impaired magnesium reabsorption is still unknown; studies in NCCT knockout mice demonstrate increased apoptosis of DCT cells, which would then lead to diminished reabsorptive surface area.[11]

Sensorineural deafness

The ClC-Kb channel is found in the basolateral membrane of the TALH, while the barttin subunits of ClC-Ka and ClC-Kb are found in the basolateral membrane of the marginal cells of the cochlear stria vascularis.

In the inner ear, an Na-K-2Cl pump, called NKCC1, on the basolateral membrane increases intracellular levels of sodium, potassium, and chloride. Potassium excretion across the apical membrane against a concentration gradient produces the driving force for the depolarizing influx of potassium through the ion channels of the sensory hair cells required for hearing. The sodium ion is excreted across the basolateral membrane by the Na-K-adenosine triphosphatase (ATPase) pump, and the ClC-K channels allow the chloride ion to exit to maintain electroneutrality.

Sensorineural deafness associated with type IV Bartter syndrome, a neonatal form of the disease (see Etiology), is due to defects in the barttin subunit of the ClC-Ka and CIC-Kb channels.

Mutations in only the ClC-Kb subunit, as occurs in type III Bartter syndrome, do not result in sensorineural deafness.

Etiology

Defects in either the sodium chloride/potassium chloride cotransporter or the potassium channel affect the transport of sodium, potassium, and chloride in the thick ascending limb of the loop of Henle (TALH). The result is the delivery of large volumes of urine with a high content of these ions to the distal segments of the renal tubule, where only some sodium is reabsorbed and potassium is secreted.

Familial and sporadic forms of Bartter and Gitelman syndromes exist. When inherited, these syndromes are passed on as autosomal recessive conditions.

Neonatal (type I and type II) Bartter syndrome

An autosomal recessive mode of inheritance is observed in some patients with neonatal Bartter syndrome, although many cases are sporadic.

Type I results from mutations in the sodium chloride/potassium chloride cotransporter gene (NKCC2; locus SLC12A1 on chromosome bands 15q15-21). (See the first image below.) Type II results from mutations in the ROMK gene (locus KCNJ1 on chromosome bands 11q24-25). (See the second image below.) Numerous mutations have been identified at those sites.[12, 13, 14]

Type I neonatal Bartter syndrome. Mutations in the Type I neonatal Bartter syndrome. Mutations in the sodium chloride/potassium chloride cotransporter gene result in defective reabsorption of sodium, chloride, and potassium.
Type II neonatal Bartter syndrome. Mutations in th Type II neonatal Bartter syndrome. Mutations in the ROMK gene result in an inability to recycle potassium from the cell back into the tubular lumen, with resultant inhibition of the sodium chloride/potassium chloride cotransporter.

Classic (type III) Bartter syndrome

Some patients have an autosomal recessive mode of inheritance in classic Bartter syndrome, although many cases are sporadic.

In classic Bartter syndrome, the defect in sodium reabsorption appears to result from mutations in the chloride-channel gene (CLCNKB, on band 1p36). The consequent inability of chloride to exit the cell inhibits the sodium chloride/potassium chloride cotransporter. (See the image below.)

Classic Bartter syndrome. Mutations in the ClC-kb Classic Bartter syndrome. Mutations in the ClC-kb chloride channel lead to an inability of chloride to exit the cell, with resultant inhibition of the sodium chloride/potassium chloride cotransporter.

Increased delivery of sodium chloride to the distal sites of the nephron leads to salt wasting, polyuria, volume contraction, and stimulation of the renin-angiotensin-aldosterone axis. These effects, combined with biologic adaptations of downstream tubular segments, specifically the distal convoluted tubule (DCT) and the collecting duct, result in hypokalemic metabolic alkalosis.[15]

The hypokalemia, volume contraction, and elevated angiotensin levels increase intrarenal prostaglandin E2 (PGE2) synthesis, which contributes to a vicious cycle by inhibiting sodium chloride reabsorption in the TALH and further stimulating the renin-aldosterone axis.

Recently, a novel mutation in the CLCNKB gene was reported in three siblings with short stature and growth retardation.  Genetic analysis showed a c.2 T>G/delta exone 1-19) compound heterozygous mutation seen in all three children.  This was associated with low basal and stimulated growth hormone and IGF-1 levels.[16]  

Type IV Bartter syndrome

Studies have identified a novel type IV Bartter syndrome.[17, 18, 19] This is a type of neonatal Bartter syndrome associated with sensorineural deafness and has been shown to be caused by mutations in the BSND gene.[18, 20, 21] BSND encodes barttin, an essential beta subunit that is required for the trafficking of the chloride channel ClC-K (ClC-Ka and ClC-Kb) to the plasma membrane in the TALH and the marginal cells in the scala media of the inner ear that secrete potassium ion ̶ rich endolymph.[17] Thus, loss-of-function mutations in barttin cause Bartter syndrome with sensorineural deafness.

In contrast to other Bartter types, the underlying genetic defect in type IV is not directly in an ion-transporting protein. The defect instead indirectly interferes with the barttin-dependent insertion in the plasma membrane of chloride channel subunits ClC-Ka and ClC-Kb.[22]

Type IVb Bartter syndrome

Type IVb Bartter syndrome is a recently renamed form. It is associated with sensorineural deafness but is not caused by mutations in the BSND gene.

Type V Bartter syndrome

Type V Bartter syndrome has been shown to be a digenic disorder resulting from loss-of-function mutations in the genes that encode the chloride channel subunits ClC-Ka and ClC-Kb.[22] The specific genetic defect includes a large deletion in the gene that encodes ClC-Kb (ie, CLCNKB) and a point mutation in the gene that encodes ClC-Ka (CLCNKA). 

An etiology of Bartter syndrome that is usually known as autosomal dominant hypocalcemia or autosomal dominant hypoparathyroidism has been described. This type V Bartter syndrome has a gain-of-function mutation in the calcium-sensing receptor (CaSR). The CaSR is expressed in the basolateral membrane of the thick ascending limb of loop of Henle. When this receptor is activated, rate of potassium efflux from ROMK channel is reduced, leading to reduction of Na-K-2Cl cotransporter activity. The lack of luminal positive charge leads to increased level of calcium and magnesium in the urine. The end result is mild renal sodium, chloride, potassium, calcium and magnesium wasting.

This form of Bartter syndrome has additional phenotypic presentation of hypocalcemia and hypomagnesemia.[6, 23]

A summary of currently identified genotype-phenotype correlations in Bartter syndrome is in the table below.

Table 1. Bartter Syndrome Genotype-Phenotype Correlations (Open Table in a new window)

Bartter Syndrome Genotype-Phenotype Correlations

Genetic Type

Defective Gene

Clinical Type

Bartter type I

NKCC2

Neonatal

Bartter type II

ROMK

Neonatal

Bartter type III

CLCNKB

Classic

Bartter type IV

BSND

Neonatal with deafness

Bartter type IVb

CLCNKB and CLCNKA

Neonatal with deafness

Bartter type V

CaSR

Classic

Epidemiology

International occurrence

Bartter syndrome is rare, and estimates of its occurrence vary from country to country. In the United States, the precise incidence is unknown.

In Costa Rica, the frequency of neonatal Bartter syndrome is approximately 1.2 cases per 100,000 live births but is higher if all preterm births are considered. No evidence of consanguinity was found in the Costa Rican cohort.[24]

In Kuwait, the prevalence of consanguineous marriages or related families in patients with Bartter syndrome is higher than 50%, and prevalence in the general population is 1.7 cases per 100,000 persons.[25]

In Sweden, the frequency has been calculated as 1.2 cases per 1 million persons. Of the 28 patients Rudin reported, 7 came from 3 families; the others were unrelated.[26]

Age-related demographics

Neonatal Bartter syndrome can be suspected before birth or can be diagnosed immediately after birth. In the classic form, symptoms begin in neonates or in infants aged 2 years or younger. Gitelman syndrome is often not diagnosed until adolescence or early adulthood.[27, 28]

Prognosis

Bartter and Gitelman syndromes are autosomal recessive disorders, and neither is curable. The degree of disability depends on the severity of the receptor dysfunction, but the prognosis in many cases is good, with patients able to lead fairly normal lives.

The effects of prostaglandin synthetase inhibition include an increase in the plasma potassium concentration (however, this rarely exceeds 3.5 mEq/L), a decrease in the magnitude of polyuria, and improved general well-being.

With treatment, plasma renin and aldosterone levels normalize. Therapy improves the patient's clinical condition and allows catch-up growth.

Bone age is usually appropriate for chronological age, and pubertal and intellectual development are normal with treatment.

The effectiveness of long-term use of prostaglandin synthetase inhibitors is well established. Some patients may experience a recurrence of hypokalemia, which can be managed by adjusting the indomethacin dose or with potassium supplementation. The disease does not recur in the patient with a transplanted kidney.

Morbidity and mortality

Significant morbidity and mortality occur if Bartter syndrome is untreated. With treatment, the outlook is markedly improved; however, long-term prognosis remains guarded because of the slow progression to chronic renal failure due to interstitial fibrosis.

Sensorineural deafness

Sensorineural deafness associated with Bartter syndrome IV is due to defects in the barttin subunit of the ClC-Ka and CIC-Kb channels.[17, 29]

Nephrocalcinosis

A review of 61 cases of Bartter syndrome reported 29 with nephrocalcinosis, a condition that is often associated with hypercalciuria.

Renal failure

Renal failure is fairly uncommon in Bartter syndrome. In a review of 63 patients, 5 developed progressive renal disease requiring dialysis or transplantation.

In 2 reports of patients who underwent biopsies before developing end-stage renal disease (ESRD), 1 patient had interstitial nephritis, and the other had mesangial and interstitial fibrosis.

One report relates the case of a patient developing reversible acute renal failure from rhabdomyolysis due to hypokalemia.

Short stature/growth retardation

Nearly all patients with Bartter syndrome have growth retardation. In a review of 66 patients, 62 had growth retardation, often severe (below the fifth percentile for age). Treatment with potassium, indomethacin, and growth hormone (GH) has been effective.

Additional complications

Other complications in Bartter syndrome include the following:

  • Cardiac arrhythmia and sudden death - May result from electrolyte imbalances

  • Failure to thrive and developmental delay - Common in untreated patients

  • Significant decrease in bone mineral density - Has been documented in patients with either the neonatal or classic form

Patient Education

Patients and their parents must understand that no cure exists for the constellation of mutations that causes the various forms of Bartter syndrome. This chronic condition requires taking medications consistently, as prescribed, which is often difficult for children and adolescents. Patients should be aware of potential adverse effects of medical therapy, especially gastrointestinal (GI) irritation and bleeding.

Patients tend to become volume depleted if they are sodium and water restricted. Adequate fluid and electrolyte replacement should be available, especially in hot weather and during exercise. Patients should avoid strenuous exercise because of the danger of dehydration and functional cardiac abnormalities secondary to potassium imbalance.

With regard to diet, patients should be educated about which foods have high potassium content.

Bartter and Gitelman syndromes are autosomal recessive disorders; ie, mutations are required on each allele in the chromosome pair. Offspring carry at least 1 mutated allele. In consanguineous marriages or in marriages between closely related families, genetic counseling may be advisable.

For patient education information, see Growth Hormone Deficiency, Growth Failure in Children, Growth Hormone Deficiency in Children, and Growth Hormone Deficiency FAQs.

 

Presentation

History

Neonatal Bartter syndrome

Maternal polyhydramnios, secondary to fetal polyuria, is evident by 24-30 weeks' gestation. Delivery often occurs before term. The newborn has massive polyuria (rate as high as 12-50 mL/kg/h).

The subsequent course is characterized by life-threatening episodes of fluid loss, clinical volume depletion, and failure to thrive. Volume depletion increases thirst, and the normal response is to increase fluid intake.

A subset of patients with neonatal Bartter syndrome (types IV and V) develop sensorineural deafness.

Classic Bartter syndrome

Patients have a history of maternal polyhydramnios and premature delivery. Symptoms include the following:

  • Polyuria
  • Polydipsia
  • Vomiting
  • Constipation
  • Salt craving
  • Tendency for volume depletion
  • Failure to thrive
  • Linear growth retardation

Other symptoms, which appear during late childhood, include fatigue, muscle weakness, cramps, and recurrent carpopedal spasms.

Developmental delay and minimal brain dysfunction with nonspecific electroencephalographic changes are also present.

Physical Examination

Neonatal Bartter syndrome

Patients are thin and have reduced muscle mass and a triangularly shaped face, which is characterized by a prominent forehead, large eyes, protruding ears, and drooping mouth. Strabismus is frequently present. Blood pressure is within the reference range.

A subset of patients with Bartter syndrome (types IV and V) develop sensorineural deafness, which is detectable with audiometry.

Classic Bartter syndrome

The patient's facial appearance may be similar to that encountered in the neonatal type. However, this finding is infrequent.

 

DDx

Diagnostic Considerations

Patients with Gitelman syndrome tend to have milder symptoms than do those with Bartter syndrome and to present in adolescence and early adulthood. Often, patients have minimal symptomatology and lead relatively normal lives.[26, 30]

In a study of 163 patients with type III Bartter syndrome, Gitelman syndrome, or pseudo-Bartter syndrome/Gitelman syndrome, patients with pseudo- Bartter syndrome/Gitelman syndrome were significantly older at diagnosis than those in the other two groups. Compared with the Gitelman syndrome group, the pseudo-Bartter syndrome/Gitelman syndrome group included a significantly higher percentage of women and had a lower estimated glomerular filtration rate and body mass index.[31]  

Hypomagnesemia and hypocalciuria were observed in all three groups. Chronic kidney disease was observed in 40% of patients with type III Bartter syndrome, 12% of those with Gitelman syndrome, and 63% of those with pseudo- Bartter syndrome/Gitelman syndrome.[31]

Consider possible renal tubular disorder if patients, especially dehydrated infants and young children, are found to have hypokalemia and a high serum bicarbonate concentration that do not correct with potassium and chloride replacement treatment.

Cystic fibrosis (CF) may initially present as Pseudo-Bartter syndrome with electrolyte and acid-base abnormalities such as hypochloremia, hyponatremia, hypokalemia and metabolic alkalosis, especially in early childhood.[32]

Conditions to consider in the differential diagnosis of Bartter syndrome include the following:

  • Diuretic abuse
  • Gitelman syndrome
  • Hyperprostaglandin E syndrome
  • Familial hypomagnesemia with hypercalciuria/nephrocalcinosis
  • Activating mutations of the CaSR calcium-sensing receptor
  • Cyclical vomiting
  • Congenital chloride diarrhea
  • Gullner syndrome - Familial hypokalemic alkalosis with proximal tubulopathy
  • Mineralocorticoid excess
  • Pyloric stenosis
  • Hypomagnesemia
  • Cystic fibrosis
  • Hypochloremic alkalosis
  • Hypokalemia
 

Workup

Approach Considerations

The severity and site of the mutation determines the age at which symptoms first develop. Completely dysfunctional mutations in the receptors and ion channels in the thick ascending limb of the loop of Henle (TALH) are probably not compatible with life.

Most cases of Bartter syndrome are discovered in infancy or early adolescence. Bartter syndrome can also be diagnosed prenatally, when the fetus develops polyhydramnios and intrauterine growth retardation. Many of the neonates are born prematurely. Children diagnosed early in life usually have more severe electrolyte disorders and symptoms. Because of Bartter syndrome's heterogeneity, patients with minimal symptomatology may be discovered relatively late.

Electrocardiography

An electrocardiogram (ECG) may reveal changes characteristic of hypokalemia, such as flattened T waves and prominent U waves.

Histologic findings

Although renal biopsy is not usually required, histologic findings may be useful in confirming the diagnosis of Bartter syndrome.

In neonatal and classic Bartter syndrome, the cardinal finding is hyperplasia of the juxtaglomerular apparatus. Less frequently, hyperplasia of the medullary interstitial cells is present.

Glomerular hyalinization, apical vacuolization of the proximal tubular cells, tubular atrophy, and interstitial fibrosis may be present as a consequence of chronic hypokalemia.

Inpatient care

For patients initially diagnosed in the hospital, the goal is to stabilize the patient sufficiently for discharge. This includes stabilization of potassium and other electrolytes, as well as volume and, perhaps, acid-base parameters.

Consultations

Contact a nephrologist or pediatric nephrologist whenever a patient fitting the clinical picture of Bartter or Gitelman syndrome is identified. The specialist can assist with the initial diagnosis and carry out periodic outpatient evaluation of growth, development, renal function, serum electrolytes, and response to therapy.

Monitoring

Patients initially need frequent outpatient follow-up care until the metabolic abnormalities caused by the renal tubular transporter mutation are stabilized with medications. The length of time to stability depends on the severity of the mutation and the degree of patient compliance.

Laboratory Studies

Potassium

Initiate timed urine collection to determine potassium levels. In hypokalemia, normal kidneys retain potassium.[33] Elevated urinary potassium levels with low blood potassium levels suggest that the kidneys are having problems retaining potassium.

Aldosterone

Next, initiate timed urine collection to determine aldosterone levels. Aldosterone levels should be low in volume-replete patients. If urinary aldosterone levels are high despite volume replacement, there is an abnormal stimulation of aldosterone.

Patients with primary hyperaldosteronism in a volume-replete state usually have normal to high blood pressure. Low or low-normal blood pressure with high aldosterone excretion suggests that the primary problem is something else and that the aldosterone response is secondary to the undiagnosed primary abnormality.

Chloride

Next, initiate a timed urine collection to determine chloride levels. Extrarenal volume depletion is a possible reason for low blood pressure, high aldosterone excretion, and potassium loss. In this case, the kidneys retain sodium and chloride, and urinary chloride concentrations should be low.

High urine chloride levels with low blood pressure, high aldosterone secretion, and high urinary potassium levels are found only with long-term diuretic use and Bartter or Gitelman syndrome. If diuretic abuse is suspected, a urine screen for diuretics can be ordered. Otherwise, the diagnosis is Bartter or Gitelman syndrome.

Calcium/magnesium

Patients with Bartter syndrome have high urinary excretion of calcium and normal urinary excretion of magnesium, except for type V Bartter syndrome. Patients with type V Bartter syndrome have elevated urinary calcium and urinary magnesium level.

In patients with Gitelman syndrome, the opposite is true, with tests showing low urinary excretion of calcium and high urinary excretion of magnesium.

Hyperuricemia

Hyperuricemia is present in 50% of patients with Bartter syndrome. In Gullner syndrome, hypouricemia is present, secondary to impaired proximal tubular function.

Complete blood count

Polycythemia may be present from hemoconcentration.

Mutations

Mutations in the different transporters cause Bartter syndrome. The older methods of determining the presence of mutations require more detailed physiologic investigations, including determination of serum magnesium levels and further urine collections to assess calcium, magnesium, and PGE2 levels.

In Bartter syndrome, urine calcium excretion is high, leading to nephrocalcinosis, while serum magnesium levels are normal except for type V Bartter syndrome. Patients with type V Bartter syndrome have both hypocalcemia and hypomagnesemia.

With the transporter mutations that cause Gitelman syndrome, hypomagnesemia is common and is accompanied by hypocalciuria.

Genetic analysis has become the preferred methodology for determining whether a mutation in one of the transporters has occurred. An analysis of the genes for the transporters shows multiple problems leading to abnormal gene function, including missense, frame-shift, loss-of-function, and large deletion mutations. (Not all mutations lead to a marked loss of function.)[34, 35, 36, 37, 38, 39]

Thiazide testing

The thiazide test may be used to aid in the diagnosis of Gitelman syndrome. In this test, patients are given an oral dose of 50 mg (1 mg/kg in children and adolescents). Urine electrolytes are then measured, and electrolyte excretion is evaluated as fractional excretion, with creatinine as a marker for glomerular filtration rate.[40]

Over 3 hours, patients with Gitelman syndrome typically show a blunted fractional clearance of chloride (< 2.3%), whereas patients with Bartter syndrome and pseudo–Bartter syndrome show a normal response; indeed, patients with pseudo–Bartter syndrome may have an increased response.  Colussi and colleagues concluded that in patients a Gitelman syndrome phenotype marked by normotensive hypokalemic alkalosis, thiazide test results allow sufficiently sensitive and specific prediction of the Gitelman syndrome genotype that genetic testing may be unnecessary.[40]

On thiazide testing, normomagnesemic patients may exhibit a stronger reaction than hypomagnesemic patients. In a comparison study of 17 Gitelman syndrome patients with SLC12A3 gene mutations, including five patients with no history of hypomagnesemia, and 20 healthy controls, a sevenfold increase in sodium and chloride excretion was seen in the controls after thiazide administration, while an approximately twofold increase was seen in the normomagnesemic Gitelman syndrome patients, and no change was observed in the hypomagnesemic Gitelman syndrome patients. Clearance of chloride in one patient with chronic renal insufficiency was overestimated. These researchers recommended that in patients with chronic renal insufficiency, chloride and sodium clearance rates rather than the fractional excretion should be used in the evaluation of the thiazide test results.[41]

Amniotic fluid

If the diagnosis is being made prenatally, assess the amniotic fluid. The chloride content may be elevated in either Gitelman or Bartter syndrome. Increased aldosterone levels and low total protein levels in amniotic fluid have also been reported.[42]

Glomerular filtration rate

The glomerular filtration rate (GFR) is preserved during the early stages of the disease; however, it may decrease as a result of chronic hypokalemia. One study, however, hypothesizes that GFR is affected more by secondary hyperaldosteronism than by hypokalemia.[43]

Imaging Studies

Neonatal Bartter syndrome can be diagnosed best prenatally by ultrasonography. The fetus may have polyhydramnios and intrauterine growth retardation. Amniotic chloride levels may be elevated.[44]

After birth, especially if the disease is diagnosed in older patients who have hypercalciuria, consider a renal ultrasonogram or flat plate of the abdomen for nephrocalcinosis. Sonographic findings include diffusely increased echogenicity, hyperechoic pyramids, and interstitial calcium deposition.

Because continued calcium loss may affect bones, dual-energy radiographic absorptiometry scans to determine bone mineral density may be advisable in older patients.

Nephrocalcinosis can occur and is often associated with hypercalciuria. It can be diagnosed with abdominal radiographs, intravenous pyelograms (IVPs), renal ultrasonograms, or spiral computed tomography (CT) scans.

 

Treatment

Approach Considerations

Since the first description of Bartter syndrome in 1962, several types of medical treatment have been used, including the following:

  • Sodium and potassium supplements - Used for the electrolyte imbalances
  • Aldosterone antagonists and diuretic spironolactone - Are mainstays of therapy
  • Angiotensin-converting enzyme (ACE) inhibitors - Used to counteract the effects of angiotensin II (ANG II) and aldosterone
  • Indomethacin or ibuprofen [45] - Used to decrease prostaglandin excretion
  • Growth hormone (GH) - Used to treat short stature
  • Calcium or magnesium supplements - May occasionally be needed if tetany or muscle spasms are present

Pregnancy-related considerations

Reports associated with Bartter syndrome in pregnant women are limited because Bartter syndrome is a rare disease. Complications related to electrolyte loss (eg, hypokalemia, hypomagnesemia) responded well to supplementation. Fetuses were unaffected and carried to term.

In Rudin's report of 28 pregnant patients, no problems were noted except asymptomatic hypokalemia.[26] In another study, of 40 patients, 30 reported normal pregnancies and terminated by normal parturition; however, many of the patients who were pregnant probably had Gitelman syndrome.

Renal Transplantation

Bartter and Gitelman syndromes, by themselves, do not lead to chronic renal insufficiency; however, in patients with these syndromes who develop end-stage renal disease (ESRD) for other reasons, transplants from living relatives are an option and result in normal urinary handling of sodium, potassium, calcium, and magnesium.

Reports of renal transplants from living relatives in ESRD patients with Bartter syndrome suggest that many endocrinologic abnormalities in Bartter syndrome improve or normalize after transplantation.

Because the genetic abnormality in Bartter syndrome may be found only in the kidneys (which is certain in Na-K-Cl cotransporter but may not be the case for some of the other mutations), transplantation corrects the problem by replacing unhealthy kidneys with normal ones.

Donors

Bartter syndrome is an autosomal recessive disorder. Both parents carry at least 1 gene for the disorder. Statistically, only 1 of 4 siblings will be completely healthy. Whether carrying 1 gene for this abnormality leads to long-term problems late in life if 1 kidney is removed is unknown. Transplants from living, unrelated persons or cadavers are options for patients with ESRD.

Preemptive Surgery

One approach to the management of severe Bartter syndrome involves preemptive nephrectomy and renal transplantation.[46] The rationale for this approach lies in the fact that Bartter syndrome is an incurable genetic disease, and the poorly controlled forms may result in frequent life-threatening episodes of dehydration and electrolyte imbalances. Preemptive bilateral nephrectomies and successful kidney transplantation prior to the onset of ESRD has resulted in correction of metabolic abnormalities and excellent graft function.

Special Surgical Concerns

Electrolytes

Special attention should be paid to correcting electrolyte abnormalities when patients with Bartter syndrome undergo surgical procedures.

Anesthesia

The multiple biochemical abnormalities that occur in patients with Bartter syndrome may present a challenge to anesthesiologists when general anesthesia is used. Potential problems include difficulties in fluid and electrolyte management, acid-base abnormalities, and a decreased response to vasopressors.

Renal function must be monitored carefully, and dose adjustments must be made for drugs dependent on renal excretion if renal function declines. Moreover, metabolic alkalosis has been reported to alter drug protein binding for some anesthetic agents.

Patients with Bartter syndrome may also have platelet dysfunction if routinely treated with nonsteroidal anti-inflammatory agents.

Diet and Activity

Diet

Adequate salt and water intake is necessary to prevent hypovolemia, and adequate potassium intake is essential to replace urinary potassium losses. Patients should consume foods and drinks that contain high levels of potassium (eg, tomatoes, bananas, orange juice).

With growth retardation, adequate overall nutritional balance (protein-calorie intake) is important. Whether other dietary supplements (eg, citrate, magnesium, vitamins) are helpful is not clear.

Activity

No restriction on general activity is required, but precautions against dehydration should be taken. Patients should avoid strenuous exercise avoided because of the danger of dehydration and functional cardiac abnormalities secondary to potassium imbalance.

 

Guidelines

Guidelines Summary

In 2021, the European Rare Kidney Disease Reference Network published guidelines for the diagnosis and management of Bartter syndrome. Because of the rarity of the syndrome, the guidelines are based on the expert consensus of the organization's Working Group for Tubular Disorders.[47]

Diagnosis

Key recommendations for the diagnosis of Bartter syndrome include the following[47] :

  • Prenatal diagnosis should be considered in the presence of a polyhydramnios of fetal origin; polyhydramnios due to excessive fetal polyuria is virtually always caused by Bartter syndrome. 
  • Prenatal molecular genetic testing should be done according to country-specific ethical and legal standards and with appropriate genetic counseling.
  • If genetic testing is unavailable, consider the assessment of the “Bartter index” (alpha fetoprotein [AFP] × total protein) in the amniotic fluid for prenatal diagnosis.
  • The assessment of electrolytes and/or aldosterone from amniotic fluid for prenatal diagnosis is not recommended.
  • Postnatal diagnosis should be considered in patients with renal salt wasting, polyuria, rapid weight loss, and signs of dehydration.
  • Failure to thrive, recurrent vomiting, repeated fever, hypochloremic and hypokalemic metabolic alkalosis, and nephrocalcinosis beyond the neonatal period should raise suspicion of Bartter syndrome.

The guidelines recommend the following approach in the initial postnatal workup for Bartter syndrome[47] :

  • Medical history focus :  Polyhydramnios, premature birth, growth failure, and family history
  • Biochemical panel: Serum electrolytes (sodium, chloride, potassium, calcium, magnesium), acid-base status, renin, aldosterone, creatinine, fractional excretion of chloride, and urinary calcium-creatinine ratio
  • Kidney ultrasound:Evidence of medullary nephrocalcinosis and/or kidney stones

The diagnosis should be confirmed by genetic testing where available and genetic counseling should be offered. The following genes should be included in genetic testing for Bartter syndrome[47] :

  • SLC12A1
  • KCNJ1
  • CLCNKB
  • CLCNKA
  • BSND
  • MAGED2
  • SLC12A3
  • CASR
  • KCNJ10
  • SLC26A3
  • CLDN10
  • SCNN1A
  • SCNN1B
  • SCNN1G
  • NR3C2

Tubular function tests with furosemide or thiazides are not recommended if genetic testing is available.[47]

Management

Key recommendations for the management of Bartter syndrome include the following[47] :

  • Prenatal therapy aimed at reduction of amniotic fluid volume should be undertaken only after weighing the potential risks for the fetus, such as premature closure of the ductus arteriosus or necrotizing enterocolitis. A multidisciplinary team including maternal-fetal medicine specialist, neonatologist, pediatric nephrologist, and pediatric cardiologist should be consulted.
  • Sodium chloride supplementation should be considered for postnatal treatment.
  • Potassium chloride is preferred for potassium supplementation; complete normalization of plasma potassium levels is not recommended.
  • If needed, provide oral magnesium supplements.
  • Salt and electrolyte supplements should be spread out throughout the day as much as possible.
  • In symptomatic patients, consider treatment with nonsteroidal anti-inflammatory drugs (NSAIDs).
  • Use gastric acid inhibitors together with nonselective cyclooxygenase inhibitors.
  • Use of potassium-sparing diuretics, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs) is not recommended.
  • Use of thiazides to reduce hypercalciuria are not recommended.
 

Medication

Medication Summary

Salt and water depletion due to an inability to conserve sodium in the thick ascending limb of the loop of Henle (TALH) or the distal convoluted tubule (DCT) leads to activation of the renin-angiotensin-aldosterone system (RAAS) and high aldosterone levels. This helps the kidneys retain sodium distal to the site of the mutation, but at the expense of losing potassium.

Aldosterone inhibitors and angiotensin-converting enzyme (ACE) inhibitors help to block the RAAS and to prevent potassium loss in the distal tubules. The body conserves potassium, and less oral potassium supplementation is needed.

Short stature and growth failure are common in Bartter syndrome. Exogenous growth hormone (GH) increases the growth rate and helps patients with GH deficiency attain normal height. Although not well studied, at least 1 report describes a patient with low GH levels and Gitelman syndrome who was below the third percentile for height and whose growth rate improved 4-fold during GH treatment. Dose depends on brand used. Somatropin (up to 0.3 mg/kg weekly SC) and somatropin (rDNA origin, 0.1 mg/kg daily SC) have been used.

Potassium Supplements

Class Summary

These are used to treat hypokalemia associated with Bartter syndrome. Correction of hypokalemia is the most important goal of medical therapy.

Potassium chloride (K-Dur, Klor-Con, Micro K)

Dosage depends on the degree of receptor dysfunction and hypokalemia. Serum potassium levels often run in the range of 2-3 mEq/L, which may require several hundred milliequivalents of potassium per day.

Potassium can be administered in various formulations, but chloride salt is recommended because of coexisting chloride deficiencies in patients with Bartter syndrome. Potassium is essential for the transmission of nerve impulses, the contraction of cardiac muscle, the maintenance of intracellular tonicity, skeletal and smooth muscles, and the maintenance of normal renal function.

Diuretics, Potassium-Sparing

Class Summary

These medications enhance the effect of potassium supplementation by decreasing urinary potassium losses.

Spironolactone (Aldactone)

Spironolactone is a specific antagonist of aldosterone, primarily by competitively binding to receptors at the aldosterone-dependent sodium-potassium exchange site in the DCT. This agent increases water excretion while retaining potassium and hydrogen ions.

Amiloride

Amiloride inhibits sodium reabsorption at the DCT, cortical collecting tubule, and collecting duct. This decreases the net negative potential of the tubular lumen and reduces potassium and hydrogen secretion and their subsequent excretion.

Triamterene (Dyrenium)

Triamterene interferes with potassium/sodium exchange (active transport) in the distal tubule, cortical collecting tubule, and collecting duct by inhibiting sodium/potassium adenosine triphosphatase (ATPase). This agent decreases calcium excretion and increases magnesium loss.

ACE Inhibitors

Class Summary

ACE inhibitors block the conversion of angiotensin I (ANG I) to ANG II and prevent the secretion of aldosterone from the adrenal cortex.

Captopril

Captopril prevents the conversion of ANG I to ANG II, a potent vasoconstrictor, resulting in lower aldosterone secretion. It is also helpful in preventing potassium loss.

Enalapril (Vasotec)

Enalapril is a competitive inhibitor of ACE. It reduces ANG II levels, decreasing aldosterone secretion.

Lisinopril (Prinivil, Zestril)

Lisinopril prevents the conversion of ANG I to ANG II, a potent vasoconstrictor, resulting in lower aldosterone secretion.

Benazepril (Lotensin)

Benazepril prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in increased levels of plasma renin and a reduction in aldosterone secretion.

When pediatric patients are unable to swallow tablets or the calculated dose does not correspond with tablet strength, an extemporaneous suspension can be compounded. Combine 300 mg (15 tablets of 20-mg strength) in 75 mL of Ora-Plus suspending vehicle, and shake well for at least 2 minutes. Let the tabs sit and dissolve for at least 1 hour, then shake again for 1 minute. Add 75 mL of Ora-Sweet. The final concentration is 2 mg/mL, with a total volume of 150 mL. The expiration time is 30 days with refrigeration.

Fosinopril

Fosinopril is a competitive ACE inhibitor. It prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in increased levels of plasma renin and a reduction in aldosterone secretion. It decreases intraglomerular pressure and glomerular protein filtration by decreasing efferent arteriolar constriction.

Quinapril (Accupril)

Quinapril is a competitive ACE inhibitor. It reduces angiotensin II levels, decreasing aldosterone secretion.

NSAIDs

Class Summary

These medications blunt prostaglandin overproduction, which is responsible for the pressor resistance to ANGII and norepinephrine, hyperreninemia, and increased sympathoadrenal activity. By inhibiting PGE2 synthesis, these agents also contribute to the correction of the hemoconcentration defect.

Indomethacin (Indocin)

Indomethacin is a nonsteroidal drug with anti-inflammatory, antipyretic, and analgesic properties that are thought to be mediated by its potent prostaglandin inhibitory effect; ensuing hyporeninemic hypoaldosteronism is thought to be responsible for potassium retention.

Naproxen (Anaprox, Aleve, Naprosyn, Naprelan)

Naproxen is used for the relief of mild to moderate pain. It inhibits inflammatory reactions and pain by decreasing the activity of the enzyme cyclo-oxygenase (COX), which results in prostaglandin synthesis.

Sulindac (Clinoril)

Sulindac decreases COX activity and, in turn, inhibits prostaglandin synthesis. This results in decreased formation of inflammatory mediators.

Meloxicam (Mobic)

Meloxicam decreases COX activity and this, in turn, inhibits prostaglandin synthesis. These effects decrease the formation of inflammatory mediators.

Ketoprofen

Ketoprofen is used for relief of mild to moderate pain and inflammation. Small dosages are indicated initially in small patients, elderly patients, and patients with renal or liver disease. Doses higher than 75 mg do not increase the therapeutic effects. Administer high doses with caution, and closely observe the patient's response.

Flurbiprofen

Flurbiprofen may inhibit COX, thereby, in turn, inhibiting prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Ibuprofen (Motrin, Advil, Ultraprin, Addaprin)

Ibuprofen inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

 

Questions & Answers

Overview

What is Bartter syndrome?

How is Bartter syndrome classified?

What is the pathophysiology of Bartter syndrome?

What is the pathophysiology of sensorineural deafness in Bartter syndrome?

What causes classic (type IVb) Bartter syndrome?

What causes Bartter syndrome?

What causes neonatal (type I and type II) Bartter syndrome?

What causes classic (type III) Bartter syndrome?

What causes classic (type IV) Bartter syndrome?

What causes classic (type V) Bartter syndrome?

What is the prevalence of Bartter syndrome in the US?

How does the prevalence of Bartter syndrome vary by geography?

At what age is Bartter syndrome typically diagnosed?

What is the prognosis of Bartter syndrome?

What is the mortality and morbidity associated with Bartter syndrome?

What is included in patient education about Bartter syndrome?

Presentation

Which clinical history findings are characteristic of neonatal Bartter syndrome?

Which clinical history findings are characteristic of classic Bartter syndrome?

Which physical findings are characteristic of neonatal Bartter syndrome?

Which physical findings are characteristic of classic Bartter syndrome?

DDX

How is Bartter syndrome differentiated from Gitelman syndrome?

Which conditions are included in the differential diagnoses of Bartter syndrome?

Workup

Which factors affect when symptoms develop in Bartter syndrome?

What is the role of electrocardiography in the workup of Bartter syndrome?

Which histologic findings are characteristic of Bartter syndrome?

When is inpatient care indicated for the treatment of Bartter syndrome?

Which specialist consultations are beneficial to patients with Bartter syndrome?

What is included in long-term monitoring of Bartter syndrome?

What is the role of potassium measurement in the workup of Bartter syndrome?

What is the role of aldosterone measurement in the workup of Bartter syndrome?

What is the role of chloride measurement in the workup of Bartter syndrome?

What is the role of calcium and magnesium in the workup of Bartter syndrome?

What is the prevalence of hyperuricemia in Bartter syndrome?

What is the role of CBC count in the workup of Bartter syndrome?

What is the role of genetic testing in the workup of Bartter syndrome?

What is the role of thiazide testing in the workup of Bartter syndrome?

What is the role of prenatal testing the workup of Bartter syndrome?

What is the role of GFR in the workup of Bartter syndrome?

What is the role of imaging studies in the workup of Bartter syndrome?

Treatment

How is Bartter syndrome treated?

How does Bartter syndrome affect pregnancy outcomes?

What is the role of renal transplantation in the treatment of Bartter syndrome?

What are considerations for donor selection in renal transplantation for Bartter syndrome?

What is the role of preemptive nephrectomy in the treatment of Bartter syndrome?

What concerns should be addressed in patients with Bartter syndrome undergoing surgical procedures?

What are potentials complications of anesthesia in patients with Bartter syndrome?

Which dietary modifications are used in the treatment of Bartter syndrome?

Which activity modifications are used in the treatment of Bartter syndrome?

Guidelines

Which organizations have published guidelines on the diagnosis and management of Bartter syndrome?

What are the European Rare Kidney Disease Reference Network guidelines for diagnosis of Bartter syndrome?

What are the European Rare Kidney Disease Reference Network guidelines for the initial diagnosis workup of Bartter syndrome?

What are the European Rare Kidney Disease Reference Network guidelines for confirmation of a Bartter syndrome diagnosis?

What are the European Rare Kidney Disease Reference Network guidelines for the management of Bartter syndrome?

Medications

What is the role of medications in the treatment of Bartter syndrome?

Which medications in the drug class NSAIDs are used in the treatment of Bartter Syndrome?

Which medications in the drug class ACE Inhibitors are used in the treatment of Bartter Syndrome?

Which medications in the drug class Diuretics, Potassium-Sparing are used in the treatment of Bartter Syndrome?

Which medications in the drug class Potassium Supplements are used in the treatment of Bartter Syndrome?