title: A case of gain-of-function mutation in calcium-sensing receptor: supplemental hydration is required for renal protection.
abstract: OBJECTIVE
  The calcium-sensing receptor (CaSR) regulates the extracellular calcium level, mainly by controlling parathyroid hormon secretion and renal calcium reabsorption. In gain-of-function CaSR mutations, the genetic abnormalities increase CaSR activity leading to the development of such clinical manifestations as hypercalciuric hypocalcemia and hypoparathyroidism. We report a Japanese case of CaSR gain-of-function mutation and represent a therapeutic intervention based on the functional characteristics of CaSR in renal tubule.
  DNA sequence analysis revealed a heterozygous G to T mutation identified in a 12-year-old Japanese girl presenting with sporadic onset of hypercalciuric hypocalcemia and hypoparathyroidism. The mutation is located in the N-terminal extracellular domain of the CaSR gene, one of the most important parts for the three-dimensional construction of the receptor, resulting in the substitution of phenylalanine for cysteine at amino acid 131 (C131F) in exon 3. Based on the diagnosis of the gain-of-function mutation in the CaSR, oral hydrochlorothiazide administration and supplemental hydration were started in addition to calcium supplementation. The combination therapy of thiazide and supplemental hydration markedly reduced both renal calcium excretion and urinary calcium concentration from 0.4-0.7 to less than 0.1 mg/mg (urinary calcium/creatinine ratio) and from 10-15 to 3-5 mg/dl (urinary calcium concentration), respectively. This therapy stopped the progression of renal calcification during the follow-up period.
  
  
  CONCLUSIONS
  Supplemental hydration should be considered essential for the following reasons: (1) calcium supplementation activates the CaSR in the kidney and suppresses renal urinary concentrating ability, (2) the thiazide has a diuretic effect, (3) as calcium supplementation increases renal calcium excretion, the supplemental hydration decreases urinary calcium concentration by increasing urinary volume, thereby diminishing the risk of intratubular crystallization of calcium ion.
authors.affiliation: Division of Molecular Medicine, Center for Translational and Advanced Animal Research, Tohoku University School of Medicine, Sendai, Japan. mmitsu2i@mail.tains.tohoku.ac.jp
authors.forename: M
authors.initials: M
authors.lastname: Suzuki
authors.forename: T
authors.initials: T
authors.lastname: Aso
authors.forename: T
authors.initials: T
authors.lastname: Sato
authors.forename: M
authors.initials: M
authors.lastname: Michimata
authors.forename: I
authors.initials: I
authors.lastname: Kazama
authors.forename: H
authors.initials: H
authors.lastname: Saiki
authors.forename: R
authors.initials: R
authors.lastname: Hatano
authors.forename: Y
authors.initials: Y
authors.lastname: Ejima
authors.forename: N
authors.initials: N
authors.lastname: Miyama
authors.forename: A
authors.initials: A
authors.lastname: Sato
authors.forename: M
authors.initials: M
authors.lastname: Matsubara
mesh_terms: D000284:Administration, Oral; D002118:Calcium / Q000652:urine; D002648:Child; D004247:DNA / Q000235:genetics*; D004252:DNA Mutational Analysis; D045604:Extracellular Fluid / Q000378:metabolism; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006852:Hydrochlorothiazide / Q000008:administration & dosage / Q000031:analogs & derivatives / Q000627:therapeutic use; D006996:Hypocalcemia / Q000150:complications / Q000235:genetics* / Q000378:metabolism; D007011:Hypoparathyroidism / Q000150:complications / Q000235:genetics* / Q000378:metabolism; D007674:Kidney Diseases / Q000209:etiology / Q000517:prevention & control*; D009154:Mutation; D016133:Polymerase Chain Reaction; D044169:Receptors, Calcium-Sensing / Q000235:genetics* / Q000378:metabolism; D014867:Water / Q000008:administration & dosage*
chemical_list: D044169:Receptors, Calcium-Sensing; D014867:Water; D006852:Hydrochlorothiazide; D004247:DNA; D002118:Calcium; C009732:buthiazide