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Biomedical subjects

G Vezzoli

Publications and source records attributed to G Vezzoli.

At least 19 recordsLinked to original sources

R990G polymorphism of the calcium-sensing receptor and renal calcium excretion in patients with primary hyperparathyroidism.

CONTEXT: Primary hyperparathyroidism (PHPT) shows a great variability in clinical course and severity. Data concerning the association between polymorphic variants of the gene encoding the calcium-sensing receptor (CaSR) and clinical characteristics of PHPT are not conclusive. OBJECTIVE: To evaluate the frequency of three polymorphisms; A986S, R990G, and Q1011E of CaSR in patients with PHPT and to correlate the genotypes with clinical and biochemical parameters. PATIENTS AND METHODS: The study included 94 consecutive unrelated patients referred to our Departments for PHPT diagnosis and management between 2000 and 2005 and 137 age and sex-matched healthy subjects. Patients and controls were genotyped according to standard procedures. Due to the rarity of 990G allele, homozygous and heterozygous subjects were grouped in R/G+G/G set. All PHPT patients were studied for calcium metabolism parameters and renal and bone complications. RESULTS: The proportion of CaSRvariants was similar in PHPT patients and controls. In PHPT patients, only R990G polymorphism was associated with disease parameters; in comparison with R/R, R/G+G/G patients showed lower mean serum parathyroid hormone (PTH) and phosphate levels (139.9 +/- 62.2 vs 199.9 +/- 136.3 pg/ml, P < 0.05 and 0.69 +/- 0.12 vs 0.81 +/- 0.18 mmol/l, P = 0.031 respectively), higher mean 24-h urine calcium concentration and calcium excretion (9.05 +/- 2.05 vs 6.77 +/- 4.31 mmol/24 h, P = 0.012 and 67 +/- 20 vs 51 +/- 26 mumol/l GF, P = 0.039), and increased prevalence of nephrolithiasis (90.0 vs 44.2%, P = 0.007). CONCLUSIONS: The study showed that patients with PHPT, bearing the 990G allele, had lower serum PTH levels and higher urinary calcium excretion in comparison with the other genotype, suggesting an increased sensitivityof the variant receptor to extracellular calcium. Since this variant was associated with increased occurrence of nephrolithiasis, analysis of this polymorphism might help to predict renal complication of the disease.

Aged↗

Erythrocyte calcium influx is related to severity of ventricular arrhythmias in uraemic patients.

BACKGROUND: Myocardial disorders are a remarkable cause of morbidity and mortality in chronic haemodialysed patients (HD). They could be favoured by alteration of cell Ca(2+) handling. In previous studies we characterized an erythrocyte Ca(2+) influx, sensitive to membrane potential and inhibited by Ca(2+) antagonists. Since its maximal influx rate was decreased in HD patients, this study investigates if Ca(2+) influx alterations are related to myocardial disorders in HD patients. METHODS: Voltage-sensitive erythrocyte Ca(2+) influx was measured in 30 healthy controls and in 53 patients (47 HD patients and six patients with left ventricular hypertrophy and normal kidney function), using fura 2. In 29 HD patients and in six healthy subjects Ca(2+) influx was also determined in the presence of parathyroid hormone (PTH) in vitro. Patients were classified according to Lown's ventricular arrhythmias classification after 24-h Holter electrocardiograph (ECG) monitoring. Forty-six patients underwent echocardiography. RESULTS: Voltage-sensitive erythrocyte Ca(2+) influx was significantly reduced in HD patients. Maximal influx rate was significantly higher in HD patients of Lown's classes 3 and 4 (0.789 +/- 0.156 nmol/s, n = 8; P < 0.01) than in patients of classes 1 and 2 (0.499 +/- 0.055 nmol/s, n=15), or without ventricular arrhythmias (0.400 +/- 0.041 nmol/s, n = 24). Maximal influx rate was directly correlated to left ventricular mass index (LVM) (r = 0.353, P < 0.05). Subjects with left ventricular hypertrophy and normal kidney function displayed erythrocyte Ca(2+) influx similar to that of normal subjects. Multiple regression indicates that LVM and Ca(2+) influx were independently related to severity of arrhythmias. When added to the influx assay, PTH increased the maximal influx rate only in patients with ventricular arrhythmias. CONCLUSION: Myocardial dysfunction and altered ventricular excitability could be related in uraemic HD patients to alterations of calcium transport, as found in the erythrocyte model. Reduced resistance to PTH could contribute to this phenomenon.

Arrhythmias, Cardiac↗

Chloride fluxes activated by parathyroid hormone in human erythrocytes.

We used the chloride fluorescent probe, 6-methoxy-N-(3-sulfopropyl)quinolinium (SPQ), to study chloride fluxes in human erythrocytes. The SPQ load was made by hypotonic buffer (150 mOsm, 10 min). Intracellular fluorescence was monitored continuously at 360 nm excitation and 410 nm emission wavelengths. The leakage of SPQ out of cells was <5% h(-1) and the Stern-Volmer constant for quenching of intracellular SPQ by Cl was 0.023 mM(-1). The time course of intracellular [Cl] was measured and the influence of PTH, forskolin, and phorbol 12-myristate 13-acetate (PMA) on erythrocyte Cl transport was examined. The results establish a direct method to measure intracellular [Cl] continuously in erythrocytes and show that PTH induces a Cl efflux inhibited by 4, 4'-diisothiocyanatostilbene-2,2'-disulfonate. This effect was similar to those induced by forskolin, which stimulates cAMP generation, and by PMA, which stimulates protein kinase C.

Adult↗

Plasma phospholipid arachidonic acid content and calcium metabolism in idiopathic calcium nephrolithiasis.

BACKGROUND: Reports of an increase in plasma and erythrocyte phospholipid arachidonic acid content and in urinary prostaglandin E2 (PGE2) excretion in patients with idiopathic calcium nephrolithiasis suggested their crucial role in the pathogenesis of hypercalciuria, a well-known risk factor for lithogenesis. METHODS: To confirm this hypothesis, 15 healthy subjects and 20 nephrolithiasis patients were evaluated for plasma phospholipid polyunsaturated fatty acid content and PGE2 concentration, serum parathyroid hormone, 25 hydroxyvitamin D3, 1, 25-dihydroxyvitamin D3, and bone-specific alkaline phosphatase levels, as well as urinary excretion of calcium, biochemical markers of bone resorption (hydroxyproline and crossLaps), and intestinal calcium absorption. Furthermore, the effect of a 30-day fish-oil diet supplementation on the previously mentioned parameters was investigated in the patients. RESULTS: At baseline, patients compared with controls showed higher levels of plasma phospholipid arachidonic acid content (P = 0.002), PGE2 (P = 0.0004), serum 25-vitamin D3 (P = 0.001), and 1,25-vitamin D3 (P = 0.001), urinary excretion of calcium (P = 0.001), hydroxyproline (P = 0.007), and crossLaps (P = 0.019), as well as intestinal calcium absorption (P = 0.03 at 60 min). Fish oil supplementation induced a reduction in the plasma phospholipid arachidonic acid level (P < 0.0001), and except for serum concentrations of 25-vitamin D3, normalized baseline blood and urinary parameters, including intestinal calcium absorption. A close correlation between plasma PGE2 and serum 1,25-vitamin D3 (P = 0.004) and between phospholipid arachidonic acid and intestinal calcium absorption (P = 0.0002) and calciuria (P = 0.007) was observed, as well as between urine excretion of crossLaps and hydroxyproline (P < 0.0001), crossLaps and calcium (P < 0.0001), and hydroxyproline and calcium (P < 0.0001). CONCLUSIONS: These findings indicate that the phospholipid arachidonic acid content anomaly could represent the primary event responsible for the mosaic of metabolic and clinical alterations that are distinctive features of renal stone formers, and suggest that a common pathogenetic mechanism might account for the several forms of hypercalciuria detected in idiopathic calcium nephrolithiasis.

Adult↗

Choroidal calcifications in patients with Gitelman's syndrome.

Gitelman's syndrome is a renal tubular disorder characterized by a sodium and chloride reabsorption defect in distal tubular cells that determines hypokalemia, metabolic alkalosis, hypomagnesemia, and low calcium excretion. The presence of choroidal calcifications was sought in five patients with Gitelman's syndrome by ophthalmic examination, fluorescein angiography, indocyanine green angiography, and ocular ultrasonography. Calcifications observed in the choroid of two patients were shown by ultrasonography in both patients. Ophthalmic and fluorangiographic examinations detected this alteration in one of the two subjects. Chondrocalcinosis was found in one patient with choroidal calcifications. These findings suggest that precipitation of calcium salts can occur in the choroidal tissue of patients with Gitelman's syndrome. Deposits appeared to be well seen by ultrasonography because of their depth in ocular tissues. Sclerochoroidal calcifications may be favored by the low calcium excretion, which is associated with normal intestinal calcium absorption in patients with Gitelman's syndrome.

Adolescent↗

Erythrocyte voltage-dependent calcium influx is reduced in hemodialyzed patients.

BACKGROUND: Uremia displays increased cytosolic free calcium ([Ca2+]i) in many different cell types, supporting the hypothesis of an altered Ca2+ transport modifying the functional activity of calcium signaling pathway. METHODS: Thirty-five hemodialyzed patients and 20 age-matched subjects were studied. Erythrocyte resting [Ca2+]i and Ca2+ influx were measured by the fluorescent Ca2+-sensitive dye fura-2. RESULTS: We found an increase of resting [Ca2+]i in erythrocytes from uremic hemodialyzed patients compared with matched healthy controls (103 +/- 2.5 nM, N = 20, vs. 90 +/- 4, N = 20, P < 0.01). Moreover, we found an altered voltage-dependent Ca2+ influx showing a reduced transport rate (0.42 +/- 0.03 nM/second vs. 0.74 +/- 0.08, P < 0.01). High levels of plasma parathyroid hormone (PTH) were related to augmented Ca2+ entry (r = 0.511, P < 0.05), contributing to maintain a high level of [Ca2+]i. Hemodialysis had no effect on cell calcium level and Ca2+ influx indices. The therapy with Ca2+ antagonists did not modify the values of resting [Ca2+]i or Ca2+ influx indices, but the correlation between PTH and influx indices was lost. CONCLUSIONS: In conclusion, we found evidence for an alteration of erythrocyte Ca2+ influx caused by uremic toxicity that could be related to some organ disorders in uremia. The chronic increase of cellular calcium may contribute to influx derangement.

Adult↗

Study of calcium metabolism in idiopathic hypercalciuria by strontium oral load test.

Calcium excretion and absorption were evaluated in hypercalciuric calcium stone formers by the study of Sr2+ excretion and absorption after an oral load. Ca2+ stone formers (n = 140) were studied, and the results were compared in the 83 of them who had idiopathic hypercalciuria and in the 57 who had Ca2+ excretion within reference values. Hypercalciuric patients showed increased renal Sr2+ clearance (CRE; 5.26 +/- 0.358 vs 3.29 +/- 0.277 mL/min; P <0.001), whereas Sr2+ absorption [assessed as the area under the serum concentration-time curve (AUC)] was increased at 30 and 60 min (1.53 +/- 0.087 vs 1.21 +/- 0.071 mmol. L-1. min; P <0.05), but not at 240 min after the load. In hypercalciuric patients, the AUCs were positively correlated with urinary Sr2+ fractional excretion (P <0. 001). Conversely, in normocalciuric patients plasma parathyroid hormone (PTH) was negatively correlated with the AUCs (P <0.01) and CRE (P <0.05), whereas 1,25-dihydroxyvitamin D plasma concentrations normalized to PTH were positively correlated with the AUCs (P <0.05). The results of Sr2+ load tests suggest that in the hypercalciuric population, Ca2+ absorption is altered predominantly in the duodenum and that the normal regulation exerted by calciotropic hormones on tubular and enteral Ca2+ handling is lost.

Administration, Oral↗

Strontium absorption and excretion in normocalciuric subjects: relation to calcium metabolism.

The relationships of Sr intestinal absorption and renal excretion with biohumoral factors regulating Ca metabolism were studied in 47 normocalciuric subjects with Ca kidney stones. Sr concentrations were measured in serum and urine after an oral load of stable Sr (30.2 mumol/kg body wt). Enteral absorption of the ion (9.77 +/- 0.438 mmol.L-1.min, 240 min after Sr administration), expressed as the area under the plasma concentration-time curve (AUC), and renal clearance (CRE) in these subjects during the test (2.80 +/- 0.336 mL/min) were not different from values for 27 controls. CRE was not correlated with AUCs. Plasma concentrations of parathyroid hormone (PTH) negatively correlated with AUCs (P < 0.01) and correlated with CRE after one outlier was excluded (P < 0.05). Plasma concentrations of 1,25-dihydroxyvitamin D correlated positively with AUCs (P < 0.01) when normalized to the plasma concentration of PTH. Multiple stepwise regression showed that PTH and phosphatemia were significantly related to AUC values at 240 min (P < 0.01). These findings suggest that Sr absorption and excretion reflect the regulation of Ca metabolism, but some differences in renal handling of the two ions may exist.

Administration, Oral↗

Characterization of voltage-dependent calcium influx in human erythrocytes by fura-2.

Thus far, the methods used to determine erythrocyte Ca2+ influx have not allowed the assessment of the kinetics of ion uptake. To overcome this drawback, we studied a new method, using the fluorescent Ca2+-chelator fura-2, which directly quantifies intracellular Ca2+ changes in human erythrocytes. This method has the advantage over previous techniques that it monitors continuously cellular Ca2+ levels. The Ca2+ influx is modulated by cellular membrane potential in the presence of a transmembrane Ca2+ concentration gradient and exhibits a first slow increase of the intracellular Ca2+ concentration, followed, after the reachment of a threshold value of 125 +/- 13 nM Ca2+, by a faster increase until a plateau is reached. The influx rate is inhibited by dihydropyridines in the micromolar range. These findings support the hypothesis that erythrocyte Ca2+ influx is mediated by a carrier similar to the slow Ca2+ channels and is dependent on membrane depolarization.

4,4'-Diisothiocyanostilbene-2,2'-Disulfonic Acid↗

Nonacidotic proximal tubulopathy transmitted as autosomal dominant trait.

The family of a patient with a nonacidotic and hypercalciuric proximal tubulopathy was studied. The proband showed glycosuria, aminoaciduria, tubular proteinuria, renal hypophosphatemia, and urate tubular hyporeabsorption without bicarbonate loss. He also presented increased urine calcium excretion, plasma 1,25-dihydroxyvitamin D, and enteral calcium absorption. Clinical consequences of the tubulopathy were osteopenia and calcium kidney stones. Fifteen of the proband's relatives were studied; six of them had renal hypophosphatemia, 10 presented hypercalciuria, and three showed both hypercalciuria and hypophosphatemia. No other reabsorption defects were observed. High plasma levels of 1,25-dihydroxyvitamin D were found in 13 family members; their values correlated positively with calcium excretion and negatively with tubular phosphate reabsorption. None produced stones or had reduced mineral bone density. Hypophosphatemia and hypercalciuria occurred in the two generations studied; their transmission was independent of gender, and male-to-male transmission occurred for both defects. Our findings suggest that a genetic alteration of proximal tubular function could cause multiple reabsorption defects in the proband or renal phosphate leakage in the proband's relatives. The genotypic alteration causing the proximal dysfunctions may be monogenic, with an autosomal dominant pattern of inheritance and variable expressivity. Increased calcium excretion may be due to the proximal tubular alteration; alternatively, it may be the result of a genetic background predisposing to idiopathic hypercalciuria. Phosphate and calcium loss could stimulate 1,25-dihydroxyvitamin D synthesis in proximal tubular cells.

Absorption↗

Erythrocyte calpain activity and left ventricular mass in essential hypertension.

BACKGROUND: Calpains are cytoplasmic proteases widely distributed among eucaryotic cells. Low levels of calpain activity were found in hypertrophic hearts from hypertensive rats, but its role in hypertrophic hearts from human hypertensives is unknown. Therefore, calpain activity was investigated in erythrocytes from essential hypertensive patients in relation to their left ventricular mass. OBJECTIVE: To study the role of calpain activity in the development of left ventricular hypertrophy (LVH) in human essential hypertension. METHODS: A total of 115 hypertensives (72 untreated and 43 with treatment interrupted for at least 4 months) were included in the study. Calpain I activity was measured in human erythrocytes and LVH was measured as left ventricular mass index (LVMI) by M-mode echocardiography. RESULTS: Values are given as mean+/-SEM. The hypertensives (97 men and 18 women) were 43.5+/-0.9 years old with mild to moderate levels of hypertension (systolic/diastolic blood pressure of 147.9+/-1.4/98.7+/-0.9 mmHg) and relatively recent LVH onset (3.5+/-0.5 years). An inverse relation between LVMI and erythrocytic calpain activity was present in all (P = 0.0023, R2 = 7.9%). This relation was still present considering only untreated hypertensives (P = 0.008; R2 = 9.7%), but was lost in the 43 previously treated hypertensives. Moreover, in the untreated hypertensives, after excluding the possible confounding effects of sex, age, body mass index, blood pressure and duration of hypertension, a stepwise regression showed that only two variables remained significantly related to LVMI: calpain (F = 6.23) and mean arterial pressure (F = 4.689). No relations were found between LVMI and calpastatin activity either in the whole population, or in treated or untreated hypertensives. CONCLUSIONS: If we assume that the level of erythrocyte calpain activity mirrors the level in cardiomyocytes, these data seem to suggest that increased protein degradation by calpain may prevent the development of LVH in hypertensive patients. This effect is independent of the duration and severity of hypertension.

Adult↗

Association between plasma membrane (Ca+Mg) ATPase and calpain/calpastatin system in rat erythrocytes.

We studied the activity of plasma membrane (Ca+Mg)ATPase from erythrocytes of Milan hypertensive rat strain (MHS) and Milan low calpastatin rat strain (MLCS), that show an activity level of the specific calpain inhibitor, calpastatin, about five fold reduced in comparison with the Milan normotensive rat strain (MNS), while the protease activity level is similar. This imbalance of calpain:calpastatin ratio leads to a decrease of the erythrocyte plasma membrane (Ca+Mg)ATPase activity and to the appearance of 124 kDa fragments, which are the typical products of proteolytic calpain action on the 136 kDa (Ca+Mg)ATPase native form.

Animals↗

(Ca+Mg)ATPase and calcium influx in erythrocytes of patients with idiopathic hypercalciuria.

Increased erythrocyte (Ca+Mg)ATPase activity was previously observed in idiopathic hypercalciuria. In order to verify if this alteration is a primary or a secondary event, we studied Sr influx in erythrocytes from subjects with idiopathic hypercalciuria. (Ca+Mg)ATPase activity was significantly higher in hypercalciuric than in hypercalciuric than in normocalciuric subjects whereas no difference in Sr influx was found between the two groups. (Ca+Mg)ATPase activity positively correlated with the erythrocyte Sr content found after 5 min of incubation and with urine Ca excretion. The normal Sr permeability suggests that (Ca+Mg)ATPase is primarily altered in idiopathic hypercalciuria. The primary increase of (Ca+Mg)ATPase activity may enhance passive Ca influx by reduction of cellular Ca concentration. It may induce a defect in cellular Ca metabolism that may cause idiopathic hypercalciuria by stimulating bone Ca turn-over and enteral Ca absorption.

Biological Transport↗

Nonacidotic kidney proximal tubulopathy with absorptive hypercalciuria.

We studied three patients with proximal tubulopathy characterized by defective reabsorption of phosphate, glucose, amino acids, urate, and low molecular weight proteins. This tubulopathy differs from Fanconi syndrome in that the patients had normal plasma bicarbonate and absorptive hypercalciuria associated with increased 1,25-dihydroxyvitamin D levels. The youngest patient was rachitic and may be classified with previously described patients, whereas the other two patients presented with nonrachitic osteopenic bone disease and their tubulopathy started during adult life. Kidney defects appeared sequentially in one of the nonrachitic patients. The two brothers of the youngest patient had similar kidney and bone disturbances. One of the other two patients had a brother with similar kidney reabsorption defects; an additional brother was probably affected and a sister presented with glycosuria, but no other reabsorption defects. The findings in these two families suggest a genetic transmission of proximal tubulopathy. The third case was sporadic. Renal histology of the three patients showed a great number of giant cells in the tubular lumen. We conclude that, at least in our adult patients, tubulopathy may represent a new entity among the proximal tubular dysfunction cases described to date. The features of this proximal defect suggest that it may be caused by a selective alteration of luminal cell membrane transport of phosphate, glucose, amino acids, urate, and proteins in the presence of a normal sodium gradient across the tubular cell membrane.

Amino Acids↗

Intestinal calcium absorption as shown by stable strontium test in celiac disease before and after gluten-free diet.

OBJECTIVES: To investigate the effect of gluten-free diet on mineral and bone metabolism in women with celiac disease and, using the strontium test, to assess intestinal calcium absorption. METHODS: We studied body mass index, biochemical and bone mineral indices, strontium absorption test, and bone mineral density in 18 women (mean age 36.8 yr, range 18-68 yr) with celiac disease at diagnosis and after 12 months of gluten-free diet. RESULTS: Mean strontium absorption at diagnosis was markedly decreased with respect to control values (13.84 +/- 9.03% vs 22.47 +/- 4.21%, p < 0.0001), and 11 of the 18 patients (61%, subgroup A) had low values. In all patients, mean hemoglobin, serum potassium, magnesium, plasma calcium, urinary calcium, and phosphorus were significantly abnormal at diagnosis, whereas only the subgroup A had significantly reduced body mass index, 25 OH vitamin D, and elevated alkaline phosphatase. This subgroup differed in body mass index (p < 0.003) and calciuria (p < 0.035) with respect to the other patients. Strontium absorption correlated with body mass index, calcemia, and 25 OH vitamin D. After the gluten-free diet, all biochemical variables and strontium absorption normalized (23.23 +/- 5.54%), whereas bone mineral density did not change. CONCLUSIONS: At diagnosis, the patients frequently had intestinal calcium malabsorption, as demonstrated by strontium test, with an early renal compensatory mechanism. After the gluten-free diet, the normalization of calcium absorption and the decrease of mid-molecule parathyroid hormone suggested a normalization of mineral metabolism, although a positive effect on bone mineral density was not evident at that time.

Adult↗

Erythrocyte membrane calcium transport in patients with primary hyperparathyroidism.

The chronic effect of PTH on erythrocyte membrane Ca transport was examined. (Ca+Mg)ATPase activity and passive Sr influx were measured to assess the rate of passive Ca influx (total and inhibited by dihydropyridines [DHPs]), in erythrocytes from patients with primary hyperparathyroidism and normal controls. Erythrocyte Sr influx was lower in patients, due to a decreased DHP-sensitive Sr influx. Conversely, efflux activity of (Ca+Mg)ATPase was not different in patients and controls. We hypothesize that in primary hyperparathyroidism chronic PTH stimulation may induce a downregulation of the erythrocyte Ca influx mediated by DHP-sensitive Ca carrier.

Biological Transport↗

Chylothorax after blunt chest trauma: an unusual case with a long latent period.

We report on a case of closed chest trauma with an unusual latent period of 11 weeks in a woman 26 years old. The patient had a dual thoracic duct with a dual lesion and was evaluated using lymphography and CT. We discuss the pathogenetic mechanism and the unusual radiological appearance with discontinuity of the duct, and an increase in back pressure which promotes dilatation of lymphatic vessels and nodes. The dual duct had two separate traumatic consequences: a chyloma on the right and leakage in the pleura on the left. Pleuroperitoneal shunting was effective after failure of conservative treatment. Two years after discharge the patient is asymptomatic with normal chest X-ray image. She is near term in a normal pregnancy and without signs of silent malignancy.

Adult↗

Heritability estimate of erythrocyte Na-K-Cl cotransport in normotensive and hypertensive families.

Na-K-Cl cotransport was measured in 209 essential hypertensive patients (EH) and in 114 normotensive controls (NT). The distribution of Na-K-Cl cotransport was bimodal in EH and unimodal in NT. The EH with higher Na-K-Cl cotransport values had increased passive permeability to Na in fresh erythrocytes and increased Li-Na countertransport compared to NT. Li-Na countertransport was significantly increased in the EH as a whole, but the increase was accounted for by some EH individuals with elevated Na-K-Cl cotransport values. A simple biometric analysis of the Na-K-Cl cotransport was performed for 287 individuals of 86 families with different prevalence of hypertension (neither parent hypertensive, 39 families; one, 31 families; or both, 16 families). Na-K-Cl cotransport was not correlated between spouses, but was correlated highly significantly between the average value of the two parents (mid-parent) and offspring. The polygenic additive heritability (h2) was about 50% for all families considered together. It increased slightly for the hypertensive families analyzed alone (no significant correlation was found, and hence genetic heritability, in the normotensive families). Finally, after applying arbitrary cut-off points to the Na-K-Cl cotransport values, segregation analysis showed that some major gene, recessive for the high allele, also contributes to the phenotypic value of Na-K-Cl cotransport.

Alleles↗