Hypertension affects one billion people and is a principal reversible risk factor for cardiovascular disease. Pseudohypoaldosteronism type II (PHAII), a rare Mendelian syndrome featuring hypertension, hyperkalaemia and metabolic acidosis, has revealed previously unrecognized physiology orchestrating the balance between renal salt reabsorption and K+ and H+ excretion1. Here we used exome sequencing to identify mutations in kelch-like 3 (KLHL3) or cullin 3 (CUL3) in PHAII patients from 41 unrelated families. KLHL3 mutations are either recessive or dominant, whereas CUL3 mutations are dominant and predominantly de novo. CUL3 and BTB-domain-containing kelch proteins such as KLHL3 are components of cullin–RING E3 ligase complexes that ubiquitinate substrates bound to kelch propeller domains2,3,4,5,6,7,8. Dominant KLHL3 mutations are clustered in short segments within the kelch propeller and BTB domains implicated in substrate9 and cullin5 binding, respectively. Diverse CUL3 mutations all result in skipping of exon 9, producing an in-frame deletion. Because dominant KLHL3 and CUL3 mutations both phenocopy recessive loss-of-function KLHL3 mutations, they may abrogate ubiquitination of KLHL3 substrates. Disease features are reversed by thiazide diuretics, which inhibit the Na–Cl cotransporter in the distal nephron of the kidney; KLHL3 and CUL3 are expressed in this location, suggesting a mechanistic link between KLHL3 and CUL3 mutations, increased Na–Cl reabsorption, and disease pathogenesis. These findings demonstrate the utility of exome sequencing in disease gene identification despite the combined complexities of locus heterogeneity, mixed models of transmission and frequent de novo mutation, and establish a fundamental role for KLHL3 and CUL3 in blood pressure, K+ and pH homeostasis.
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NCBI Reference Sequence
mRNA and protein sequences are available at NCBI under accession numbers NM_017415.2 and NP_059111.2 (KLHL3), NM_003590.3 and NP_003581.1 (CUL3); mutation data is available at dbSNP under batch accession 1056535.
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We thank the PHAII subjects, their families, and the health care professionals whose participation made this study possible; S. Umlauf and the staff of the Yale Center for Genome Analysis; J. Santosuosso; H. Tirrell and the staff of Beckman Coulter Genomics; V. Klump, Y. Lu, U. Scholl and J. Zhou for providing reagents; W. Hill for artistic assistance with Fig. 1d; and E. Boyden, S. Boyden, L. Cooley and M. Hochstrasser for helpful discussions. This work was supported in part by the Leducq Transatlantic Network on Hypertension and grants from the National Institutes of Health (P30-DK079310 and UL1-RR024139).
The authors declare no competing financial interests.
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Biochemistry and Cell Biology (2019)
Physiological Reviews (2019)
Pharmacological Research (2019)
Pharmacology & Therapeutics (2019)
Nature Reviews Nephrology (2019)