Proton-secretory defect is thought to be a major pathophysiologic mechanism leading to classic distal renal tubular acidosis (dRTA). However, there have been only two case reports demonstrating the absence of proton pump in renal tissues of the patients with Sjögren's syndrome. This study presents two cases of classic dRTA in which the absence of intact H(+)-ATPase was shown in their renal biopsy tissues by immunohistochemistry using a rabbit polyclonal antibody against the 70 kDa catalytic subunit of H(+)-ATPase from bovine brain clathrin-coated vesicles; one of the cases is diagnosed as subclinical Sjögren's syndrome and the other is idiopathic dRTA. A normal human kidney (NC) and the renal biopsy tissues from a patient with chronic tubulointerstitial nephritus whose proton secretory capacity was intact (DC) were compared as controls. The first patient, a 26-year-old woman, presented with quadriparesis. Her serologic tests revealed positive autoantibodies (ANA, SSA; SSB & RF), and a lower lip biopsy confirmed the diagnosis of Sjögren's syndrome. The second patient, a 43-year-old woman, who initially presented with a pathologic fracture of both femoral necks was referred for an evaluation for hypokalemia by the Department of Orthopedic Surgery. Her renal ultrasonography showed medullary calcification, and no autoantibodies were positive. Serum electrolytes and blood gas analyses of the two patients indicated severe hypokalemia and metabolic acidosis, and proton secretory defects were shown by a failure to lower the urine pH during marked acidemia induced by NH4Cl loading and an abnormally low urine-blood pCO2 difference during bicarbonate administration. While stainings with the anti-H(+)-ATPase antibody in NC and DC were strongly positive in intercalated cells in the connecting tubules and collecting ducts, the tissues from both patients with dRTA were devoid of any anti-H(+)-ATPase staining in the intercalated cells. These results support that the pathophysiologic basis of impaired H+ secretion in idiopathic classic dRTA as well as Sjögren's syndrome is the absence of intact H(+)-ATPase pumps in the intercalated cells.