Gitelman syndrome (GS), characterized as an autosomal recessive tubulopathy due to SLC12A3 mutations, disrupts the sodium-chloride cotransporter (NCC) within the renal distal convoluted tubule. This condition results in a clinical presentation marked by hypokalemia, hypomagnesemia, metabolic alkalosis, and hypocalciuria. Despite the well-defined biochemical characteristics associated with GS, achieving an accurate diagnosis can be formidable due to the variability in phenotypic expression and the potential for overlapping with other acquired electrolyte disorders. Emerging evidence identifies heterozygous SLC12A3 mutations may experience a reduced risk of developing hypertension, hinting at a potential protective effect conferred by NCC haploinsufficiency are found to have an elevated susceptibility to diabetes, which is mechanistically associated with insulin resistance and dysfunction of β-cells stemming from hypomagnesemia. Furthermore, current diagnostic limitations highlight the necessity for standardized genetic interpretation and the identification of functional NCC biomarkers. Moreover, it is critical to emphasize that therapeutic approaches should focus on individualized electrolyte management and ongoing monitoring for neuromuscular and cardiac complications. Looking towards the future, the increasing application of SGLT2 inhibitors, the formulation of mutation-specific pharmacotherapies, and the progress in CRISPR-Cas9 gene editing technologies present promising opportunities for enhanced therapeutic strategies. A more comprehensive understanding of extrarenal pathophysiology, coupled with improved diagnostic protocols, is anticipated to significantly improve patient outcomes through earlier detection and customized treatment plans.Copyright © 2025 Elsevier B.V. All rights reserved.