Metabolic assessment in patients with urinary lithiasis

INTRODUCTION: Metabolic investigation in patients with urinary lithiasis is very important for preventing recurrence of disease. The objective of this work was to diagnose and to determine the prevalence of metabolic disorders, to assess the quality of the water consumed and volume of diuresis as potential risk factors for this pathology. PATIENTS and METHODS: We studied 182 patients older than 12 years. We included patients with history and/or imaging tests confirming at least 2 stones, with creatinine clearance > 60 mL/min and negative urine culture. The protocol consisted in the collection of 2, 24-hour urine samples, for dosing Ca, P, uric acid, Na, K, Mg, Ox and Ci, glycemia and serum levels of Ca, P, Uric acid, Na, K, Cl, Mg, U and Cr, urinary pH and urinary acidification test. RESULTS: 158 patients fulfilled the inclusion criteria. Among these, 151 (95.5%) presented metabolic changes, with 94 (62.2%) presenting isolated metabolic change and 57 (37.8%) had mixed changes. The main disorders detected were hypercalciuria (74%), hypocitraturia (37.3%), hyperoxaluria (24.1%), hypomagnesuria (21%), hyperuricosuria (20.2%), primary hyperparathyroidism (1.8%) secondary hyperparathyroidism (0.6%) and renal tubular acidosis (0.6). CONCLUSION: Metabolic change was diagnosed in 95.5% of patients. These results warrant the metabolic study and follow-up in patients with recurrent lithiasis in order to decrease the recurrence rate through specific treatments, modification in alimentary and behavioral habits.

Urinary lithiasis and idiopathic hypercalciuria: the importance of dietary intake evaluation

PUSPOSE: To evaluate food intake of patients with urinary lithiasis and idiopathic hypercalciuria (IH). MATERIALS and METHODS: Between August 2007 and June 2008, 105 patients with lithiasis were distributed into 2 groups: Group 1 (n = 55) - patients with IH (urinary calcium excretion > 250 mg in women and 300 mg in men with normal serum calcium); Group 2 (n = 50) - normocalciuria (NC) patients . Inclusion criteria were: age over 18, normal renal function (creatinine clearance = 60 mL/min), absent proteinuria and negative urinary culture. Pregnant women, patients with some intestinal pathology, chronic diarrhea or using corticoids were excluded. The protocol of metabolic investigation was based on non-consecutive collection of two 24-hour samples for dosages of: calcium, sodium, uric acid, citrate, oxalate, magnesium and urinary volume. Food intake was evaluated through the quantitative method of Dietary Register of three days. RESULTS: Urinary excretion of calcium (433.33 ± 141.92 vs. 188.93 ± 53.09), sodium (280.08 ± 100.94 vs. 200.44.93 ± 65.81), uric acid (880.63 ± 281.50 vs. 646.74 ± 182.76) and magnesium (88.78 ± 37.53 vs. 64.34 ± 31.84) was significantly higher in the IH group in comparison to the NC group (p < 0.05). As regards the nutritional composition of food intake of IH and NC groups, there was no statistical significant difference in any nutrient evaluated. CONCLUSION: In our study, no difference was observed in the food intake of patients with urinary lithiasis and IH or NC.

An update on metabolic assessment in patients with urinary lithiasis

The objective of this study was to evaluate the prevalence of urinary metabolic abnormalities in patients with urolithiasis and their potential risk factors.A total of 905 stone patients were evaluated in a prospective trial from February 2000 to January 2012. Inclusion criteria were as follows: history and/or imaging tests confirming at least 2 separate or concurrent stone episodes; creatinine clearance a parts per thousand yen60 mL/min; and negative proteinuria and urine culture. Metabolic study consisted of two 24-h urine collections separated by a period of 3 months for dosing Ca, P, uric acid, Na, K, Mg, oxalate, and citrate. Serum levels of Ca, P, uric acid, Na, K, Cl, Mg, creatinine, and glucose were assessed. Urinary pH and urinary acidification tests were also performed.A total of 735 patients were included, with a mean age of the 40 +/- A 1.0 year; 96.8 % of patients presented diagnosis of one or more urinary metabolic abnormalities. The most prevalent metabolic abnormalities were hypercalciuria (50.8 %), hypomagnesuria (50.1 %), hypocitraturia (35.4 %), and hyperuricosuria (30.7 %). Body weight was significantly higher in patients with hyperuricosuria (81.20 +/- A 15.67 kg vs. 70.17 +/- A 14.13 kg, respectively, p = 0.001). Urinary sodium was significantly higher in patients with hypercalciuria than without (246.97 +/- A 103.9 mEq/24 h vs. 200.31 +/- A 91.6 mEq/24 h, p = 0.001) and hyperuricosuria compared to without (283.24 +/- A 107.95 mEq/24 h vs. 198.57 +/- A 85.3 mEq/24 h, p = 0.001).Urinary metabolic disturbances were diagnosed in 96.8 % of patients in the study. These results warrant metabolic study and follow-up in patients with recurrent lithiasis in order to decrease recurrence rate through specific treatments, modification in alimentary, and behavioral habits.

Lithiasis in 1,313 Kidney Transplants: Incidence, Diagnosis, and Management

Background. Renal transplantation remains the optimal treatment of patients with end-stage renal disease. Urinary lithiasis represents an unusual urologic complication in renal transplantation, with an incidence of <1%. Today, recipients of kidneys from deceased donors are more likely to receive grafts with undiagnosed lithiasis, which does not occur in patients from living donors, owing to screening with computerized tomography. Objective. The aim of this study was to evaluate the incidence, diagnosis, and therapeutic management of renal lithiasis in transplanted kidneys at a single institution. Methods. We reviewed the medical records for 1,313 patients who underwent kidney transplantation from February 1968 to February 2011. Results. Among the grafts, 17 patients (1.29%) had nephrolithiasis: 9 women and 8 men. Ages ranged from 32 to 63 years (mean = 45.6 years). Fifteen patients received kidneys from cadaveric and only 2 from living related donors. Two stones, both located inside the ureter, were identified during transplant surgery (11.7%). Three instances of lithiasis were incidentally diagnosed by ultrasound during graft evaluation, within 7 days after surgery (17.6%); all 3 were in the calyces. The 12 remaining patients had the stones diagnosed later (70.58%): 6 in the calyces, 3 in the renal pelvis, and 3 inside the ureter. Conclusions. Urinary lithiasis is a rare complication in renal transplantation. In most patients the condition occurs without pain. The diagnosis and treatment options for graft urolithiasis are similar to those patients with nephrofithiasis in the general population. Extracorporeal shock wave lithotripsy (ESWL) was the most common treatment method.

La lithiase rénale: un marqueur du risque cardiovasculaire [Kidney stone as a cardiovascular risk marker].

Si le passage d'un calcul rénal est souvent considéré comme un événement médical mineur, quoique très douloureux, de plus en plus d'études indiquent qu'il doit être pris au sérieux puisqu'il peut indiquer un risque cardiovasculaire augmenté. Nous revoyons ici les études qui associent risque cardiovasculaire et calcul rénal et les liens physiopathologiques qui les unissent. Nous montrons que la lithiase est un événement intervenant tôt dans la vie d'un individu à risque de développer des complications cardiovasculaires. Ainsi, la lithiase ne doit pas être banalisée, mais doit être considérée comme une première alerte devant inciter le médecin traitant à recenser précocement les facteurs de risque cardiovasculaires et à mettre en place une stratégie de prévention. Cette approche pourrait permettre de diminuer l'incidence d'événements cardiovasculaires chez les patients formeurs de lithiases. Most of the time, kidney stones are considered as minor, but painful events. However, several studies have recently shown an association between kidney stone and an increased cardio-vascular risk. We review here these studies and explore the underlying pathophysiological hypotheses. At the end, we propose that lithiasis should be considered as a red flag intervening early during life-time and allowing a check of cardiovascular risk factors and early preventive intervention. Such approach may be successful in reducing the incidence of cardio-vascular events in stone formers.

Biochemical Effect of Dicarboxylic Acids on Oxalate Metabolism in Experimental Rats and Studies on Oxalate Degrading Bacteria

The current study is an attempt to find a means of lowering oxalate concentration in individuals susceptible to recurrent calcium oxalate stone disease.The formation of renal stone composed of calcium oxalate is a complex process that remains poorly understood and treatment of idiopathic recurrent stone formers is quite difficult and this area has attracted lots of research workers. The main objective of this work are to study the effect of certain mono and dicarboxylic acids on calcium oxalate crystal growth in vitro, isolation and characterization of oxalate degrading bacteria, study the biochemical effect of sodium glycollate and dicarboxylic acids on oxalate metabolism in experimental stone forming rats and To investigate the effect of dicarboxylic acids on oxalate metabolism in experimental hyperoxaluric rats. Oxalic acid is one of the most highly oxidized organic compound widely distributed in the diets of man and animals, and ingestion of plants that contain high concentration of oxalate may lead to intoxication. Excessive ingestion of dietary oxalate may lead to hyperoxaluria and calcium oxalate stone disease.The formation of calcium oxalate stone in the urine is dependent on the saturation level of both calcium and oxalate. Thus the management of one or both of these ions in individuals susceptible to urolithiasis appears to be important. The control of endogenous oxalate synthesis from its precursors in hyperoxaluric situation is likely to yield beneficial results and can be a useful approach in the medical management of urinary stones. A variety of compounds have been investigated to curtain endogenous oxalate synthesis which is a crucial factor, most of these compounds have not proved to be effective in the in vivo situation and some of them are not free from the toxic effect. The non-operative management of stone disease has been practiced in ancient India in the three famous indigenous systems of medicine, Ayurveda, Unani and Siddha, and proved to be effective.However the efficiency of most of these substances is still questionable and demands further study. Man as well as other mammals cannot metabolize oxalic acid. Excessive ingestion of oxalic acid can arise from oxalate rich food and from its major metabolic precursors, glycollate, glyoxylate and ascorbic acid can lead to an acute oxalate toxicity. Increasedlevels of circulating oxalate, which can result in a variety of diseases including renal failure and oxalate lithiasis. The ability to enzymatically degrade oxalate to less noxious Isubstances, formate and CO2, could benefit a great number of individuals including those afflicted with hyperoxaluria and calcium oxalate stone disease.

Fatores litogênicos em pacientes com litíase urinária de Fortaleza, Ceará

Lithiasis is considered a public health issue due to its high prevalence and rates of recurrence. Objective: To identify risk factors for lithiasis in kidney stone patients from Fortaleza, Brazil. In the first stage of the study, the medical records of 197 patients with urinary lithiasis covering the period 1996 2006 were analyzed with regard to clinical and metabolic data. In the second stage, 340 kidney stones were submitted to morphological examination under 10x magnification. According to the external morphology and the cut surface, the stones were classified as pure or mixed, and major and minor components were identified. In addition, the stone fragments of 25 patients treated with lithotripsy were submitted to morphological analysis. In the third stage, a subsample of 50 stones was used in a double-blind comparison of morphological and chemical findings. Results were expressed as concordant, partly concordant (discordant for minor components) or discordant (discordant for major components). The average age of first symptoms was 35.8±13.3 years, with no significant difference between the genders. The male/female ratio was 1:1.7. Recurrence was reported in 53.3% of cases. The main metabolic changes observed were hypernatriuria (80.7%), hypercalciuria (48.7%), low urine volume (43.7%), hyperoxaluria (30.5%) and hyperuricosuria (17.3%). Pure stones represented 34.7% of the total sample of 340 stones. The most common route of elimination was spontaneous for pure stones (49.1%) and surgical for mixed stones (50.5%). Pure stones consisted most frequently of calcium oxalate (OxCa) (59.3%) and uric acid (UA) (23.7%), the former prevalent in women, the latter prevalent in men. The most frequently observed component in mixed stones was OxCa (67.1%), followed by carbapatite (11.2%) and struvite (7.9%). The main components were OxCa and UA for men, and carbapatite and struvite for women. Nearly half (48%) the 25 analyzed fragments were pure, consisting of calcium oxalate dihydrate (COD) (56%), calcium oxalate monohydrate (COM) (48%), phosphate (32%) and UA (20%). Four patients (16%) had infectious stones. In the chemical analysis of the subsample of 50 stones, the most 64 frequently observed major components were calcium (70%), oxalate (66%), ammonium (56%), urate (28%) and carbonate (24%). In the morphological analysis, the main components were calcium and magnesium phosphate (32%), COM (24%), UA (20%), COD (18%) and cystine (6%). Morphological and chemical findings were totally concordant for 38% of the stones, partly concordant in 52% and discordant in 10%. Conclusion: The risk factors for lithiasis in kidney stone patients from Fortaleza (Brazil) were hyperoxaluria, hypercalciuria with or without hypernatriuria, hyperuricosuria and low urine volume

Ureteroscopy in Pregnant Women for Ureteral Stone

Introduction: The occurrence of urolithiasis in pregnancy represents a challenge in both diagnosis and treatment of this condition, because it presents risks not only to the mother but also to the fetus. Surgical treatment may be indicated for patients with infection, persistent pain, and obstruction of a solitary kidney. We present our experience on the management of pregnant patients with ureteral calculi and a review of the literature.Materials and Methods: The charts of 19 pregnant patients with obstructive ureteral calculi were retrospectively reviewed. Gestational age ranged from 13 to 33 weeks. In all patients, ureteral stone was diagnosed on abdominal ultrasound. In regard to localization, 15 calculi were in the distal ureter, 3 in the proximal ureter, and 1 in the interior of an ureterocele. Calculi size ranged from 6 to 10 mm (mean, 8 mm). The following criteria were used to indicate ureteroscopy: persistent pain with no improvement after clinical treatment, increase in renal dilation, or presence of uterine contractions. Nine patients (47.3%) were submitted to ureteroscopy. All calculi (100%) were removed with a stone basket extractor under continuous endoscopic vision. None of the calculi demanded the use of a lithotriptor.Results: Nine patients (47.3%) treated with clinical measurements presented no obstetric complications and spontaneous elimination of the calculi. Nine patients (47.3%) submitted to ureteroscopy had no surgical complications. There was remission of pain in all cases after ureteroscopy and ureteral catheter placement.Conclusion: The diagnosis and treatment of ureteral lithiasis in pregnant women present potential risks for the fetus and the mother. Conservative management is the first option, but ureteroscopy may be performed with safety and high success rates.

The role of salt abuse on risk for hypercalciuria

Background: Elevated sodium excretion in urine resulting from excessive sodium intake can lead to hypercalciuria and contribute to the formation of urinary stones. The aim of this study was to evaluate salt intake in patients with urinary lithiasis and idiopathic hypercalciuria (IH).Methods: Between August 2007 and June 2008, 105 lithiasic patients were distributed into 2 groups: Group 1 (n = 55): patients with IH (urinary calcium excretion > 250 mg in women and 300 mg in men with normal serum calcium); Group 2 (n = 50): normocalciuric patients (NC). Inclusion criteria were: age over 18 years, normal renal function (creatinine clearance >= 60 ml/min), absent proteinuria and negative urinary culture. Pregnant women, patients with intestinal pathologies, chronic diarrhea or using corticoids were excluded. The protocol of metabolic investigation was based on non-consecutive collection of two 24-hour samples for dosages of: calcium, sodium, uric acid, citrate, oxalate, magnesium and urinary volume. Food intake was evaluated by the three-day dietary record quantitative method, and the Body Mass Index (BMI) was calculated and classified according to the World Health Organization (WHO). Sodium intake was evaluated based on 24-hour urinary sodium excretion.Results: The distribution in both groups as regards mean age (42.11 +/- 10.61 vs. 46.14 +/- 11.52), weight (77.14 +/- 16.03 vs. 75.99 +/- 15.80), height (1.64 +/- 0.10 vs. 1.64 +/- plusorminus 0.08) and BMI (28.78 +/- 5.81 vs. 28.07 +/- 5.27) was homogeneous. Urinary excretion of calcium (433.33 +/- 141.92 vs. 188.93 +/- 53.09), sodium (280.08 +/- 100.94 vs. 200.44.93 +/- 65.81), uric acid (880.63 +/- 281.50 vs. 646.74 +/- 182.76) and magnesium (88.78 +/- 37.53 vs. 64.34 +/- 31.84) was significantly higher in the IH group (p < 0.05). There was no statistical difference in calcium intake between the groups, and there was significantly higher salt intake in patients with IH than in NC.Conclusions: This study showed that salt intake was higher in patients with IH as compared to NC.

Litíase intrahepática primária. Relato de caso e revisão da literatura.

Primary intrahepatic lithiasis is an entity defined by intrahepatic stones exclusively located in the IH ducts above the emergence of the common bile duct. The disease is classified in two types: Eastern type (stones formed primarily in intrahepatic ducts; frequent in Japan) and Western type (stones formed in the extrahepatic bile system, usually in gallbladder, which migrate up to the intra-hepatic ducts). The mechanisms of lithogenesis in the entity are as yet not fully understood; multiple factors seem to operate synergistically: anatomical changes of the intrahepatic ducts, metabolic disorders, infections, idiopathic alteration. All these factors may facilitate biliary stasis leading ultimately to stone formation. We report on a case of and review the literature on primary intrahepatic lithiasis, which is a rare occurrence in the West and a disease of difficult surgical approach and high mortality.

Noninvasive aspergillosis as a maxillary antrolith: report of a rare case.

Maxillary antrolithiasis is characterized by masses of tissue of endogenous or exogenous origin that calcify within the maxillary sinuses. Aspergillosis is a fungal disease in which the maxillary sinus is a primary site of infection. Aspergillosis mycetoma, its noninvasive form, is the most prevalent modality of the disease in the maxillary sinuses. In approximately half of the cases reported in the literature, calcification of the fungal mycelia, which later became antroliths, was verified. This article reports a rare case of the accidental discovery of a maxillary antrolith associated with noninvasive aspergillosis in an immunocompetent and asymptomatic 56-year-old woman. The diagnosis and therapeutic procedures used in treating the patient are discussed as well as the probable iatrogenic origin of the fungal pathology.

Nephrocalcinosis induced by hyperoxaluria in rats

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Litíase urinária e hipercalciúria idiopática: importância da avaliação da ingestão alimentar

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Nefrocalcinose induzida pela hiperoxalúria: modelo experimental em ratos

Pós-graduação em Bases Gerais da Cirurgia - FMB