Hipercalciuria idiopática ¿se pueden evitar los diuróticos? / Idiopathic hypercalciuria: can the diuretics be avoided?

La hipercalciuria idiopática se define como la excreció;n de calcio superior a 220 y 300 mg/día en mujeres y hombres respectivamente o bien mayor a 4 mg/kg peso. En mujeres con osteoporosis se observa en el 19% de los casos, mientras que en litiasis renal varía entre el 50 y 70%. Seleccionamos 206 pacientes hipercalció;ºricos, de nuestra base de datos, con y sin litiasis renal, a los que se les había indicado una dieta restringida. Luego los dividimos, de acuerdo a la respuesta, en dieta dependiente y dieta independiente. De estos solo consideramos 122 pacientes con diagnó;sticos de hipercalciuria dieta-dependiente (105 mujeres y 17 hombres), que fueron seguidos con control dietario (800 mg de calcio, alrededor de 1 g de proteínas animales y < 100 mEq de sodio diarios). No se consideró; la aparició;n de cálculos, o la recurrencia de los mismos, como tampoco el compromiso ó;seo. Luego de una media de 17 meses todos tenían controlada la calciuria e incluso hubo 16 (13%) que luego de 42 meses de seguimiento persistían normocalció;ºricos solo con dieta. Concluimos que es fundamental la divisió;n de las hipercalciurias, segó;ºn su respuesta a una dieta restringida, con el fin de evitar o postergar el uso de diuró;©ticos y sus efectos adversos, con una administració;n adecuada de la dieta.

Idiopathic hypercalciuria is defined as calcium excretion greater than 220 and 300 mg / day in women and men respectively, or greater than 4 mg / kg body weight. In women with osteoporosis it is observed in 19% of cases, while in kidney stones cases varies between 50 and 70%. We selected 206 hypercalciuric patients from our database, with and without renal lithiasis, to whom a restricted diet had been indicated. We divided them, according to the response, into a dependent diet and an independent diet. We considered 122 patients with diagnosis of hypercalciuria diet dependent (105 women and 17 men), which were followed with dietary control (800 mg of calcium, around 1 g of animal proteins and < 100 mEq sodium a day). The appearance of stones, or the recurrence of stones, was not considered, nor was bone involvement. After an average of 17 months, everyone had their calciuria controlled and there were even 16 (13%) who, after 42 months of follow-up, continued to be normocalciuric only on a diet. We conclude that the division of the hypercalciurias is fundamental, according to their response to a restricted diet, in order to avoid or postpone the use of diuretics and its adverse effects, with an adequate management of the diet.

Respuesta de la calciuria a suplementos de vitamina D / Calcium response to vitamin D supplementation

Múltiples estudios muestran la importancia de mantener niveles suficientes de vitamina D para prevenir varias enfermedades crónicas. Sin embargo, la suplementación de vitamina D sobre la calciuria es controvertida. El objetivo de este trabajo prospectivo, intervencionista, fue evaluar la respuesta de la calciuria en mujeres con hipercalciuria y normocalciuria, luego de conseguir niveles adecuados de 25 OH D. Se estudiaron 63 mujeres con hipercalciuria idiopática (9 con litiasis renal) y 50 mujeres normocalciúricas. Ambos grupos presentaron déficit/insuficiencia de 25 OH D y fueron suplementadas con vitamina D2 o D3 semanales o vitamina D3 en dosis de 100 000 UI mensuales. A todas se les midió la calciuria basal y final al alcanzar el valor de 25 OH D deseado (> 30 ng/dl). No observamos cambios significativos en los valores de la calciuria inicial y final en las que recibieron vitamina D2 o D3 semanal ni en las que recibieron dosis mensuales. Sin embargo, un subgrupo de mujeres: 19% (n = 12) de las hipercalciúricas y 12% (n = 6) de las normocalciúricas (con vitamina D semanal) aumentaron la calciuria en forma significativa. Mientras que, con dosis mensuales, un 40% (n = 4/10) de las hipercalciúricas y 44% (n = 4/9) de las hipercalciúricas con litiasis renal aumentaron la calciuria. En conclusión, niveles adecuados de 25 OH D son seguros en la mayoría de las pacientes. En aquellas que requieren dosis de carga mensuales podrían observarse aumentos de la calciuria en forma significativa con riesgo de formar cálculos renales o perder masa ósea, cuando están genéticamente predispuestas.

Several studies show the importance of serum vitamin D sufficient levels to prevent multiple chronic diseases. However, vitamin D supplementation and its effects on urine calcium excretion remain controversial. The objective of this prospective and interventional study was to evaluate urine calcium excretion in women with normal calciuria or hypercalciuria, once serum vitamin D sufficiency was achieved. We studied 63 women with idiopathic hypercalciuria, (9 with renal lithiasis) and 50 normocalciuric women. Both groups had serum vitamin D levels low (deficiency or insufficiency). Baseline urine calcium excretion was measured before being supplemented with vitamin D2 or D3 weekly or vitamin D3 100.000 IU monthly. Once serum vitamin D levels were corrected achieving at least 30 ng/ml, a second urine calcium excretion was obtained. Although in the whole sample we did not observe significant changes in urine calcium excretion according to the way of supplementation, some of those with weekly supplementation had significant higher urine calcium excretion, 19% (n = 12) of hypercalciuric women and 12% (n = 6) of the normocalciuric group. Monthly doses, also showed higher urine calcium excretion in 40% of hypercalciuric women (n = 4/10) and in 44% (n = 4/9) of the renal lithiasis hypercalciuric patients. In conclusion, different ways of vitamin D supplementation and adequate serum levels are safe in most patients, although it should be taken into account a subgroup, mainly with monthly loading doses, that could increase the calciuria significantly eventually rising renal lithiasis risk or bone mass loss, if genetically predisposed.

Índice calcio-creatinina en una muestra matutina de orina para la estimación de hipercalciuria asociada con hematuria no glomerular observada en las edades infanto-juveniles / Calcium-creatinine ratio in a morning urine sample for the estimation of hypercalciuria associated with non-glomerular hematuria observed in children and adolescents

Resumen Introducción: La hipercalciuria suele revelarse durante el diagnóstico diferencial de la hematuria que acompaña a la litiasis renal. La exactitud diagnóstica de la excreción urinaria de calcio puede afectarse por las insuficiencias asociadas con la colección de orina de 24 horas. En este estudio se evaluó la utilidad diagnóstica del índice calcio/creatinina (ICaCre) en la estimación de la hipercalciuria asociada con hematuria y litiasis renal. Método: Se calculó el ICaCre de las concentraciones urinarias de calcio (mmol/l) y creatinina (µmol/l) en una alícuota de colección de 24 horas de orina en 169 niños y adolescentes atendidos por hematuria no glomerular (HNG) o litiasis renal (LR). La calciuria de 24 horas > 4.0 mg/kg en 24 horas se distribuyó según la presencia de HNG o LR. Resultados: El ICaCre promedio fue de 0.2 ± 0.1 mg/mg. La excreción urinaria de calcio estimada del ICaCre fue significativamente superior a la obtenida en colección de orina de 24 horas (p < 0.05). Los métodos de determinación de la calciuria concordaron en la frecuencia de hipercalciuria (ICaCre 39.5% vs. colección de 24 horas 32.1%; p > 0.05). Según la presencia de HNG o LR, la hipercalciuria se distribuyó de la siguiente manera: no HNG + no LR: 59%; no HNG + LR: 60% (diferencia: +1.0%); HNG + no LR: 68.2% (diferencia: +9.2%); HNG + LR: 73.3% (diferencia: +14.4%). Conclusiones: El ICaCre para estimar la excreción urinaria de calcio puede ser efectivo en el estudio de la hipercalciuria asociada con HNG y LR.

Abstract Background: Hypercalciuria might be revealed during the differential diagnosis of hematuria accompanying renal lithiasis (RL). In spite of this, diagnostic accuracy of calcium urinary excretion might be affected by incomplete 24-hour urine collections. In the present study, the diagnostic utility of calcium/creatinine (ICaCre) index for determining hypercalciuria associated with non-glomerular hematuria (NGH) and RL was assessed. Method: ICaCre (mg/mg) index was calculated from calcium (mmol/l) and creatinine (µmol/l) concentrations in an aliquot from a 24-hour urine collection in 169 children and adolescents with NGH or RL. Calciuria values > 4.0 mg/kg in 24 hours were distributed according to the presence of NGH or RL. Results: Mean ICaCre index was 0.2 ± 0.1 mg/mg. Calciuria values estimated from ICaCre were statistically higher to those from 24-hour urine collection (p < 0.05). The frequency of hypercalciuria was independent from the measurement method (estimated from ICaCre 39.5% vs. 24 h collection 32.1%; p > 0.05). Hypercalciuria distribution was as follows: no NGH + no RL: 59.0%; no NGH + RL: 60.0% (∆ = +1.0%); NGH + no RL: 68.2% (∆ = +9.2%); NGH + RL: 73.3% (∆ = +14.4%). Conclusions: The use of ICaCre index for determining calcium urine excretion might be effective in the study of hypercalciuria associated with NGH and RL.

Hiperparatiroidismo primario y embarazo: reporte de un caso / Primary hyperparathyroidism and pregnancy: a case report

El hiperparatiroidismo primario (HPTP) se caracteriza por una hipersecreción autónoma de paratohormona (PTH), lo que provoca hipercalcemia e hipercalciuria, con afectación ósea, renal y de otras partes del organismo, en grado variable. El HPTP tiene una prevalencia de 1 en 1000 en la población general y se presenta con mayor frecuencia en mujeres que en hombres. Es infrecuente su presentación en el embarazo, y sus complicaciones derivadas de la hipercalcemia pueden afectar tanto a la madre como al feto. Presentamos el caso de una paciente de 37 años, cursando un embarazo de 10 semanas, que ingresó al servicio con los diagnósticos de nefrocalcinosis y pielonefritis aguda, a la que se diagnosticó un hiperparatiroidismo primario, cuya etiología fue un adenoma paratiroideo único.

Primary hyperparathyroidism (HPTP) is a disorder characterized by elevated levels of parathyroid hormone (PTH), which leads to hypercalcemia and hypercalciuria, with variable osseous, renal and other systems affectation. HPTP has a prevalence of 1:1000 in general population and is more frequent in women than men. It is very rare during pregnancy, and its complications are produced by hypercalcemia and they can affect the mother and the fetus. We present the case of a 37 year old woman, with a 10+2 weeks pregnancy that was admitted in our Hospital with nephrocalcinosis and urinary tract infection, whom was diagnosed primary hyperparathyroidism, whose etiology was a single parathyroid adenoma.

Idiopathic hypercalciuria in Iranian children

The aim of this study was to determine the prevalence of idiopathic hypercalciuria [IH] in school children in Ahvaz, a city with different ethnic groups located in the Southwest of Iran. In a descriptive cross sectional study from October to December 2006, we determined urinary calcium [UCa] and urinary creatinine [UCr] in the morning urine samples of 500 primary school children. The levels of 24-hour UCa and UCr were measured in these children. Level of 24-hour UCa exceeding 4 mg/kg/day was considered as hypercalciuria, and UCa/UCr ratio exceeding 0.21 [mg/kg] was considered abnormal. Children who had hypercalciuria with a normal concentration of serum Ca were categorized as idiopathic hypercalciuric. Of 500 children aged 6-12 years, 231 were males and 269 females. In the first screening, 64 [12.8%] children [45 males, 19 females] had an abnormal UCa/UCr ratio. But in the end only 15 had the criteria of IH, i.e. the prevalence of IH was 3% [1.8-4.8%, confidence interval of 95%]. The prevalence in females and males was 0.74% and 5.6%, respectively [P= 0.003]. Of these children 10 had hematuria [including 2 cases of gross hematuria], 8 children gave a history of recurrent abdominal pain, 5 children suffered from dysuria and 3 persons had a history of personal or familial urolithiasis The study showed that 3% of primary school children in Ahvaz had IH predisposing to short-term and long-term complications of the disease. IH was significantly more common in boys than in girls