Research progress on renal calculus associate with inborn error of metabolism / 浙江大学学报·医学版

Renal calculus is a common disease with complex etiology and high recurrence rate. Recent studies have revealed that gene mutations may lead to metabolic defects which are associated with the formation of renal calculus, and single gene mutation is involved in relative high proportion of renal calculus. Gene mutations cause changes in enzyme function, metabolic pathway, ion transport, and receptor sensitivity, causing defects in oxalic acid metabolism, cystine metabolism, calcium ion metabolism, or purine metabolism, which may lead to the formation of renal calculus. The hereditary conditions associated with renal calculus include primary hyperoxaluria, cystinuria, Dent disease, familial hypomagnesemia with hypercalciuria and nephrocalcinosis, Bartter syndrome, primary distal renal tubular acidosis, infant hypercalcemia, hereditary hypophosphatemic rickets with hypercalciuria, adenine phosphoribosyltransferase deficiency, hypoxanthine-guanine phosphoribosyltransferase deficiency, and hereditary xanthinuria. This article reviews the research progress on renal calculus associated with inborn error of metabolism, to provide reference for early screening, diagnosis, treatment, prevention and recurrence of renal calculus.

Principais distúrbios metabólicos em adolescentes portadores de nefrolitíase / Main metabolic disorders in adolescents with nephrolithiasis

Introdução: Os cálculos renais compreendem uma das mais comuns patologias do trato urinário e têm apresentado maior incidência em adolescentes nos últimos anos. Objetivos: Identificar os distúrbios metabólicos causadores de cálculo renal mais prevalentes em adolescentes. Métodos: Foram analisados os prontuários de 135 indivíduos portadores de nefrolitíase, com idade entre 12 e 18 anos, de ambos os sexos. Na análise laboratorial, incluiu-se: duas amostras de urina de 24 horas, contendo cálcio, citrato, oxalato e ácido úrico; uma amostra sanguínea, contendo creatinina, paratormônio, ácido úrico e cálcio; pH urinário após 12 horas de restrição hídrica e jejum; urocultura e cistinúria qualitativa. Resultados: 88 pacientes apresentaram hipercaIciúria (65,2%), 42 apresentaram hipocitratúria (31,1%) e 29 hiperuricosúria (21,5%). As demais alterações observadas foram: volume urinário reduzido (14,8%), infecções do trato urinário (9,6%), hiperoxalúria (5,2%), hiperparatireoidismo (1,5%) e acidose tubular renal (1,5%). Os distúrbios metabólicos mais frequentemente observados nos adolescentes portadores de cálculo renal foram hipercalciúria, hipocitratúria e hiperuricosúria

Introduction: Kidney stones are one of the most common pathologies of the urinary tract and have had a higher incidence in adolescents in recent years. Objectives: To identify the most prevalent metabolic disorders that cause kidney stones in adolescents. Methods: The medical records of 135 individuals with nephrolithiasis, aged between 12 and 18 years, of both sexes, were analyzed. The laboratory analysis included: two 24-hour urine samples containing calcium, citrate, oxalate and uric acid; a blood sample, containing creatinine, parathyroid hormone, uric acid, and calcium; urinary pH after 12 hours of fluid restriction and fasting; uroculture and qualitative cystinuria. Results: 88 patients had hyperuricosuria (65.2%), 42 had hypocitraturia (31.1%) and 29 had hyperuricosuria (21.5%). The other changes observed were: reduced urinary volume (14.8%), urinary tract infections (9.6%), hyperoxaluria (5.2%), hyperparathyroidism (1.5%) and renal tubular acidosis (1.5 %). Conclusions: The metabolic disorders most frequently observed in adolescents with kidney stones were hypercalciuria, hypocitraturia and hyperuricosuria.

Trastornos metabólicos urinarios en pacientes urolitiásicos con enfermedad renal poliquística y sin ella / Urinary metabolic disorders in urolithiasis patients with and without polycystic kidney disease

Introducción: La urolitiasis se ha incrementado en las últimas décadas. La enfermedad renal poliquística autosómica dominante (ERPAD), enfermedad renal hereditaria más frecuente, ocupa un lugar preponderante. Objetivos: Identificar la frecuencia de presentación de los trastornos metabólicos urinarios en pacientes litiásicos cubanos con ERPAD y sin ella Métodos: Estudio descriptivo, transversal. Fueron estudiados 579 pacientes adultos sin ERPAD, seleccionados por muestreo simple aleatorio y los 21 pacientes con ERPAD, del total de pacientes con litiasis urinaria que se realizó estudio metabólico renal en el Laboratorio de Fisiopatología Renal del Instituto de Nefrología, en el periodo 2010-2015. Los datos fueron tomados de la historia clínica y del informe de estudio metabólico renal. La información se procesó de forma automatizada (SPSS 22.0). Se utilizó el promedio, desviación estándar, análisis de distribución de frecuencias y el test de homogeneidad. Resultados: En los pacientes con ERPAD predominó el sexo femenino (57,1 por ciento), mientras que en los pacientes sin ERPAD, el masculino (63,4 por ciento). Los trastornos más frecuentes en la población no poliquística fueron hipercalciuria (45,3 por ciento) e hipofosfatemia (17,1 por ciento). En los poliquísticos, aclaramiento aumentado de ácido úrico (38,1 por ciento) e hipercalciuria (23,8 por ciento). Se encontraron diferencias estadísticamente significativas para aumento del aclaramiento de ácido úrico (p = 0,01) e hiperfosfatemia (p = 0,04). Conclusiones: Los principales trastornos metabólicos de los pacientes litiásicos, tanto poliquísticos como no poliquísticos, son el aclaramiento de ácido úrico aumentado, hipercalciuria, hiperuricosuria e hipofosfatemia, aunque el orden de presentación es diferente. El aclaramiento de ácido úrico aumentado y la hiperfosfatemia se presentan con mayor frecuencia en los pacientes litiásicos poliquísticos(AU)

Introduction: Urolithiasis has increased in recent decades. Autosomal dominant polycystic kidney disease (ADPKD), the most common of all hereditary kidney diseases, occupies a predominant position in terms of incidence. Objectives: Identify the frequency of occurrence of urinary metabolic disorders in Cuban urolithiasis patients with and without ADPKD. Methods: A descriptive cross-sectional study was conducted of 579 adult patients without ADPKD selected by simple random sampling, and 21 patients with ADPKD, from the total urolithiasis patients undergoing renal metabolic evaluation at the Renal Physiopathology Laboratory of the Institute of Nephrology in the period 2010-2015. Data were obtained from medical records and reports of renal metabolic studies. Information was processed with the statistical software SPSS version 22.0. Average and standard deviation were estimated and use was made of frequency distribution analysis and homogeneity testing. Results: A predominance was found of female sex among patients with ADPKD (57.1 percent) and male sex among patients without ADPKD (63.4 percent). The most common disorders were hypercalciuria (45.3 percent) and hypophosphatemia (17.1 percent) in the non-polycystic population, and increased uric acid clearance (38.1 percent) and hypercalciuria (23.8 percent) in polycystic patients. Statistically significant differences were found in uric acid clearance increase (p = 0.01) and hyperphosphatemia (p = 0.04). Conclusions: The main metabolic disorders of lithiasis patients, polycystic as well as non-polycystic, are increased uric acid clearance, hypercalciuria, hyperuricosuria and hypophosphatemia, with a varying order of presentation. Increased uric acid clearance and hyperphosphatemia are more common in polycystic lithiasis patients(AU)

Litiasis renal en niños / Renal lithiasis in children

Resumen Justificación y objetivo: La litiasis renal se debe a la precipitación de cristales por un desequilibrio en la orina entre sustancias promotoras y las sustancias inhibitorias. Es una patología con una prevalencia entre 2-10% en la población pediátrica, con una incidencia que ha aumentado en los últimos 25 años; razón por la cual este estudio pretende conocer la prevalencia, las manifestaciones clínicas y metabólicas de la litiasis renal en la población pediátrica del Hospital Nacional de Niños de Costa Rica. Métodos: Es un estudio retrospectivo, descriptivo y observacional, mediante la revisión de expedientes de pacientes menores a 18 años con el diagnóstico de litiasis renal, atendidos en el Hospital Nacional de Niños, en el periodo comprendido entre enero del año 2000 al 2018. Resultados: Se incluyeron un total de 106 pacientes. El 57,5% hombres, la edad promedio al diagnóstico de 6,6 ± 3,8 años; la frecuencia de casos se ha incrementado en 5,5 veces en los últimos 5 años. Factores de riesgo detectados: anormalidades del tracto urinario 22,6% y antecedentes familiares de litiasis 17,9%. El análisis metabólico mostró un gasto urinario bajo en el 74,3%, hiperfosfaturia en un 43,2%, hipomagnesuria 39,2% e hipercalciuria 37,8%. Etiologías determinadas: metabólica 54,7%, malformaciones de las vías urinarias 16% e idiopática en un 30,9%. La litotricia intracorpórea se aplicó en un 61,2%. La recidiva se observó en el 28,5% de los casos, se encontró relación entre la incidencia de recidiva con el tamaño del lito (p = 0,001) y el tratamiento quirúrgico. (p = 0,010). Conclusiones: Existe un aumento en la frecuencia de casos de litiasis pediátrica con una etiología multifactorial en el Hospital Nacional de Niños de Costa Rica.

Abstract Background and aim: Renal lithiasis is due to the precipitation of crystals due to an imbalance in the urine between promoter substances and inhibitory substances. It is a pathology with a prevalence between 2-10% in the pediatric population, with an incidence that is increasing in the last 25 years, because of that, this study pretend to know the prevalence, the clinical and metabolic, manifestation of the renal lithiasis in the pediatric population. Methods: It is a retrospective, descriptive and observational study, by reviewing records of patients under 18 years of age with a diagnosis of renal lithiasis, treated at the Hospital Nacional de Niños, in the period of 2000 to 2018. Results: A total of 106 patients were included, 57,5% men, the average age at diagnosis of 6,6+- 3,8 years, the frequency of cases has increased 5,5 times in the last 5 years. Risk factors detected: urinary trac abnormalities 22,6% and family history of nephrolithiasis 17,9%. The metabolic analysis showed a low urinary flow rate in 74,3%, hyperphosphaturia in 43,2%, hypomagnesuria 39,2% and hypercalciuria 37,8%. Etiologies determined: metabolic 54,7%, malformations of the urinary trac 16% and idiopathic in 30,9%. Intracorporeal lithotripsy was applied in 61,2%. Recurrence was observe in 28,5 % of cases, a relationship was found between the incidence of recurrence with the size of litho (p= 0.001) and surgical treatment (p= 0.01). Conclusions: There is a significant increase in the incidence of pediatric lithiasis cases with a multifactorial etiology.

Aspectos clínicos, epidemiológicos y terapéuticos en niños y adolescentes con hipercalciuria idiopática / Clinical, epidemiological and therapeutic aspects in children and adolescents with idiopathic hypercalciuria

Introducción: La hipercalciuria idiopática es un trastorno metabólico frecuente y poco reconocido, cuyo curso clínico depende en gran medida de cambios en los hábitos dietéticos desde la infancia. Objetivo: Caracterizar a niños y adolescentes con hipercalciuria idiopática según variables clínicas, epidemiológicas y terapéuticas. Métodos: Se realizó una investigación observacional, longitudinal y prospectiva de 44 pacientes con hipercalciuria idiopática, atendidos en el Servicio de Miscelánea del Hospital Pediátrico Docente Sur Antonio María Béguez César de Santiago de Cuba, desde enero de 2014 hasta diciembre de 2015. Resultados: Las formas sintomáticas de la enfermedad resultaron ser las más frecuentes (68,2 %); asimismo, predominó el sexo masculino (72,7 %) y el promedio de edad fue de 7,2 ± 4 años. Existió asociación estadística entre las edades preescolar y escolar en cuanto al diagnóstico de hipercalciuria idiopática. La hematuria macroscópica recurrente fue el síntoma más usual en la mayoría de los casos (59,1 %); en tanto, 25,0 % de los pacientes presentó litiasis renal y el tratamiento no farmacológico a base de líquidos y dieta se relacionó con una evolución satisfactoria en 68,2 % de los afectados, a pesar de que el restante 31,8 % necesitó tratamiento medicamentoso. Conclusiones: Las características clínicas y epidemiológicas de los pacientes con hipercalciuria idiopática de esta casuística no difirieron de las registradas a nivel mundial, considerando que este trastorno metabólico es relativamente frecuente en los servicios de pediatría.

Introduction: The idiopathic hypercalciuria is a frequent and not very recognized metabolic disorder which clinical course depends in great extent on changes in the dietary habits from the childhood. Objective: To characterize children and adolescents with idiopathic hypercalciuria according to the clinical, epidemiological and therapeutic variables. Methods: An observational, longitudinal and prospective investigation was carried out in 44 patients with idiopathic hypercalciuria, assisted in the Miscellaneous Service of Antonio María Béguez Cesar Southern Teaching Children Hospital in Santiago de Cuba, from January, 2014 to December, 2015. Results: The symptomatic forms of the disease were the most frequent (68.2 %); also, the male sex prevailed (72.7 %) and the average age was 7.2 ± 4 years. Statistical association existed among the preschool and school ages as for the diagnosis of idiopathic hypercalciuria. The recurrent macroscopic hematuria was the most usual symptom in the majority of cases (59.1 %); as long as, the 25.0 % of patients presented renal lithiasis and the diet and liquids-based non pharmacological treatment was associated with a satisfactory evolution in 68.2 % of the affected patients, although the remaining 31.8 % needed drugs treatment. Conclusions: The clinical and epidemiological characteristics of patients with idiopathic hypercalciuria of this case material didn't differ from the ones registered worldwide, taking into account that this metabolic disorder is relatively frequent in pediatric services.

Renal manifestations of sarcoidosis: from accurate diagnosis to specific treatment

ABSTRACT Sarcoidosis is a multisystem granulomatous disease characterized by epithelioid noncaseating granulomas associated with clinical and radiologic findings. The cause of this disease is still uncertain. Sarcoidosis affects mostly lungs and lymph nodes and is not usually considered a urological disease, therefore, this etiology may be overlooked in several urological disorders, such as hypercalcemia, hypercalciuria and nephrolithiasis. It affects all races and genders. This review aims to describe the urological manifestations of sarcoidosis and to elucidate how the disease may affect the management of numerous urological conditions.

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.

Hipercalciuria hidiopática como factor predisponente de infección urinaria / Idiopathic hypercalciuria as predisposing factor of urinary infection

Introducción: La hipercalciuria idiopática es una alteración metabólica relativamente frecuente y existen escasas publicaciones de su relación con la infección del tracto urinario. Objetivos: Precisar si existe asociación entre la infección urinaria e hipercalciuria idiopática para determinar si esta alteración metabólica constituye un factor de riesgo de infección urinaria. Métodos: Estudio descriptivo longitudinal prospectivo en pacientes de edad pediátrica con diagnóstico de infección urinaria atendidos en el Hospital Pediátrico Universitario William Soler entre 1ro. enero de 2016 y 31 de diciembre de 2017. Dos semanas después de controlada la infección se recogió muestra de orina de la primera micción del día para determinación de índice calcio/creatinina y precisar la excreción de calcio en 24 horas. Si esta prueba arroja resultados positivos, entre dos y cuatro semanas posteriores, se repite la muestra y si ambas son positivas y el calcio en sangre es normal se diagnostica hipercalciuria idiopática. Resultados: Se incluyeron en el estudio 130 pacientes. En 43,8 por ciento se encontró hipercalciuria idiopática. En su primer episodio infeccioso se estudiaron 52,3 por ciento y los restantes con antecedentes de infección o recurrencia. En 86,2 por ciento la infección fue catalogada como pielonefrítica. La distribución por sexo de la hipercalciuria no mostró diferencia y el síntoma hematuria con dolor abdominal recurrente resultó sugestivo de infección asociada a hipercalciuria (p < 0,05). El germen infectante no contribuye a pensar en hipercalciuria. Conclusión: La hipercalciuria idiopática constituye un factor predisponente de infección del tracto urinario(AU)

Introduction: Idiopathic hypercalciuria is a relatively frequent metabolic alteration and there are scarce publications on its relation with the urinary tract´s infection. Objective: To specify if there is a relation between urinary infection and idiopathic hypercalciuria, in order to determine if this last one constitutes a risk factor of urinary infection. Methods: Prospective, descriptive and longitudinal study in pediatric age's patients with a diagnosis of urinary infection that were attended in William Soler University Pediatric Hospital from January 1st, 2016 to December 31st, 2017. After two weeks of the infection being controlled, a urine sample from the first micturition of the day was collected to determine calcium/creatinine index and to specify calcium excretion in 24 hours. If this test shows positive results, after two to four weeks the sample is repeated, and if both are positive and calcium level in blood is normal, so idiopathic hypercalciuria is diagnosed. Results: 130 patients were included in the study. In 43.8 percent idiopathic hypercalciuria was found. 52.3 percent were studied during the first infectious episode, and there is presented a history of infection or recurrence. In 86.2 percent of the patients, the infection was catalogued as pyelonephritis. Hypercalciuria´s gender distribution didn't show any differences, and the symptom called hematuria with recurrent abdominal pain was suggestive to an infection related to hypercalciuria (p < 0.05). The infectious germ does not induce to think in hypercalciuria. Conclusions: Idiopathic hypercalciuria constitutes a predisposing factor of urinary tract's infection(AU)

Riñón en esponja y litiasis renal / Sponge kidney and renal lithiasis

Introducción: El riñón en esponja es una malformación renal, de los túbulos colectores, que se suele asociar a nefrocalcinosis o acidosis tubular distal. La asociación con la litiasis renal se observa entre un 4-20%. Objetivo: El objetivo de nuestro trabajo fue describir factores de riesgo bioquímicos para litiasis renales, en pacientes con riñón en esponja. Material y métodos: Se realizó un estudio retrospectivo, observacional de corte, entre los años 2000 y 2017 en donde se estudiaron 37 pacientes con riñón en esponja y litiasis renal (26 mujeres y 11 hombres) de 37.3 ± 13.2 años. El diagnóstico de riñón en esponja se hizo mediante urograma excretor. Resultados: Fue observada nefrocalcinosis en el 95%. El diagnóstico bioquímico más frecuente fue la hipercalciuria idiopática que como única y asociada alteración se observó en el 59.4%. La hiperuricosuria fue el segundo diagnóstico encontrado en el 32.4% (única y asociada) seguido por la, hipocitraturia, hipomagnesuria y el pHu persistentemente ácido. En los hombres llamó la atención que un 46.2% no presentaron alteración bioquímica. Conclusiones: En conclusión se destaca la asociación relativamente frecuente de riñón en esponja y litiasis renal. La hipercalciuria idiopática fue la alteración metabólica más frecuente como causa de litogénesis, seguida por la hiperuricosuria, similar a lo descripto en la literatura, aunque en menor proporción. Otras alteraciones, como la hipocitraturia, hipomagnesuria y pHu persistentemente ácido también deben ser consideradas en el estudio de estos pacientes.

Introduction: Sponge kidney is a renal malformation of the collecting tubules, which is usually associated with nephrocalcinosis or distal tubular acidosis. The association with renal lithiasis is observed between 4-20%. Objective: The aim of our work was to describe the biochemical risk factors of renal lithiasis in patients with sponge kidney. Methods: A retrospective, observational, cross-sectional study was conducted between 2000 and 2017, in which 37 patients with sponge kidney and renal lithiasis (26 women and 11 men), aged 37.3 ± 13.2 years, were studied. The diagnosis of sponge kidney was made by excretory urography. Results: Nephrocalcinosis was observed in 95% of patients. The most frequent biochemical diagnosis was idiopathic hypercalciuria, which was observed, as a single and associated alteration, in 59.4% of cases. Hyperuricosuria was the second diagnosis found in 32.4% (single and associated) followed by hypocitraturia, hypomagnesuria and persistently acid pHu. Surprisingly, 46.2% of men presented no biochemical alteration. Conclusions: Our findings highlight the relatively frequent association of sponge kidney and renal lithiasis. Idiopathic hypercalciuria was the most common metabolic alteration as the cause of lithogenesis, followed by hyperuricosuria, similar to that described in the literature, but to a lesser extent. Other alterations, such as hypocitraturia, hypomagnesuria and persistently acid pHu, should also be considered in the study of these patients.

Etiología de la hematuria monosintomática en pediatría / Etiology of monosymptomatic hematuria in Pediatrics

Introducción: La hematuria es el hallazgo clínico más frecuente entre las enfermedades genitourinarias, después de las infecciones del tracto urinario a cualquier edad. Objetivo: Identificar las características generales y etiología de la hematuria monosintomática en pacientes pediátricos. Métodos: Investigación descriptiva longitudinal y prospectiva con los pacientes atendidos con hematuria monosintomática en el Servicio de Nefrología del Hospital Pediátrico Docente William Soler entre el primero de enero de 2014 y 31 de diciembre de 2015. Resultados: Se reclutaron 45 pacientes. Predominó en escolares (40 por ciento) y adolescentes (40 por ciento), sexo masculino (55,5 por ciento). Se recogió el antecedente personal o familiar de hematuria en 44,5 por ciento y 55,5 por ciento, respectivamente. La urolitiasis familiar estuvo presente en 37,7 por ciento. El tipo de hematuria más frecuente fue la macroscópica (75,8 por ciento), no glomerular (71,2 por ciento), sin proteinuria (77,8 por ciento), y hematíes eumórficos (62,2 por ciento). La causa más frecuente fue la hipercalciuria idiopática (51,1 por ciento) y el 80 por ciento de todos los pacientes solo recibió tratamiento higieno-dietético. En 20 por ciento de los pacientes no se pudo precisar la causa etiológica. Conclusiones: La causa más frecuente de hematuria fue no glomerular (hipercalciuria idiopática) y en aquellos con hematuria cuya causa etiológica no se pudo precisar, es obligado mantener un seguimiento prolongado(AU)

Introduction: Hematuria is the most frequent clinical finding among genitourinary diseases afterwards urinary tract infection at any age. Objective: To identify general characteristics and etiology of monosymptomatic hematuria in in pediatrics patients. Methods: Descriptive, longitudinal and prospective research of the patients by monosymptomatic hematuria attended at the Nephrology service in William Soler Teaching Pediatric Hospital from January 1, 2014 to December 31, 2015. Results: 45 patients were recruited. Schoolchildren (40 percent) were predominant and adolescents (40 percent), and males (55.5 percent). It was collected personal or familial records of hematuria in 44.5 percent and 55.5 percent, respectively. Familial urolithiasis was present in 37.7 percent. The most common type of hematuria was the macroscopic (75.8 percent), non-glomerular (71.2 percent), without proteinuria (77.8 percent) and with eumorphic hematies (62.2 percent). The most frequent etiological cause was idiopathic hypercalciuria (51.1 percent), and 80 percent of all patients only received hygiene-dietetic treatment. In the 20 percent of the patients was not possible to determine the etiological cause. Conclusions: The most frequent cause of hematuria was non-glomerular (idiopathic hypercalciuria); and in those patients with hematuria of non-precised etiological cause, it is mandatory to keep long-term follow-up(AU)

Effect of vitamin D supplementation on 24-hour urine calcium in patients with calcium Urolithiasis and vitamin D deficiency

ABSTRACT Purpose: Hypercalciuria is one of the risk factors for calcium kidney stone formation (the most common type of urinary stones). Although vitamin D deficiency is prevalent among urolithiasis patients, the effect of vitamin D supplementation on urine calcium in these patients is still unclear. Materials and Methods: In this retrospective study, medical and laboratory tests records of 26 patients with recurrent calcium kidney stones and vitamin D deficiency treated with 50000IU vitamin D per week for 8-12 weeks were analyzed. The changes in 24-hour urine calcium (24-h Ca), serum 25-hydroxyvitamin D (25 (OH) D), serum parathormone (PTH), other 24-hour urine metabolites and calculated relative supersaturations of calcium oxalate (CaOxSS), calcium phosphate (CaPSS) and uric acid (UASS) were assessed. Moreover, correlations between changes in 24-h Ca and other aforementioned variables were assessed. Results: Serum 25 (OH) D and 24-h Ca increased after vitamin D supplementation, while serum PTH decreased (p < 0.001, for all analyses). The levels of 24-hour urine sodium and urea increased significantly (p = 0.005 and p = 0.031, respectively). The levels of CaOxSS and CaPSS increased, but the changes were not significant (p = 0.177, and p = 0.218, respectively). There were no correlations between the changes in 24-h Ca and serum 25 (OH) D or PTH. Conclusions: The result of current study suggests that although urine Ca increased in vitamin D supplemented patients, this increase was not associated with the increase in serum vitamin D and may be due to other factors such as dietary factors. Further randomized clinical trials considering other factors associated with urine Ca are warranted.

Response to vitamin D replacement in overweight and normal weight children with vitamin D deficiency

PURPOSE: It is well known that obesity is related to vitamin D deficiency (VDD). We investigated the response to vitamin D replacement in normal-weight and overweight children. METHODS: This was a prospective study including 62 Korean children with VDD. VDD was defined as a serum 25-hydroxycholecalciferol (25(OH)D) concentration <20 ng/mL. Overweight was defined as a body mass index (BMI)≥the 85th percentile (n=21), and normal weight as a BMI between the 5th and 84th percentiles (n=41). All participants received vitamin D3 supplementation (2,000 IU/day) for 8 weeks. The serum levels of 25(OH)D, PTH and biochemical parameters were measured before and after treatment. RESULTS: The mean age was 10.0±1.4 years in normal-weight children and 10.0±2.1 years in overweight children (P=0.93). After 8 weeks of treatment, 61.9% of normal-weight children and 47.6% of overweight children achieved vitamin D sufficiency (P =0.30). The mean serum 25(OH)D levels after vitamin D replacement were 33.8±7.6 ng/mL and 30.3±6.6 ng/mL in normal-weight and overweight children, respectively (P =0.10). The mean calcium/creatinine ratios after treatment were 0.09±0.07 and 0.08±0.06 in the normal-weight and overweight groups, respectively, and no hypercalciuria was found. In multiple regression analysis, the response to vitamin D replacement was influenced by the BMI (β=-1.0, P=0.03) and sex (β=-4.0, P=0.04). CONCLUSIONS: Eight weeks of vitamin D replacement (2,000 IU/day) is sufficient to overcome vitamin D deficiency in normal-weight and overweight children without any complications.

Reference range of random urinary calcium creatinine ratio in North Indian children and adolescents

PURPOSE: Urinary calcium creatinine ratio (UCaCrR) is a reliable indicator for monitoring hypercalciuria following vitamin D supplementation. However, the reference range varies from region to region. Previous studies did not take vitamin D and parathyroid hormone status into account while evaluating UCaCrR. Hence, we undertook this study to establish the 95th percentile of UCaCrR as an indicator of hypercalciuria in North Indian children and adolescents. METHODS: Four hundred seventy-three participants (boys 62.2%, girls 37.8%) with adequate dietary calcium intake, normal serum levels of 25-hydroxy-vitamin D (>20 ng/mL), and without secondary hyperparathyroidism following supplementation were selected for evaluation of UCaCrR. RESULTS: The mean age and body mass index of subjects were 11.2±2.6 years and 18.0±3.6 kg/m2, respectively. The 95th percentile of UCaCrR in the study population was 0.126. The mean, median, and 95th percentile of UCaCrR was significantly higher in prepubertal children (age ≤10 years) (0.0586±0.0374, median=0.0548, 95th percentile=0.136) compared to those >10 years old (0.0503±0.0363, median=0.0407, 95th percentile=0.123, P=0.02). No significant difference in UCaCrR was observed between genders and different weight categories. CONCLUSIONS: UCaCrR of 0.13 defines the cutoff value for hypercalciuria in North Indian children and adolescents with adequate dietary intake of calcium and sufficient serum vitamin D levels.

Infantile hypercalcemia with novel compound heterozygous mutation in SLC34A1 encoding renal sodium-phosphate cotransporter 2a: a case report

Idiopathic infantile hypercalcemia is characterized by hypercalcemia, dehydration, vomiting, and failure to thrive, and it is due to mutations in 24-hydroxylase (CYP24A1). Recently, mutations in sodium-phosphate cotransporter (SLC34A1) expressed in the kidney were discovered as an additional cause of idiopathic infantile hypercalcemia. This report describes a female infant admitted for evaluation of nephrocalcinosis. She presented with hypercalcemia, hypercalciuria, low intact parathyroid hormone level, and high 1,25-dihydroxyvitamin D3 level. Exome sequencing identified novel compound heterozygous mutations in SLC34A1 (c.1337G>A, c.1483C>T). The patient was treated with fluids for hydration, furosemide, a corticosteroid, and restriction of calcium/vitamin D intake. At the age of 7 months, the patient's calcium level was within the normal range, and hypercalciuria waxed and waned. Renal echogenicity improved on the follow-up ultrasonogram, and developmental delay was not noted. In cases of hypercalcemia with subsequent hypercalciuria, DNA analysis for SLC34A1 gene mutations and CYP24A1 gene mutations should be performed. Further studies are required to obtain long-term data on hypercalciuria and nephrocalcinosis.

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.

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.

Effects of Altered Calcium Metabolism on Cardiac Parameters in Primary Aldosteronism

BACKGROUND: Increasing evidence supports interplay between aldosterone and parathyroid hormone (PTH), which may aggravate cardiovascular complications in various heart diseases. Negative structural cardiovascular remodeling by primary aldosteronism (PA) is also suspected to be associated with changes in calcium levels. However, to date, few clinical studies have examined how changes in calcium and PTH levels influence cardiovascular outcomes in PA patients. Therefore, we investigated the impact of altered calcium homeostasis caused by excessive aldosterone on cardiovascular parameters in patients with PA. METHODS: Forty-two patients (mean age 48.8±10.9 years; 1:1, male:female) whose plasma aldosterone concentration/plasma renin activity ratio was more than 30 were selected among those who had visited Severance Hospital from 2010 to 2014. All patients underwent adrenal venous sampling with complete access to both adrenal veins. RESULTS: The prevalence of unilateral adrenal adenoma (54.8%) was similar to that of bilateral adrenal hyperplasia. Mean serum corrected calcium level was 8.9±0.3 mg/dL (range, 8.3 to 9.9). The corrected calcium level had a negative linear correlation with left ventricular end-diastolic diameter (LVEDD, ρ=−0.424, P=0.031). Moreover, multivariable regression analysis showed that the corrected calcium level was marginally associated with the LVEDD and corrected QT (QTc) interval (β=−0.366, P=0.068 and β=−0.252, P=0.070, respectively). CONCLUSION: Aldosterone-mediated hypercalciuria and subsequent hypocalcemia may be partly involved in the development of cardiac remodeling as well as a prolonged QTc interval, in subjects with PA, thereby triggering deleterious effects on target organs additively.

De novo a novel variant of CaSR gene in a neonate with congenital hypoparathyroidism

Autosomal-dominant hypocalcemia with hypercalciuria (ADHH) is a genetic disease characterized by hypoparathyroidism with hypercalciuria. Most patients with ADHH have calcium-sensing receptor (CaSR) gene mutations. The CaSR gene controls parathyroid secretions, and mutations in this gene can be detected via changes in serum calcium level. The activating mutation of the CaSR gene results in familial or sporadic ADHH. Most activating mutations of the CaSR gene are reportedly de novo missense mutations. This is the first case report of a novel activating variant of the CaSR gene in a neonate with congenital hypoparathyroidism with hypomagnesemia and hypercalciuria. We also report the 3-month follow-up management of the patient.

Hypercalciuria and febrile convulsion in children under 5 years old / 소아과

PURPOSE: The association between hypercalciuria and febrile convulsion is controversial. The present study aimed to investigate the statistical association between hypercalciuria and childhood febrile convulsions. METHODS: Overall, 160 children aged 6 months to 5 years, including 80 children with febrile convulsion and 80 febrile children without convulsion (comparison group), were recruited. All laboratory tests, including 24-hour urine calcium, were undertaken in an academic clinical laboratory. RESULTS: Forty-five children of the febrile convulsion group (60%) and 30 of the comparison group (40%) had hypercalciuria. There was a significant difference between the 2 groups (P=0.02). CONCLUSION: Our results indicated that there is a statistical association between convulsion and hypercalciuria in children. Since we found this association with a cross-sectional assessment, further studies, especially prospective and controlled designs, are needed.