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Prospective therapeutic studies in nephrolithiasis.

Prospective randomized trials with respect to stone prophylaxis deal mainly with idiopathic calcium stone disease. There is a lot of evidence that alkali citrate, thiazides and allopurinol are effective in many patients. However, appropriate patient selection seems to be crucial. Alkali citrate and allopurinol have proven clinical efficacy in patients with hypocitraturia or hyperuricosuria, respectively. The correct method of patient selection for treatment with thiazides remains unclear. Despite the lack of prospective randomized trials, it is generally accepted that the first steps in the prophylaxis of idiopathic calcium stone disease are high fluid intake and a sensible diet.

Calcium Oxalate↗

Nephrolithiasis: current concepts in medical management.

Advances in renal lithiasis research have contributed to a better understanding of the many varied factors that contribute to renal calculus formation. Utilizing the newer techniques of ambulatory metabolic evaluation, we can establish a specific diagnosis in 95% of recurrent stone-formers. Since a significant percentage of initial stone-formers will never have a second episode, it is essential to establish the natural history of the patient's stone disease prior to initiating potentially life-long medical therapy. The majority of initial stone-formers can be managed with education concerning modest dietary restrictions and increased fluid intake. For the recurrent stone-former with metabolically active stone disease, it is probably best to design medical therapy to treat the specific urinary chemical abnormality or disease process.

Acidosis, Renal Tubular↗

The effects of calcitonin on idiopathic nephrolithiasis. Evidence of bone involvement in fasting hypercalciuria.

This study was performed to evaluate the antihypercalciuric effect of calcitonin (CT), a potent inhibitor of bone osteoclastic activity, on idiopathic hypercalciuria (IH). Forty-two stone formers were studied: 18 suffered from fasting hypercalciuria (FH), 12 from nonfasting hypercalciuria (NFH) and 12 were normocalciuric stone formers (NSF). All patients received CT, 25 U/day sc for a period of 15 days. CT caused a statistically significant drop in urine calcium, phosphorus and hydroxyproline (OH-proline) excretion in FH patients and a concomitant increase in serum PTH levels. In this group the percentage variation (D%) of urine calcium decrease was linearly correlated with D% decrease in urine OH-proline. These results support the hypothesis that pathological bone reabsorption might be involved in the genesis of FH.

Calcitonin↗

[Postoperative evaluation in uroradiology. Part 1: Nephrolithiasis, renal tumors and diseases ot the ureter].

Therapeutic strategies and operative techniques in urology develop rapidly. In particular, surgery becomes more and more differentiated and complex. Radiologists, especially uroradiologists wil have to provide special knowledge about urologic therapy and operative techniques in order to critically look at postoperative changes. Part I of this review will cover therapy and postoperative evaluation in nephrolitiasis, renal tumors and disease of the ureter. Using the appropriate modality at the appropriate time in postoperative course is discussed. Typical postoperative changes are shown. There is a focus on evaluation and typical radiologic findings in postoperative complications.

Humans↗

Oxalate binding proteins in calcium oxalate nephrolithiasis.

The existence of several oxalate specific binding proteins have been demonstrated in human and rat kidney. These occur in both cortical and medullary cells and are distributed mostly in the subcellular organelles. About 1/3 of the total cellular oxalate binding was localised in the inner mitochondrial membrane while the rest was in the nucleus. The purified mitochondrial oxalate binding protein (62 kDa) was composed, with a higher molar proportion, of basic amino acids, and could accumulate oxalate on incorporation into liposomes. In the nucleus, histone H(1B) (27.5 kDa), nuclear membrane protein (68 kDa) and nuclear pore complex protein (205 kDa) were present with oxalate binding activities. In addition, a 45 kDa calcium oxalate binding protein was identified in most of the subcellular organelles. Both mitochondrial and nuclear oxalate binding proteins and calcium oxalate binding protein have shown the kinetic properties of specificity, saturability, pH and temperature dependency, energy of activation and inhibition by substrate analogues. All oxalate binding proteins were sensitive to the transport inhibitor 4'-4' diisothiocyano stilbene-2-2 disulphonic acid (DIDS), which is known to interact with the lysine moiety of the proteins. Calcium oxalate monohydrate (COM) crystals adsorbed oxalate binding proteins from human and rat kidney, and oxalate binding proteins isolated from human kidney stone matrix also exhibited the above kinetic properties. In experimental hyperoxaluria, all of the renal oxalate binding proteins showed enhanced oxalate binding activity with increased protein concentration. This enhanced oxalate binding activity was also attributed to increased lipid peroxidation, which correlated positively, and to decreased thiol status, which correlated negatively. A positive correlation was observed between the lipid peroxidation and both the oxalate binding activity of the in vitro peroxidised subcellular organelles and the purified protein. Similarly, in an in vivo hyperoxaluric condition, a negative correlation was observed between thiol content and both the oxalate binding activity of the peroxidised subcellular organelles and the purified protein. In the calcium oxalate crystal growth system, the oxalate binding proteins behaved either as promoters or inhibitors of the nucleation and aggregation of crystals. Following the peroxidation of the proteins, the degree of effect of the promoter protein was further stimulated while the degree of inhibition caused by the inhibitor protein further declined. Similar observations were duplicated with the proteins derived from hyperoxaluric rat kidney or kidney homogenate subjected to in vitro lipid peroxidation. The oxalate binding proteins were thought to modulate the crystallisation process in an hyperoxaluric condition similar to calcium specific binding protein modulators.

Animals↗

Renal phosphate leak in patients with idiopathic hypercalciuria and calcium nephrolithiasis.

Although urine phosphate loss has been associated with hypercalciuria, it is debated how frequently renal phosphate leak is present in hypercalciuric patients. We reviewed the records of 100 consecutive adult patients who were diagnosed with idiopathic hypercalciuria and calcium urolithiasis, searching for the presence of renal phosphate leak. The renal phosphate threshold, normalized for the glomerular filtration rate (TmPO4/GFR), of the hypercalciuric patients followed a normal distribution and had a good correlation with serum phosphate ( r=0.77; p<0.0001). There were no correlations between TmPO4/GFR and urinary calcium or between serum phosphorus and urinary calcium. We found only nine patients (9%) with renal phosphate leak. These patients had a mean TmPO4/GFR of 2.19 mg% (0.70 mmol/l) and serum phosphorus of 2.65 mg% (0.85 mmol/l). Nevertheless, urinary calcium was not significantly different between patients with or without low TmPO4/GFR. We conclude that renal phosphate leak is an infrequent finding in patients with idiopathic hypercalciuria and is not associated with a higher urinary calcium loss.

Adult↗

International comparison of cost effectiveness of medical management strategies for nephrolithiasis.

Although medical therapy is known to reduce the risk of kidney stone recurrence, the cost effectiveness of medical prophylaxis is controversial. We evaluated medical treatment strategies including dietary measures (conservative), empiric medical therapy (empiric) or directed medical therapy (directed) based on comprehensive metabolic evaluation (CME) for patients with recurrent kidney stones, and compared the costs of these strategies using cost data from ten different countries. We previously established rates of stone formation in recurrent stone-formers, risk reduction of medical therapy, sensitivity of CME and rates of spontaneous stone passage from a comprehensive literature search (Lotan et al. 2004 J Urol 172: 2275). The costs of medication, surgical therapy, emergency room visits and CME for ten different countries were obtained from a published report of an international cost survey (Chandhoke 2002 J Urol 168: 937) as well as from our own county hospital in the US. Medication costs in the US were obtained from two national pharmacy chains. A decision tree model was created to compare the costs of different treatment strategies assuming cost accrual for metabolic evaluation, medical therapy and surgery or emergency room visits. For medical therapy, we assumed the distribution of medication use described in the published report, consisting of potassium citrate (60%), thiazide (30%) and allopurinol (10%). A nearly 20-fold difference in the costs of shock-wave lithotripsy, ureteroscopy and medication was found among different countries. From the model (US dollars/patient/year), conservative therapy alone was the most cost effective approach followed by empiric and directed medical therapy in all countries except in the UK. In the UK, the cost of drug therapy (estimated at dollar 29/patient/year) resulted in empiric therapy being the most cost effective strategy for recurrent stone formers. The low likelihood of surgical intervention, as well as the low relative cost of surgery to medication, contributed to the higher cost of empiric and directed medical therapy strategies. Of note, despite the higher cost, drug treatment strategies were associated with significantly lower stone recurrence rates. We found that drug treatment strategies are more costly than conservative treatment but produce good control of stone formation. In all but one country (UK), dietary therapy was the most cost effective approach due to the relatively low cost of surgery compared with medication. The differential resource allocation to different components of a healthcare system (i.e. subsidized medication versus surgical treatment) in different countries determines the cost effectiveness of various treatment strategies.

Cost-Benefit Analysis↗

Preventive treatment of nephrolithiasis with alkali citrate--a critical review.

Using the keywords "urolithiasis and citrate treatment", "nephrolithaisis and citrate treatment", "kidney stones and citrate treatment", a Medline search revealed 635 articles published between 1 January 1966 and 1 December 2004. For the present analysis, only studies meeting all of the following criteria were included: (1) publications in English or German, (2) studies on preventive alkali citrate treatment in patients with calcium oxalate, uric acid and infection stone disease, (3) clinical studies including at least ten subjects, and (4) treatment phases of at least 1 week duration. A total of 43 studies met the inclusion criteria and were further subclassified according to intermediate or ultimate endpoints as well as to study design. With stone recurrence as the ultimate endpoint, 21 uncontrolled studies in almost 1,000 patients demonstrated a reduction in stone forming rate by 47-100%. In four randomized controlled trials including 227 patients, 53.5% on alkali citrate vs 35% on placebo remained stone-free after at least 1 year of treatment (P<0.0005). Similar values (66% vs 27.5% for alkali citrate vs placebo, P<0.0005) were obtained in 104 patients from two randomized trials with dissolution/clearance of residual stones as endpoint. Unfortunately, up to 48% of alkali citrate treated patients left the studies prematurely, primarily due to adverse effects such as eructation, bloating, gaseousness or frank diarrhea.

Alkalies↗

A new animal model of hyperoxaluria and nephrolithiasis in rats with small bowel resection.

An association between small bowel resection and stone disease has been noted, which is primarily due to increased gut oxalate absorption and resulting excretion by the kidney. In order to better understand the factors affecting both oxalate absorption and renal excretion, and the resulting renal lesions, we have developed a rodent model of small bowel resection and hyperoxaluria. Using this model, we have studied the renal histology in animals with hyperoxaluria over time spans from 2 weeks to 7 months. The initial lesion appears to be crystal formation along the brush border of the proximal tubule, with eventual crystal deposition in collecting ducts and papillary interstitium, and eventual tubule obstruction, interstitial inflammation and fibrosis. Crystal formation appears to dissociate from urinary supersaturation. We hypothesize that oxalate transporters in the proximal tubule may increase local saturations, leading to crystal formation at this site initially. Further studies are required to better characterize the causes and consequences of hyperoxaluria in this animal model.

Animals↗

Prevention of nephrolithiasis by Lactobacillus in stone-forming rats: a preliminary study.

Hyperoxaluria is a risk factor for renal stones. It appears to be sustained by increased dietary load or increased intestinal absorption. The aim of this study was to evaluate whether oral administration of lactobacilli could prevent urolithiasis in stone-forming rats. Oxalate-degrading activities of lactobacilli were evaluated by measuring the oxalate level in a culture medium after inoculation with lactobacilli. Only the strains of Lactobacillus having oxalate-degrading activity were used. Sprague-Dawley rats were fed a powdered standard diet containing 3% sodium oxalate and/or received 100 mg/kg of celecoxib for the first 8 days by gavage, before or after the beginning of this experiment (groups with previous treatment or with co-treatment). Rats were sacrificed after 4 weeks and kidneys were harvested for the assay of crystal formation under a dissecting microscope. Twenty-four-hour urine collections were performed before kidney harvest. Only two strains, Lactobacillus casei HY2743 and L. casei HY7201 out of 31 strains of Lactobacillus were able to degrade oxalate. In both groups of co-treatment and previous treatment with L. casei HY2743 and L. casei HY7201, urine oxalate excretion decreased compared to the group without lactobacilli. The dissecting microscope examination of kidneys in the rats in two previous treatment groups and the co-treatment group with L. casei HY7201 showed less abundant crystals than control groups. Our results show that lactobacilli may be used as a potential therapeutic strategy in the prevention of urinary stones.

Animals↗

Evidence suggesting that high intake of fluoride provokes nephrolithiasis in tribal populations.

The present study was designed to evaluate the role of fluoride in urolithiasis in humans. Two areas were selected for this purpose, a fluoride endemic area (EA) and a fluoride non-endemic area (NEA). The prevalence of uroliathiasis was 4.6 times higher in EA than in NEA. Furthermore, the prevalence was almost double in subjects with fluorosis than without fluorosis in the endemic area. No relationship was observed between urolithiasis and the duration of fluorosis. The fluoride levels in drinking water ranged from 3.5 to 4.9 ppm in EA and subjects from this area excreted more fluoride. A comparison of normal subjects (NS) from EA and NEA revealed that endemic subjects tend to have slightly higher mean serum thiobarbituric acid reactive substance (TBAR) levels and excrete more oxalate and fluoride than their non-endemic counterparts. The urinary stone formers (SF) from the two areas showed a similar tendency, though again the difference was not significant. Citrate excretion in SF was almost normal in the EA, but NEA SF had significantly lower excretion levels. Urinary stones from endemic patients had higher fluoride, oxalate and calcium levels than those from non-endemic patients. In vitro studies suggested that fluoride did not influence the heterogonous mineralization of calcium oxalate. In conclusion, the data suggest that fluoride in vivo may behave as a mild promoter of urinary stone formation by (a) excretion of insoluble calcium fluoride, (b) increasing oxalate excretion and (c) mildly increasing the oxidative burden.

Adult↗