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Ranjan SK, Mittal A, Mirza AA, Kumar S, Panwar VK, Navriya S, Mandal AK, Mammen KJ. Metabolic evaluation of first-time uncomplicated renal stone formers: A prospective study. Curr Urol 2023; 17:36-40. [PMID: 37692144 PMCID: PMC10487292 DOI: 10.1097/cu9.0000000000000169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 12/03/2021] [Indexed: 12/23/2022] Open
Abstract
Background Nephrolithiasis is a global health problem. The recurrence rate after the first stone clearance is approximately 50% at 5 years. Metabolic abnormalities are an important factor responsible for stone recurrence. Our prevalidated study aimed to evaluate metabolic abnormalities associated with first-time uncomplicated renal stone formers (FTURSF). Materials and methods In this prospective, exploratory, time-bound, descriptive study, 30 first-time renal stone formers were evaluated for metabolic abnormalities. High-risk stone formers were excluded from the study. Data were collected in a predefined proforma, transferred to an Excel sheet, and analyzed using the Statistical Package for Social Sciences 20 and Epi Info 7. Fisher exact test, Mann-Whitney U test, paired t test, and Pearson correlation coefficient were used for statistical analyses. Results The mean age of the participants was 35.57 ± 11.07 years, with a male-to-female ratio of 1.72. The most common abnormality was a 24-hour urine volume of <2.5 L in 73.33% of the participants. One or more metabolic abnormalities were detected in 76.67% of the participants. Other common metabolic abnormalities detected were hypocitraturia (60%), hypercalciuria (16.67%), hyperoxaluria (13.33%), and hyperuricosuria (3.33%). Parathyroid adenoma was detected in one participant (3.33%). Conclusions Our study documented significant metabolic abnormalities in FTURSF. Therefore, a simplified metabolic evaluation protocol should be adopted while evaluating FTURSF. Detection of an underlying metabolic abnormality would enable the early institution of preventive measures to reduce stone recurrence and related complications.
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Affiliation(s)
| | | | | | - Sunil Kumar
- Department of Urology, AIIMS, Rishikesh, India
| | | | | | | | - Kim Jacob Mammen
- Department of Urology, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, India
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2
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Uribarri J, Goldfarb DS, Raphael KL, Rein JL, Asplin JR. Beyond the Urine Anion Gap: In Support of the Direct Measurement of Urinary Ammonium. Am J Kidney Dis 2022; 80:667-676. [PMID: 35810828 DOI: 10.1053/j.ajkd.2022.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/10/2022] [Indexed: 02/02/2023]
Abstract
Ammonium is a major urinary buffer that is necessary for the normal excretion of the daily acid load. Its urinary rate of excretion (UNH4) may be increased several fold in the presence of extrarenal metabolic acidosis. Therefore, measurement of UNH4 can provide important clues about causes of metabolic acidosis. Because UNH4 is not commonly measured in clinical laboratories, the urinary anion gap (UAG) was proposed as its surrogate about 4 decades ago, and it is still frequently used for that purpose. Several published studies strongly suggest that UAG is not a good index of UNH4 and support the concept that direct measurement of UNH4 is an important parameter to define in clinical nephrology. Low UNH4 levels have recently been found to be associated with a higher risk of metabolic acidosis, loss of kidney function, and death in persons with chronic kidney disease, while surrogates like the UAG do not recapitulate this risk. In order to advance the field it is necessary for the medical community to become more familiar with UNH4 levels in a variety of clinical settings. Herein, we review the literature, searching for available data on UNH4 under normal and various pathological conditions, in an attempt to establish reference values to interpret UNH4 results if and when UNH4 measurements become available as a routine clinical test. In addition, we present original data in 2 large populations that provide further evidence that the UAG is not a good predictor of UNH4. Measurement of urine NH4 holds promise to aid clinicians in the care of patients, and we encourage further research to determine its best diagnostic usage.
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Affiliation(s)
- Jaime Uribarri
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
| | | | - Kalani L Raphael
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon
| | - Joshua L Rein
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John R Asplin
- Litholink Corporation, Laboratory Corporation of America Holdings, Chicago, Illinois
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3
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Abstract
Two papers, one in 1986 and another one in 1988, reported a strong inverse correlation between urinary anion gap (UAG) and urine ammonia excretion (UNH4) in patients with metabolic acidosis and postulated that UAG could be used as an indirect measure of UNH4 This postulation has persisted until now and is widely accepted. In this review, we discuss factors regulating UAG and examine published evidence to uncover errors in the postulate and the design of the original studies. The essential fact is that, in the steady state, UAG reflects intake of Na, K, and Cl. Discrepancy between intake and urinary output of these electrolytes (i.e, UAG) indicates selective extrarenal loss of these electrolytes or nonsteady state. UNH4 excretion, which depends, in the absence of renal dysfunction, mainly on the daily acid load, has no consistent relationship to UAG either theoretically or in reality. Any correlation between UAG and UNH4, when observed, was a fortuitous correlation and cannot be extrapolated to other situations. Furthermore, the normal value of UAG has greatly increased over the past few decades, mainly due to increases in dietary intake of potassium and widespread use of sodium salts with anions other than chloride as food additives. The higher normal values of UAG must be taken into consideration in interpreting UAG.
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Affiliation(s)
- Jaime Uribarri
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Man S. Oh
- Renal Division, Department of Medicine, State University of New York at Downstate, Brooklyn, New York
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4
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Patel PM, Kandabarow AM, Aiwerioghene E, Blanco-Martinez E, Hart S, Leehey DJ, Farooq A, Baldea KG, Turk TMT. Proton-pump inhibitors associated with decreased urinary citrate excretion. Int Urol Nephrol 2020; 53:679-683. [PMID: 33206338 DOI: 10.1007/s11255-020-02719-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/07/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Proton-pump inhibitors (PPIs) may increase the risk of kidney stone formation, but the mechanism has not been elucidated. There is a paucity of literature evaluating the effects of PPIs on urinary metabolites and urine pH. METHODS We performed a retrospective review of nephrolithiasis patients treated at our institution and compared patients who were taking PPIs to those who were not at the time of their 24-h urine collections. Hierarchical multivariate linear regression was used to evaluate the independent relationship between PPI use and urinary mineral composition. RESULTS We identified 301 consecutive patients, 88 (29%) of whom were taking PPIs at the time of their 24-h urine collections. Patients taking PPIs were older and more likely to have medical comorbidities associated with metabolic syndrome such as hypertension, diabetes, and dyslipidemia (p < 0.01). Controlling for these factors, patients taking PPIs were found to have 12% lower 24-h urine citrate excretion (β = - 0.12, ΔF = 4.24, p = 0.04). There were no other differences in urinary mineral composition between the groups. CONCLUSION Our findings suggest that patients who take PPIs regularly may be at risk for decreased urinary citrate excretion. The consequent decrease in urinary citrate may become clinically significant for patients with other predisposing factors for hypocitraturia.
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Affiliation(s)
- Parth M Patel
- Department of Urology, Loyola University Medical Center, 2160 S. 1st Ave., Fahey Building, 2nd Floor, Maywood, IL, 60153, USA.
| | - Alexander M Kandabarow
- Department of Urology, Loyola University Medical Center, 2160 S. 1st Ave., Fahey Building, 2nd Floor, Maywood, IL, 60153, USA
| | | | | | - Spencer Hart
- Department of Urology, Loyola University Medical Center, 2160 S. 1st Ave., Fahey Building, 2nd Floor, Maywood, IL, 60153, USA
| | - David J Leehey
- Department of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Ahmer Farooq
- Department of Urology, Loyola University Medical Center, 2160 S. 1st Ave., Fahey Building, 2nd Floor, Maywood, IL, 60153, USA
| | - Kristin G Baldea
- Department of Urology, Loyola University Medical Center, 2160 S. 1st Ave., Fahey Building, 2nd Floor, Maywood, IL, 60153, USA
| | - Thomas M T Turk
- Department of Urology, Loyola University Medical Center, 2160 S. 1st Ave., Fahey Building, 2nd Floor, Maywood, IL, 60153, USA
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5
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[Interpretation of the metabolic study in renal lithiasis and its treatment]. Semergen 2020; 47:38-46. [PMID: 32819805 DOI: 10.1016/j.semerg.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 11/20/2022]
Abstract
Urolithiasis is a common disease, and is an important health problem that is associated with a great economic burden. The nature of stone disease varies according by dietary and lifestyle factors, including, among others, climate variations. The majority of patients will suffer a new lithiasic episode at some point in their life, unless preventive measures, such as changing lifestyles and dietary habits, are put in place to avoid it. The risk factors involved in lithogenesis should be evaluated in order to reduce recurrences. In the majority of these patients, metabolic changes are observed in the urine that predispose lithogenesis. The kind of evaluation depends on stone composition and on the clinical presentation. A diagnosis of systemic and renal diseases of lithogenic nature can be diagnosed with these studies, and they also enable the adoption of precise prophylactic measures that achieve control of recurrence in a great number of patients.
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6
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Patel PM, Kandabarow AM, Druck A, Hart S, Blackwell RH, Kadlec A, Farooq A, Turk TMT, Baldea KG. Association of Impaired Renal Function With Changes in Urinary Mineral Excretion and Stone Composition. Urology 2020; 141:45-49. [PMID: 32294484 DOI: 10.1016/j.urology.2020.03.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/03/2020] [Accepted: 03/15/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the effect of kidney function on stone composition and urinary mineral excretion in patients undergoing surgical intervention for nephrolithiasis. METHODS Using our institutional kidney stone database, we performed a retrospective review of stone patients who underwent surgical intervention between 2004 and 2015. Patients' demographic information, 24-hour urinary mineral excretion, and stone characteristics were reported. The patients' estimated glomerular filtration rates (eGFR) were compared with their stone compositions and 24-hour urine mineral excretions. RESULTS A statistically significant difference was noted between the groups, with uric acid stones being associated with lower eGFR and calcium phosphate stones associated with higher eGFR. No relationship could be demonstrated between eGFR and calcium oxalate or struvite stones. Patients with lower eGFR also demonstrated a statistically significant association with lower urinary pH as well as lower urinary excretion of calcium and citrate. CONCLUSION While various factors have been found to play significant roles in kidney stone formation and composition, our findings demonstrate a definite relationship between these and renal function. This paper highlights the fact that renal function evaluation should be considered an important component in the evaluation, counseling, and management of patients with nephrolithiasis.
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Affiliation(s)
- Parth M Patel
- Department of Urology, Loyola University Medical Center, Maywood, IL.
| | | | - Aleksander Druck
- Stritch School of Medicine, Loyola University Medical Center, Maywood, IL
| | - Spencer Hart
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | | | | | - Ahmer Farooq
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Thomas M T Turk
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Kristin G Baldea
- Department of Urology, Loyola University Medical Center, Maywood, IL
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7
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Wollin DA, Kaplan AG, Preminger GM, Ferraro PM, Nouvenne A, Tasca A, Croppi E, Gambaro G, Heilberg IP. Defining metabolic activity of nephrolithiasis - Appropriate evaluation and follow-up of stone formers. Asian J Urol 2018; 5:235-242. [PMID: 30364613 PMCID: PMC6197397 DOI: 10.1016/j.ajur.2018.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/10/2018] [Accepted: 04/11/2018] [Indexed: 11/24/2022] Open
Abstract
Considering the variation in metabolic evaluation and medical management of kidney stone disease, this consensus review was created to discuss the metabolic activity of nephrolithiasis, define the difference between single and recurrent stone formers, and develop a schema for metabolic and radiologic follow-up. A systematic review of the literature was performed to identify studies of metabolic evaluation and follow-up of patients with nephrolithiasis. Both single and recurrent stone formers share many similarities in metabolic profiles. The study group determined that based on an assessment of risk for stone recurrence and metabolic activity, single and recurrent stone formers should be evaluated comprehensively, including two 24 h urine studies on a random diet. Targeted medication and dietary recommendations are effective for many patients in reducing the risk of stone recurrence. Follow-up of those with stone disease should be obtained depending on the level of metabolic activity of the patient, the risk of chronic kidney disease and the risk of osteoporosis/osteopenia. A standard scheme includes a baseline metabolic profile, a repeat study 3-6 months after initiation of treatment, and then yearly when stable, with abdominal imaging obtained every 1-2 years.
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Affiliation(s)
- Daniel A. Wollin
- Duke Comprehensive Kidney Stone Center, Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Adam G. Kaplan
- Duke Comprehensive Kidney Stone Center, Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Glenn M. Preminger
- Duke Comprehensive Kidney Stone Center, Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Pietro Manuel Ferraro
- Columbus-Gemelli University Hospital, Division of Nephrology, Department of Medical Sciences, Rome, Italy
| | - Antonio Nouvenne
- University of Parma, Department of Clinical and Experimental Medicine, Parma, Italy
| | - Andrea Tasca
- S. Bortolo Hospital, Department of Urology, Vicenza, Italy
| | - Emanuele Croppi
- Columbus-Gemelli University Hospital, Division of Nephrology, Department of Medical Sciences, Rome, Italy
| | - Giovanni Gambaro
- Columbus-Gemelli University Hospital, Division of Nephrology, Department of Medical Sciences, Rome, Italy
| | - Ita P. Heilberg
- Universidade Federal de São Paulo, Nephrology Division, São Paulo, Brazil
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8
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Nayan M, Punjani N, Grober E, Lo K, Jarvi K. The use of assisted reproductive technology before male factor infertility evaluation. Transl Androl Urol 2018; 7:678-685. [PMID: 30211059 PMCID: PMC6127534 DOI: 10.21037/tau.2018.06.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Some centers offer assisted reproductive technologies (ARTs) [intra-uterine insemination (IUI) and in-vitro fertilization (IVF)], to treat certain couples with male factor infertility without having the men assessed by male infertility specialists. We sought to compare characteristics of couples having or not having prior ART use. Methods We used our prospectively collected database to identify men undergoing an initial evaluation for male infertility between 1995-2017. We obtained data on patient demographics, use of IUI and IVF, and semen analysis parameters. We used multivariable logistic regression to identify characteristics associated with prior use of ART. Results One thousand and five hundred forty-five out of 8,962 (17.2%) men reported use of ARTs prior to evaluation. Of these, 258 tried both IUI and IVF. More than one attempt was reported in 470 (37.2%) and 154 (28.2%) of men with prior IUI and IVF, respectively. Younger male age [adjusted odds ratio (aOR) 0.97/year; 95% confidence interval (CI), 0.95 to 0.99], older female partner age (aOR 1.07/year; 95% CI, 1.04 to 1.10), and year of visit (aOR 1.05/year; 95% CI, 1.01 to 1.09) were significantly associated with prior IUI. Older female partner age (aOR 1.07/year; 95% CI, 1.02 to 1.12) was significantly associated with prior IVF, but not male age or year of visit. Semen analysis parameters were not associated with prior ART. Conclusions The prior use of ART is common among men presenting for an initial evaluation at a male infertility specialty clinic. Older female partner age was associated with use of reproductive technologies prior to evaluation, however, semen analysis parameters were not.
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Affiliation(s)
- Madhur Nayan
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Nahid Punjani
- Division of Urology, London Health Sciences Centre, Western University, London, Canada
| | - Ethan Grober
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - Kirk Lo
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada.,Lunenfeld Tannenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, Canada
| | - Keith Jarvi
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada.,Lunenfeld Tannenbaum Research Institute, Mount Sinai Hospital, Toronto, Canada.,Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, Canada
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9
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Abstract
PURPOSE OF REVIEW Urinary risk factors, such as hypercalciuria, hypocitraturia, and hyperoxaluria, either in combination or alone, are associated with calcium stones. Dietary habits as well as underlying medical conditions can influence urinary risk factors. Evaluation of the conglomerate of patients' stone risks provides evidence for individualized medical management, an effective and patient-supported approach to prevention. RECENT FINDINGS Many patients with stones desire prevention to avoid repeated surgical interventions. Yet, recent practice pattern assessments and health care utilization data show that many patients are rarely referred for metabolic evaluation or management. Innovations in metabolic management over the past decade have improved its effectiveness in reducing risk and preventing calcium stones. Although no new pharmacologic agents for calcium stone prevention have recently become available, there is relatively new thinking about some diet-based approaches. This review will synthesize current evidence to support individualized metabolic management of calcium stones.
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Affiliation(s)
- Kristina L Penniston
- Clinical Nutrition Services, University of Wisconsin Hospital and Clinics, 600 Highland Avenue, Madison, WI, 53792, USA. .,Department of Urology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, 3258 Medical Foundation Centennial Building, Madison, WI, 53705-2281, USA.
| | - Stephen Y Nakada
- Department of Urology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, 3258 Medical Foundation Centennial Building, Madison, WI, 53705-2281, USA.,Department of Medicine, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, Madison, WI, 53705-2281, USA.,Department of Radiology, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
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10
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Ellison JS, Hollingsworth JM, Langman CB, Asplin JR, Schwaderer AL, Yan P, Bierlein M, Barraza MA, Defoor WR, Figueroa TE, Jackson EC, Jayanthi VR, Johnson EK, Joseph DB, Shnorhavorian M. Analyte variations in consecutive 24-hour urine collections in children. J Pediatr Urol 2017; 13:632.e1-632.e7. [PMID: 28739373 DOI: 10.1016/j.jpurol.2017.06.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Accepted: 06/08/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The metabolic evaluation of children with nephrolithiasis begins with a 24-h urine collection. For adults, the diagnostic yield increases with consecutive collections; however, little is known regarding the variability of multiple 24-h studies in the pediatric population. We sought to evaluate the variability of consecutive 24-h urine collection in children through a multi-institutional study hypothesizing that compared with a single collection, consecutive 24-h urine collections would reveal a greater degree of clinically useful information in the evaluation of children at risk for nephrolithiasis. MATERIALS AND METHODS Including data from six institutions, we identified children less than 18 years of age considered at risk for recurrent nephrolithiasis, undergoing metabolic evaluation. We evaluated a subset of patients performing two collections with urine creatinine varying by 10% or less during a 7-day period. Discordance between repeat collections based on normative urine chemistry values was evaluated. RESULTS A total of 733 children met inclusion criteria, and in over a third both urine calcium and urine volume differed by 30% or more between samples. Urine oxalate demonstrated greater variation between collections in children <5 years than among older children (p = 0.030) while variation in other parameters did not differ by age. Discordance between repeat samples based on normative values was most common for urine oxalate (22.5%) and the derived relative supersaturation ratios for both calcium phosphate (25.1%) and calcium oxalate (20.5%). The proportion of discordant samples, based on normative thresholds, as well as variability greater ≥30% and 50%, respectively, are shown in the table. CONCLUSIONS Our analysis indicates that stone risk in as many as one in four children may be misclassified if normative values of only a single 24-h urine are used. In light of these findings, repeat 24-h urine collections prior to targeted intervention to modify stone risk are advised to increase diagnostic yield in children at risk for nephrolithiasis.
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Affiliation(s)
| | | | - Craig B Langman
- Feinberg School of Medicine, Northwestern University and the Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - John R Asplin
- Litholink Corporation, Laboratory Corporation of America Holdings, Chicago, IL, USA
| | | | - Phyllis Yan
- Department of Urology, University of Michigan Medical School, MI, USA
| | - Maggie Bierlein
- Department of Urology, University of Michigan Medical School, MI, USA
| | | | - William R Defoor
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | - Emilie K Johnson
- Feinberg School of Medicine, Northwestern University and the Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Rajabnia Chenari M, Fazeli F, Jahantigh M, Dehghan J, Zarghami A, Bahadoram M, Ghorbani A, Mirshahvalad S. Urinary level of interleukin-1alpha and interleukin-6 in patients underwent extracorporeal shock wave lithotripsy. J Renal Inj Prev 2017. [DOI: 10.15171/jrip.2017.43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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12
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How Much Information is Lost When You Only Collect One 24-Hour Urine Sample during the Initial Metabolic Evaluation? J Urol 2016; 196:1143-8. [DOI: 10.1016/j.juro.2016.04.074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2016] [Indexed: 11/21/2022]
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13
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Abstract
Nephrolithiasis, or stones, is one of the oldest urological diseases, with descriptions and treatment strategies dating back to ancient times. Despite the enormous number of patients affected by stones, a surprising lack of conceptual understanding of many aspects of this disease still exists. This lack of understanding includes mechanisms of stone formation and retention, the clinical relevance of different stone compositions and that of formation patterns and associated pathological features to the overall course of the condition. Fortunately, a number of new tools are available to assist in answering such questions. New renal endoscopes enable kidney visualization in much higher definition than was previously possible, while micro-CT imaging is the optimal technique for assessment of stone microstructure and mineral composition in a nondestructive fashion. Together, these tools have the potential to provide novel insights into the aetiology of stone formation that might unlock new prevention and treatment strategies, and enable more effective management of patients with nephrolithiasis.
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14
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McGuire BB, Bhanji Y, Sharma V, Frainey BT, McClean M, Dong C, Rimar K, Perry KT, Nadler RB. Predicting Patients with Inadequate 24- or 48-Hour Urine Collections at Time of Metabolic Stone Evaluation. J Endourol 2015; 29:730-5. [PMID: 25423010 DOI: 10.1089/end.2014.0544] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE We aimed to understand the characteristics of patients who are less likely to submit adequate urine collections at metabolic stone evaluation. METHODS Inadequate urine collection was defined using two definitions: (1) Reference ranges for 24-hour creatinine/kilogram (Cr/24) and (2) discrepancy in total 24-hour urine Cr between 24-hour urine collections. There were 1502 patients with ≥1 kidney stone between 1998 and 2014 who performed a 24- or 48-hour urine collection at Northwestern Memorial Hospital and who were identified retrospectively. Multivariate analysis was performed to analyze predictor variables for adequate urine collection. RESULTS A total of 2852 urine collections were analyzed. Mean age for males was 54.4 years (range 17-86), and for females was 50.2 years (range 8-90). One patient in the study was younger than 17 years old. (1) Analysis based on the Cr 24/kg definition: There were 50.7% of patients who supplied an inadequate sample. Females were nearly 50% less likely to supply an adequate sample compared with men, P<0.001. Diabetes (odds ratio [OR] 1.42 [1.04-1.94], P=0.026) and vitamin D supplementation (OR 0.64 [0.43-0.95], P=0.028) predicted receiving an adequate/inadequate sample, respectively. (2) Analysis based on differences between total urinary Cr: The model was stratified based on percentage differences between samples up to 50%. At 10%, 20%, 30%, 40%, and 50% differences, inadequate collections were achieved in 82.8%, 66.9%, 51.7%, 38.5%, and 26.4% of patients, respectively. Statistical significance was observed based on differences of ≥40%, and this was defined as the threshold for an inadequate sample. Female sex (OR 0.73 [0.54-0.98], P=0.037) predicted supplying inadequate samples. Adequate collections were more likely to be received on a Sunday (OR 1.6 [1.03-2.58], P=0.038) and by sedentary workers (OR 2.3 [1.12-4.72], P=0.023). CONCLUSION Urine collections from patients during metabolic evaluation for nephrolithiasis may be considered inadequate based on two commonly used clinical definitions. This may have therapeutic or economic ramifications and the propensity for females to supply inadequate samples should be investigated further.
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Affiliation(s)
- Barry B McGuire
- Department of Urology, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Yasin Bhanji
- Department of Urology, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Vidit Sharma
- Department of Urology, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Brendan T Frainey
- Department of Urology, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Megan McClean
- Department of Urology, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Caroline Dong
- Department of Urology, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Kalen Rimar
- Department of Urology, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Kent T Perry
- Department of Urology, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Robert B Nadler
- Department of Urology, Northwestern University Feinberg School of Medicine , Chicago, Illinois
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15
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Abstract
Office management of stone disease is an important component of a urologist's practice. Evaluation should include analysis of stone composition, 24-hour urine studies, identification of modifiable risk factors, and targeted dietary, lifestyle, and/or medical therapy. A sizeable portion of investigated etiologies and risk factors for stone disease have centered on the complex interplay between obesity, diabetes, and other disease states that comprise the metabolic syndrome. Alternatives to traditional preventive therapy, such as probiotics and various fruit juices, are still being studied but may prove useful adjuncts to traditional preventive therapy, where the mainstays remain increased fluid intake, dietary modification, and pharmacologic therapy. Future studies on preventive therapy of urolithiasis are likely to focus on strategies to increase compliance, cost-effectiveness, and systems-based implementation.
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16
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Karsli O, Izol V, Aridogan IA, Borekoglu A, Satar N. Metabolic risk factors and the effect of metaphylaxis in pediatric stone disease with hypocitraturia. Urolithiasis 2013; 41:9-13. [PMID: 23532417 DOI: 10.1007/s00240-012-0539-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Accepted: 12/18/2012] [Indexed: 10/27/2022]
Abstract
To describe the metabolic risk factors and investigate the effect of prophylaxis based on these factors on long-term recurrence of urolithiasis in pediatric patients with hypocitraturia. One-hundred and twenty-nine pediatric patients who underwent percutaneous nephrolithotomy between January 2008 and June 2011 were evaluated for metabolic risk factors. The patients with hypocitraturia were enrolled in this study and the data were analyzed using statistical methods for a mean period of 2 years for metabolic abnormalities, stone type, and the effect of potassium citrate prophylaxis on stone recurrence. A 24-h urine metabolite analysis revealed one or more metabolic risk factors in 115 (89.2 %) of the patients, whereas 14 (10.8 %) of the patients had no metabolic abnormalities. Eighty-two (63.5 %) of 129 patients had hypocitraturia. Of them, 43 (52 %) were male and 39 (48 %) were female, with a mean age of 9.7 ± 4.9 and 6.7 ± 4.4 (1-16) years, respectively(p = 0.102). Thirty-five (42.7 %) had pure hypocitraturia, and 47 (57.3 %) had two or more metabolic abnormalities. The most common dual metabolic abnormality was hypocitraturia and hypomagnesuria. Seventy-one patients (87 %) with hypocitraturia received medical prophylaxis and continued regularly, whereas 11 (13 %) patients did not receive medical prophylaxis despite being advised to do so. After a mean follow-up of 26.5 ± 9.4 months, the rate of recurrence was 1.4 % in the patients with hypocitraturia who continued prophylaxis and occurred in all of the patients who did not receive prophylaxis (p < 0.001). Calcium oxalate stones (95.2 %) were the most commonly found stones in the stone analysis. Detailed clinical and laboratory evaluations should be performed in children with urolithiasis. Appropriate prophylactic treatment as potassium citrate, should be given to prevent reformation of stones in patient with hypocitraturia.
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Affiliation(s)
- Onur Karsli
- Faculty of Medicine, Department of Urology, University of Çukurova, Adana, Turkey
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Healy KA, Hubosky SG, Bagley DH. 24-Hour Urine Collection in the Metabolic Evaluation of Stone Formers: Is One Study Adequate? J Endourol 2013; 27:374-8. [DOI: 10.1089/end.2012.0216] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Kelly A. Healy
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Scott G. Hubosky
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Demetrius H. Bagley
- Department of Urology, Thomas Jefferson University, Philadelphia, Pennsylvania
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18
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Nayan M, Elkoushy MA, Andonian S. Variations between two 24-hour urine collections in patients presenting to a tertiary stone clinic. Can Urol Assoc J 2012; 6:30-3. [PMID: 22396364 DOI: 10.5489/cuaj.11131] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The current Canadian Urological Association (CUA) guideline recommends two 24-hour urine collections in the metabolic evaluation for patients with urolithiasis. The aim of the present study was to compare two consecutive 24-hour urine collections in patients with a history of urolithiasis presenting to a tertiary stone clinic. METHODS We retrospectively reviewed 188 patients who had two 24-hour collections upon presentation between January 2010 and December 2010. Samples were collected on consecutive days and examined for the following 11 urinary parameters: volume, creatinine, sodium, calcium, uric acid, citrate, oxalate, potassium, phosphorous, magnesium and urea nitrogen. For each parameter, the absolute value of the difference between the two samples rather than the direct difference was compared with zero. Similarly, the percent difference between samples was calculated for each parameter. RESULTS The means of the absolute differences between the two samples were significantly different for all 11 urinary parameters (p < 0.0001). The percent differences for all urinary parameters ranged from 20.5% to 34.2%. Furthermore, 17.1% to 47.6% of patients had a change from a value within normal limits to an abnormal value, or vice-versa. Significance was maintained when patients with incomplete or over-collections were excluded. CONCLUSIONS Significant variations among the two 24-hour urine collections were observed in all of the 11 urinary parameters analyzed. This variation may change clinical decision-making in up to 47.6% of patients if only a single 24-hour urine collection is obtained. The present study supports the CUA guideline of performing two 24-hour urine collections.
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Affiliation(s)
- Madhur Nayan
- Division of Urology, Department of Surgery, McGill University Health Centre, McGill University, Montreal, QC
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19
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High Dietary Magnesium Intake Decreases Hyperoxaluria in Patients With Nephrolithiasis. Urology 2012; 80:780-3. [DOI: 10.1016/j.urology.2012.06.033] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 05/09/2012] [Accepted: 06/18/2012] [Indexed: 11/24/2022]
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20
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Eisner BH, Sheth S, Dretler SP, Herrick B, Pais VM. Abnormalities of 24-Hour Urine Composition in First-time and Recurrent Stone-formers. Urology 2012; 80:776-9. [DOI: 10.1016/j.urology.2012.06.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2011] [Revised: 05/09/2012] [Accepted: 06/18/2012] [Indexed: 10/28/2022]
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Abstract
Childhood urolithiasis is an evolving condition with an increasing incidence and prevalence over the last 2 decades. Over that time the underlying cause has shifted from predominantly infectious to metabolic in nature. This review describes the pathophysiology, underlying metabolic abnormalities, clinical presentation, evaluation, and management of childhood urolithiasis. A comprehensive metabolic evaluation is essential for all children with renal calculi, given the high rate of recurrence and the importance of excluding inherited progressive conditions.
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Affiliation(s)
- Lawrence Copelovitch
- Division of Nephrology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Eisner BH, Thavaseelan S, Sheth S, Haleblian G, Pareek G. Relationship between serum vitamin D and 24-hour urine calcium in patients with nephrolithiasis. Urology 2012; 80:1007-10. [PMID: 22698470 DOI: 10.1016/j.urology.2012.04.041] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Revised: 03/21/2012] [Accepted: 04/20/2012] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To examine the relationship between serum 25-OH vitamin D and 24-hour urine calcium in patients with nephrolithiasis. METHODS A retrospective review was performed. Patients evaluated in 2 metabolic stone clinics were included for analysis. Multivariate linear regression models were adjusted for known risk factors for stone disease (age, gender, body mass index, hypertension, diabetes mellitus, gout, relevant medications, and 24-hour urine composition). RESULTS One-hundred sixty-nine patients were included in the study. Female to male ratio was 69:100, mean age was 50.9 years (SD 13.7), and mean body mass index was 27.4 (SD 6.4). Vitamin D deficiency (25-OH vitamin D <20 ng/mL) was present in 18.9% of patients, vitamin D insufficiency (>20, <30 ng/mL) was present in 34.9% of patients, and vitamin D was within normal limits (≥ 30 ng/mL) in 46.1% of patients. On age-adjusted and multivariate linear regression, serum 25-OH vitamin D was not related to 24-hour urine calcium (age adjusted β = -0.31 m 95% CI -1.9 to 1.3; multivariate adjusted β = 0.08, 95% CI -1.3 to 1.5). CONCLUSION Although 25-OH vitamin D is involved in the body's calcium homeostasis, our study does not show a relationship between serum vitamin D level and 24-hour urine calcium excretion in stone-formers. This information may have implications regarding the safety of vitamin D repletion in patients with nephrolithiasis.
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Affiliation(s)
- Brian H Eisner
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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23
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Eisner BH, Sheth S, Dretler SP, Herrick B, Pais VM. Effect of socioeconomic status on 24-hour urine composition in patients with nephrolithiasis. Urology 2012; 80:43-7. [PMID: 22608802 DOI: 10.1016/j.urology.2011.12.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2011] [Revised: 12/08/2011] [Accepted: 12/12/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To examine the relationship between the poverty and education levels and 24-hour urine composition in patients with nephrolithiasis because little is known about the relationship between socioeconomic status and kidney stone risk. METHODS A retrospective review was performed of patients evaluated at 2 metabolic stone clinics. The poverty level (ie, percentage of those living below the poverty level) and education level (ie, percentage of those with a high school education or greater) for each postal code were determined from the U.S. Census Bureau data. Multivariate linear regression analysis was used to examine the relationship between the poverty and education levels and 24-hour urine composition. RESULTS A total of 435 patients were included in the present study. Of the 435 patients, 173 were women and 262 were men (40% women), the mean age was 52.5 ± 14.4 years, and the mean body mass index was 28.6 ± 6.5 kg/m(2). The mean percentage of those below the poverty level was 8.2% ± 6.2%, and the mean percentage of those with a high school education or greater was 87.4% ± 7.4%. On multivariate linear regression analysis, an increasing local poverty level was associated with significant increases in urine calcium (β = 1.51, 95% confidence interval [CI] 0.16-2.86). A decreasing local level of education (ie, decreasing percentage of those with a high school diploma or greater) was associated with significant increases in urine calcium (β = 1.26, 95% CI 0.10-2.42), supersaturation of calcium oxalate (β = 0.04, 95% CI 0.006-0.09), and supersaturation of calcium phosphate (β = 0.013, 95% CI 0.0002-0.03). No other associations were found between the poverty and education levels and any urine constituents or supersaturations. CONCLUSION In the present study of patients with stone formation, increasing poverty was associated with increased urine calcium, and increasing education appeared to be protective by decreasing urine calcium and the supersaturation of calcium oxalate and calcium phosphate. Additional studies are important to elucidate the mechanisms underlying these findings.
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Affiliation(s)
- Brian H Eisner
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Gershman B, Sheth S, Dretler SP, Herrick B, Lang K, Pais VM, Eisner BH. Relationship between glomerular filtration rate and 24-hour urine composition in patients with nephrolithiasis. Urology 2012; 80:38-42. [PMID: 22608801 DOI: 10.1016/j.urology.2011.12.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 11/15/2011] [Accepted: 12/12/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine the relationship between GFR and 24-hour urine composition in patients with nephrolithiasis to understand how renal function may affect stone risk. Alterations in glomerular filtration rate (GFR) are associated with a number of physiological changes. METHODS A retrospective, institutional review board-approved review of patients from 2 metabolic stone clinics was performed. One-way analysis of variance and multivariate linear regression models were used to evaluate the relationship between GFR quintile and 24-hour urine composition. RESULTS A total of 403 patients (241 male, 162 female) with a mean age of 52.6 ± 14.2 years were included in the study. On univariate analysis, decreasing GFR by quintile was associated with significant reductions in urine calcium, citrate, supersaturation of calcium oxalate, and supersaturation of calcium phosphate (P < .05 for each). In multivariate linear regression models, decreasing GFR by quintile was associated with significant decreases in urine calcium (β = -11.2, 95% CI = -18.3 to 4.01), urine citrate (β = -32.4, 95% CI = -54.1 to 10.8), oxalate (β = -1.83, 95% CI = -2.85 to 0.81), supersaturation of calcium oxalate (β = -0.58, 95% CI = 0.84 to 0.33) and supersaturation of calcium phosphate (β = -0.09, 95% CI = 0.17 to 0.02), as well as an increase in urine magnesium (β = 3.40, 95% CI = 0.7 to 6.1). CONCLUSION Reduction in GFR is associated with decreased urine calcium, oxalate, and citrate, and increased urine magnesium. These findings have implications for treatment of patients with stone disease and impaired renal function.
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Affiliation(s)
- Boris Gershman
- Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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Clinical presentation and metabolic features of overt and occult urolithiasis. Pediatr Nephrol 2012; 27:101-7. [PMID: 21688190 DOI: 10.1007/s00467-011-1940-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 05/27/2011] [Accepted: 05/27/2011] [Indexed: 12/14/2022]
Abstract
Although pediatricians are frequently confronted with patients presenting urolithiasis symptoms without obvious stones, the syndrome of occult urolithiasis may be still viewed with some skepticism. We have compared the clinical and metabolic features of 197 children with obvious calculi, 189 with microcalculi (diameter ≤ 3 mm based on renal sonography), and 114 with symptoms of urolithiasis and normal renal sonography findings. Only microcalculi and normal sonography subjects with a urinary abnormality potentially leading to urolithiasis were included in the study. Age at presentation increased significantly (p = 0.0001) in the groups in the order normal sonography to microcalculi to calculi groups. There was no significant difference among the three groups in terms of family history of urolithiasis, gender distribution, and degree of hypercalciuria, hyperuricosuria, hyperoxaluria, or hypocitraturia. The average frequency of pain attacks of patients with recurrent abdominal pain (RAP) ranged from 3.6 to 4.6 days of pain per month among the three groups, which is four to ninefold lower than that reported for children with functional or organic gastrointestinal RAP. The consistency of many clinical and urinary metabolic characteristics indicates a common underlying disorder in overt and occult urolithiasis. The increase of age at presentation from the normal sonography to microcalculi and calculi groups may reflect progressive crystal accretion leading ultimately to overt stone formation.
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Abstract
Nephrolithiasis is a prevalent and costly condition with high recurrence rate. A medical evaluation to identify abnormalities responsible for nephrolithiasis and guide subsequent therapy has been advocated to reduce the risk of stone recurrence. The evaluation of kidney stone formers generally comprises an extensive medical history to identify metabolic, environmental, dietary and/or genetic factors contributing to stone formation. Imaging studies are utilized to evaluate and follow stone burden. Laboratory studies including stone composition analysis and serum and urinary chemistries are commonly obtained to further assess for any underlying systemic disorders, to detect environmental and metabolic processes contributing to stone disease, and to guide initial and follow-up dietary and pharmacological therapy. The nature and extent of such an evaluation is discussed in this review article.
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Affiliation(s)
- Naim Maalouf
- Department of Internal Medicine and Charles and Jane Pak Center for Mineral Metabolism, University of Texas Southwestern Medical Center Dallas, TX, U.S.A
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27
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Coe FL. Stones. A matter of doubt--how best to evaluate stone formers. Nat Rev Urol 2010; 7:483-5. [PMID: 20818325 DOI: 10.1038/nrurol.2010.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Once again the question of one versus two 24 h urine collections for diagnosis in kidney stone prevention has been raised. As in all previous studies, no difference is seen in the mean levels of analytes between first and second collections. However, variation within patients is so marked that at least two collections are needed for confidence.
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Affiliation(s)
- Fredric L Coe
- University of Chicago, Renal Section MC 5100, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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