NEPHROCALCINOSIS IN CREATINISM

Etiology of nephrocalcinosis in northern Indian children

This retrospective survey examines the etiology of nephrocalcinosis (NC) in 40 patients (26 boys), over an 8-year period. The median age at onset of symptoms and presentation was 36 months and 72 months, respectively. Clinical features included marked failure to thrive (82.5%), polyuria (60%) and bony deformities (52.5%). The etiology of NC included distal renal tubular acidosis (RTA) in 50% patients and idiopathic hypercalciuria and hyperoxaluria in 7.5% each. Other causes were Bartter syndrome, primary hypomagnesemia with hypercalciuria, severe hypothyroidism and vitamin D excess. No cause for NC was found in 12.5% patients. Specific therapy, where possible, ameliorated the biochemical aberrations, although the extent of NC remained unchanged. At a median (range) follow up of 35 (14-240) months, glomerular filtration rate (GFR) had declined from 82.0 (42-114) ml/min per 1.73 m2 body surface area to 70.8 (21.3-126.5) ml/min per 1.73 m2 body surface area (P = 0.001). Our findings confirm that, even with limited diagnostic facilities, protocol-based evaluation permits determination of the etiology of NC in most patients.

The incidence of transient renal medullary hyperechogenicity in neonatal ultrasound examination

A prospective ultrasound study of the urinary tracts of 85 neonates (64 term, 21 preterm) was performed to assess the incidence of transient renal medullary hyperechogenicity (RMH) in the first week of life. None of the neonates examined had evidence of renal dysfunction. Echogenic material was observed in the renal papillae/calyces, ureter, or bladder of 33 of the 64 term babies, but in the bladder of only one pre-term infant. The distribution of the echogenicity differs from that seen in medullary hyperechogenicity due to crystal deposition, suggesting that calyceal involvement is a common feature. Follow-up ultrasound scans at 10-14 days were possible in eight of the term neonates and demonstrated complete resolution of the RMH. The aetiology of transient neonatal RMH is unclear, although it may be related to protein cast deposition in the renal tubules. RMH may rarely be associated with transient renal dysfunction, but in healthy neonates should be recognized as a normal variant.

Causes of increased renal medullary echogenicity in Turkish children

The primary disorders of 50 children with increased renal medullary echogenicity on renal ultrasound were studied; 28 girls and 22 boys aged from 1 month to 16 years were classified into four groups based on underlying disease and ultrasound findings. Group 1 was composed of 17 patients with distal renal tubular acidosis (34%); intense echoes throughout the pyramid were predominant. Group 2 consisted of 14 patients with vitamin D toxicity (28%) and an intense echogenic rim around the pyramids. Group 3 included 10 patients with different types of tubulopathies. A slight hyperechogenic rim around the sides and tip of the medullary pyramids was detected. Group 4 was made up of 9 patients with rare underlying conditions. Abdominal X-rays detected medullary calcinosis in only 12 (24%) of the total 50 patients. Ultrasonography appears to be an important tool in the early diagnosis of increased renal medullary echogenicity and medullary nephrocalcinosis.

Reversible hypocalciuric hypercalcemia associated with hypothyroidism

Hypothyroidism is known to affect calcium homeostasis by decreasing bone turnover and serum calcium level, and by increasing parathyroid hormone and 1,25-dihydroxyvitamin D concentrations. A 52-year-old hypothyroid woman is described who had hypercalcemia associated with elevated parathyroid hormone and 1,25-dihydroxyvitamin D levels, but decreased 24-hour urinary calcium excretion and ratio of calcium to creatinine clearance. These parameters normalized following thyroid hormone replacement therapy. Hypercalcemia appeared to result from a combination of reduced renal calcium excretion and a change in the "set point" for calcium feedback inhibition of the parathyroid glands. These data suggest that thyroid hormone has a direct effect on the parathyroid glands, regulating parathyroid hormone secretion, and on the kidney's ability to excrete calcium. It is recommended that parathyroid hormone, 1,25-dihydroxyvitamin D, and urinary calcium excretion values be interpreted in light of thyroid hormone status.

Nephrocalcinosis in children

Nephrocalcinosis is an uncommon condition is childhood. The commonest cause is renal tubular acidosis, although this may not manifest itself radiographically until adolescence. Recognizing the calcification as either cortical, medullary or mixed is not always possible, but may sometimes be an aid to differentiate metabolic from vascular causes.

Comparative response to parathyroid hormone in hyperthyroidism and hypothyroidism

The effects of exogenous parathyroid hormone, administered for 3 days, were compared in six hyperthyroid and six hypothyroid subjects. Maximum increments were much greater in hyperthyroid than in hypothyroid subjects for serum calcium (3.5 mg/100 ml versus 1.6 mg/100 ml), urine calcium (476 mg versus 79 mg), urine hydroxyproline (56 mg versus 11 mg), and urine phosphorus (671 mg versus 192 mg). Maximum decrease in serum phosphorus (minus0.9 mg/100 ml versus minus 0.1 mg/100 ml) was also greater in hyperthyroid subjects. Serum parathyroid hormone immunoreactivity was significantly higher in hypothyroid subjects (0.48 ng/ml) that either normals (0.21 ng/ml) or hyperthyroid subjects (0.19 ng/ml). The data support the concept that excess thyroid hormone sensitizes and deficient thyroid hormone blunts the responsiveness of bone to parathyroid hormone. This may lead to a state of hypoparathyroidism in hyperthyroidism and hyperparathyroidism in hypothyroidism.