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Stone HK, VandenHeuvel K, Bondoc A, Flores FX, Hooper DK, Varnell CD. Primary hyperoxaluria diagnosed after kidney transplant: A review of the literature and case report of aggressive renal replacement therapy and lumasiran to prevent allograft loss. Am J Transplant 2021; 21:4061-4067. [PMID: 34254430 PMCID: PMC8639665 DOI: 10.1111/ajt.16762] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/01/2021] [Accepted: 07/03/2021] [Indexed: 01/25/2023]
Abstract
Primary hyperoxaluria type 1 is a rare inherited disorder caused by abnormal liver glyoxalate metabolism leading to overproduction of oxalate, progressive kidney disease, and systemic oxalosis. While the disorder typically presents with nephrocalcinosis, recurrent nephrolithiasis, and/or early chronic kidney disease, the diagnosis is occasionally missed until it recurs after kidney transplant. Allograft outcomes in these cases are typically very poor, often with early graft loss. Here we present the case of a child diagnosed with primary hyperoxaluria type 1 after kidney transplant who was able to maintain kidney function, thanks to aggressive renal replacement therapy as well as initiation of a new targeted therapy for this disease. This case highlights the importance of having a high index of suspicion for primary hyperoxaluria in patients with chronic kidney disease and nephrocalcinosis/nephrolithiasis or with end stage kidney disease of uncertain etiology, as initiating therapies early on may prevent poor outcomes.
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Affiliation(s)
- Hillarey K. Stone
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Katherine VandenHeuvel
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH,Division of Pathology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alexander Bondoc
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Francisco X. Flores
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David K. Hooper
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH,James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Charles D. Varnell
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH,James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Cai Z, Ding M, Chen R, Zhu J, Li L, Wu X. Primary hyperoxaluria diagnosed after kidney transplantation: a case report and literature review. BMC Nephrol 2021; 22:393. [PMID: 34837989 PMCID: PMC8626922 DOI: 10.1186/s12882-021-02546-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 09/29/2021] [Indexed: 12/02/2022] Open
Abstract
Background Primary hyperoxaluria (PH) is a rare inherited autosomal recessive disease caused by disturbed glyoxylate metabolism. The disease is characterized by calcium oxalate crystal deposition in various organs, especially in the kidney. Due to the lack of current understanding of PH, nearly all patients are only initially diagnosed with PH when recurrent lithiasis and progressive end-stage renal disease occur. Many cases are not diagnosed in patients until renal allograft insufficiency occurs after renal transplantation. This case report and literature review aim to emphasize the need for careful pre-transplant PH screening of patients with bilateral nephrocalcinosis or nephrolithiasis. Case presentation Renal allograft insufficiency was diagnosed as PH after kidney transplantation. Here, we detail the complete clinical course, including computed tomography images of the original kidney and renal graft, histopathological images of a biopsy of the transplanted kidney, the results of laboratory and molecular genetic tests, and the treatment. In addition, we reviewed the literature from 2000 to 2021 and analyzed 19 reported cases of PH diagnosed after kidney transplantation, and provide a summary of the characteristics, complications, treatment, and prognosis of these cases. Conclusions By reviewing and analyzing these cases, we concluded that patients with a history of nephrocalcinosis or nephrolithiasis in both kidneys need preoperative screening for PH and appropriate treatment before kidney transplantation. Delayed graft function caused by PH is easily misdiagnosed as acute rejection, and needle biopsy should be performed at an early stage. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02546-0.
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Affiliation(s)
- Zhitao Cai
- Center of Nephrology, Dialysis and Transplantation, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China
| | - Mao Ding
- Center of Nephrology, Dialysis and Transplantation, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China
| | - Rengui Chen
- Center of Nephrology, Dialysis and Transplantation, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China
| | - Jiefu Zhu
- Center of Nephrology, Dialysis and Transplantation, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China
| | - Lian Li
- Center of Nephrology, Dialysis and Transplantation, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China
| | - Xiongfei Wu
- Center of Nephrology, Dialysis and Transplantation, Renmin Hospital of Wuhan University, No.238 Jiefang Road, Wuchang District, Wuhan, 430060, Hubei, China.
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3
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Cai R, Lin M, Chen Z, Lai Y, Huang X, Zhao G, Guo X, Xiong Z, Chen J, Chen H, Jiang Q, Liu S, Yang Y, Liang W, Zou M, Liu T, Chen W, Liu H, Peng J. Primary hyperoxaluria diagnosed after kidney transplantation failure: lesson from 3 case reports and literature review. BMC Nephrol 2019; 20:224. [PMID: 31215412 PMCID: PMC6582561 DOI: 10.1186/s12882-019-1402-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 05/28/2019] [Indexed: 12/16/2022] Open
Abstract
Background Primary hyperoxaluria (PH) is a rare inborn disorder of the metabolism of glyoxylate, which causes the hallmark production oxalate and forms insoluble calcium oxalate crystals that accumulate in the kidney and other organs. Since the manifestation of PH varies from recurrent nephrolithiasis, nephrocalcinosis, and end-stage renal disease with age at onset of symptoms ranging from infancy to the sixth decade, the disease remains undiagnosed until after kidney transplantation in some cases. Case presentation Herein, we report 3 cases of PH diagnosed after kidney transplantation failure, providing the comprehensive clinical course, the ultrasonic image of renal graft and pathologic image of the biopsy, highlighting the relevance of biopsy findings and the results of molecular genetic testing. We also focus on the treatment and the unfavorable outcome of the patients. Meanwhile, we review the literature and show the additional 10 reported cases of PH diagnosed after kidney transplantation. Additionally, we discuss the progressive molecular understanding of the mechanisms involved in PH and molecular therapy. Conclusions Overall, the necessity of preoperative screening of PH in all patients even with a minor history of nephrolithiasis and the importance of proper treatment are the lessons we learn from the 3 cases, which prompt us to avoid tragedies. Electronic supplementary material The online version of this article (10.1186/s12882-019-1402-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ruiming Cai
- Department of Organ Transplantation, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Minzhuang Lin
- Department of Organ Transplantation, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Zhiyong Chen
- Department of Organ Transplantation, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Yongtong Lai
- Department of Organ Transplantation, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Xianen Huang
- Department of Organ Transplantation, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Guozhi Zhao
- Department of Organ Transplantation, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Xuekun Guo
- Department of Organ Transplantation, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Zhongtang Xiong
- Department of Pathology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, People's Republic of China
| | - Juan Chen
- Department of Pathology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, People's Republic of China
| | - Hui Chen
- Department of Pathology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, People's Republic of China
| | - Qingping Jiang
- Department of Pathology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, People's Republic of China
| | - Shaoyan Liu
- Department of Pathology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, People's Republic of China
| | - Yuexin Yang
- Department of Pathology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, People's Republic of China
| | - Weixiang Liang
- Department of Ultrasound, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Minhui Zou
- Department of Ultrasound, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Tao Liu
- Department of Ultrasound, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510150, China
| | - Wenfang Chen
- Department of Pathology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China
| | - Hongzhou Liu
- Department of Clinical Laboratory, Guangzhou Kingmed Center for Clinical Laboratory Co., Ltd, Guangzhou, 510330, China
| | - Juan Peng
- Department of Pathology, The Third Affiliated Hospital of Guangzhou Medical University, 63 Duobao Road, Guangzhou, 510150, People's Republic of China.
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Clifford-Mobley O, Tims C, Rumsby G. The comparability of oxalate excretion and oxalate:creatinine ratio in the investigation of primary hyperoxaluria: review of data from a referral centre. Ann Clin Biochem 2014; 52:113-21. [DOI: 10.1177/0004563214529937] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Urine oxalate measurement is an important investigation in the evaluation of renal stone disease. Primary hyperoxaluria (PH) is a rare inherited metabolic disease characterised by persistently elevated urine oxalate, but the diagnosis may be missed in adults until renal failure has developed. Urine oxalate results were reviewed to compare oxalate:creatinine ratio and oxalate excretion, and to estimate the potential numbers of undiagnosed PH. Methods Urine oxalate results from August 2011 to April 2013 were reviewed. Oxalate excretion and oxalate:creatinine ratio were evaluated for 24 h collections and ratio alone for spot urine samples. Results Oxalate:creatinine ratio and oxalate excretion were moderately correlated (R = 0.63) in 24-h urine collections from patients aged 18 years and above. Sex-related differences were found requiring implementation of male and female reference ranges for oxalate:creatinine ratio. Of samples with both ratio and excretion above the reference range, 7% came from patients with confirmed PH. There were 24 patients with grossly elevated urine oxalate who had not been evaluated for PH. Conclusions Oxalate:creatinine ratio and oxalate excretion were discordant in many patients, which is likely to be a result of intra-individual variation in creatinine output and imprecision in the collection itself. Some PH patients had urine oxalate within the reference range on occasion, and therefore it is not possible to exclude PH on the finding of a single normal result. A significant number of individuals had urine oxalate results well above the reference range who potentially have undiagnosed PH and are consequently at risk of renal failure.
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Affiliation(s)
| | | | - Gill Rumsby
- Department of Clinical Biochemistry, UCLH, London, UK
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Beloncle F, Sayegh J, Duveau A, Besson V, Croue A, Subra JF, Augusto JF. An unexpected cause of progressive renal failure in a 66-year-old male after liver transplantation: secondary hyperoxaluria. Int Urol Nephrol 2012; 45:1209-13. [PMID: 22395848 DOI: 10.1007/s11255-012-0140-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 02/06/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperoxaluria is a rare metabolic disorder characterized by calcium oxalate deposition in different tissues. It is caused either by an inherited disease of oxalate metabolism [primary hyperoxalurias (PH)] or by an acquired disturbance (secondary hyperoxaluria). CASE We report here an atypical presentation of enteric hyperoxaluria-induced renal failure that occurred after liver transplantation. Despite adapted treatment and intensive haemodialysis, the patient did not recover. This case allows the reviewing of the multiple pathophysiological mechanisms involved in this disease. CONCLUSION Oxalate nephropathy should be considered in the differential diagnosis of acute renal failure, especially when previous renal impairment and fat malabsorption are present. We suggest performing renal biopsy early to allow a prompt diagnosis and therapeutic intervention.
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Affiliation(s)
- François Beloncle
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, 4 rue Larrey, 49933, Angers cedex 9, France
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Spasovski G, Beck BB, Blau N, Hoppe B, Tasic V. Late diagnosis of primary hyperoxaluria after failed kidney transplantation. Int Urol Nephrol 2009; 42:825-9. [PMID: 20020206 DOI: 10.1007/s11255-009-9690-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Accepted: 11/30/2009] [Indexed: 12/22/2022]
Abstract
Primary hyperoxaluria type 1 (PH1) is a rare autosomal recessive inborn error of the glyoxylate metabolism that is based on absence, deficiency or mislocalization of the liver-specific peroxisomal enzyme alanine:glyoxylate aminotransferase. Hyperoxaluria leads to recurrent formation of calculi and/or nephrocalcinosis and often early end-stage renal disease (ESRD) accompanied by systemic calcium oxalate crystal deposition. In this report, we describe an adult female patient with only one stone passage before development of ESRD. With unknown diagnosis of PH, the patient received an isolated kidney graft and developed an early onset of graft failure. Although initially presumed as an acute rejection, the biopsy revealed calcium oxalate crystals, which then raised a suspicion of primary hyperoxaluria. The diagnosis was later confirmed by hyperoxaluria, elevated plasma oxalate levels and mutation of the AGXT gene, showing the patient to be compound heterozygous for the c.33_34InsC and c.508G > A mutations. Plasma oxalate levels did not decrease after high-dose pyridoxine treatment. Based on this case report, we would recommend in all patients even with a minor history of nephrolithiasis but progression to chronic renal failure to exclude primary hyperoxaluria before isolated kidney transplantation is considered.
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Affiliation(s)
- Goce Spasovski
- University Department of Nephrology, Medical Faculty, University of Skopje, Vodnjanska 17, 1000 Skopje, Macedonia.
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Hiel AL, Tintillier M, Cuvelier C, Léonard A, Pochet JM. Acute renal failure secondary to oxalosis in a recipient of a simultaneous kidney-pancreas transplant: was mycophenolate the cause? Nephrol Dial Transplant 2008; 24:326. [PMID: 18854417 DOI: 10.1093/ndt/gfn578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Stewart GD, Bariol SV, Smith G, Moussa SA, Tolley DA. Controversial Cases in Endourology. J Endourol 2006; 20:612-5. [PMID: 16999609 DOI: 10.1089/end.2006.20.612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Grant D Stewart
- Scottish Lithotripter Centre, Western General Hospital, Edinburgh, UK
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