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PubMed1990

Long-term outcome of reversal of small intestinal bypass operations.

Between 1976 and 1987, 43 patients underwent reversal of jejunoileal bypass operations because of metabolic complications of the operation. Electrolyte imbalance, malnutrition, and diarrhea (16 patients); cirrhosis (9); nephrolithiasis (9); arthritis (7); and pathologic fractures (1) were the primary indications for reconstruction. Many patients had multiple complications of the jejunoileal bypass operation. Twenty-nine patients underwent gastroplasty at the time of reversal and 14 did not. Seventy three +/- 5 months after reversal, patients with a gastroplasty weighed significantly less than patients without a gastroplasty. Patients with electrolyte imbalance, malnutrition, and diarrhea were all improved after reconstruction. Two patients with cirrhosis died of liver failure after reconstruction; the distinguishing preoperative characteristic was ascites. Postoperative interval liver biopsies indicated improvement in histologic appearance in four patients and no change in three. Nephrolithiasis improved or disappeared in all patients after reconstruction, whereas arthritis improved in 5 of 7 patients. Gastroplasty produced no benefit in alleviation of metabolic complications of jejunoileal bypass operations. Although the survival rate in these patients at last follow-up was 95 percent, 28 percent were incapacitated. Simultaneous gastroplasty performed at the time of reversal significantly decreases body weight when compared with patients undergoing reversal without a gastroplasty.

Arthritis↗
PubMed1997

Ion chromatographic characterization of toxic solutions: analysis and ion chemistry of biological liquids.

The literature on the analysis of biological fluids by ion chromatography is reviewed herein. It has been demonstrated that ion chromatography is the method of choice for the determination of anions such as chloride, nitrite, bromide, phosphate, nitrate, sulfate, oxalate, thiocyanate, thiosulfate, citrate, isocitrate, carbonate, and similar species. Cations such as sodium, ammonium, potassium, magnesium, and calcium in various biological solutions have also been successfully identified and quantified. The technique fulfils several requirements of a reliable microanalytical method by providing sufficient speed, automation, case of use, and accuracy. For many types of analyses, very little or even no sample preparation is required. Because of this, as presented in this review, ion chromatography is widely used not only to obtain reliable clinical data, but also to study ion chemistry. It has been an invaluable tool in nephrolithiasis and dental research. This review should provide a useful reference for analysts and researchers involved in clinical studies. The review is presented in four sections: (1) introduction, (2) methods of analysis, (3) ion chemistry and (4) critical comments and concluding remarks. Section 1, as usual, deals with the general introduction of the subject and objectives. Section 2 includes the review of the literature on ion chromatography (IC) methods developed for routine analysis of various analytes present in biological fluids. Section 3 deals with the applications of IC used in the understanding of ion chemistry of biological fluids. Specifically, it deals with the physical chemistry aspects related to nephrolithiasis and dental research, such as speciation, driving force for crystals formation and crystallization, and pathophysiology. Section 4 contains critical comments and concluding remarks.

Animals↗
PubMed2000

Dietary manipulation of delta-6-desaturase modifies phospholipid arachidonic acid levels and the urinary excretion of calcium and oxalate in the rat: insight in calcium lithogenesis.

An anomalous n-6 polyunsaturated fatty acid composition in plasma and erythrocyte membrane phospholipids, namely increased levels of arachidonic acid (AA), has been reported in calcium nephrolithiasis and has been proposed to play an important role in its pathogenesis. To confirm this, in rats we modified phospholipid AA levels by dietary manipulation of the delta-6-desaturase, the rate-limiting enzyme of the fatty acid biosynthetic pathway, and evaluated the effect on cellular and renal functions predisposing to lithogenesis. Increased AA levels led to conditions at risk for nephrolithiasis: higher oxalate flux and lower sodium cotransport in erythrocytes and a rise in urinary prostaglandin E2, calcium, sodium, and oxalate levels; reduced AA levels reversed these changes. In vitro, in human erythrocytes the incorporation of exogenous AA into membranes increased band 3 protein phosphorylation directly activating the Ser/Thr protein kinase CK1 and induced a parallel raise in band 3-mediated oxalate transport. These findings demonstrate the pivotal role of phospholipid AA in modulating erythrocyte and renal transport of calcium and oxalate.

Animals↗
PubMed1994

Renal acidification in children with idiopathic hypercalciuria.

Distal renal tubular acidosis is frequently associated with hypercalciuria. To further investigate the cause-and-effect relationships between the two conditions, we examined 20 children (5 to 18 years of age) with idiopathic hypercalciuria for evidence of renal tubular acidosis. Serum electrolytes and urine citrate levels were normal in all subjects. After a single dose of furosemide, 1 of the 20 subjects did not show a decrease in urine pH < 5.5, which suggests an acidification defect in the cortical collecting duct. Three other patients failed to show an increase in urine-minus-blood partial pressure of carbon dioxide > 20 mmHg after urine alkalinization with orally administered acetazolamide, a finding compatible with a rate-dependent distal renal tubular acidosis. These four subjects underwent acute acid loading with arginine hydrochloride. In all four subjects urine pH decreased < 5.5 but urinary ammonium excretion failed to increase normally; this supports the diagnosis of a defect in distal acidification. Four of six patients with nephrolithiasis had evidence of distal renal tubular acidosis, in contrast to none of the 14 patients without stones (p = 0.003). We conclude that distal acidification abilities seem to be intact in children with hypercalciuria in the absence of nephrolithiasis. We speculate that calcium precipitation may lead to tubular damage, including distal renal tubular acidosis.

Acetazolamide↗
PubMed2006

Temporal trends in the use of percutaneous nephrolithotomy.

PURPOSE: Treatment for nephrolithiasis has evolved because of the dissemination of less invasive techniques, such as ureteroscopy and shock wave lithotripsy. We examined temporal trends in PCNL use and characterized the determinants of a prolonged LOS and in-hospital mortality to provide insight into the evolution of practice patterns for nephrolithiasis treatment. MATERIALS AND METHODS: We abstracted data on 12,948 patients undergoing percutaneous procedures for urinary calculi between 1988 and 2002 from the Nationwide Inpatient Sample using International Classification of Disease, 9th revision, Clinical Modification procedure and diagnostic codes. A weighted sample was used to estimate national PCNL use rates. Adjusted models were constructed to measure the association of hospital structure and patient demographics with mortality and a prolonged LOS (greater than 90th percentile). RESULTS: Annual PCNL use increased temporally during the study from 1.2/100,000 to 2.5/100,000 United States residents (p <0.0001). The in-hospital mortality rate was low at 0.2%, although a volume-outcome relationship was still evident (high and low volume 0.1% and 0.2%, respectively, p = 0.002). Treatment at hospitals with lower hospital PCNL volume and lower discharge volume (all diagnoses) was associated with an increasing likelihood of in-hospital mortality (each p <0.01). CONCLUSIONS: Despite the advent of less invasive techniques PCNL remains a popular means of managing stone disease. Although mortality was rare, it was significantly lower at high than at low volume hospitals. Low short-term mortality rates coupled with shorter LOS and high success rates may make PCNL increasingly palatable from a patient perspective and provide a potential basis for its increasing use.

Adult↗
PubMed2000

Serum phosphate in stone formers: what does a low serum phosphate level mean?

PURPOSE: Metabolic evaluation is indicated in stone formers to identify and subsequently modify risk factors for nephrolithiasis. Some believe that serum phosphate may be an important indicator of nephrolithiasis risk. We determined whether serum phosphate is an independent risk factor for recurrent calcium stone formation and whether it may be used as an early marker for occult disease, such as hyperparathyroidism. MATERIALS AND METHODS: The charts of all patients with regular long-term stone clinic followup were reviewed. Initial serum phosphate levels were compared with stone recurrence, complications due to stones, initial visit urinary laboratory values and the medical diagnoses made during followup. Unpaired 2-sample t tests, and correlation and logistic regression analyses were performed with statistical significance at p <0.05. RESULTS: Data were available on 51 men and 25 women 22 to 74 years old (mean age 52). Of the patients 50 were recurrent and 26 were single stone formers. Serum phosphate levels were lower in women than in men. No consistent associations existed between initial or future serum phosphate levels and stone recurrence, complications from stones, urinary values or other medical diagnoses made during followup. CONCLUSIONS: Serum phosphate does not appear to be an independent risk factor for urinary tract stone recurrence or complications, or a reliable early predictor of occult disease.

Adult↗
PubMed1999

Incorporation of patient preferences in the treatment of upper urinary tract calculi: a decision analytical view.

PURPOSE: Patient preferences, or utilities, may be crucial to select an appropriate treatment plan for stone disease. We used decision modeling to understand better patient choices and decision making in the overall management of recurrent nephrolithiasis. MATERIALS AND METHODS: We interviewed 180 consecutive patients with active stone disease. Demographic data and historical experiences with calculi were recorded. Patients were presented with 6 hypothetical clinical scenarios and various treatment options. The standard gamble method was used to obtain utility values for each option. RESULTS: Nephrectomy had the lowest mean utility value of 0.883. Percutaneous nephrolithotomy for severe, moderate and mild pain had utilities of 0.924, 0.932 and 0.947, respectively. Shock wave lithotripsy for the management of mild pain was the most attractive option (mean utility 0.968). The utility for long-term medical therapy was 0.949, which was between that of percutaneous nephrolithotomy and shock wave lithotripsy for mild pain. Patients with a surgical history of stone removal assigned lower utilities to invasive procedures (nephrectomy, percutaneous nephrolithotomy, p <0.05). As the incidence of spontaneous stone passage increased, a higher utility was given to long-term medical therapy (p <0.05). Patients on medical therapy less than 1 year did not appreciate a significant benefit of medical prophylaxis. However, longer compliance with medical management led patients to perceive increasing benefits of continuing such medical treatment (p <0.05). Patients who had undergone stone removal via endoscopic or open surgery also had a higher preference for medical therapy (p <0.05). CONCLUSIONS: Patients who had undergone stone removal wanted to avoid future invasive procedures. They ranked long-term medical therapy below shock wave lithotripsy but above invasive procedures, such as percutaneous nephrolithotomy. Most importantly, patients appreciated the benefits of medical therapy the longer that they complied with specific recommendations. These results support the concept that patients perceive long-term medical therapy to prevent recurrent nephrolithiasis as a desirable treatment option.

Adolescent↗
PubMed1993

Effect of orange juice consumption on urinary stone risk factors.

The value of orange juice consumption in kidney stone prevention was examined in 8 healthy men and 3 men with documented hypocitraturic nephrolithiasis. They underwent 3 phases of a metabolic study, a placebo phase and 2 treatment phases in which they ingested either 1.2 l. orange juice (containing 60 mEq. potassium and 190 mEq. citrate per day) with meals or potassium citrate tablets (60 mEq. per day) with water and meals. Compared to potassium citrate, orange juice delivered an equivalent alkali load and caused a similar increase in urinary pH (6.48 versus 6.75 from 5.71) and urinary citrate (952 versus 944 from 571 mg. per day). Therefore, orange juice, like potassium citrate, decreased urinary undissociated uric acid levels and increased the inhibitor activity (formation product) of brushite (calcium phosphate). However, orange juice increased urinary oxalate and did not alter calcium excretion, whereas potassium citrate decreased urinary calcium without altering urinary oxalate. Thus, orange juice lacked the ability of potassium citrate to decrease urinary saturation of calcium oxalate. Overall, orange juice should be beneficial in the control of calcareous and uric acid nephrolithiasis.

Adult↗
PubMed1990

Effect of magnesium citrate and magnesium oxide on the crystallization of calcium salts in urine: changes produced by food-magnesium interaction.

The effect of magnesium citrate and magnesium oxide on urinary biochemistry and on the crystallization of calcium salts was examined in 7 normal subjects and 4 patients with recurrent calcium oxalate nephrolithiasis. When magnesium citrate or magnesium oxide was administered on an empty stomach (10 mEq. 4 times per day or 486 mg. magnesium per day for 2 weeks) urinary magnesium increased by only 77 to 79 mg. per day and urinary citrate increased by 98 to 142 mg. per day. However, urinary calcium increased by 21 to 25 mg. per day. No significant changes were noted in urinary saturation of calcium oxalate or brushite or in the limit of metastability (formation product) of these salts. However, when magnesium salts were provided with meals there were more prominent increases in urinary magnesium (by 92 to 96 mg. per day) and in citrate (by 218 to 226 mg. per day). Moreover, urinary oxalate decreased. Owing to these changes the urinary saturation of calcium oxalate decreased and the formation product increased. If magnesium citrate and magnesium oxide are to be used in the management of recurrent calcium oxalate nephrolithiasis, they should be administered with meals.

Adult↗
PubMed1987

The role of oxalate and calcium oxalate activity and formation product ratio in patients with renal stones before and during treatment.

The participation of oxalate in nephrolithiasis was evaluated in 202 stone patients. The activity product and formation product ratios of calcium oxalate were substantially altered in the stone population. Treatment with thiazide derivatives and/or allopurinol was able to decrease urine oxalate and normalize the activity product and formation product ratios. Stone activity decreased in the stone population after treatment. Our data suggest that oxalate may have a critical role in nephrolithiasis activity.

Allopurinol↗
PubMed1985

Prevention of recurrent calcium stone formation with potassium citrate therapy in patients with distal renal tubular acidosis.

Distal renal tubular acidosis is a common cause of intractable calcium nephrolithiasis. We examined the effect of oral potassium citrate therapy in 9 patients with incomplete distal renal tubular acidosis diagnosed on the basis of an abnormal response to an oral ammonium chloride load. Patients were studied during a control phase and after 3 months of potassium citrate treatment (60 to 80 mEq. daily). Potassium citrate caused a significant increase in urinary pH and urinary citrate, and a decrease in urinary calcium. The urinary relative saturation ratio of calcium oxalate significantly decreased during treatment, while that of brushite did not change. Potassium citrate also was shown to inhibit new stone formation. During a mean treatment period of 34 months none of the 9 patients had new stones, although 39.3 plus or minus 79.7 (standard deviation) stones per patient formed during the 3 years preceding treatment. The results support the potential clinical advantage of potassium citrate therapy in patients with distal renal tubular acidosis and recurrent calcium nephrolithiasis.

Acidosis, Renal Tubular↗
PubMed1982

Should patients with single renal stone occurrence undergo diagnostic evaluation?

Diagnostic evaluation was conducted on 34 patients with a single episode of renal stone formation. Absorptive hypercalciuria as disclosed in 55.9 per cent (23.5 percent type I and 32.4 per cent type II), renal hypercalciuria in 11.8 per cent, primary hyperparathyroidism in 2.9 per cent, hyperuricosuric calcium oxalate nephrolithiasis in 8.8 per cent and no metabolic abnormality in 20.6 per cent. Compared to the group with recurrent stone formation the group with a single stone episode had just as severe biochemical abnormalities or laboratory results, such as hypercalciuria and exaggerated calciuric response to oral calcium load in absorptive hypercalciuria, high fasting urinary calcium and cyclic adenosine monophosphate in renal hypercalciuria, hyperuricosuria in hyperuricosuria calcium oxalate nephrolithiasis and low urine volume in no metabolic abnormality. The results suggest that the same physiological and environmental disturbances characterize stone formation in patients with a single stone episode as in those with recurrent stone formation and indicate the need for diagnostic evaluation.

Adult↗
PubMed1997

Is familial hyperparathyroidism a unique disease?

BACKGROUND: Familial hyperparathyroidism is a rare condition reported to behave more aggressively than sporadic hyperparathyroidism. METHODS: A retrospective (1975 to 1995) analysis was performed on 30 such patients. All patients had at least one first-degree relative with surgically treated hyperparathyroidism and no personal or family history of multiple endocrine neoplasia. RESULTS: There were 19 women and 11 men with a mean age of 39 years (range, 13 to 78 years). Fourteen patients (47%) had nephrolithiasis. The mean serum calcium level was 11.6 mg/dl (range, 10.5 to 15.3 mg/dl). Twenty-three primary and 15 repeat explorations (eight recurrent and seven persistent disease) were performed during the study period. Follow-up was obtained on all patients and ranged from 1 to 21 years (mean, 12 years). At the conclusion of the study, hypercalcemia (five recurrent and one persistent) was present in six patients (20%). CONCLUSIONS: Familial hyperparathyroidism is a distinct and unique entity. Patients are diagnosed at a young age and have a high incidence of nephrolithiasis. Long-term follow-up is mandatory because of the high incidence of both recurrent and persistent hyperparathyroidism. Surgical treatment should include subtotal parathyroidectomy and routine transcervical thymectomy performed in centers with experience in the management of multiple-gland parathyroid disease.

Adolescent↗
PubMed2000

Percutaneous management of stones in a patient with sacral agenesis.

We report a case of a patient with sacral agenesis and nephrolithiasis in whom percutaneous nephrostolithotomy was used to treat the stone disease. Sacral agenesis is an uncommon congenital anomaly involving the lower vertebral bodies and is associated with urinary tract dysfunction. Nephrolithiasis in a patient with sacral agenesis poses a problem in access for percutaneous nephrostolithotomy because of the associated presence of renal ectopia. We describe our technique and the special considerations necessary for successful access.

Abnormalities, Multiple↗
PubMed2001

Ureteropelvic junction obstruction and coexisting renal calculi in children: role of metabolic abnormalities.

OBJECTIVES: To identify the role of metabolic risk factors in the development of renal calculi associated with ureteropelvic junction obstruction (UPJO) in children. METHODS: A metabolic evaluation, including serum biochemistry and measurement of daily urinary calcium, creatinine, oxalate, citrate, magnesium, urate, and inorganic phosphorus, was carried out in three different populations as follows: UPJO group, 12 children with UPJO and coexisting nephrolithiasis (median age 6 years); calcium stone formation (CSF) group, 90 children with normal urologic anatomy and calcium urolithiasis (median age 7 years); control group, 24 healthy children (median age 7.3 years). The investigation data of the three groups were compared. RESULTS: The stone composition was calcium oxalate in 9 of the 12 children with UPJO. The investigation data of the UPJO group and CSF group were not significantly different. Both groups differed from the control group in a similar manner. The UPJO and CSF groups excreted more oxalate (P = 0.067 and 0.014, respectively) and less citrate (P = 0.020 and 0.010, respectively) than did the control subjects. CONCLUSIONS: Abnormal urinary biochemistry seems to have an additional role in the high incidence of nephrolithiasis in children with upper tract anatomic anomalies, and the urinary biochemistry should be screened in such children.

Calcium Oxalate↗
PubMed2002

Donor-gifted allograft urolithiasis: early percutaneous management.

OBJECTIVES: To describe our successful early management of donor-gifted nephrolithiasis by percutaneous nephrolithotomy. Donor-gifted nephrolithiasis is a rare and frustrating complication of renal transplantation. In the past, initial conservative management with relief of obstruction and shock wave lithotripsy has been recommended. METHODS: We treated 3 cases of donor-gifted cadaveric kidney transplant stones by a percutaneous approach 1 to 2 months postoperatively. Two patients presented with hydronephrosis-associated renal deterioration and febrile urinary tract infection, and the third was diagnosed incidentally on routine postoperative ultrasonography. RESULTS: Percutaneous nephrolithotomy was performed with ultrasound stone fragmentation after initial nephrostomy tube drainage in 1 patient. In the second patient, the stone was successfully removed in a basket in an antegrade fashion. The third patient's ureteral stone was successfully removed by antegrade ureteroscopy. Postoperatively, no residual stones were noted on nephrostography, and renal function returned to normal. CONCLUSIONS. Post-transplant renal calculi can be managed successfully by percutaneous techniques in the early postoperative period and renal function can be salvaged. Pretransplant renal sonography may be considered to limit donor-gifted calculi.

Cadaver↗
PubMed1997

Medical therapy, calcium oxalate urolithiasis.

The development of diagnostic protocols that identify specific risk factors for calcium oxalate nephrolithiasis has led to the formulation of directed medical regimens that are aimed at correcting the underlying metabolic disturbances. Initiation of these treatment programs has reduced markedly the rate of stone formation in the majority of patients who form stones. This article discusses the rationale that underlies the choice of medical therapy for the various pathophysiologic causes of calcium oxalate nephrolithiasis and the appropriate use of available medications.

Calcium↗
PubMed1993

Successful treatment of cystinuria with captopril.

Cystinuria is an autosomal recessive hereditary disorder associated with nephrolithiasis and its attendant complications. Traditional management aimed at increasing urinary cystine solubility using oral alkali, D-penicillamine, or mercaptopropionyglycine is often unsuccessful due to intolerable side effects. Two cystinuric patients intolerant of traditional therapy were treated with captopril for 1 year, resulting in a marked decline in urinary cystine excretion. Neither patient experienced recurrent nephrolithiasis or adverse drug effects. Captopril should be considered an alternative to traditional drug management of cystinuria.

Adult↗