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Biomedical Science
Causes and Prevention of Calcium-containing Renal Calculi
ROGER A. L SUTrON, DM, FRCP, FRCPC, Vancouver, British Columbia

Presented at the Plenary Session, Western Association of Physicians, Cannel, California, February 6, 1991.

Renal calculi are common; the lifetime risk for men in North America is about 20%, and the likelihood of a recurrence after the first stone is 50% at five years. It would be convenient to be able to predict which patients are going to have a stone recurrence when deciding how to investigate and treat them. A recent study from Sweden has examined this issue. I In this study, men in the population were screened at age 50 and again ten years later at age 60, with particular reference to their history of kidney stones, as well as many other aspects of their health. Factors that were associated with an increased likelihood of a recurrence in stone patients included a positive family history and an early age of the occurrence of stones. When a patient has stone disease start at age 25 compared with 45, or a positive family history, the likelihood of the recurrence of stones is approximately doubled.

T$&E 2,f-.Risk Factors li,rOxal:t Calcim Sts

D

lncreasld 1excrtIo o-f C$ci um, such as idopti ypercalciuria and pnmary hyperparathyroidism
Oxalate Uric acid Decreased ecretion of Volume. : 0 Citrate
..,

.-

Inhibitors and Promoters of Stone Formation Natural inhibitors and promoters of crystal and stone formation exist in the urine; some of these are listed in Table 1. Magnesium, citrate, and glycosaminoglycans are naturally occurring inhibitors of oxalate stone formation. Two glycoproteins, nephrocalcin and Tamm-Horsfall protein, are probably extremely important inhibitors. Inhibition may occur at the level of crystal nucleation or growth, or the aggregation of crystals may be inhibited as they flow along the nephron. Nephrocalcin, a glycoprotein identified some years ago,2 is made in the proximal tubule and perhaps also in the loop of Henle. It contains y-carboxyglutamic acid (as does osteocalcin). Nephrocalcin from the urine of stone formers and also from renal calculi may contain reduced quantities of 'ycarboxyglutamic acid and be deficient in inhibitory action. Nephrocalcin is an inhibitor of both crystal growth and agTABLE 1.-Noturolly Occurring Inhibitors and Promoters of Calcium Oxalate Stone Formation
Inhibitors Pyrophosphate

Glycosaminoglycans Nephrocalcin Tamm-Horsfall protein

Promoters Urate

Magnesium Citrate

Tamm-Horsfall protein ? Cell membranes

gregation. Because ofits fine caliber, the thin limb ofthe loop of Henle is probably an important site at which stone formation may begin. The deep portions of the loop of Henle are also characterized by some unusual physical conditions, including a high osmolality and high sodium and calcium concentrations. Nephrocalcin retains its inhibitory action in those unusual circumstances and hence may be effective in preventing stone formation in the thin loop of Henle. The Tamm-Horsfall protein is normally excreted in urine in quantities of the order of 30 to 50 mg per day. Made exclusively in the thick ascending limb of the loop of Henle, it inhibits in a major way the aggregation of calcium oxalate crystals.3 This effect is impaired under conditions of high sodium concentration and high osmolality because the Tamm-Horsfall protein tends to self-aggregate under those conditions.4 This protein is added to the urine beyond the thin loop of Henle, where the conditions are such that it would self-aggregate. Its secretion at a more distal site in the nephron may allow it to function as an effective inhibitor of aggregation. It is possible that a high sodium intake and a high protein intake, both of which are known to promote stone formation, may impair the inhibitory action of TammHorsfall protein by encouraging its self-aggregation. When self-aggregated, in fact, it may act as a promoter of stone formation. Some of the known metabolic risk factors for calcium stones are shown in Table 2. Hyperuricosuria promotes calcium oxalate stone formation. Increasing uric acid concentration in vitro increases the precipitation of calcium oxalate from urine specimens.5 The mechanism of this effect is still uncertain. Urinary citrate complexes calcium, rendering it unavailable for precipitation as calcium phosphate or calcium oxalate. A deficiency of citrate in the urine (hypocitraturia) is probably the major factor encouraging stone formation in patients with renal tubular acidosis and in patients being treated with acetazolamide. In addition, idiopathic calcium

(Sutton RAL: Causes and prevention of calcium-containing renal calculi. West J Med 1991 Sep; 155:249-252)
From the Department of Medicine, Division of Nephrology, University of British Columbia Faculty of Medicine, Vancouver. The Medical Research Council of Canada, through grant MT-5279, provided research support. Reprint requests to Roger A. L. Sutton, DM, FRCP, FRCPC, Department of Medicine, University of British Columbia Faculty of Medicine, LSP-3, 910 W 10th Ave, Vancouver, BC, Canada V5Z 4E3.

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TABLE 3.-Clinical Presentation of Primary Hyperparathyroidism'

Presentation

Cases, 9b 1967 1990 England Canada

...........

Renal calculi .... Ostitis fibrosa cystica . ............ Neither.

'Unpublished data.

59 20 21

15 <5 >80

oxalate stone formers frequently have subnormal urinary citrate excretions,6 probably related to diet. A high protein intake, for example, induces a mild metabolic acidosis, the major known cause for the depression of urinary citrate excretion.

Primary Hyperparathyroidism as a Cause of Kidney Stones Important causes of hypercalciuria include primary hyperparathyroidism and idiopathic hypercalciuria. The clinical presentation of primary hyperparathyroidism has changed in recent years (Table 3). Renal calculi used to be the most common clinical presentation, but less than 10% of patients now diagnosed as having primary hyperparathyroidism have urolithiasis. Twenty years ago, osteitis fibrosa cystica, the traditional cystic bone disease of primary hyperparathyroidism, was present in as much as 20% of cases, but now it is extremely rare, at least in North America. In a series from Paris, patients with osteitis fibrosa cystica were older and had poor nutritional vitamin D supplies, an unusual occurrence in North America because of the supplementation of dairy products with vitamin D (which is not usual in Europe.)7 A recent study from New York compared patients with primary hyperparathyroidism presenting with or without renal stones.8 Patients with stones tended to have more hypercalciuria (although not when it was expressed in relation to creatinine excretion) and somewhat higher excretion of urinary hydroxyproline. Hypercalciuria alone does not account for stone formation because the amount of urinary calcium excretion between patients with and without stones overlaps considerably. The clue to what may be contributing to stones in some patients with primary hyperparathyroidism may lie in an older study of crystal formation in urine.9 These investigations determined the upper limit of metastability for calcium oxalate, the point at which crystals begin to form as the urine is increasingly saturated. The hyperparathyroid patients with stones were noted to have a much lower limit, that is, crystals formed at a lesser degree of supersaturation than in controls or in various other groups of stone patients. The simplest interpretation of this would be that there is an abnormal promoter of stone formation in the urine of patients with hyperparathyroidism and stones.

absorption is or is not vitamin D-mediated. Other areas of considerable current interest are the role of the skeleton in idiopathic hypercalciuria and the role of dietary factors. In patients with calcium stones, urinary sodium and urinary calcium excretions are strongly and positively correlated. In other words, a high urinary sodium excretion may contribute to the high calcium excretion. For a given increment in sodium excretion, stone patients tend to have greater increments in calcium excretion than do control subjects. Similarly, for a given increase in dietary protein (estimated from urinary urea excretion) men with calcium stone diathesis show a much steeper increase in urinary calcium excretion than do controls, a significant difference. 10 The same is true, although the differences are less significant, when women with stone formation are compared with suitable controls. There appears to be a hypersensitivity to the hypercalciuria-inducing effect of dietary protein in patients with stone diathesis. Restricting dietary protein is therefore increasingly becoming a mode of therapy to try to prevent calcium oxalate calculi. Whether this hypercalciuric effect of ingested protein is on the skeleton, on the renal tubule, or even in the gut has not yet been clarified. In idiopathic hypercalciuria, whatever its pathogenesis, intestinal calcium is hyperabsorbed. The mean serum calcitriol level in hypercalciuric stone formers is greater than in normal controls but not sufficiently so to explain the observed calcium hyperabsorption. Other mechanisms that might promote calcium absorption in these patients are therefore being sought. In a recent study, calcium-magnesium-adenosine triphosphatase activity in erythrocytes from hypercalciuric patients was found to be significantly higher than in controls.11 Furthermore, this erythrocytic enzyme activity was positively correlated with the excretory rate of urinary calcium. This might suggest the presence of a generalized abnormality of calcium transport in idiopathic hypercalciuria affecting cell membranes other than those of the gut and the kidney. A rat model of idiopathic hypercalciuria has been obtained by selective breeding for hypercalciuria.12 In this model the hypercalciuria is clearly not vitamin D-mediated in that the serum calcitriol levels of these exceedingly hypercalciuric rats with greatly increased rates of calcium absorption are not different from those of the controls. The fact that calcitriol levels are not suppressed in the hypercalciuric rats could indicate a subtle defect in its metabolism, but the problem is not simply one of overproduction of calcitriol. Conventional metabolic balance studies usually show an overall negative calcium balance in patients with idiopathic hypercalciuria. This suggests that skeletal resorption may be contributing to the hypercalciuria. Furthermore, a decrease in bone density, particularly that of trabecular bone, and an
TABLE 4.-Abnormalities Described in Idiopathic Hypercalciuria
Absorptive hypercalciuria Renal leak of calcium with secondary hyperabsorption Increased sensitivity to the hypercalciuric effect of Dietary sodium Dietary protein Increased calcium-magnesium-ATPase activity (erythrocytes) Increased skeletal turnover Increased interleukin-1 (in monocytes)
ATPase - adenosine triphosphatase

Idiopathic Hypercalciuria In idiopathic hypercalciuria, patients excrete abnormally large amounts of calcium in the urine ( > 4 mg per kg per 24 hours), but plasma total and ionized calcium levels are normal. The pathophysiology of this disorder, the subject of controversy for many years, is still unclear (Table 4). Unresolved issues include whether the primary defect is an intestinal hyperabsorption of calcium or a renal tubular defect with calcium wasting and whether intestinal calcium hyper-

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increase in urinary hydroxyproline have been reported. For example, we measured urinary hydroxyproline levels in three 8-hour periods during the day in stone formers and in normal subjects and observed that, especially during the daytime hours, the urinary hydroxyproline levels were higher in patients than in controls.13 Patients and controls were on gelatin-free diets, so the urinary hydroxyproline was presumed to reflect endogenous bone turnover. We interpreted these results to suggest that in patients with stone, the normal slowing of bone resorption during the daytime, when calcium is being ingested, may not occur. Interleukin- 1 activity has been determined in circulating peripheral monocytes in stone patients and controls.14 Patients who were stone formers were divided into those with fasting hypercalciuria (a high calcium excretion after an overnight fast, probably in part due to increased skeletal resorption) and those with absorptive hypercalciuria who did not have increased calcium excretion after a fast but did hyperabsorb ingested calcium. The remaining patients had normal urinary calcium excretion. The mean interleukin-1 activity in the cultured peripheral monocytes was greatly increased in patients with fasting hypercalciuria, although there was some overlap with the controls. These data suggest that increased interleukin-1 production by circulating monocytes (which are related to osteoclasts in the bone) might be the mechanism of increased bone resorption in idiopathic hypercalciuria. Patients with fasting hypercalciuria also had a reduced trabecular bone density (determined by computed tomography) and an increased urinary excretion of hydroxyproline in comparison with the other two groups. In the treatment of idiopathic hypercalciuria, some dietary factors to which attention should initially be directed, notably high dietary salt and protein, have already been mentioned. Thiazide diuretics, which are effective in reducing stone recurrences,15 lower urinary calcium levels by enhancing calcium reabsorption by the distal renal tubule. Over time the use of thiazides may also cause an increase in bone density as evidenced by both formal bone density measurements in the spine and the limbs14'6 and by a reduced incidence of hip fractures."'

Abnormalities in Oxalate Metabolism Calcium oxalate is the most frequent crystalloid component of kidney stones. Oxalic acid, named after the plant wood sorrel, or Oxalis, is an end product of metabolism in vertebrates. Vertebrates lack enzymes to metabolize oxalate further, and this simple molecule has no known role in mammalian physiology. Recently a chloride-oxalate exchanger has been demonstrated on the brush border of cells of the proximal renal tubule,'8 in addition to the chloride-formate exchanger that had previously been identified. 9 It is possible that the oxalate-chloride exchanger might have a role in the reabsorption of sodium chloride in the proximal tubule. Alternatively, it may simply be involved in the oxalate secretory process that is known to occur along the nephron. Oxalate's clinical importance relates only to the extreme insolubility in water of its calcium salt. At less than 0.1 mmol per liter, it is much less soluble than, for example, calcium phosphate or calcium carbonate. The process of crystal or stone formation in the urinary tract has long been thought to be related to supersaturation of the urine with insoluble urinary constituents. The saturation of a solution with respect to calcium oxalate can be considered in relation to the behavior

of calcium oxalate seed crystals added to the solution. In a supersaturated solution, the crystals will tend to grow, whereas in an unsaturated solution they will tend to dissolve. The formation product is the degree of supersaturation at which spontaneous crystal formation occurs. A modest increase in urinary oxalate levels may actually be more important than a proportionately similar increase in urinary calcium as a risk factor for calcium oxalate stones. Urinary oxalate is unbound, whereas urinary calcium is partially chelated by citrate. Another reason may be the high molar ratio of calcium to oxalate in the urine. Mild hyperoxaluria may occur in as much as 40% of patients in whom idiopathic calcium oxalate stones form, often along with other metabolic abnormalities such as hypercalciuria. Occasionally a high dietary oxalate may be responsible for hyperoxaluria. In a study carried out in Saudi Arabia, hyperoxaluria was frequently found in stone-forming patients and was thought to result from unusually low dietary calcium intakes, which may enhance the absorption of dietary oxalate.20 This observation has led to the introduction of calcium citrate as a mode of therapy in such patients.20 We have identified a few patients of this type in Vancouver and are treating them similarly. This condition is analogous to enteric hyperoxaluria, but the patients have no evidence of bowel disease. The precise enzyme defect in severe type 1 primary hyperoxaluria has recently been identified,2' and efforts are now being made to determine whether idiopathic mild hyperoxaluria could be due, in some patients, to a minor abnormality of this enzyme. This seems unlikely, however, because urinary glycolate levels, which are increased along with oxalate in type 1 hereditary hyperoxaluria, are usually not increased in patients with mild idiopathic hyperoxaluria. Finally, some patients may have a renal oxalate transport defect, which could be a manifestation of a generalized oxalate transport defect in stone formers. The exchange of labeled oxalate across erythrocyte membranes has been reported to be greatly increased in idiopathic calcium stone formers when compared with controls or with other patients.22 It was proposed that this might reflect an abnormality in membrane permeability to oxalate that might also affect oxalate transport in the gut and the kidneys. Interestingly, this defect in the erythrocytes was corrected with the use of thiazide diuretics, but the nature of the defect remains unclear. The treatment of mild idiopathic hyperoxaluria is unlikely to be entirely satisfactory until the pathophysiology is understood. The use of calcium in enteric hyperoxaluria has already been mentioned. An alternative may be compounds such as complex organic alginates that adsorb oxalate in the gut lumen and inhibit its absorption from the diet."2 Patients with type 1 primary hyperoxaluria may respond to a regimen of pyridoxine hydrochloride, and some patients have received a liver transplant with reversal of the metabolic abnormality. Pyridoxine may have a place in the treatment of the mild idiopathic form, but results have generally not been encouraging. Finally, we can speculate about the possibility of gene therapy for the treatment of hyperoxaluria. As mentioned earlier, vertebrates cannot metabolize oxalate further, but some bacteria possess an oxalate decarboxylase. Conceivably it might be possible to use such an enzyme to degrade oxalate in higher animals. I am indebted to A. B. Peck, MD, and colleagues of Gainesville, Florida, for allowing me

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7. Patron P, Gardin JP, Paillard M: Renal mass and reserve of vitamin D: Determinants in primary hyperparathyroidism. Kidney Int 1987; 31:1174-1180 8. Silverberg SJ, Shane E, Jacobs TP, et al: Nephrolithiasis and bone involvement in primary hyperparathyroidism. Am J Med 1990; 89:327-334 9. Pak CYC, Holt K: Nucleation and growth of brushite and calcium oxalate in urine of stone-formers. Metabolism 1976; 25:665-673 10. Wasserstein AG, Stolley PD, Soper KA, Goldfarb S, Maislin G, Agus Z: Casecontrol study of risk factors for idiopathic calcium nephrolithiasis. Miner Electrolyte Metab 1987; 13:85-95 11. Bianchi G, Vezzoli G, Cusi D, et al: Abnormal red-cell calcium pump in patients with idiopathic hypercalciuria. N Engl J Med 1988; 319:897-901 12. Bushinsky DA, Favus MJ: Mechanism of hypercalciuria in genetic hypercalciuric rats-Inherited defect in intestinal calcium transport. J Clin Invest 1988; 82:1585-1591 13. Sutton RAL, Walker VR: Bone resorption and hypercalciuria in calcium stoneformers. Metabolism 1986; 35:485-488 14. Pacifici R, Rothstein M, Rifas L, et al: Increased monocyte interleukin-l activity and decreased vertebral bone density in patients with fasting idiopathic hypercalciuria. J Clin Endocrinol Metab 1990; 71:138-145 15. Yendt ER, Cohanim M: Prevention of calcium stones with thiazides. Kidney Int 1978; 13:397-409 16. Barkin J, Wilson DR, Manuel MA, Bayley A, Murray T, Harrison J: Bone mineral content in idiopathic calcium nephrolithiasis. Miner Electrolyte Metab 1985; 11: 19-24 17. LaCroix AZ, Wienpahl J, White LR, et al: Thiazide diuretic agents and the incidence of hip fracture. N EngI J Med 1990; 322:286-290 18. Karniski LP, Aronson PS: Anion exchange pathways for Cl-transport in rabbit renal microvillus membranes. Am J Physiol 1987; 253 (Pt 2):F513-F521 19. Karniski LP, Aronson PS: Chloride-formate exchange with formic acid recycling: A mechanism of active chloride transport across epithelial membranes. Proc Natl Acad Sci USA 1985; 82:6362-6365 20. Walker VR, Sutton RAL, Bissada N, et al: Urinary calcium and oxalate in stone formers and normal subjects in Saudi Arabia, In Walker VR, Sutton RAL, Cameron EC, Pak CYC, Robertson WG (Eds): Urolithiasis. New York, NY, Plenum, 1989, pp 351-354 21. Danpure CJ, Jennings PR: Peroxisomal alanine: Glyoxylate aminotransferase deficiency in primary hyperoxaluria type I. FEBS Lett 1986; 201:20-24 22. Baggio B, Gambaro G, Marchini F, et al: An inheritable anomaly of red-cell oxalate transport in 'primary' calcium nephrolithiasis correctable with diuretics. N Engl J Med 1986; 314:599-604 23. Lindsjo M, Fellstrom B, Ljunghall S, Wikstrom B, Danielson BG: Treatment of enteric hyperoxaluria with calcium-containing organic marine hydrocolloid. Lancet 1989; 2:701-704 24. Lung H, Cornelius JG, Peck AB: Cloning and expression of the oxalyl-CoA decarboxylase gene from the bacterium, Oxalobacterformigenes: Prospects for gene therapy to control calcium oxalate kidney stone formation. Am J Kidney Dis, in press

to present some as-yet-unpublished material.24 These investigators have cloned the oxalate decarboxylase enzyme from the bacterium Oxalobacter formigenes, and they have recently succeeded in expressing it in Escherichia coli, thus conferring the ability on this species to convert oxalate to formate. The next step would be to transfer this enzyme into a mammalian cell and possibly one day use it to treat severe human hyperoxaluric disorders.

Summary Kidney stones are common, and recurrences are the rule. At least 90% of patients with kidney stones probably have some identifiable metabolic risk factor. Effective prophylaxis is often available, but with the relatively low rate of
recurrence, compliance with the treatment may be a problem. Studies are required to determine the cost-effectiveness of metabolic investigation and prophylactic therapy versus the possible need for repeated treatment by means of extracorporeal lithotripsy, especially in patients having a first calcium oxalate stone.
REFERENCES
1. Ljunghall S, Lithell H, Skarfors E: Prevalence of renal stones in 60-year-old men-A 10-year follow-up study of a health survey. Br J Urol 1987; 60:10-13 2. Nakagawa Y, Abram V, Parks JH, Lau HSH, Kawooya JK, Coe FL: Urine glycoprotein crystal growth inhibitors-Evidence for a molecular abnormality in calcium oxalate nephrolithiasis. J Clin Invest 1985; 76:1455-1462 3. Hess B, Nakagawa Y, Coe FL: Inhibition of calcium oxalate monohydrate crystal aggregation by urine proteins. Am J Physiol 1989; 257:F99-F106 4. Coe FL, Parks JH: Defenses of an unstable compromise: Crystallization inhibitors and the kidney's role in mineral regulation. Kidney Int 1990; 38:625-631 5. Grover PK, Ryall RL, Marshall VL: The effect of increasing urate concentration on the precipitation of calcium oxalate from human urine, In Walker VR, Sutton RAL, Cameron EC, Pak CYC, Robertson WG (Eds): Urolithiasis. New York, NY, Plenum, 1989, pp 461-463 6. Nicar MJ, Skurla C, Sakhaee K, Pak CYC: Low urinary citrate excretion in nephrolithiasis. Urology 1983; 21:8-14