Association of calcium oxalate monohydrate crystals with MDCK cells

Sialic acid-containing glycoproteins on renal cells determine nucleation of calcium oxalate dihydrate crystals

BACKGROUND

The interaction between the surfaces of renal epithelial cells and calcium oxalate dihydrate (COD), the most common crystal in human urine, was studied to identify critical determinants of kidney stone formation.

METHODS

A novel technique utilizing vapor diffusion of oxalic acid was employed to nucleate COD crystals onto the apical surface of living cells. Confluent monolayers were grown in the inner 4 wells of 24-well culture plates. To identify cell surface molecules that regulate crystal nucleation, cells were pretreated with a protease (trypsin or proteinase K) to alter cell surface proteins, neuraminidase to alter cell surface sialoglycoconjugates, or buffer alone. COD crystals were nucleated on the surface of cells by diffusion of oxalic acid vapor into a calcium-containing buffer overlying the cells. Crystal face-specific nucleation was evaluated by scanning electron microscopy.

RESULTS

Nucleation and growth of a COD crystal onto an untreated control cell occurred almost exclusively via its (001) face, an event rarely observed during COD crystallization. In contrast, when COD crystals were nucleated onto protease- or neuraminidase-treated cells, they did so via the (100) face of the crystal.

CONCLUSIONS

Specific sialic acid-containing glycoproteins, and possibly glycolipids (sialoglycoconjugates), appear to be critical determinants of face-specific nucleation of COD crystals on the apical renal cell surface. We hypothesize that crystal retention within the nephron, and the subsequent development of a kidney stone, may result when the number or composition of these cell surface molecules is modified by genetic alterations, cell injury, or drugs in tubular fluid.

Phenotypic characterization of human umbilical vein endothelial (ECV304) and urinary carcinoma (T24) cells: endothelial versus epithelial features

ECV304 cells reported as originating from human umbilical vein endothelial cells by spontaneous transformation have been used as a model cell line for endothelia over the last decade. Recently, deoxyribonucleic acid fingerprinting revealed an identical genotype for ECV304 and T24 cells (urinary bladder carcinoma cell line). In order to resolve the apparent discrepancy between the identical genotype and the fact that ECV304 cells phenotypically show important endothelial characteristics, a comparative study was performed. Immortalized porcine brain microvascular endothelial cells/C1-2, and Madin Darby canine kidney cells were included as typical endothelial and epithelial cells, respectively. Various methods, such as confocal laser scanning microscopy. Western blot, and protein activity tests, were used to study the cell lines. ECV304 and T24 cells differ in criteria, such as growth behavior, cytoarchitecture, tight junction arrangement. transmembrane electrical resistance, and activity of gamma-glutamyltransferase. Several endothelial markers (von Willebrand factor, uptake of low-density lipoprotein, vimentin) could clearly be identified in ECV304, but not in T24 cells. Desmoglein and cytokeratin, both known as epithelial markers, were found in ECV304 as well as in T24 tells. However, differences were found for the two cell lines with respect to the type of cytokeratin: in ECV304 cells mainly cytokeratin 18 (45 kDa) is found, whereas in T24 cells cytokeratin 8 (52 kDa) is predominant. As we could demonstrate, the ECV304 cell line exposes many endothelial features which, in view of the scarcity of suitable endothelial cell lines, still make it an attractive in vitro model for endothelia.

Mechanisms of calcium oxalate crystal attachment to injured renal collecting duct cells

BACKGROUND

Renal cell or tissue injury results in a loss of membrane lipid asymmetry and/or loss of cell polarity, and both events lead to changes on the surface of the cell membranes that enhance crystal attachment. We have proposed two distinct mechanisms of crystal attachment following membrane changes induced by various modes of injury.

METHODS

Annexin V was used to determine whether phosphatidylserine (PS) exposure on the cell membrane surface plays a role in calcium oxalate monohydrate (COM) crystal attachment to cells that have lost their polarity as well as to cells that have lost their lipid asymmetry. We utilized two different experimental models of injury to renal epithelial cells in culture. The first model used calcium ionophore A23187 to induce a loss of lipid asymmetry, and the second model used EGTA to break down tight junctions and lose cell polarity.

RESULTS

Inner medullary collecting duct cells that have lost lipid asymmetry demonstrated an increase in the number of cells that bound annexin V. However, when cells lost their polarity, they did not bind annexin V. In addition, the attachment of crystals to cells following a loss of cell polarity was not inhibited by annexin V.

CONCLUSIONS

This study indicates that both individual cell injury (loss of lipid asymmetry) and generalized cell monolayer injury (loss of cell polarity) result in the presentation of different cell surfaces and that both forms of injury result in an increased affinity for crystal attachment. Both mechanisms could be important independently or collectively in the retention of microcrystals to renal collecting duct cells in urolithiasis.

Effect of experimental hyperoxaluria on renal calcium oxalate monohydrate binding proteins in the rat

OBJECTIVE

To determine the functional role of calcium oxalate binding proteins in the nucleation, aggregation and retention of calcium oxalate crystals under physiological and hyperoxaluric conditions. Materials and methods Hyperoxaluria was induced in rats using 0.75% of ethylene glycol in drinking water. Calcium oxalate binding proteins were isolated and fractionated by cellulose column chromatography. Three major protein peak fractions were obtained (73 kDa in Tris-HCl buffer, 20 kDa in 0.05 mol/L NaCl buffer and 23 kDa in 0.3 mol/L buffer). Oxalate binding and the inhibition of crystal nucleation and aggregation by these fractions were determined.

RESULTS

The adsorption of calcium oxalate monohydrate (COM) was ubiquitous in rat tissues and subcellular organelles, but the percentage adsorption varied; maximum absorption occurred in kidneys and pancreas, with microsomes showing maximal adsorption in the kidney. Hyperoxaluric rat tissues showed a greater percentage adsorption. Microsomes were enriched with the 20 kDa protein, while nuclei contained the 23 kDa protein in higher concentrations. COM-binding proteins derived from hyperoxaluric rat kidney had a greater content of 74 kDa and 23 kDa proteins with increased oxalate-binding activities. In the crystal-growth studies, the 74 kDa protein was a promoter, while the other protein fractions inhibited crystallization. In hyperoxaluria, the crystal-growth promoting activity of the 74 kDa protein was further increased, while the inhibition by the 20 and 23 kDa proteins was decreased. The 74 kDa protein derived from control rats formed single COM crystals in a crystal growth system, while the hyperoxaluric rat fraction induced the aggregation of COM crystals.

CONCLUSION

COM-binding proteins (the 74 and 23 kDa fractions) were expressed more in hyperoxaluric rats. In hyperoxaluria the 74 kDa protein tended to promote crystal nucleation and aggregation, and the 20 and 23 kDa proteins were less inhibitory, which increases the risk of stone formation.

Identification of hyaluronan as a crystal-binding molecule at the surface of migrating and proliferating MDCK cells

BACKGROUND

The adherence of calcium oxalate crystals to the renal tubule epithelium is considered a critical event in the pathophysiology of calcium nephrolithiasis. Calcium oxalate monohydrate (COM) crystals cannot adhere to the surface of a functional Madin-Darby canine kidney (MDCK) monolayer, but they bind avidly to the surface of proliferating and migrating cells.

METHODS

To identify crystal-binding molecules (CBMs) at the surface of crystal-attracting cells, we applied metabolic labeling protocols in combination with differential enzymatic digestion and gel filtration, which was compared with [14C]COM crystal binding and confirmed by confocal microscopy.

RESULTS

The indication that hyaluronan [hyaluronic acid (HA)] might act as a CBM in subconfluent cultures came from studies with glycosaminoglycan (GAG)-degrading enzymes. Subsequently, metabolic-labeling studies revealed that hyaluronidase cleaved significantly more radiolabeled glycoconjugates from crystal-attracting cells than from cells without affinity for crystals. During wound repair, crystal binding could be prevented by pretreating the healing cultures with hyaluronate lyase, an enzyme that specifically hydrolyzes HA. Binding to immobilized HA provided evidence that COM crystals physically can become associated with this polysaccharide. Finally, confocal microscopy demonstrated that fluorescently labeled HA binding protein (HABP) adhered to the surface of proliferating cells in subconfluent cultures as well as to cells involved in closing a wound, but not to cells in confluent monolayers.

CONCLUSIONS

These results identify HA as binding molecule for COM crystals at the surface of migrating and proliferating MDCK cells.

Bladder calculi in augmentation cystoplasty in children

OBJECTIVES

To determine the best preventive strategies for bladder calculi in children with an augmented bladder, the risk factors and prevention strategies for urolithiasis were evaluated.

METHODS

The records of 89 patients following augmentation cystoplasty were reviewed to assess the results of augmentation cystoplasties and in particular the formation and prevention of calculi.

RESULTS

The median follow-up was 4.9 years after augmentation. Most patients (71) had an ileocystoplasty. Bladder calculi occurred in 14 of the 89 patients (16%) and recurred in 4 patients. Girls had a higher incidence of urolithiasis. Other risk factors were cloacal malformations, vaginal reconstructions, anal atresia, clean intermittent catheterization problems and retention, bladder neck surgery, and symptomatic urinary tract infections.

CONCLUSIONS

Subgroups with cloacal malformations, vaginal reconstructions, ureter reimplantation, and bladder neck surgery were identified that have an increased risk for stone formation and therefore warrant special care in the follow-up after augmentation. This care should include clear emphasis on the role of treating symptomatic urinary tract infections, especially in patients with cloacal malformations and vaginal reconstructions. Girls have a higher incidence of bladder calculi than boys.

Circulating adhesion molecules and neutral endopeptidase enzymuria in patients with urolithiasis and hydronephrosis

OBJECTIVES

To measure the concentrations of adhesion molecules (intercellular adhesion molecule-1 ¿ICAM-1, E-selectin, and L-selectin) in the serum of patients with renal stones and patients with hydronephrosis caused by obstructive ureteral stones. Renal tubular enzymes were examined from their urine samples to evaluate whether neutral endopeptidase (NEP) behaved as traditional tubular enzyme markers (N-acetyl-beta-glucosaminidase ¿NAG and beta-galactosidase ¿beta-GAL) in their disease state.

METHODS

Three groups were studied. Group 1 included 15 normal volunteers, group 2 included 12 patients with ureteral stones and ipsilateral hydronephrosis, and group 3 included 17 patients with renal stones in one kidney without hydronephrosis or hydrocalycosis. A single, overnight fasting blood and urine sample was collected from each subject. Serum levels of ICAM-1, E-selectin, and L-selectin were measured by enzyme-linked immunosorbent assay. NEP, NAG, and beta-GAL were measured from urine samples, and the enzyme activities were expressed per gram of creatinine.

RESULTS

Serum levels of ICAM-1 were higher in groups 2 and 3 (522 +/- 95 and 329 +/- 42 ng/mL, respectively), but the differences were only significant between group 2 and group 1 (263 +/- 32 ng/mL) and group 2 and group 3 (P <0.05). Serum levels of L-selectin were lower in group 3 and were significantly different when compared with groups 1 and 2 (P <0. 05). The serum levels of E-selectin were not significantly different among these three groups. Urinary levels of NEP were lower in group 2, although the levels of NAG and beta-GAL were more elevated than in group 1.

CONCLUSIONS

Serum levels of ICAM-1 were elevated in patients with unilateral hydronephrosis caused by a ureteral stone, and E-selectin and L-selectin levels did not change significantly. These findings suggest that ICAM-1 may play a role in renal immune injury to ureteral obstruction. The urinary NEP values were lower in patients with hydronephrosis caused by ureteral stones, and the traditional lysosomal enzymes were increased. The lower urinary NEP values might suggest impairment of ipsilateral renal function. Renal stones per se resulted in no significant changes in serum adhesion molecule levels, although the levels of L-selectin were significantly decreased.

Regulation of renal epithelial cell affinity for calcium oxalate monohydrate crystals

The binding and internalization of calcium oxalate monohydrate (COM) crystals by tubular epithelial cells may be a critical step leading to kidney stone formation. Exposure of MDCK cells to arachidonic acid (AA) for 3 days, but not oleic or linoleic acid, decreased COM crystal adhesion by 55%. Exogenous prostaglandin PGE(1) or PGE(2) decreased crystal binding 96% within 8 h, as did other agents that raise intracellular cAMP. Actinomycin D, cycloheximide, or tunicamycin each blocked the action of PGE(2), suggesting that gene transcription, protein synthesis, and N-glycosylation were required. Blockade of crystal binding by AA was not prevented by the cyclooxygenase inhibitor flurbiprofen, and was mimicked by the nonmetabolizable AA analog eicosatetryanoic acid (ETYA), suggesting that generation of PGE from AA is not the pathway by which AA exerts its effect. These studies provide new evidence that binding of COM crystals to renal cells is regulated by physiological signals that could modify exposure of cell surface molecules to which the crystals bind. Intrarenal AA, PGs, and/or other agents that raise the intracellular concentration of cAMP may serve a protective function by preventing crystal adhesion along the nephron, thereby defending the kidney against crystal retention and stone formation.

The effects of human urine on the adhesion of calcium oxalate crystal to Madin-Darby canine kidney cells

OBJECTIVE

To determine the effect of human urine on the adhesion of calcium oxalate monohydrate (COM) crystals to Madin-Darby canine kidney (MDCK) cells in a model system in vitro.

MATERIALS AND METHODS

MDCK cells were exposed to COM crystals in the presence of various human urine samples. COM crystals adhering on MDCK cells were quantified by measuring the calcium concentration using atomic absorption analysis. The inhibitory activities were estimated individually for various urine samples from healthy subjects and recurrent stone formers.

RESULTS

Human urine inhibited the adhesion of COM crystals to MDCK cells, with some variations between individual samples. The most potent inhibition of crystal adhesion was expressed by the macromolecular fraction of the urine. Pretreatment of crystals with human urine before exposure to the cells significantly reduced crystal adhesion, suggesting that human urine altered the properties of the crystal surface but not the cell surface.

CONCLUSION

Coating of the crystals by some component(s) of human urine might be an important physiological event in preventing adhesion or retention of crystals in the renal tubules. Although the mechanisms by which crystal adhesion is prevented are unknown, a low potential for inhibiting adhesion may be a risk factor in stone formation because it permits crystal adhesion and retention in the tubules.

Cell type-specific acquired protection from crystal adherence by renal tubule cells in culture

BACKGROUND

Adherence of crystals to the surface of renal tubule epithelial cells is considered an important step in the development of nephrolithiasis. Previously, we demonstrated that functional monolayers formed by the renal tubule cell line, Madin-Darby canine kidney (MDCK), acquire protection against the adherence of calcium oxalate monohydrate crystals. We now examined whether this property is cell type specific. The susceptibility of the cells to crystal binding was further studied under different culture conditions.

METHODS

Cell-type specificity and the influence of the growth substrate was tested by comparing calcium oxalate monohydrate crystal binding to LLC-PK1 cells and to two MDCK strains cultured on either permeable or impermeable supports. These cell lines are representative for the renal proximal tubule (LLC-PK1) and distal tubule/collecting duct (MDCK) segments of the nephron, in which crystals are expected to be absent and present, respectively.

RESULTS

Whereas relatively large amounts of crystals adhered to subconfluent MDCK cultures, the level of crystal binding to confluent monolayers was reduced for both MDCK strains. On permeable supports, MDCK cells not only obtained a higher level of morphological differentiation, but also acquired a higher degree of protection than on impermeable surfaces. Crystals avidly adhered to LLC-PK1 cells, irrespective of their developmental stage or growth substrate used.

CONCLUSIONS

These results show that the prevention of crystal binding is cell type specific and expressed only by differentiated MDCK cells. The anti-adherence properties acquired by MDCK cells may mirror a specific functional characteristic of its in situ equivalent, the renal distal tubule/collecting ducts.

Effects of etidronate disodium on crystallizations in synthetic urine and calcium oxalate crystal adhesion to Madin-Darby canine kidney (MDCK) cells

BACKGROUND

Several reports in the 1970s suggested that etidronate disodium might be clinically useful to prevent calcium stones, but the use of etidronate in the urolithiasis field was discontinued due to adverse effects of this drug on skeletal turnover and mineralization. Because the drug might affect not only crystallization, but also crystal-tubular interactions, we investigated the minimum dose of etidronate necessary to effectively prevent stone recurrence without adverse side effects.

METHODS

We examined the effect of etidronate on the crystallization of calcium oxalate, calcium phosphate and magnesium ammonium phosphate using synthetic urine and measured by an aggregometer. We also studied its effect on the adhesion of calcium oxalate monohydrate crystals to Madin-Darby canine kidney (MDCK) cells in vitro.

RESULTS

Etidronate affected the crystallization+ of not only calcium phosphate and calcium oxalate, but also magnesium ammonium phosphate in synthetic urine. The inhibitory activities on these crystallizations were detected at extremely low drug concentrations. Etidronate also had a strong inhibitory activity against the adhesion of calcium oxalate crystals to MDCK cells.

CONCLUSION

Although further studies are necessary regarding the effects of etidronate on crystallization and crystal adhesion both in vivo and in vitro, and the appropriate schedule of dosing to prevent side effects, it is possible that etidronate may be useful in the treatment of urinary stones.

Direct nucleation of calcium oxalate dihydrate crystals onto the surface of living renal epithelial cells in culture

BACKGROUND

The interaction of the most common crystal in human urine, calcium oxalate dihydrate (COD), with the surface of monkey renal epithelial cells (BSC-1 line) was studied to identify initiating events in kidney stone formation.

METHODS

To determine if COD crystals could nucleate directly onto the apical cell surface, a novel technique utilizing vapor diffusion of oxalic acid was employed. Cells were grown to confluence in the inner four wells of 24-well plates. At the start of each experiment, diethyloxalate in water was placed into eight adjacent wells, and the plates were sealed tightly with tape so that oxalic acid vapor diffused into a calcium-containing buffer overlying the cells.

RESULTS

Small crystals were visualized on the cell surface after two hours, and by six hours the unambiguous habitus of COD was confirmed. Nucleation onto cells occurred almost exclusively via the (001) face, one that is only rarely observed when COD crystals nucleate onto inanimate surfaces. Similar results were obtained when canine renal epithelial cells (MDCK line) were used as a substrate for nucleation. Initially, COD crystals were internalized almost as quickly as they formed on the apical cell surface.

CONCLUSIONS

Face-specific COD crystal nucleation onto the apical surface of living renal epithelial cells followed by internalization is a heretofore unrecognized physiological event, suggesting a new mechanism to explain crystal retention within the nephron, and perhaps kidney stone formation when this process is dysregulated or overwhelmed.

Increased calcium oxalate monohydrate crystal binding to injured renal tubular epithelial cells in culture

The retention of crystals in the kidney is considered to be a crucial step in the development of a renal stone. This study demonstrates the time-dependent alterations in the extent of calcium oxalate (CaOx) monohydrate (COM) crystal binding to Madin-Darby canine kidney (MDCK) cells during their growth to confluence and during the healing of wounds made in confluent monolayers. As determined by radiolabeled COM crystal binding studies and confirmed by confocal-scanning laser microscopy, relatively large amounts of crystals (10.4 +/- 0.4 micrograms/cm2) bound to subconfluent cultures that still exhibited a low transepithelial electrical resistance (TER < 400 omega.cm2). The development of junctional integrity, indicated by a high resistance (TER > 1,500 omega.cm2), was followed by a decrease of the crystal binding capacity to almost undetectable low levels (0.13 +/- 0.03 microgram/cm2). Epithelial injury resulted in increased crystal adherence. The highest level of crystal binding was observed 2 days postinjury when the wounds were already morphologically closed but TER was still low. Confocal images showed that during the repair process, crystals selectively adhered to migrating cells at the wound border and to stacked cells at sites were the wounds were closed. After the barrier integrity was restored, crystal binding decreased again to the same low levels as in undamaged controls. These results indicate that, whereas functional MDCK monolayers are largely protected against COM crystal adherence, epithelial injury and the subsequent process of wound healing lead to increased crystal binding.

Adhesion, internalization and metabolism of calcium oxalate monohydrate crystals by renal epithelial cells

The interaction between crystals that nucleate in the nephron lumen and tubular cells could be an important determinant of renal calcification. Kidney epithelial cells in monolayer culture (BSC-1 line), used to model the tubule, rapidly bound and internalized crystals of calcium oxalate monohydrate (COM), the most common constituent of renal stones. Transmission and scanning electron microscopy, enzyme histochemistry, and kinetic analysis of [14C]-labeled crystals were used to study the interaction between renal cells and COM crystals. Electron microscopy revealed that adherent crystals on the apical cell surface can serve as sites for aggregation of additional crystals. Enhanced binding of exogenous crystals to plasma membrane domains overlying internalized crystals was observed for at least 24 hours after the initial cell-crystal interaction. Following internalization, crystals appeared to dissolve within lysosomal inclusion bodies during the ensuing five to seven weeks. Over this time, many cells still containing crystals clustered together in the monolayer. These observations suggest that adhesion and internalization can promote crystal retention in the nephron, whereas intracellular dissolution of crystals may serve as an important, hitherto unrecognized defense against pathologic renal calcification.

Renal cell osteopontin production is stimulated by calcium oxalate monohydrate crystals

Specific anions in tubular fluid, including uropontin (UP), the urinary form of human osteopontin (OPN), block adhesion to renal tubular cells of the most common crystal in kidney stones, calcium oxalate monohydrate (COM). In this study, monkey renal epithelial cells (BSC-1 line) in monolayer culture constitutively secreted UP into the culture medium. COM crystals added to the medium avidly bound previously secreted UP, reducing its concentration by 46% one hour later. However, the net UP content of cultures after a 24-hour exposure to COM crystals was increased by 18%. Northern blotting showed that the constitutively expressed gene encoding human OPN was maximally stimulated in BSC-1 cells after exposure to COM crystals for 12 hours. Two other calcium-containing crystals, hydroxyapatite and brushite, did not alter OPN gene expression or protein production. OPN mRNA expression was enhanced in canine renal epithelial cells (MDCK line) after exposure to COM crystals for six hours, whereas the constitutive expression of murine OPN mRNA by 3T3 fibroblasts was unchanged. In vivo this glycoprotein could defend the cell against adhesion of crystals in tubular fluid, and/or promote renal interstitial fibrosis in subjects with heavy crystalluria.

Oxalate transport and calcium oxalate renal stone disease

Hyperoxaluria is considered to play a crucial role in calcium oxalate (CaOx) renal stone disease. The amount of oxalate excreted into the urine depends on intestinal absorption, endogenous production, renal clearance and renal tubular transport. Since a primary disorder has not been found so far in most CaOx stone formers and since oxalate is freely filtered at the glomerulus, most studies are presently focussed on alterations in epithelial oxalate transport pathways. Oxalate can be transported across an epithelium by the paracellular (passive) and transcellular (active) pathway. Oxalate transport across cellular membranes is mediated by anion-exchange transport proteins. A defect in the structure of these transport proteins could explain augmented transcellular oxalate transport. Little is known about the physiological regulation of oxalate transport. In this review cellular transport systems for oxalate will be summarized with special attention for the progress that has been made to study oxalate transport in a model of cultured renal tubule cells. Better understanding of the physiological processes that are involved in oxalate transport could yield information on the basis of which it might be possible to design new approaches for an effective treatment of CaOx stone disease.

Cell cultures and nephrolithiasis

While the physical chemistry of stone formation has been intensively studied during the last decade, it has become clear that the pathophysiology of renal stone disease cannot be explained by crystallization processes only. In recent years, evidence has emerged that the cells lining the renal tubules can have an active role in creating the conditions under which stones may develop. Since it is difficult to study these mechanisms in vivo, cultured renal tubular cells have become increasingly popular for the study of physiological and cell biological processes that are possibly linked to stone disease. In this paper, we discuss the possible contribution of cellular processes such as transepithelial oxalate transport and crystal--cell interaction to the formation of renal stones. Experimental studies that have been performed with cultured renal cells to elucidate the mechanisms involved in these processes will be summarized.

Oxalate transport and calcium oxalate renal stone disease

Hyperoxaluria is considered to play a crucial role in calcium oxalate (CaOx) renal stone disease. The amount of oxalate excreted into the urine depends on intestinal absorption, endogenous production, renal clearance and renal tubular transport. Since a primary disorder has not been found so far in most CaOx stone formers and since oxalate is freely filtered at the glomerulus, most studies are presently focussed on alterations in epithelial oxalate transport pathways. Oxalate can be transported across an epithelium by the paracellular (passive) and transcellular (active) pathway. Oxalate transport across cellular membranes is mediated by anion-exchange transport proteins. A defect in the structure of these transport proteins could explain augmented transcellular oxalate transport. Little is known about the physiological regulation of oxalate transport. In this review cellular transport systems for oxalate will be summarized with special attention for the progress that has been made to study oxalate transport in a model of cultured renal tubule cells. Better understanding of the physiological processes that are involved in oxalate transport could yield information on the basis of which it might be possible to design new approaches for an effective treatment of CaOx stone disease.