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Aydin Z, Bilgin H, Cilasun C, Aydin IH. Hypouricemia with recurrent nephrolithiasis: an overlooked entity: Answers. Pediatr Nephrol 2023; 38:3283-3284. [PMID: 37140710 DOI: 10.1007/s00467-023-06003-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/20/2023] [Accepted: 04/20/2023] [Indexed: 05/05/2023]
Affiliation(s)
- Zehra Aydin
- Department of Nephrology, Batman Training and Research Hospital, Batman, Turkey.
| | - Huseyin Bilgin
- Department of Pediatric Metabolism and Nutrition, Diyarbakir Children's Hospital, Diyarbakir, Turkey
| | - Ceyda Cilasun
- Department of Pediatric Metabolism and Nutrition, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Ilyas Halil Aydin
- Department of Pediatric Surgery, Ankara Etlik City Hospital, Ankara, Turkey
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Meagher MF, Bechis SK. Recurrent Xanthine Stones in a Young Patient with Lesch-Nyhan Syndrome. J Endourol Case Rep 2021; 6:268-270. [PMID: 33457651 DOI: 10.1089/cren.2020.0046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Lesch-Nyhan syndrome results from a rare X-linked inborn error of metabolism leading to a total body accumulation of uric acid. Clinical manifestations include self-mutilating behavior, poor muscle control, intellectual disability, gout, and kidney disease. Unfortunately, life expectancy is limited to the second or third decade of life because of symptoms associated with hyperuricemia, particularly renal failure. Patients with this condition frequently necessitate urologic intervention as the buildup of lithogenic substances predispose individuals to the development of kidney and bladder stones. Case Presentation: We present the case of a 23-year-old white man with known Lesch-Nyhan syndrome and recurrent bilateral xanthine stones despite repeated urologic interventions. Conclusion: Therapy for Lesch-Nyhan syndrome consists of reduction of uric acid achieved through allopurinol. However, excess allopurinol dosing can lead to development of xanthine kidney and bladder stones. Thus, the treating clinician must maintain a delicate balance between managing hyperuricemia and avoiding xanthine urolithiasis.
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Affiliation(s)
- Margaret F Meagher
- Department of Urology, UC San Diego School of Medicine, La Jolla, California, USA
| | - Seth K Bechis
- Department of Urology, Comprehensive Kidney Stone Center, UC San Diego Health, San Diego, California, USA
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Sighinolfi MC, Eissa A, Bevilacqua L, Zoeir A, Ciarlariello S, Morini E, Puliatti S, Durante V, Ceccarelli PL, Micali S, Bianchi G, Rocco B. Drug-Induced Urolithiasis in Pediatric Patients. Paediatr Drugs 2019; 21:323-344. [PMID: 31541411 DOI: 10.1007/s40272-019-00355-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Drug-induced nephrolithiasis is a rare condition in children. The involved drugs may be divided into two different categories according to the mechanism involved in calculi formation. The first one includes poorly soluble drugs that favor the crystallization and calculi formation. The second category includes drugs that enhance calculi formation through their metabolic effects. The diagnosis of these specific calculi depends on a detailed medical history, associated comorbidities and the patient's history of drug consumption. There are several risk factors associated with drug-induced stones, such as high dose of consumed drugs and long duration of treatment. Moreover, there are some specific risk factors, including urinary pH and the amount of fluid consumed by children. There are limited data regarding pediatric lithogenic drugs, and hence, our aim was to perform a comprehensive review of the literature to summarize these drugs and identify the possible mechanisms involved in calculi formation and discuss the management and preventive measures for these calculi.
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Affiliation(s)
- Maria Chiara Sighinolfi
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy.
| | - Ahmed Eissa
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
- Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Luigi Bevilacqua
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Ahmed Zoeir
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
- Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Silvia Ciarlariello
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Elena Morini
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Stefano Puliatti
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Viviana Durante
- Pediatric Surgery Department, University of Modena & Reggio Emilia, Modena, Italy
| | - Pier Luca Ceccarelli
- Pediatric Surgery Department, University of Modena & Reggio Emilia, Modena, Italy
| | - Salvatore Micali
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Giampaolo Bianchi
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Bernardo Rocco
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
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Madeo A, Di Rocco M, Brassier A, Bahi-Buisson N, De Lonlay P, Ceballos-Picot I. Clinical, biochemical and genetic characteristics of a cohort of 101 French and Italian patients with HPRT deficiency. Mol Genet Metab 2019; 127:147-157. [PMID: 31182398 DOI: 10.1016/j.ymgme.2019.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/31/2019] [Accepted: 06/01/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND HPRT deficiency is a rare disorder of purine metabolism whose natural history is not fully understood. No optimal management recommendations exist. The objective of the present study is to characterize a large cohort of patients with HPRT deficiency, comparing Lesch-Nyhan Disease (LND) and its attenuated variants, with the purpose of helping clinicians in disease management and prognostic definition. METHODS Genetic and clinical features of French and Italian patients with a confirmed diagnosis of HPRT deficiency were collected. RESULTS A hundred and one patients were studied, including 66 LND, 22 HND (HPRT-related Neurological Dysfunction) and 13 HRH (HPRT-Related Hyperuricemia) patients. The clinical manifestations at onset were not specific, but associated with an orange coloration of diapers in 22% of patients. The overall neurological involvement was more severe in LND than in HND patients. Behavioural disturbances were not limited to self-injuries and were not exclusive of LND. Median age of involuntary movements and self-injuries appearance in LND was 1.0 and 3 years, respectively. Renal manifestations (66.3% of patients) occurred at any age with a median onset age of 1.1 years, while gout (25.7% of patients) appeared later in disease course (median onset age 18 years) and was more frequent in attenuated variants than in LND. HPRT activity and genotype showed a significant correlation with the severity of the neurological disease. On the contrary, there were no significant differences in the development of nephropathy or gout. For the treatment of neurological aspects, botulinum toxin injections, oral or intrathecal baclofen and gabapentin were partially efficacious and well tolerated, while deep brain stimulation was associated to a worsening of patients' condition. CONCLUSIONS The present study improves the knowledge of the natural history of HPRT deficiency and could represent a starting point for the development of future management guidelines.
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Affiliation(s)
- Annalisa Madeo
- Department of Pediatrics, Unit of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Maja Di Rocco
- Department of Pediatrics, Unit of Rare Diseases, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Anaïs Brassier
- Reference Centre of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Imagine, University Paris Descartes, INEM, INSERM 1151, Filière G2M, MetabERN, Paris, France
| | - Nadia Bahi-Buisson
- Pediatric Neurology, Hospital Necker Enfants Malades, APHP, University Paris Descartes, Paris, France
| | - Pascale De Lonlay
- Reference Centre of Inherited Metabolic Diseases, Hospital Necker Enfants Malades, APHP, Imagine, University Paris Descartes, INEM, INSERM 1151, Filière G2M, MetabERN, Paris, France
| | - Irène Ceballos-Picot
- Metabolic Biochemistry Laboratory, Hospital Necker Enfants Malades, APHP, University Paris Descartes, Paris, France
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Ng N, Kaur A, Shenoy M. Recurrent kidney stones in a child with Lesch-Nyhan syndrome: Answers. Pediatr Nephrol 2019; 34:425-427. [PMID: 30112657 DOI: 10.1007/s00467-018-4037-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 07/24/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Natasha Ng
- Royal Manchester Children's Hospital, Manchester, M13 9WL, UK.
| | - Amrit Kaur
- Royal Manchester Children's Hospital, Manchester, M13 9WL, UK
| | - Mohan Shenoy
- Royal Manchester Children's Hospital, Manchester, M13 9WL, UK
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6
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Shields LBE, Peppas DS, Rosenberg E. Xanthine calculi in a patient with Lesch-Nyhan syndrome and factor V Leiden treated with allopurinol: case report. BMC Pediatr 2018; 18:231. [PMID: 30001695 PMCID: PMC6043999 DOI: 10.1186/s12887-018-1197-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 06/27/2018] [Indexed: 11/10/2022] Open
Abstract
Background Lesch-Nyhan syndrome is a rare inborn error of purine metabolism marked by a complete deficiency of the enzyme hypoxanthine-guanine phosphoribosyltransferase (HPRT). Inherited as an X-linked recessive genetic disorder that primarily affects males, patients with Lesch-Nyhan syndrome exhibit severe neurological impairments, including choreoathetosis, ballismus, cognitive dysfunction, and self-injurious behavior. Uric acid levels are usually abnormally high, leading to kidney and bladder stones which often necessitate urological intervention. Factor V Leiden is an autosomal dominant disorder of blood clotting associated with hypercoagulability, thrombophilia, and renal disease. Case presentation We present the first reported case of xanthine calculi in a patient with Lesch-Nyhan syndrome and Factor V Leiden who was treated with allopurinol. A renal ultrasound and CT scan demonstrated bilateral staghorn calculi in the kidneys as well as nephrocalcinosis. Two years earlier the patient underwent cystoscopy with bilateral ureteroscopy and laser lithotripsy, and he was stone free afterwards. The patient subsequently underwent bilateral percutaneous nephrolithotomy (PCNL) and was stone free following the procedure. Patients with endogenous overproduction of uric acid who are being treated with allopurinol have a higher chance of developing xanthine stones. Conclusions Pediatricians treating these children should be aware of these rare conditions and promptly manage the potential complications that may require medical or surgical intervention.
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Affiliation(s)
- Lisa B E Shields
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY, 40202, USA
| | - Dennis S Peppas
- Norton Children's Urology, Norton Healthcare, Louisville, KY, 40207, USA
| | - Eran Rosenberg
- Norton Children's Urology, Norton Healthcare, Louisville, KY, 40207, USA.
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7
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Ronda L, Marchetti M, Piano R, Liuzzi A, Corsini R, Percudani R, Bettati S. A Trivalent Enzymatic System for Uricolytic Therapy of HPRT Deficiency and Lesch-Nyhan Disease. Pharm Res 2017; 34:1477-1490. [PMID: 28508122 PMCID: PMC5445154 DOI: 10.1007/s11095-017-2167-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/25/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE Because of the evolutionary loss of the uricolytic pathway, humans accumulate poorly soluble urate as the final product of purine catabolism. Restoration of uricolysis through enzyme therapy is a promising treatment for severe hyperuricemia caused by deficiency of hypoxanthine-guanine phosphoribosyltransferase (HPRT). To this end, we studied the effect of PEG conjugation on the activity and stability of the enzymatic complement required for conversion of urate into the more soluble (S)-allantoin. METHODS We produced in recombinant form three zebrafish enzymes required in the uricolytic pathway. We carried out a systematic study of the effect of PEGylation on the function and stability of the three enzymes by varying PEG length, chemistry and degree of conjugation. We assayed in vitro the uricolytic activity of the PEGylated enzymatic triad. RESULTS We defined conditions that allow PEGylated enzymes to retain native-like enzymatic activity even after lyophilization or prolonged storage. A combination of the three enzymes in an appropriate ratio allowed efficient conversion of urate to (S)-allantoin with no accumulation of intermediate metabolites. CONCLUSIONS Pharmaceutical restoration of the uricolytic pathway is a viable approach for the treatment of severe hyperuricemia.
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Affiliation(s)
- Luca Ronda
- Department of Medicine and Surgery,, University of Parma, Parco Area delle Scienze 23/A, 43124, Parma, Italy
| | - Marialaura Marchetti
- Department of Chemistry, Life Sciences, and Environmental Sustainability, University of Parma,, Parco Area delle Scienze 23/A, 43124, Parma, Italy
| | - Riccardo Piano
- Department of Medicine and Surgery,, University of Parma, Parco Area delle Scienze 23/A, 43124, Parma, Italy
| | - Anastasia Liuzzi
- Department of Chemistry, Life Sciences, and Environmental Sustainability, University of Parma,, Parco Area delle Scienze 23/A, 43124, Parma, Italy
| | - Romina Corsini
- Department of Chemistry, Life Sciences, and Environmental Sustainability, University of Parma,, Parco Area delle Scienze 23/A, 43124, Parma, Italy
| | - Riccardo Percudani
- Department of Chemistry, Life Sciences, and Environmental Sustainability, University of Parma,, Parco Area delle Scienze 23/A, 43124, Parma, Italy.
| | - Stefano Bettati
- Department of Medicine and Surgery,, University of Parma, Parco Area delle Scienze 23/A, 43124, Parma, Italy. .,National Institute of Biostructures and Biosystems, Viale Medaglie d'Oro 305, 00136, Rome, Italy.
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Zennaro C, Tonon F, Zarattini P, Clai M, Corbelli A, Carraro M, Marchetti M, Ronda L, Paredi G, Rastaldi MP, Percudani R. The renal phenotype of allopurinol-treated HPRT-deficient mouse. PLoS One 2017; 12:e0173512. [PMID: 28282408 PMCID: PMC5345830 DOI: 10.1371/journal.pone.0173512] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 02/21/2017] [Indexed: 12/02/2022] Open
Abstract
Excess of uric acid is mainly treated with xanthine oxidase (XO) inhibitors, also called uricostatics because they block the conversion of hypoxanthine and xanthine into urate. Normally, accumulation of upstream metabolites is prevented by the hypoxanthine-guanine phosphoribosyltransferase (HPRT) enzyme. The recycling pathway, however, is impaired in the presence of HPRT deficiency, as observed in Lesch-Nyhan disease. To gain insights into the consequences of purine accumulation with HPRT deficiency, we investigated the effects of the XO inhibitor allopurinol in Hprt-lacking (HPRT-/-) mice. Allopurinol was administered in the drinking water of E12-E14 pregnant mothers at dosages of 150 or 75 μg/ml, and mice sacrificed after weaning. The drug was well tolerated by wild-type animals and heterozygous HPRT+/- mice. Instead, a profound alteration of the renal function was observed in the HPRT-/- model. Increased hypoxanthine and xanthine concentrations were found in the blood. The kidneys showed a yellowish appearance, diffuse interstitial nephritis, with dilated tubules, inflammatory and fibrotic changes of the interstitium. There were numerous xanthine tubular crystals, as determined by HPLC analysis. Oil red O staining demonstrated lipid accumulation in the same location of xanthine deposits. mRNA analysis showed increased expression of adipogenesis-related molecules as well as profibrotic and proinflammatory pathways. Immunostaining showed numerous monocyte-macrophages and overexpression of alpha-smooth muscle actin in the tubulointerstitium. In vitro, addition of xanthine to tubular cells caused diffuse oil red O positivity and modification of the cell phenotype, with loss of epithelial features and appearance of mesenchymal characteristics, similarly to what was observed in vivo. Our results indicate that in the absence of HPRT, blockade of XO by allopurinol causes rapidly developing renal failure due to xanthine deposition within the mouse kidney. Xanthine seems to be directly involved in promoting lipid accumulation and subsequent phenotype changes of tubular cells, with activation of inflammation and fibrosis.
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Affiliation(s)
- Cristina Zennaro
- Department of Medical, Surgery and Health Sciences, Università degli Studi di Trieste, Trieste, Italy
| | - Federica Tonon
- Department of Medical, Surgery and Health Sciences, Università degli Studi di Trieste, Trieste, Italy
| | - Paola Zarattini
- Department of Life Sciences, Università degli Studi di Trieste, Trieste, Trieste, Italy
| | - Milan Clai
- Department of Pathology and Legal Medicine, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Alessandro Corbelli
- Unit of Bio-imaging, Department of Cardiovascular Research, IRCCS Mario Negri Institute for Pharmacological Research, Milano, Italy
| | - Michele Carraro
- Department of Medical, Surgery and Health Sciences, Università degli Studi di Trieste, Trieste, Italy
| | | | - Luca Ronda
- Department of Neurosciences, University of Parma, Parma, Italy
| | - Gianluca Paredi
- Department of Pharmacy and SITEIA, PARMA Interdepartmental Center, University of Parma, Parma, Italy
| | - Maria Pia Rastaldi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
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9
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An unusual case of renal failure: Answers. Pediatr Nephrol 2017; 32:79-80. [PMID: 26754040 DOI: 10.1007/s00467-015-3300-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 11/28/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022]
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10
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Vargiami E, Printza N, Papadimiditriou E, Batzios S, Kyriazi M, Papachristou F, Zafeiriou DI. Nephrocalcinosis and Renal Failure in Lesch-Nyhan Syndrome: Report of Two Familial Cases and Review of the Literature. Urology 2016; 97:194-196. [PMID: 27079129 DOI: 10.1016/j.urology.2016.04.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Revised: 02/18/2016] [Accepted: 04/04/2016] [Indexed: 11/15/2022]
Abstract
Lesch-Nyhan syndrome is an X-linked recessive inborn error of purine metabolism, due to deficiency of the enzyme HPRT (hypoxanthine-guanine phosphoribosyl transferase) and underlying HPRT gene mutations (over 300 mutations identified up to date). It is characterized by a wide range of neurological symptoms and signs (mainly a combination of spastic diplegia with choreoathetosis and an overall psychomotor redardation). Herein, we report of two cousins with Lesch-Nyhan syndrome and a confirmed novel HPRT gene mutation: c.65T>C, who both developed nephrocalcinosis and renal failure, findings not been previously published in children with HPRT deficiency.
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Affiliation(s)
- Euthymia Vargiami
- 1st Department of Pediatrics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Nikoleta Printza
- 1st Department of Pediatrics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Papadimiditriou
- 1st Department of Pediatrics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Spyros Batzios
- 1st Department of Pediatrics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Kyriazi
- 1st Department of Pediatrics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Fotios Papachristou
- 1st Department of Pediatrics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios I Zafeiriou
- 1st Department of Pediatrics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Furman E, Hooijberg EH, Leidinger E, Zedinger C, Giger U, Leidinger J. Hereditary xanthinuria and urolithiasis in a domestic shorthair cat. ACTA ACUST UNITED AC 2015; 24:1325-1329. [PMID: 26478726 DOI: 10.1007/s00580-015-2072-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
A 2-year-old domestic shorthair cat was presented with a history of hematuria, stranguria and intermittent urethral obstruction. Urine sediment showed hematuria, pyuria, and yellow-brown, amorphous and spherical crystals. Upon surgical correction of the obstructed urethra by perineal urethrostomy, many dark yellow to grey, irregular, gravel-like to millet grain-sized uroliths, consisting of 100% xanthine by crystallography were found. The urinary xanthine concentration was high. The cat subsequently developed bilateral nephroliths, recurrent urinary tract infection, and chronic kidney failure. Dietary management with a low-purine diet failed in part due to poor compliance, and the cat was euthanized at 6 years of age. Xanthinuria is rare inborn error of metabolism in cats and other species but should be considered as a differential diagnosis in cases of feline urolithiasis. No associated molecular genetic defect has been elucidated, and management of these cases is difficult. In the absence of calculi for analysis, measuring urinary xanthine concentration can help in diagnosing this metabolic defect.
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Affiliation(s)
- E Furman
- Labor InVitro GmbH, Vienna, Austria
| | | | | | | | - U Giger
- School of Veterinary Medicine, University of Pennsylvania, USA
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Abstract
PURPOSE OF REVIEW Nephrolithiasis is a common systemic disease associated with both acute kidney injury (AKI) and chronic kidney disease (CKD). The purpose of this review is to discuss recent publications regarding nephrolithiasis-associated kidney damage, with an emphasis on AKI. RECENT FINDINGS Nephrolithiasis is not a common cause of adult AKI (1-2% of cases), although it may be a more important factor in young children (up to 30%). The primary mechanism of nephrolithiasis-associated AKI is obstructive nephropathy, and factors on presentation with obstructive uropathy predict the likelihood of long-term renal recovery. Crystalline nephropathy is another potential pathway in certain circumstances that is often associated with a worse outcome. Recent studies have elucidated additional pathways whereby calcium oxalate crystals can cause acute injury, implicating innate immunity and intracellular inflammasome pathways. Several large cohort studies have demonstrated an independent association of nephrolithiasis with CKD and end-stage renal disease, although the effect size is modest. Urologic comorbidities, urinary infection, and shared underlying risk factors (e.g., diabetes, hypertension) all impact nephrolithiasis-associated CKD risk. SUMMARY Obstructive nephropathy and crystalline nephropathy both contribute to nephrolithiasis-associated AKI, although the latter appears to have a worse prognosis. Nephrolithiasis is an independent, albeit small, risk factor for CKD. Further study is needed to clarify the incidence and mechanisms of nephrolithiasis-associated AKI, and the relationship between nephrolithiasis-associated AKI and CKD.
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Affiliation(s)
- Xiaojing Tang
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Division of Nephrology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
| | - John C. Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
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14
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Noone DG, Marks SD. Hyperuricemia is associated with hypertension, obesity, and albuminuria in children with chronic kidney disease. J Pediatr 2013; 162:128-32. [PMID: 22809658 DOI: 10.1016/j.jpeds.2012.06.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 04/25/2012] [Accepted: 06/04/2012] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the prevalence and associations of hyperuricemia in a cohort of pediatric patients with chronic kidney disease (CKD). STUDY DESIGN This was an observational cross-sectional study of clinical and laboratory data in pediatric patients being followed in a nephrology clinic. All patients with CKD were included. ORs and risk estimates of having stage III-V CKD (defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m(2)) with hyperuricemia were calculated. The relationships among eGFR, body mass index (BMI), and hyperuricemia were estimated using both correlation and regression models. RESULTS A total of 116 children (61% male), aged 0.4-17 years, were included in the analysis. The prevalence of hyperuricemia in those with an eGFR <60 mL/min/1.73 m(2) was 70%. Children with hyperuricemia were more likely to have an eGFR <60 mL/min/1.73 m(2) than those with a normal urate level (OR, 4.6) and were more likely to be hypertensive (OR, 2.1). Hyperuricemia was significantly associated with increased BMI, albuminuria, renal dysfunction with reduced eGFR, and hypertension. Significant linear relationships between eGFR and urate (P = .0001) and between BMI and urate (P = .0001) were detected. CONCLUSIONS Hyperuricemia is common in pediatric patients with CKD and is associated with renal dysfunction, hypertension, obesity, and albuminuria. Future prospective studies should be undertaken to further assess the role of hyperuricemia in pediatric patients with CKD.
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Affiliation(s)
- Damien G Noone
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children National Health Service Trust, London, United Kingdom
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15
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Torres RJ, Puig JG, Jinnah HA. Update on the phenotypic spectrum of Lesch-Nyhan disease and its attenuated variants. Curr Rheumatol Rep 2012; 14:189-94. [PMID: 22198833 PMCID: PMC3408650 DOI: 10.1007/s11926-011-0231-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Congenital deficiency of the enzyme hypoxanthine-guanine phosphoribosyltransferase (HPRT) results in a spectrum of clinical phenotypes. All of these phenotypes are associated with marked overproduction of uric acid and related problems such as hyperuricemia, urate nephrolithiasis, tophi, and gout. The mildest phenotypes include only problems related to overproduction of uric acid. The most severe phenotype is known as Lesch-Nyhan disease, in which the phenotype also includes severe motor handicap, intellectual disability, and self-injurious behavior. In between these two extremes is a continuous spectrum of phenotypes with varying degrees of motor and cognitive handicap but no self-injurious behavior. The pathogenesis of overproduction of uric acid in HPRT deficiency is well-understood, and treatments are available to control it. The pathogenesis of the neurobehavioral problems is less well-understood, and effective treatments for them are lacking.
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Affiliation(s)
- Rosa J. Torres
- Division of Clinical Biochemistry and Genetic Institute, Hospital Universitario La Paz, Universidad Autonoma de Madrid, Madrid, Spain
| | - Juan G. Puig
- Division of Internal Medicine, Hospital Universitario La Paz, IdiPaz, Madrid, Spain
| | - Hyder A. Jinnah
- Departments of Neurology, Human Genetics, and Pediatrics, Emory University School of Medicine, 101 Woodruff Circle, Atlanta, GA 30322, USA,
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16
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Chronic peritoneal dialysis in a 4-year-old boy with Lesch-Nyhan disease. Pediatr Nephrol 2009; 24:1089-90. [PMID: 19096880 DOI: 10.1007/s00467-008-1081-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 11/20/2008] [Accepted: 11/20/2008] [Indexed: 10/21/2022]
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17
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Pela I, Donati MA, Procopio E, Fiorini P. Lesch-Nyhan syndrome presenting with acute renal failure in a 3-day-old newborn. Pediatr Nephrol 2008; 23:155-8. [PMID: 17701224 DOI: 10.1007/s00467-007-0588-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Revised: 07/10/2007] [Accepted: 07/12/2007] [Indexed: 11/30/2022]
Abstract
Acute renal failure developed during the first 3 days after birth in a newborn subsequently diagnosed with hypoxanthine-guanine-phosphoribosyl-transferase (HPRT) deficiency. Fluid infusion and allopurinol therapy normalised renal function and serum uric acid levels. Only a few cases of acute renal failure due to acute hyperuricemic nephropathy related to HPRT deficiency have previously been reported in infants, and there are no reported cases in newborns as young as 3 days old.
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Affiliation(s)
- Ivana Pela
- Department of Paediatrics, University of Florence, Azienda Meyer, Florence, Italy.
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18
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Torres RJ, Prior C, Puig JG. Efficacy and safety of allopurinol in patients with hypoxanthine-guanine phosphoribosyltransferase deficiency. Metabolism 2007; 56:1179-86. [PMID: 17697859 DOI: 10.1016/j.metabol.2007.04.013] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2006] [Accepted: 04/05/2007] [Indexed: 11/20/2022]
Abstract
Hypoxanthine-guanine phosphoribosyltransferase (HPRT) deficiency is a genetic disease of purine metabolism resulting in uric acid overproduction. Allopurinol, which inhibits the enzyme xanthine oxidase and reduces uric acid synthesis, is widely used for the treatment of gout and uric acid overproduction. The aim of the study was to analyze the long-term efficacy and safety of allopurinol in patients with HPRT deficiency. Nineteen patients (13 with Lesch-Nyhan syndrome and 6 with partial HPRT deficiency) were treated with allopurinol (mean dose, 6.4 mg/kg body weight per day; range, 3.7-9.7 mg/kg body weight per day) and followed up for at least 12 months (mean follow-up, 7.6 years). The efficacy of allopurinol was evaluated by serial measurement of purine metabolic parameters and renal function as well as by clinical manifestations. Safety was assessed by recording adverse events. Treatment with allopurinol normalized serum urate level in all patients and resulted in a mean reduction in serum urate of 47%. Allopurinol treatment was associated with a mean 74% reduction in urinary uric acid-to-creatinine ratio. In contrast, allopurinol treatment increased mean hypoxanthine and xanthine urinary excretion rates 5.4- and 9.5-fold, respectively, compared with baseline levels. The decrease in uric acid excretion in complete and partial HPRT-deficient patients was not accompanied by a stoichiometric substitution of hypoxanthine and xanthine excretion rates. Allopurinol-related biochemical changes were similar in patients with either complete or partial HPRT deficiency. Renal function remained stable or improved with treatment. Three patients had urolithiasis during allopurinol treatment. In 2 patients, xanthine stones were documented and they required allopurinol dose adjustments aimed at reducing excessive oxypurine excretion rates. No allopurinol hypersensitivity reactions occurred. Neurologic manifestations were not influenced by allopurinol therapy. In conclusion, allopurinol is efficacious and generally safe for the treatment of uric acid overproduction in patients with HPRT deficiencies. Xanthine lithiasis, developing as a consequence of allopurinol therapy, should be preventable by adjustment of allopurinol dose.
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Affiliation(s)
- Rosa J Torres
- Division of Clinical Biochemistry, La Paz University Hospital, Madrid, Spain.
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19
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Jun IG, Chin JH, Kim YK, Kim YU, Cho SK, Hwang GS, Hwang JH. Anesthetic Experience of Percutaneous Nephrolithotomy for Renal Calculi in a Patient with Lesch-Nyhan Syndrome - A case report -. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.53.4.520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- In Gu Jun
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hyun Chin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Kug Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Uk Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Kang Cho
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyu Sam Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jai Hyun Hwang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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