Treatment of cystinuria

Cystinuria in children: diagnosis and treatment

PURPOSE

Cystinuria is the predominant hereditary factor leading to kidney stone formation in the pediatric population. The aim of this manuscript is to provide an overview of cystinuria in children.

METHODS

The authors performed a literature review on studies regarding cystinuria in children. A narrative synthesis for analysis of the studies was used.

RESULTS

Cystine is a homodimeric amino acid formed by the disulfide bonding of two cysteine molecules. The problem with this autosomal recessive condition arises from a malfunction in the process of reabsorption. Cystine filtered from the renal glomerulus cannot be reabsorbed from the proximal tubules. Therefore, due to its extremely low solubility at normal urine pH, it precipitates and causes stone formation. Recurrent stone formation is the most prominent clinical presentation of cystinuria. The patients usually present with a renal colic episode with concomitant nausea and hematuria. The aim of medical treatment is to maintain the solubility of cystine in urine. The main strategies are to increase urine volume and urinary pH. Potassium citrate or potassium bicarbonate can be used to raise the pH of the urine to 7.5 to increase cystine solubility. If the treatment with alkalinization and higher urine output fails, cystine binding agents such as tiopronin and D-penicillamine can be added to the treatment. Surgical management of pediatric patients with cystine stones is similar to that in the adult population. However, cystine stones can be resistant to ESWL. Retrograde ureteroscopy with semirigid and flexible instruments is a good option for ureteral stones and also for renal stones less than 20 mm in diameter. The golden standard option for high-volume stones larger than 20 mm in diameter is percutaneous nephrolithotomy (PCNL).

CONCLUSIONS

Cystinuria is the primary hereditary factor contributing to the formation of kidney stones throughout childhood. It is a genetic disorder that typically manifests as recurrent stone formations. The aim of the treatment of genetically caused pediatric stone diseases is to prevent stone formation with medical treatments, remove existing stones through surgical treatments, and mitigate the risk of developing chronic kidney disease in the future.

Tiopronin-induced Membranous Nephropathy Presenting with IgG4-predominant Staining Pattern

Tiopronin is a key drug used to treat cystinuria. A 41-year-old Japanese woman with cystinuria presented with eyelid edema and weight gain after the administration of tiopronin. Her serum albumin was 1.8 g/dL and her urinary protein level was 5.5 g/gCre. After cessation of tiopronin, she achieved remission of nephrotic syndrome (NS). Secondary NS due to tiopronin was evident based on the clinical course and laboratory values. A kidney biopsy showed membranous nephropathy (MN), and an immunofluorescence analysis revealed strong deposition of immunoglobulin G4 (IgG4). However, a previous case report of tiopronin-induced MN showed staining for IgG1 and IgG3. This case report suggests a novel etiology for tiopronin-induced MN.

Carbon dots based AuAg@AuNPs with oxidase-like activity for SERS dual-readouts detection of D-penicillamine

An oxidase (OXD) -like AuAg@AuNPs nanozyme was prepared by Au seeds growth using dopamine carbon dots as reducing and capping agents. The AuAg@AuNPs show excellent OXD-like and surface-enhanced Raman spectroscopy (SERS) activities and can oxidize the non-Raman-active leucomalachite green (LMG) into the Raman-active malachite green (MG). The research displays that D-penicillamine (D-PA) can effectively inhibit the OXD-like activity of Au@AgNPs and enhance the SERS signals as substrate. It is attributed to the formation of S-Au bond due to thiol (-SH) in D-PA. Therefore, a highly sensitive and specific SERS dual-readout sensing platform was proposed to assay D-PA with a limit of detection of 0.1 μg/mL (direct SERS mode) and 6.64 μg/L (indirect SERS mode). This approach was successfully used to determine D-PA in actual pharmaceutical formulations.

Construction and Application of an Electrochemical Sensor for Determination of D-Penicillamine Based on Modified Carbon Paste Electrode

D-penicillamine (D-PA) is a sulfur-containing drug that has been used for various health conditions. However, like any medication, overdosing on D-PA can have adverse effects and may require additional treatment. Therefore, developing simple and sensitive methods for sensing D-PA can play a crucial role in improving its efficacy and reducing its side effects. Sensing technologies, such as electrochemical sensors, can enable accurate and real-time measurement of D-PA concentrations. In this work, we developed a novel electrochemical sensor for detecting D-PA by modifying a carbon paste electrode (CPE) with a multi-walled carbon nanotube-Co3O4 nanocomposite, benzoyl-ferrocene (BF), and ionic liquid (IL) (MWCNT-Co3O4/BF/ILCPE). Cyclic voltammetry (CV), differential pulse voltammetry (DPV), and chronoamperometry (CHA) were employed to explore the electrochemical response of D-PA on the developed sensor, the results of which verified a commendable electrochemical performance towards D-PA. Under optimized conditions, the developed sensor demonstrated a rapid response to D-PA with a linear dynamic range of 0.05 μM-100.0 μM, a low detection limit of 0.015 μM, and a considerable sensitivity of 0.179 μA μM-1. Also, the repeatability, stability, and reproducibility of the MWCNT-Co3O4/BF/ILCPE sensor were studied and showed good characteristics. In addition, the detection of D-PA in pharmaceutical and biological matrices yielded satisfactory recoveries and relative standard deviation (RSD) values.

Hydration and Nephrolithiasis in Pediatric Populations: Specificities and Current Recommendations

Renal lithiasis is less frequent in children than in adults; in pediatrics, lithiasis may be caused by genetic abnormalities, infections, and complex uropathies, but the association of urological and metabolic abnormalities is not uncommon. The aim of this study is to provide a synthesis of nephrolithiasis in children and to emphasize the role of hydration in its treatment. As an etiology is reported in 50% of cases, with a genetic origin in 10 to 20%, it is proposed to systematically perform a complete metabolic assessment after the first stone in a child. Recent data in the field reported increased incidence of pediatric urolithiasis notably for calcium oxalate stones. These changes in the epidemiology of stone components may be attributable to metabolic and environmental factors, where hydration seems to play a crucial role. In case of pediatric urolithiasis, whatever its cause, it is of utmost importance to increase water intake around 2 to 3 L/m² per day on average. The objective is to obtain a urine density less than 1010 on a dipstick or below 300 mOsm/L, especially with the first morning urine. Some genetic diseases may even require a more active 24 h over-hydration, e.g., primary hyperoxaluria and cystinuria; in such cases naso-gastric tubes or G-tubes may be proposed. Tap water is adapted for children with urolithiasis, with limited ecological impact and low economical cost. For children with low calcium intake, the use of calcium-rich mineral waters may be discussed in some peculiar cases, even in case of urolithiasis. In contrast, sugar-sweetened beverages are not recommended. In conclusion, even if parents and patients sometimes have the feeling that physicians do not propose "fancy" therapeutic drugs, hydration and nutrition remain cornerstones of the management of pediatric urolithiasis.

Development of Polydiphenylamine@Electrochemically Reduced Graphene Oxide Electrode for the D-Penicillamine Sensor from Human Blood Serum Samples Using Amperometry

D-penicillamine (PA) is a sulfur group-containing drug prescribed for various health issues, but overdoses have adverse effects. Therefore, regular, selective, and sensitive sensing is essential to reduce the need for further treatment. In this study, diphenylamine (DPA) was electropolymerized in an aqueous acidic medium. The PA detection sensitivity, selectivity, and limit of detection were enhanced by electropolymerizing DPA on an electrochemically reduced graphene oxide (ERGO)/glassy carbon (GC) surface. The formation of p-DPA and ERGO was investigated using various techniques. The as-prepared p-DPA@ERGO/GC revealed the excellent redox-active (N-C to N=C) sites of p-DPA. The p-DPA@ERGO/GC electrode exhibited excellent electrochemical sensing ability towards PA determination because of the presence of the -NH-functional moiety and effective interactions with the -SH group of PA. The p-DPA@ERGO/GC exhibited a high surface coverage of 9.23 × 10-12 mol cm-2. The polymer-modified p-DPA@ERGO/GC electrode revealed the amperometric determination of PA concentration from the 1.4 to 541 μM wide range and the detection limit of 0.10 μM. The real-time feasibility of the developed p-DPA@ERGO/GC electrode was tested with a realistic PA finding in human blood serum samples and yielded a good recovery of 97.5-101.0%, confirming the potential suitability in bio-clinical applications.

Ca2+-mediated higher-order assembly of heterodimers in amino acid transport system b0,+ biogenesis and cystinuria

Cystinuria is a genetic disorder characterized by overexcretion of dibasic amino acids and cystine, causing recurrent kidney stones and kidney failure. Mutations of the regulatory glycoprotein rBAT and the amino acid transporter b^0,+AT, which constitute system b^0,+, are linked to type I and non-type I cystinuria respectively and they exhibit distinct phenotypes due to protein trafficking defects or catalytic inactivation. Here, using electron cryo-microscopy and biochemistry, we discover that Ca²⁺ mediates higher-order assembly of system b^0,+. Ca²⁺ stabilizes the interface between two rBAT molecules, leading to super-dimerization of b^0,+AT-rBAT, which in turn facilitates N-glycan maturation and protein trafficking. A cystinuria mutant T216M and mutations of the Ca²⁺ site of rBAT cause the loss of higher-order assemblies, resulting in protein trapping at the ER and the loss of function. These results provide the molecular basis of system b^0,+ biogenesis and type I cystinuria and serve as a guide to develop new therapeutic strategies against it. More broadly, our findings reveal an unprecedented link between transporter oligomeric assembly and protein-trafficking diseases.

Thiol antioxidants protect human lens epithelial (HLE B-3) cells against tert-butyl hydroperoxide-induced oxidative damage and cytotoxicity

Oxidative damage to lens epithelial cells plays an important role in the development of age-related cataract, and the health of the lens has important implications for overall ocular health. As a result, there is a need for effective therapeutic agents that prevent oxidative damage to the lens. Thiol antioxidants such as tiopronin or N-(2-mercaptopropionyl)glycine (MPG), N-acetylcysteine amide (NACA), N-acetylcysteine (NAC), and exogenous glutathione (GSH) may be promising candidates for this purpose, but their ability to protect lens epithelial cells is not well understood. The effectiveness of these compounds was compared by exposing human lens epithelial cells (HLE B-3) to the chemical oxidant tert-butyl hydroperoxide (tBHP) and treating the cells with each of the antioxidant compounds. MTT cell viability, apoptosis, reactive oxygen species (ROS), and levels of intracellular GSH, the most important antioxidant in the lens, were measured after treatment. All four compounds provided some degree of protection against tBHP-induced oxidative stress and cytotoxicity. Cells treated with NACA exhibited the highest viability after exposure to tBHP, as well as decreased ROS and increased intracellular GSH. Exogenous GSH also preserved viability and increased intracellular GSH levels. MPG scavenged significant amounts of ROS, and NAC increased intracellular GSH levels. Our results suggest that both scavenging ROS and increasing GSH may be necessary for effective protection of lens epithelial cells. Further, the compounds tested may be useful for the development of therapeutic strategies that aim to prevent oxidative damage to the lens.

[Cystinuria]

Cystinuria is the most common monogenic nephrolithiasis disorder. Because of its poor solubility at a typical urine pH of less than 7, cystine excretion results in recurrent urinary cystine stone formation. A high prevalence of high blood pressure and of chronic kidney disease has been reported in these patients. Alkaline hyperdiuresis remains the cornerstone of the preventive medical treatment. To reach a urine pH between 7.5 and 8 and a urine specific gravity less than or equal to 1.005 should be the goal of medical treatment. D-penicillamine and tiopronin, two cysteine-binding thiol agents, should be considered as second line treatments with frequent adverse events that should be closely monitored.

Medical evaluation and pharmacotherapeutical strategies in management of urolithiasis

Treatment of urolithiasis depends on several important factors which include stone location, size, composition, and patient symptoms. Although significant advancements have been made in the surgical management of urolithiasis in the last decade, pharmacotherapy which can prevent the formation of new stones and decrease the recurrence of urolithiasis has not experienced the same level of success. Currently, urolithiasis is regarded as a complicated syndrome that is determined by numerous factors, and any treatment plan for urolithiasis should be individualized while considering any potential damage arising from stone-forming factors. This review introduces the most popular methods currently used to evaluate urolithiasis and the pharmacotherapy of urolithiasis based on patient-specific factors.

Advances in biomedical and pharmaceutical applications of protein-stabilized gold nanoclusters

The interest in using gold nanoclusters (AuNCs) as imaging probes is growing, covering wide ranges of applications. The stabilization of AuNCs with protein ligands enhances their biomedical and pharmaceutical applications. This is due to the biocompatibility, water solubility and bioactivity of proteins. Different factors can control the optical properties of AuNCs such as protein size, amino acids content and conformational structure. Controlling the synthesis conditions can result in tuning the AuNCs excitation, emission, fluorescence intensity and physicochemical properties to fulfill different applications. NIR-emitting protein-stabilized AuNCs are promising as imaging agents for targeting and visualization of cancer in vitro and in vivo. They are promising to be included as an important part of multifunctional theranostic nanosystems, due to their potential dual functions as imaging and photosensitizing agent for photodynamic therapy. Additionally, the protein around AuNCs represents a rich environment of active functional groups that are susceptible for conjugation with various biomolecules. Protein-AuNCs can act as fluorescent probes for rapid and selective analysis of different analytes in solution, cells or biological fluids. In conclusion, the variability of protein-AuNC applications can advance research in different biomedical and pharmaceutical fields.

A phase II randomized controlled trial of tiopronin for aneurysmal subarachnoid hemorrhage

OBJECTIVE

Delayed cerebral ischemia (DCI) is a significant contributor to poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). The neurotoxin 3-aminopropanal (3-AP) is upregulated in cerebral ischemia. This phase II clinical trial evaluated the efficacy of tiopronin in reducing CSF 3-AP levels in patients with aSAH.

METHODS

In this prospective, randomized, double-blind, placebo-controlled, multicenter clinical trial, 60 patients were assigned to receive tiopronin or placebo in a 1:1 ratio. Treatment was commenced within 96 hours after aSAH onset, administered at a dose of 3 g daily, and continued until 14 days after aSAH or hospital discharge, whichever occurred earlier. The primary efficacy outcome was the CSF 3-AP level at 7 ± 1 days after aSAH.

RESULTS

Of the 60 enrolled patients, 29 (97%) and 27 (93%) in the tiopronin and placebo arms, respectively, received more than one dose of the study drug or placebo. At post-aSAH day 7 ± 1, CSF samples were available in 41% (n = 12/29) and 48% (n = 13/27) of patients in the tiopronin and placebo arms, respectively. No difference in CSF 3-AP levels at post-aSAH day 7 ± 1 was observed between the study arms (11 ± 12 nmol/mL vs 13 ± 18 nmol/mL; p = 0.766). Prespecified adverse events led to early treatment cessation for 4 patients in the tiopronin arm and 2 in the placebo arm.

CONCLUSIONS

The power of this study was affected by missing data. Therefore, the authors could not establish or refute an effect of tiopronin on CSF 3-AP levels. Additional observational studies investigating the role of 3-AP as a biomarker for DCI may be warranted prior to its use as a molecular target in future clinical trials.Clinical trial registration no.: NCT01095731 (ClinicalTrials.gov).

Protective effects of tiopronin on oxidatively challenged human lung carcinoma cells (A549)

Tiopronin (MPG) is a thiol antioxidant drug that has been explored as a treatment for various oxidative stress-related disorders. However, many of its antioxidant capabilities remain untested in well-validated cell models. To more thoroughly understand the action of this promising pharmaceutical compound against acute oxidative challenge, A549 human lung carcinoma cells were exposed to tert-butyl hydroperoxide (tBHP) and treated with MPG. Analyses of cell viability, intracellular glutathione (GSH) levels, and the prevalence of reactive oxygen species (ROS) and mitochondrial superoxide were used to examine the effects of MPG on tBHP-challenged cells. MPG treatment suppressed intracellular ROS and mitochondrial superoxide and prevented tBHP-induced GSH depletion and apoptosis. These results indicate that MPG is effective at preserving redox homeostasis against acute oxidative insult in A549 cells if present at sufficient concentrations during exposure to oxidants such as tBHP. The effects of treatment gleaned from this study can inform experimental design for future in vivo work on the therapeutic potential of MPG.

Renal stones

Renal stone disease is a worldwide problem which carries significant morbidity. It frequently requires specialist urology intervention. Patients with recurrent disease and those at high risk require specialist investigations and review. Certain cases benefit from medical and surgical intervention. In this review, we discuss the pathophysiology, risk assessment, specialist investigations and various interventions, their rationale and evidence base. This review aims to provide an update of the previous publication in 2001 in this journal on this topic.

Case Report: Cystinuria and Polycystic Kidney Disease

Cystinuria and polycystic kidney disease are 2 genetic disorders that affect the genitourinary tract but rarely together. This case report presents 2 pediatric patients diagnosed with polycystic kidney disease and cystinuria requiring surgical treatment. Both subjects presented acutely with stone disease. Imaging studies and stone analysis established the diagnoses. Although coexistence of these 2 conditions is rare, cystinuria should be considered in the differential diagnosis when evaluating patients with cystic disease who develop renal calculi.

How should patients with cystine stone disease be evaluated and treated in the twenty-first century?

Cystinuria continues to be one of the most challenging stone diseases. During the latest decades our knowledge of the molecular basis of cystinuria has expanded. Today 160 different mutations in the SLC3A1 gene and 116 in the SLC7A9 gene are listed. The full implications of type A, B or AB status are not yet fully understood but may have implications for prognosis, management and treatment. Despite better understanding of the molecular basis of cystinuria the principles of recurrence prevention have remained essentially the same through decades. No curative treatment of cystinuria exists, and patients will have a life long risk of stone formation, repeated surgery, impaired renal function and quality of life. Therapy to reduce stone formation is directed towards lowering urine cystine concentration and increasing cystine solubility. Different molecules that could play a role in promoting nucleation and have a modulating effect on cystine solubility may represent new targets for cystinuria research. Investigation of newer thiol-containing drugs with fewer adverse effects is also warranted. Determining cystine capacity may be an effective tool to monitor the individual patient's response. Compliance in cystinuric patients concerning both dietary and pharmacological intervention is poor. Frequent clinical follow-up visits in dedicated centres seem to improve compliance. Cystinuric patients should be managed in dedicated centres offering the complete range of minimal invasive treatment modalities, enabling a personalized treatment approach in order to reduce risk and morbidity of multiple procedures.

Risks associated with drug treatments for kidney stones

INTRODUCTION

Renal stones are one of the most painful medical conditions patients experience. For many they are also a recurrent problem. Fortunately, there are a number of drug therapies available to treat symptoms as well as prevent future stone formation.

AREAS COVERED

Herein, we review the most common drugs used in the treatment of renal stones, explaining the mechanism of action and potential side effects. Search of the Medline databases and relevant textbooks was conducted to obtain the relevant information. Further details were sourced from drug prescribing manuals. Recent studies of drug effectiveness are included as appropriate.

EXPERT OPINION

Recent controversies include medical expulsive therapy trials and complex role of urinary citrate in stone disease. Future directions in research will involve new medical therapies for stone prevention, for example new drugs for hyperoxaluria.

Novel cystine ester mimics for the treatment of cystinuria-induced urolithiasis in a knockout mouse model

OBJECTIVE

To assess the effectiveness of l-cystine dimethyl ester (CDME), an inhibitor of cystine crystal growth, for the treatment of cystine urolithiasis in an Slc3a1 knockout mouse model of cystinuria.

MATERIALS AND METHODS

CDME (200 μg per mouse) or water was delivered by gavage daily for 4 weeks. Higher doses by gavage or in the water supply were administered to assess organ toxicity. Urinary amino acids and cystine stones were analyzed to assess drug efficacy using several analytical methods.

RESULTS

Treatment with CDME led to a significant decrease in stone size compared with that of the water group (P = .0002), but the number of stones was greater (P = .005). The change in stone size distribution between the 2 groups was evident by micro computed tomography. Overall, cystine excretion in urine was the same between the 2 groups (P = .23), indicating that CDME did not interfere with cystine metabolism. Scanning electron microscopy analysis of cystine stones from the CDME group demonstrated a change in crystal habit, with numerous small crystals. l-cysteine methyl ester was detected by ultra-performance liquid chromatography-mass spectrometer in stones from the CDME group only, indicating that a CDME metabolite was incorporated into the crystal structure. No pathologic changes were observed at the doses tested.

CONCLUSION

These data demonstrate that CDME promotes formation of small stones but does not prevent stone formation, consistent with the hypothesis that CDME inhibits cystine crystal growth. Combined with the lack of observed adverse effects, our findings support the use of CDME as a viable treatment for cystine urolithiasis.

Assaying embryotoxicity in the test tube: current limitations of the embryonic stem cell test (EST) challenging its applicability domain

Testing for embryotoxicity in vitro is an attractive alternative to animal experimentation. The embryonic stem cell test (EST) is such a method, and it has been formally validated by the European Centre for the Validation of Alternative Methods. A number of recent studies have underscored the potential of this method. However, the EST performed well below the 78% accuracy expected from the validation study using a new set of chemicals and pharmaceutical compounds, and also of toxicity criteria, tested to enlarge the database of the validated EST as part of the Work Package III of the ReProTect Project funded within the 6th Framework Programme of the European Union. To assess the performance and applicability domain of the EST we present a detailed review of the substances and their effects in the EST being nitrofen, ochratoxin A, D-penicillamine, methylazoxymethanol, lovastatin, papaverine, warfarin, β-aminopropionitrile, dinoseb, furosemide, doxylamine, pravastatin, and metoclopramide. By delineation of the molecular mechanisms of the substances we identify six categories of reasons for misclassifications. Some of these limitations might also affect other in vitro methods assessing embryotoxicity. Substances that fall into these categories need to be included in future validation sets and in validation guidelines for embryotoxicity testing. Most importantly, we suggest conceivable improvements and additions to the EST which will resolve most of the limitations.

Collateral sensitivity as a strategy against cancer multidrug resistance

While chemotherapy remains the most effective treatment for disseminated tumors, acquired or intrinsic drug resistance accounts for approximately 90% of treatment failure. Multidrug resistance (MDR), the simultaneous resistance to drugs that differ both structurally and mechanistically, often results from drug efflux pumps in the cell membrane that reduce intracellular drug levels to less than therapeutic concentrations. Expression of the MDR transporter P-glycoprotein (P-gp, MDR1, ABCB1) has been shown to correlate with overall poor chemotherapy response and prognosis. This review will focus on collateral sensitivity (CS), the ability of compounds to kill MDR cells selectively over the parental cells from which they were derived. Insights into CS may offer an alternative strategy for the clinical resolution of MDR, as highly selective and potent CS agents may lead to drugs that are effective at MDR cell killing and tumor resensitization. Four main mechanistic hypotheses for CS will be reviewed, followed by a discussion on quantitative and experimental evaluation of CS.

Nephrolithiasis related to inborn metabolic diseases

Nephrolithiasis associated with inborn metabolic diseases is a very rare condition with some common characteristics: early onset of symptoms, family history, associated tubular impairment, bilateral, multiple and recurrent stones, and association with nephrocalcinosis. The prognosis of such diseases may lead to life threatening conditions, not only because of unabated kidney damage but also because of progressive extra-renal involvement, either in a systemic form (e.g. primary hyperoxaluria type 1, requiring combined liver and kidney transplantation), or in a neurological form (Lesch-Nyhan syndrome leading to auto-mutilation and disability, phosphoribosyl pyrophosphate synthetase superactivity, which is associated with mental retardation). Patients with other inborn metabolic diseases present only with recurrent stone formation, such as cystinuria, adenine phosphoribosyl-transferase deficiency, xanthine deficiency. Finally, nephrolithiasis may be secondarily part of some other metabolic diseases, such as glycogen storage disease type 1 or inborn errors of metabolism leading to Fanconi syndrome (nephropathic cystinosis, tyrosinaemia type 1, fructose intolerance, Wilson disease, respiratory chain disorders, etc.). The diagnosis is based on highly specific investigations, including crystal identification, biochemical analyses and DNA study. The treatment of nephrolithiasis requires hydration as well as specific measures. Compliance is a major issue regarding the progression of renal damage, but the overall outcome mainly depends on extra-renal involvement in relation to the metabolic defect.

[Inherited monogenic kidney stone diseases: recent diagnostic and therapeutic advances]

Hereditary monogenic kidney stone diseases are rare diseases, since they account for nearly 2% of nephrolithiasis cases in adults and 10% in children. Most of them are severe, because they frequently are associated with nephrocalcinosis and lead to progressive impairment of renal function unless an early and appropriate etiologic treatment is instituted. Unfortunately, treatment is often lacking or started too late since they are often misdiagnosed or overlooked. The present review reports the genotypic and phenotypic characteristics of monogenic nephrolithiases, with special emphasis on the recent advances in the field of diagnosis and therapeutics. Monogenic stone diseases will be classified into three groups according to their mechanism: (1) inborn errors of the metabolism of oxalate (primary hyperoxalurias), uric acid (hereditary hyperuricemias) or other purines (2,8-dihydroxyadeninuria), which, in addition to stone formation, result in crystal deposition in the renal parenchyma; (2) congenital tubulopathies affecting the convoluted proximal tubule (such as Dent's disease, Lowe syndrome or hypophosphatemic rickets), the thick ascending limb of Henlé's loop (such as familial hypomagnesemia and Bartter's syndromes) or the distal past of the nephron (congenital distal tubular acidosis with or without hearing loss), which are frequently associated with nephrocalcinosis, phosphatic stones and extensive tubulointerstitial fibrosis; (3) cystinuria, an isolated defect in tubular reabsorption of cystine and dibasic aminoacids, which results only in the formation of stones but requires a cumbersome treatment. Analysis of stones appears of crucial value for the early diagnosis of these diseases, as in several of them the morphology and composition of stones is specific. In other cases, especially if nephrocalcinosis, phosphatic stones or proteinuria are present, the evaluation of blood and urine chemistry, especially with regard to calcium, phosphate and magnesium, is the key of diagnosis. Search for mutations is now increasingly performed in as much as genetic counselling is important for the detection of heterozygotes in autosomic recessive diseases and of carrier women in X-linked diseases. In conclusion, better awareness to the rare monogenic forms of nephrolithiasis and/or nephrocalcinosis should allow early diagnosis and treatment which are needed to prevent or substantially delay progression of end-stage renal disease. Analysis of every first stone both in children and in adults should never be neglected, in order to early detect unusual forms of nephrolithiasis requiring laboratory evaluation and deep etiologic treatment.

Simultaneous determination of tiopronin and d-penicillamine in human urine by liquid chromatography with ultraviolet detection

d-Penicillamine and tiopronin are drugs widely used for the treatment of many diseases. Because of the relatively high frequency of side effects to these compounds, some of which are dose-related, drug monitoring in urine samples during treatment is advisable. In this paper, we describe a simple method for the determination of tiopronin and d-penicillamine in human urine. The method was based on derivatization with 2-chloro-1-methylquinolinium tetrafluoroborate followed by ion-pairing reversed-phase liquid chromatography separation and ultraviolet-absorbance detection. 2-S-quinolinium derivatives of thiols were detected at 355 nm. The derivatization was optimized in terms of pH and time of the reaction. Baseline separation was achieved on an analytical Zorbax SB C-18 (5 microm, 150 mm x 4.6 mm) column with a mobile phase consisting of pH 2.0 0.09 mol L(-1) trichloroacetic acid buffer (component A) and acetonitrile (component B) pumped at 1.0 mL min(-1). Gradient elution was used: 0-4 min, 12% B; 4-8 min, 12-40% B; 8-12 min, 40-12% B. The d-penicillamine and tiopronin standards added to the urine show that the response of the detector is linear within the range studied, from 1 to 200 micromol L(-1) urine. The imprecision ranges for tiopronin and d-penicillamine were within 1.61-8.24% and 2.92-10.60%, respectively. The analytical accuracy for determined compounds was from 97.24 to 109.39%. The lower limits of detection and quantitation were 0.5 micromol L(-1) and 1.0 micromol L(-1) urine, respectively. This method can be used for routine clinical monitoring of the title thiol-drugs. Cysteine can be measured concurrently, if needed.

Urological intervention in patients with cystinuria is decreased with medical compliance

PURPOSE

Theoretically patients with cystinuria compliant with medical treatment should undergo fewer surgical procedures than those noncompliant with treatment. We describe a single urologist's experience (SYN) with the effects of medical management on the number of surgical interventions required in patients with cystinuria treated at our metabolic stone clinic (MSC).

MATERIALS AND METHODS

The records of 20 patients with cystine stones seen at our MSC (mean followup of 42.5 months) were evaluated. The number of surgical interventions (endourology or open surgery) during followup were recorded as surgical events. Patients were placed into a compliant or noncompliant category based on their attendance record at scheduled appointments at our MSC and whether they adhered to the prescribed medical regimen by report. Patients were classified in an active disease category if recent imaging revealed a clinically significant stone burden greater than 3 mm. Statistical analysis of the number of surgical events for stone-free patients compliant with treatment versus noncompliant was conducted (Student's t test).

RESULTS

Of the 20 patients 11 were categorized as compliant and 9 as noncompliant. Of the compliant patients the average number of surgical events was 1.0 per patient versus 4.0 in the noncompliant group (p <0.05). Of the 11 compliant patients 8 (73%) were stone-free compared to 3 (33%) in the noncompliant group.

CONCLUSIONS

The majority of our patients with cystinuria compliant with treatment underwent a significantly fewer number of surgical procedures per year than those noncompliant with treatment. Active medical management in patients with cystinuria compliant with treatment decreases the incidence of surgical interventions.

Evidence for association of SLC7A9 gene haplotypes with cystinuria manifestation in SLC7A9 mutation carriers

Cystinuria is a complex genetic disorder. In the present study, we report on the strict linkage disequilibrium of SLC7A9 mutations with the wild type SLC7A9 haplotype of 15 single nucleotide polymorphisms (SNPs) and their effect on cystinuria manifestation and classification. Specifically, screening for mutations and polymorphisms was performed in the family members of ten cystinuric patients with SLC7A9 gene mutations. The molecular genetic and clinical data of cystinuric patients and their relatives were combined to construct the SLC7A9 SNP haplotypes and evaluate the manifestation of the disorder in carriers for a SLC7A9 gene mutation. It was found that all carriers of a SLC7A9 mutation manifested cystinuria if their normal allele had non-wild type nucleotides in two or more of the identified polymorphic sites. Subsequently, the polymorphic background of the SLC7A9 gene probably affects the expression of the disorder in SLC7A9 mutation carriers and points to a revised genetic classification of cystinuric patients.