1
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Langman CB, Assimos D, Blank M, Calle J, Grauer A, Kausz A, Milliner D, Nazzal L, Smith K, Tasian G, Thompson A, Wood KD, Worcester E, Yang S, Malley MA, Knauf F, Lieske JC. End Point Considerations for Clinical Trials in Enteric Hyperoxaluria. Clin J Am Soc Nephrol 2023; 18:1637-1644. [PMID: 37342976 PMCID: PMC10723917 DOI: 10.2215/cjn.0000000000000234] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/14/2023] [Indexed: 06/23/2023]
Abstract
Enteric hyperoxaluria is a medical condition characterized by elevated urinary oxalate excretion due to increased gastrointestinal oxalate absorption. Causative features include fat malabsorption and/or increased intestinal permeability to oxalate. Enteric hyperoxaluria has long been known to cause nephrolithiasis and nephrocalcinosis, and, more recently, an association with CKD and kidney failure has been shown. Currently, there are no US Food and Drug Administration-approved therapies for enteric hyperoxaluria, and it is unclear what end points should be used to evaluate the efficacy of new drugs and biologics for this condition. This study represents work of a multidisciplinary group convened by the Kidney Health Initiative to review the evidence supporting potential end points for clinical trials in enteric hyperoxaluria. A potential clinical outcome is symptomatic kidney stone events. Potential surrogate end points include ( 1 ) an irreversible loss of kidney function as a surrogate for progression to kidney failure, ( 2 ) asymptomatic kidney stone growth/new stone formation observed on imaging as a surrogate for symptomatic kidney stone events, ( 3 ) urinary oxalate and urinary calcium oxalate supersaturation as surrogates for the development of symptomatic kidney stone events, and ( 4) plasma oxalate as a surrogate for the development of the clinical manifestations of systemic oxalosis. Unfortunately, because of gaps in the data, this Kidney Health Initiative workgroup was unable to provide definitive recommendations. Work is underway to obtain robust information that can be used to inform trial design and medical product development in this space.
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Affiliation(s)
- Craig B. Langman
- Feinberg School of Medicine, Department of Pediatrics, Northwestern University, Chicago, Illinois
| | - Dean Assimos
- Department of Urology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melanie Blank
- Office of Therapeutic Products, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Juan Calle
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Dawn Milliner
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Lama Nazzal
- Department of Medicine, Division of Nephrology, New York University School of Medicine, NYU Langone Health, New York, New York
| | - Kimberly Smith
- Office of Medical Policy, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Greg Tasian
- University of Pennsylvania Perelman School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aliza Thompson
- Division of Cardiology and Nephrology, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Kyle D. Wood
- Department of Urology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Elaine Worcester
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Sixun Yang
- Division of Vaccines and Related Products Applications, Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | | | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - John C. Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- Department of Laboratory Medicine and Nephrology, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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2
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Baltazar P, de Melo Junior AF, Fonseca NM, Lança MB, Faria A, Sequeira CO, Teixeira-Santos L, Monteiro EC, Campos Pinheiro L, Calado J, Sousa C, Morello J, Pereira SA. Oxalate (dys)Metabolism: Person-to-Person Variability, Kidney and Cardiometabolic Toxicity. Genes (Basel) 2023; 14:1719. [PMID: 37761859 PMCID: PMC10530622 DOI: 10.3390/genes14091719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 09/29/2023] Open
Abstract
Oxalate is a metabolic end-product whose systemic concentrations are highly variable among individuals. Genetic (primary hyperoxaluria) and non-genetic (e.g., diet, microbiota, renal and metabolic disease) reasons underlie elevated plasma concentrations and tissue accumulation of oxalate, which is toxic to the body. A classic example is the triad of primary hyperoxaluria, nephrolithiasis, and kidney injury. Lessons learned from this example suggest further investigation of other putative factors associated with oxalate dysmetabolism, namely the identification of precursors (glyoxylate, aromatic amino acids, glyoxal and vitamin C), the regulation of the endogenous pathways that produce oxalate, or the microbiota's contribution to oxalate systemic availability. The association between secondary nephrolithiasis and cardiovascular and metabolic diseases (hypertension, type 2 diabetes, and obesity) inspired the authors to perform this comprehensive review about oxalate dysmetabolism and its relation to cardiometabolic toxicity. This perspective may offer something substantial that helps advance understanding of effective management and draws attention to the novel class of treatments available in clinical practice.
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Affiliation(s)
- Pedro Baltazar
- Centro Hospitalar Universitário de Lisboa Central, E.P.E, 1150-199 Lisboa, Portugal; (P.B.); (N.M.F.); (M.B.L.); (L.C.P.); (J.C.)
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal; (A.F.d.M.J.); (C.O.S.); (L.T.-S.); (E.C.M.); (C.S.); (J.M.)
- Centro Clínico Académico de Lisboa, 1159-056 Lisboa, Portugal
| | - Antonio Ferreira de Melo Junior
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal; (A.F.d.M.J.); (C.O.S.); (L.T.-S.); (E.C.M.); (C.S.); (J.M.)
- Centro Clínico Académico de Lisboa, 1159-056 Lisboa, Portugal
| | - Nuno Moreira Fonseca
- Centro Hospitalar Universitário de Lisboa Central, E.P.E, 1150-199 Lisboa, Portugal; (P.B.); (N.M.F.); (M.B.L.); (L.C.P.); (J.C.)
- Centro Clínico Académico de Lisboa, 1159-056 Lisboa, Portugal
| | - Miguel Brito Lança
- Centro Hospitalar Universitário de Lisboa Central, E.P.E, 1150-199 Lisboa, Portugal; (P.B.); (N.M.F.); (M.B.L.); (L.C.P.); (J.C.)
| | - Ana Faria
- CHRC, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal;
| | - Catarina O. Sequeira
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal; (A.F.d.M.J.); (C.O.S.); (L.T.-S.); (E.C.M.); (C.S.); (J.M.)
| | - Luísa Teixeira-Santos
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal; (A.F.d.M.J.); (C.O.S.); (L.T.-S.); (E.C.M.); (C.S.); (J.M.)
- Centro Clínico Académico de Lisboa, 1159-056 Lisboa, Portugal
| | - Emilia C. Monteiro
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal; (A.F.d.M.J.); (C.O.S.); (L.T.-S.); (E.C.M.); (C.S.); (J.M.)
- Centro Clínico Académico de Lisboa, 1159-056 Lisboa, Portugal
| | - Luís Campos Pinheiro
- Centro Hospitalar Universitário de Lisboa Central, E.P.E, 1150-199 Lisboa, Portugal; (P.B.); (N.M.F.); (M.B.L.); (L.C.P.); (J.C.)
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal; (A.F.d.M.J.); (C.O.S.); (L.T.-S.); (E.C.M.); (C.S.); (J.M.)
- Centro Clínico Académico de Lisboa, 1159-056 Lisboa, Portugal
| | - Joaquim Calado
- Centro Hospitalar Universitário de Lisboa Central, E.P.E, 1150-199 Lisboa, Portugal; (P.B.); (N.M.F.); (M.B.L.); (L.C.P.); (J.C.)
- Centro Clínico Académico de Lisboa, 1159-056 Lisboa, Portugal
- ToxOmics, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal
| | - Cátia Sousa
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal; (A.F.d.M.J.); (C.O.S.); (L.T.-S.); (E.C.M.); (C.S.); (J.M.)
- Centro Clínico Académico de Lisboa, 1159-056 Lisboa, Portugal
| | - Judit Morello
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal; (A.F.d.M.J.); (C.O.S.); (L.T.-S.); (E.C.M.); (C.S.); (J.M.)
| | - Sofia A. Pereira
- iNOVA4Health, NOVA Medical School|Faculdade de Ciências Médicas, NMS|FCM, Universidade NOVA de Lisboa, 1150-082 Lisboa, Portugal; (A.F.d.M.J.); (C.O.S.); (L.T.-S.); (E.C.M.); (C.S.); (J.M.)
- Centro Clínico Académico de Lisboa, 1159-056 Lisboa, Portugal
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3
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Bering JL, Wiedmeier-Nutor JE, Sproat L, DiBaise JK. Bone marrow oxalosis with pancytopenia in a patient with short bowel syndrome: Report of a case and review of the literature. JPEN J Parenter Enteral Nutr 2023; 47:165-170. [PMID: 36181457 DOI: 10.1002/jpen.2453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/15/2022] [Accepted: 09/27/2022] [Indexed: 01/11/2023]
Abstract
Systemic oxalosis is a condition in which calcium oxalate crystals deposit into various bodily tissues. Although this may occur as the result of a rare primary syndrome in which an error of glyoxylate metabolism causes an overproduction of oxalate, it is more often seen as a secondary process characterized by increased enteric oxalate absorption. Here, we describe a patient with short bowel syndrome on long-term parenteral nutrition support who developed a unique manifestation of systemic oxalosis, leading to deposition of oxalate crystals within the bone marrow contributing to pancytopenia. In this report, in addition to reviewing the literature on this presumably rare manifestation of oxalosis, we also discuss its pathogenesis in the setting of short bowel syndrome and its management, including prevention.
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Affiliation(s)
- Jamie L Bering
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
| | | | - Lisa Sproat
- Division of Hematology and Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - John K DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona, USA
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4
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D'Ambrosio V, Ferraro PM. Lumasiran in the Management of Patients with Primary Hyperoxaluria Type 1: From Bench to Bedside. Int J Nephrol Renovasc Dis 2022; 15:197-206. [PMID: 35747094 PMCID: PMC9211742 DOI: 10.2147/ijnrd.s293682] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 06/03/2022] [Indexed: 12/12/2022] Open
Abstract
Primary hyperoxaluria (PH) is a rare genetic disease caused by excessive hepatic production and elevated urinary excretion of oxalate that leads to recurrent nephrolithiasis, nephrocalcinosis and, eventually, kidney failure. As glomerular filtration rate declines, oxalate accumulates leading to systemic oxalosis, a debilitating condition with high morbidity and mortality. Although PH is usually diagnosed during infancy, it can present at any age with different phenotypes, ranging from mild symptoms to extremely debilitating manifestations. PH is an autosomal recessive disorder and, to date, three types have been identified: PH1, PH2 and PH3. PH1 is the most common and most aggressive type, accounting for almost 80% of primary hyperoxaluria diagnoses. Until 2020, general treatment for PH1 consisted mainly in high fluid intake, urine alkalization, surgical management of recurrent nephrolithiasis and eventually, if and when kidney failure occurred, intensive dialysis regimens and transplantation strategies (simultaneous or sequential liver-kidney transplant or isolated liver/kidney transplant in carefully selected patients). Specific treatment did and still consists in administration of pyridoxine hydrochloride, although it is only effective in a subset of PH1 patients. Lumasiran, a novel biological drug based on mRNA interference that has been recently approved in the US and European Union, showed promising results and is set to be a turning point in the management of PH1. This literature review aims to summarize the available evidence on PH1 treatment with lumasiran, in order to provide both pediatric and adult nephrologists and clinicians with the knowledge for the identification and management of PH1 patients suitable for treatment.
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Affiliation(s)
- Viola D'Ambrosio
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, U.O.C. Nefrologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, U.O.C. Nefrologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Roma, Italia.,Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italia
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5
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Pfau A, Grujic D, Keddis MT, Kausz AT, Lieske JC, Knauf F. Pilot study of reloxaliase in patients with severe enteric hyperoxaluria and hyperoxalemia. Nephrol Dial Transplant 2021; 36:945-948. [PMID: 33416876 PMCID: PMC8075375 DOI: 10.1093/ndt/gfaa379] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/14/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Anja Pfau
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Mira T Keddis
- Division of Nephrology and Hypertension, Mayo Clinic Rochester, Rochester, MN, USA
| | | | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic Rochester, Rochester, MN, USA
| | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Internal Medicine, Section of Nephrology, Yale University School of Medicine, New Haven, CT, USA
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6
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Witting C, Langman CB, Assimos D, Baum MA, Kausz A, Milliner D, Tasian G, Worcester E, Allain M, West M, Knauf F, Lieske JC. Pathophysiology and Treatment of Enteric Hyperoxaluria. Clin J Am Soc Nephrol 2021; 16:487-495. [PMID: 32900691 PMCID: PMC8011014 DOI: 10.2215/cjn.08000520] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Enteric hyperoxaluria is a distinct entity that can occur as a result of a diverse set of gastrointestinal disorders that promote fat malabsorption. This, in turn, leads to excess absorption of dietary oxalate and increased urinary oxalate excretion. Hyperoxaluria increases the risk of kidney stones and, in more severe cases, CKD and even kidney failure. The prevalence of enteric hyperoxaluria has increased over recent decades, largely because of the increased use of malabsorptive bariatric surgical procedures for medically complicated obesity. This systematic review of enteric hyperoxaluria was completed as part of a Kidney Health Initiative-sponsored project to describe enteric hyperoxaluria pathophysiology, causes, outcomes, and therapies. Current therapeutic options are limited to correcting the underlying gastrointestinal disorder, intensive dietary modifications, and use of calcium salts to bind oxalate in the gut. Evidence for the effect of these treatments on clinically significant outcomes, including kidney stone events or CKD, is currently lacking. Thus, further research is needed to better define the precise factors that influence risk of adverse outcomes, the long-term efficacy of available treatment strategies, and to develop new therapeutic approaches.
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Affiliation(s)
- Celeste Witting
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Craig B. Langman
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois,Division of Kidney Diseases, Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Dean Assimos
- Department of Urology, University of Alabama-Birmingham, Birmingham, Alabama
| | - Michelle A. Baum
- Division of Nephrology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Dawn Milliner
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Greg Tasian
- Department of Surgery, Division of Urology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaine Worcester
- Department of Medicine, University of Chicago, Chicago, Illinois
| | | | | | - Felix Knauf
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - John C. Lieske
- Allena Pharmaceuticals, Inc., Newton, Massachusetts,Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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7
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Abstract
Background Oxalate nephropathy is a rare disorder that can result in acute kidney injury (AKI) and progresses to end-stage kidney disease (ESKD). The causes can be either primary or secondary. Primary hyperoxaluria includes a group of hereditary disorders with enzymatic defects in the glyoxylate pathway, resulting in decreased oxalate metabolism. Secondary hyperoxaluria, often overlooked can result from increased intestinal absorption, nutritional deficiencies, decreased fluid intake, impaired excretion, and increased dietary consumption of oxalate. Case presentation We present a Caucasian case of acute oxalate induced nephropathy associated with consumption of large quantities of green vegetables in a patient with chronic kidney disease (CKD). Imaging study showed no evidence of kidney stone, but a kidney biopsy revealed acute tubular injury, tubular atrophy, interstitial fibrosis, and dense tubular deposition of calcium oxalate crystals. Upon further questioning the patient, we learned that in the months prior to presentation, he had very significantly increased his consumption of green vegetables. Because of no clinical improvement, the patient was initiated and maintained on hemodialysis. Conclusion This report illustrates a case of acute oxalate nephropathy in the setting of very high dietary consumption of oxalate-rich foods in a patient with advanced CKD. Special attention should be given to the secondary causes of hyperoxaluria in patients with predisposing conditions such as CKD.
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8
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Zhou J, Yu X, Su T, Wang S, Yang L. Critically ill, tubular injury, delayed early recovery: characteristics of acute kidney disease with renal oxalosis. Ren Fail 2021; 43:425-432. [PMID: 33663319 PMCID: PMC7939555 DOI: 10.1080/0886022x.2021.1885443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objects This study aimed to analyze the clinicopathological features of acute kidney disease (AKD) with renal oxalosis. Methods Data for biopsy-proven AKD with oxalosis diagnosed from Jan 2011 to Oct 2018 was collected. The underlying diseases, dietary habits, clinical and pathological characteristics of newly emerging kidney disease were analyzed. The long-term renal prognosis was observed. Results A total of 23 patients were included, comprised of 18 men and 5 women with a mean age of 51.6 ± 15.9 years. The peak Scr was 669.9 ± 299.8 μmol/L, and 95.7% of patients had stage 3 acute kidney injury (AKI). Drug-induced tubulointerstitial nephritis (TIN) was the most common cause (65.2%) of AKD, followed by severe nephrotic syndrome (17.4%). All patients had pathological changes indicating TIN, and 11 patients were complicated with the newly emerging glomerular disease (GD). The risk of oxalosis caused by increased enterogenous oxalate absorption accounted for only 26.1%, and others came from new kidney diseases. The majority (75%) of abundant (medium to severe) oxalosis occurred in patients without GD. There were no significant differences in the score for tubular injury (T-IS) and interstitial inflammation with different severities of oxalosis. Rate of Scr decrease (ΔScr%) at 2 weeks was negatively correlated with the severity of oxalosis (R = −0.542, p = 0.037), score for T-IS (R = −0.553, p = 0.033), and age (R = −0.736, p = 0.002). The decrease in Scr at 4 weeks was correlated with T-IS (R = −0.433), but had no correlation with oxalosis. Conclusions The present findings revealed that 95.7% of AKD with secondary renal oxalosis occurred in critically ill patients. AKD from tubular injury was the prominent cause. Severe oxalosis contributed to delayed early recovery of AKD.
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Affiliation(s)
- Jing Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Beijing, China.,Renal Division, Department of Medicine, Kailuan General Hospital, Tangshan, China
| | - Xiaojuan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Beijing, China
| | - Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Beijing, China
| | - Suxia Wang
- Renal Pathology Center, Institute of Nephrology, Beijing, China.,Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
| | - Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Beijing, China
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9
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Huang F, Sun XY, Chen XW, Ouyang JM. Effects of Selenized Astragalus Polysaccharide on the Adhesion and Endocytosis of Nanocalcium Oxalate Dihydrate after the Repair of Damaged HK-2 Cells. ACS Biomater Sci Eng 2021; 7:739-751. [PMID: 33464816 DOI: 10.1021/acsbiomaterials.0c01318] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
An oxidative damage model of human proximal renal epithelial cells (HK-2) was established using oxalate damage. The repair effects of Astragalus polysaccharide (APS) and selenized APS (Se-APS) on damaged HK-2 cells were investigated. Differences in the adhesion and endocytosis of HK-2 cells to calcium oxalate dihydrate crystals with a size of approximately 100 nm before and after APS and Se-APS repair were also explored. The results showed that after being repaired by APS and Se-APS, HK-2 cells exhibited increased cell viability, restored cell morphology, reduced reactive oxygen species level, increased mitochondrial membrane potential, reduced phosphatidylserine eversion, and osteopontin expression. Moreover, the amount of adherent crystals on the cell surface decreased, but the amount of endocytic crystals increased. At the same concentration, Se-APS exhibited better repair effects on the damaged HK-2 cells than APS. All these findings revealed that Se-APS may be a potential drug candidate for inhibiting the formation of kidney stones.
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Affiliation(s)
- Fang Huang
- Institute of Biomineralization and Lithiasis Research, Jinan University, Guangzhou 510632, China
| | - Xin-Yuan Sun
- Department of Urology, Guangzhou Institute of Urology, Guangdong Key Laboratory of Urology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, Guangdong 510230, China
| | - Xue-Wu Chen
- Institute of Biomineralization and Lithiasis Research, Jinan University, Guangzhou 510632, China
| | - Jian-Ming Ouyang
- Institute of Biomineralization and Lithiasis Research, Jinan University, Guangzhou 510632, China
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10
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Quintero E, Bird VY, Liu H, Stevens G, Ryan AS, Buzzerd S, Klimberg IW. A Prospective, Double-Blind, Randomized, Placebo-Controlled, Crossover Study Using an Orally Administered Oxalate Decarboxylase (OxDC). KIDNEY360 2020; 1:1284-1290. [PMID: 35372879 PMCID: PMC8815515 DOI: 10.34067/kid.0001522020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/03/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND Hyperoxaluria is typically associated with excessive oxalate intake in the diet, decreased dietary calcium, hyperabsorption of oxalate, or increased endogenous production of oxalate. The disorder spectrum extends from recurrent kidney stones to ESKD. This clinical trial sought to evaluate the effectiveness of an acid stable oxalate decarboxylase (OxDC) to reduce urinary oxalate in healthy subjects on a high-oxalate diet. METHODS In this prospective, double-blind, randomized, placebo-controlled, crossover clinical trial, 33 healthy volunteers were randomized into two crossover sequences separated by a 2-day washout period. A controlled high-oxalate diet (750-800 mg oxalate, 500-550 mg calcium daily) was utilized, and six 24-hour urine collections were measured. Subjects were given approximately 1000 U (micromoles per minute per milligram) of OxDC or placebo with meals three times daily during the 4 days of treatment. RESULTS Urinary oxalate significantly decreased with OxDC treatment. The baseline corrected within-subject mean reduction in 24-hour urinary excretion (after OxDC dosing versus high-oxalate baseline preceding treatment) was 12.5 mg or 29% (P<0.001). OxDC treatment was effective (>5% reduction) in 31 of 33 subjects (94%). Compared with placebo, OxDC produced a 24% reduction (P<0.001) in 24-hour oxalate excretion. Other urinary parameters (creatinine, uric acid, citrate, magnesium, calcium) were not affected by OxDC. No serious adverse events and no product-related adverse events occurred. CONCLUSIONS An orally administered OxDC is capable of significantly reducing urinary oxalate levels in healthy volunteers on a high-oxalate diet without affecting creatinine clearance, urine creatinine, or other solutes related to supersaturation of calcium oxalate. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Evaluation of Nephure, and the Reduction of Dietary Oxalate, in Healthy Volunteers, NCT03661216.
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Affiliation(s)
- Emily Quintero
- University of Florida College of Medicine, Gainesville, Florida
| | | | | | | | - Alan S. Ryan
- Clinical Research Consulting, Boynton Beach, Florida
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11
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Dietary Oxalate Intake and Kidney Outcomes. Nutrients 2020; 12:nu12092673. [PMID: 32887293 PMCID: PMC7551439 DOI: 10.3390/nu12092673] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 08/25/2020] [Accepted: 08/30/2020] [Indexed: 12/16/2022] Open
Abstract
Oxalate is both a plant-derived molecule and a terminal toxic metabolite with no known physiological function in humans. It is predominantly eliminated by the kidneys through glomerular filtration and tubular secretion. Regardless of the cause, the increased load of dietary oxalate presented to the kidneys has been linked to different kidney-related conditions and injuries, including calcium oxalate nephrolithiasis, acute and chronic kidney disease. In this paper, we review the current literature on the association between dietary oxalate intake and kidney outcomes.
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Kletzmayr A, Ivarsson ME, Leroux JC. Investigational Therapies for Primary Hyperoxaluria. Bioconjug Chem 2020; 31:1696-1707. [PMID: 32539351 DOI: 10.1021/acs.bioconjchem.0c00268] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recent years have brought exciting new insights in the field of primary hyperoxaluria (PH), both on a basic research level as well as through the progress of novel therapeutics in clinical development. To date, very few supportive measures are available for patients suffering from PH, which, together with the severity of the disorder, make disease management challenging. Basic and clinical research and development efforts range from correcting the underlying gene mutations, preventing calcium oxalate crystal-induced kidney damage, to the administration of probiotics favoring the intestinal secretion of excess oxalate. In this review, current advances in the development of those strategies are presented and discussed.
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Affiliation(s)
- Anna Kletzmayr
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
| | | | - Jean-Christophe Leroux
- Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
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Albert A, Paul E, Rajakumar S, Saso L. Oxidative stress and endoplasmic stress in calcium oxalate stone disease: the chicken or the egg? Free Radic Res 2020; 54:244-253. [PMID: 32292073 DOI: 10.1080/10715762.2020.1751835] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Crystal modulators play a significant role in the formation of calcium oxalate stone disease. When renal cells are subjected to oxalate stress, the loss in cell integrity leads to exposure of multiple proteins that assist and/or inhibit crystal attachment and retention. Contact between oxalate and calcium oxalate with urothelium proves fatal to cells as a result of reactive oxygen species generation and onset of oxidative stress. Hence, as a therapeutic strategy it was hypothesised that supplementation of antioxidants would suffice. On the contrary to popular belief, the detection of oxalate induced endoplasmic reticulum mediated apoptosis proved the ineffectiveness of antioxidant therapy alone. Thus, the inadequacy of antioxidant supplementation in oxalate stress invoked the presence of an alternative pathway for the induction of kidney fibrosis in hyperoxaluric rats. In addition to settling this query, the link between oxidative stress and ER stress is not well understood, especially in urolithiasis.
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Affiliation(s)
| | - Eldho Paul
- Department of Biochemistry, Centre for Excellence in Genomics Science, School of Biological Sciences, Madurai Kamaraj University, Madurai, India
| | - Selvaraj Rajakumar
- Department of Pediatrics, Group of Molecular Cell Biology of Lipids, 315, Heritage Medical Research Center, University of Alberta, Edmonton, Canada
| | - Luciano Saso
- Department of Physiology and Pharmacology "Vittorio Erspamer", Sapienza University of Rome, Rome, Italy
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Abou Chakra M, Dellis AE, Papatsoris AG, Moussa M. Established and recent developments in the pharmacological management of urolithiasis: an overview of the current treatment armamentarium. Expert Opin Pharmacother 2019; 21:85-96. [DOI: 10.1080/14656566.2019.1685979] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Mohamed Abou Chakra
- Department of Urology, Al Zahraa Hospital, University Medical Center, Beirut, Lebanon
| | - Athanasios E. Dellis
- Department of Surgery, School of Medicine, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Athanasios G. Papatsoris
- 2nd Department of Urology, School of Medicine, Sismanoglio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Mohamad Moussa
- Department of Urology, Al Zahraa Hospital, University Medical Center, Beirut, Lebanon
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Mulay SR, Honarpisheh MM, Foresto-Neto O, Shi C, Desai J, Zhao ZB, Marschner JA, Popper B, Buhl EM, Boor P, Linkermann A, Liapis H, Bilyy R, Herrmann M, Romagnani P, Belevich I, Jokitalo E, Becker JU, Anders HJ. Mitochondria Permeability Transition versus Necroptosis in Oxalate-Induced AKI. J Am Soc Nephrol 2019; 30:1857-1869. [PMID: 31296606 DOI: 10.1681/asn.2018121218] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/16/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Serum oxalate levels suddenly increase with certain dietary exposures or ethylene glycol poisoning and are a well known cause of AKI. Established contributors to oxalate crystal-induced renal necroinflammation include the NACHT, LRR and PYD domains-containing protein-3 (NLRP3) inflammasome and mixed lineage kinase domain-like (MLKL) protein-dependent tubule necroptosis. These studies examined the role of a novel form of necrosis triggered by altered mitochondrial function. METHODS To better understand the molecular pathophysiology of oxalate-induced AIK, we conducted in vitro studies in mouse and human kidney cells and in vivo studies in mice, including wild-type mice and knockout mice deficient in peptidylprolyl isomerase F (Ppif) or deficient in both Ppif and Mlkl. RESULTS Crystals of calcium oxalate, monosodium urate, or calcium pyrophosphate dihydrate, as well as silica microparticles, triggered cell necrosis involving PPIF-dependent mitochondrial permeability transition. This process involves crystal phagocytosis, lysosomal cathepsin leakage, and increased release of reactive oxygen species. Mice with acute oxalosis displayed calcium oxalate crystals inside distal tubular epithelial cells associated with mitochondrial changes characteristic of mitochondrial permeability transition. Mice lacking Ppif or Mlkl or given an inhibitor of mitochondrial permeability transition displayed attenuated oxalate-induced AKI. Dual genetic deletion of Ppif and Mlkl or pharmaceutical inhibition of necroptosis was partially redundant, implying interlinked roles of these two pathways of regulated necrosis in acute oxalosis. Similarly, inhibition of mitochondrial permeability transition suppressed crystal-induced cell death in primary human tubular epithelial cells. PPIF and phosphorylated MLKL localized to injured tubules in diagnostic human kidney biopsies of oxalosis-related AKI. CONCLUSIONS Mitochondrial permeability transition-related regulated necrosis and necroptosis both contribute to oxalate-induced AKI, identifying PPIF as a potential molecular target for renoprotective intervention.
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Affiliation(s)
- Shrikant Ramesh Mulay
- Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany; .,Pharmacology Division, CSIR-Central Drug Research Institute, Lucknow, India
| | - Mohsen M Honarpisheh
- Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Orestes Foresto-Neto
- Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Chongxu Shi
- Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Jyaysi Desai
- Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Zhi Bo Zhao
- Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Julian A Marschner
- Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Bastian Popper
- Biomedical Center, Core Facility Animal Models, Ludwig Maximilian University, Planegg-Martinsried, Germany
| | - Ewa Miriam Buhl
- Division of Nephrology, Institute of Pathology, Rheinisch-Westfälische Technische Hochschule University of Aachen, Aachen, Germany
| | - Peter Boor
- Division of Nephrology, Institute of Pathology, Rheinisch-Westfälische Technische Hochschule University of Aachen, Aachen, Germany
| | - Andreas Linkermann
- Division of Nephrology, Department of Internal Medicine III, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany
| | - Helen Liapis
- Department of Pathology and Immunology, School of Medicine, Washington University in St. Louis, St. Louis, Missouri.,Arkana Laboratories, Little Rock, Arkansas
| | - Rostyslav Bilyy
- Department of Histology, Cytology, and Embryology, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Martin Herrmann
- Department of Internal Medicine 3, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Paola Romagnani
- Excellence Centre for Research, Transfer and High Education for the Development of De Novo Therapies, University of Florence, Florence, Italy
| | - Ilya Belevich
- Electron Microscopy Unit, Institute of Biotechnology, University of Helsinki, Helsinki, Finland; and
| | - Eija Jokitalo
- Electron Microscopy Unit, Institute of Biotechnology, University of Helsinki, Helsinki, Finland; and
| | - Jan U Becker
- Institute of Pathology, University of Cologne, Cologne, Germany
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany;
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Mnif K, Yaich S, Mars M, Kammoun K, Fendri F, Charfeddine K, Jarraya F, Boudawara T, Hachicha J. Crystalline Nephropathy in Renal Transplant: A Series of 4 Cases. Indian J Nephrol 2019; 28:472-476. [PMID: 30647504 PMCID: PMC6309387 DOI: 10.4103/ijn.ijn_76_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Crystals are particles of endogenous inorganic or organic composition that can trigger kidney injury when deposited or formed inside the kidney. The most common forms of crystalline nephropathies (CNs) are nephrocalcinosis and oxalate nephropathy. The causes of early allograft dysfunction are changing constantly, and recently calcium oxalate (CaOx) crystal deposition has been added to this list. CaOx deposition in renal allograft is important and probably under-recognized cause of delayed graft function that requires adequate awareness with early intervention to improve the allograft outcome. Here, we describe four cases of irreversible renal graft injury due to CNs.
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Affiliation(s)
- K Mnif
- Department of Nephrology, Hedi Chaker Hospital, Sfax, Tunisia
| | - S Yaich
- Department of Nephrology, Hedi Chaker Hospital, Sfax, Tunisia
| | - M Mars
- Department of Nephrology, Hedi Chaker Hospital, Sfax, Tunisia
| | - K Kammoun
- Department of Nephrology, Hedi Chaker Hospital, Sfax, Tunisia
| | - F Fendri
- Department of Nephrology, Hedi Chaker Hospital, Sfax, Tunisia
| | - K Charfeddine
- Department of Nephrology, Hedi Chaker Hospital, Sfax, Tunisia
| | - F Jarraya
- Department of Nephrology, Hedi Chaker Hospital, Sfax, Tunisia
| | - T Boudawara
- Department of Pathology Laboratory, Habib Bourguiba Hospital, Sfax, Tunisia
| | - J Hachicha
- Department of Nephrology, Hedi Chaker Hospital, Sfax, Tunisia
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Dindo M, Conter C, Oppici E, Ceccarelli V, Marinucci L, Cellini B. Molecular basis of primary hyperoxaluria: clues to innovative treatments. Urolithiasis 2018; 47:67-78. [PMID: 30430197 DOI: 10.1007/s00240-018-1089-z] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 11/08/2018] [Indexed: 12/21/2022]
Abstract
Primary hyperoxalurias (PHs) are rare inherited disorders of liver glyoxylate metabolism, characterized by the abnormal production of endogenous oxalate, a metabolic end-product that is eliminated by urine. The main symptoms are related to the precipitation of calcium oxalate crystals in the urinary tract with progressive renal damage and, in the most severe form named Primary Hyperoxaluria Type I (PH1), to systemic oxalosis. The therapies currently available for PH are either poorly effective, because they address the symptoms and not the causes of the disease, or highly invasive. In the last years, advances in our understanding of the molecular bases of PH have paved the way for the development of new therapeutic strategies. They include (i) substrate-reduction therapies based on small-molecule inhibitors or the RNA interference technology, (ii) gene therapy, (iii) enzyme administration approaches, (iv) colonization with oxalate-degrading intestinal microorganisms, and, in PH1, (v) design of pharmacological chaperones. This paper reviews the basic principles of these new therapeutic strategies and what is currently known about their application to PH.
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Affiliation(s)
- Mirco Dindo
- Department of Experimental Medicine, University of Perugia, P.le Gambuli 1, 06132, Perugia, Italy
| | - Carolina Conter
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Biological Chemistry, University of Verona, Strada le Grazie 8, 37134, Verona, VR, Italy
| | - Elisa Oppici
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Biological Chemistry, University of Verona, Strada le Grazie 8, 37134, Verona, VR, Italy
| | - Veronica Ceccarelli
- Department of Experimental Medicine, University of Perugia, P.le Gambuli 1, 06132, Perugia, Italy
| | - Lorella Marinucci
- Department of Experimental Medicine, University of Perugia, P.le Gambuli 1, 06132, Perugia, Italy
| | - Barbara Cellini
- Department of Experimental Medicine, University of Perugia, P.le Gambuli 1, 06132, Perugia, Italy.
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Makkapati S, D’Agati VD, Balsam L. “Green Smoothie Cleanse” Causing Acute Oxalate Nephropathy. Am J Kidney Dis 2018; 71:281-286. [DOI: 10.1053/j.ajkd.2017.08.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 08/07/2017] [Indexed: 01/01/2023]
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Mehde AA, Mehdi WA, Yusof F, Raus RA, Abidin ZAZ, Ghazali H, Rahman AA. Determination of alpha-2-MRAP gene polymorphisms in nephrolithiasis patients. Int J Biol Macromol 2017; 105:1324-1327. [DOI: 10.1016/j.ijbiomac.2017.07.167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 07/26/2017] [Accepted: 07/27/2017] [Indexed: 11/29/2022]
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Abstract
Background Enteric hyperoxaluria due to malabsorption may cause chronic oxalate nephropathy and lead to end-stage renal disease. Kidney transplantation is challenging given the risk of recurrent calcium-oxalate deposition and nephrolithiasis. Methods We established a protocol to reduce plasma oxalic acid levels peritransplantation based on reduced intake and increased removal of oxalate. The outcomes of 10 kidney transplantation patients using this protocol are reported. Results Five patients received a living donor kidney and had immediate graft function. Five received a deceased donor kidney and had immediate (n = 1) or delayed graft function (n = 4). In patients with delayed graft function, the protocol was prolonged after transplantation. In 3 patients, our protocol was reinstituted because of late complications affecting graft function. One patient with high-output stoma and relatively low oxalate levels had lost her first kidney transplant because of recurrent oxalate depositions but now receives intravenous fluid at home on a routine basis 3 times per week to prevent dehydration. Patients are currently between 3 and 32 months after transplantation and all have a stable estimated glomerular filtration rate (mean, 51 ± 21 mL/min per 1.73 m2). In 4 of 8 patients who underwent for cause biopsies after transplantation oxalate depositions were found. Conclusions This is the first systematic description of kidney transplantation in a cohort of patients with enteric hyperoxaluria. Common complications after kidney transplantation impact long-term transplant function in these patients. With our protocol, kidney transplantation outcomes were favorable in this population with unfavorable transplantation prospects and even previous unsuccessful transplants.
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Mehde AA, Yusof F, Mehdi WA, Raus RA, Farhan LO, Zainulabdeen JA, Zainal Abidin ZA, Ghazali H, Abd Rahman A. Serum E3 SUMO-protein ligase NSE2 level and peroxynitrite related to oxidative stress in nephrolithiasis patients. Asian Pac J Trop Biomed 2017. [DOI: 10.1016/j.apjtb.2016.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Mulay SR, Anders HJ. Crystal nephropathies: mechanisms of crystal-induced kidney injury. Nat Rev Nephrol 2017; 13:226-240. [DOI: 10.1038/nrneph.2017.10] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Shedding light on the morphology of calcium oxalate monohydrate crystallites present in kidney biopsies in the case of hyperoxaluria. CR CHIM 2016. [DOI: 10.1016/j.crci.2016.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Langman CB, Grujic D, Pease RM, Easter L, Nezzer J, Margolin A, Brettman L. A Double-Blind, Placebo Controlled, Randomized Phase 1 Cross-Over Study with ALLN-177, an Orally Administered Oxalate Degrading Enzyme. Am J Nephrol 2016; 44:150-8. [PMID: 27529510 DOI: 10.1159/000448766] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 07/28/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Hyperoxaluria may result from increased endogenous production or overabsorption of dietary oxalate in the gastrointestinal tract leading to nephrolithiasis and, in some, to oxalate nephropathy and chronic kidney disease. ALLN-177 is an oral formulation of a recombinant, oxalate specific, microbial enzyme oxalate decarboxylase intended to treat secondary hyperoxaluria by degrading dietary oxalate in the gastrointestinal tract, thereby reducing its absorption and subsequent excretion in the urine. METHODS This double-blind, placebo controlled, randomized, cross-over, phase 1 study of ALLN-177 evaluated the tolerability of ALLN-177 and its effect on urinary oxalate excretion in 30 healthy volunteers with hyperoxaluria induced by ingestion of a high oxalate, low calcium (HOLC) diet. The primary end point was the difference in the mean 24-hour urinary oxalate excretion during the ALLN-177 treatment period compared with the placebo treatment period. RESULTS The daily urinary oxalate excretion increased in the study population from 27.2 ± 9.5 mg/day during screening to 80.8 ± 24.1 mg/day (mean ± SD) on the HOLC diet before introducing ALLN-177 or placebo therapy for 7 days. Compared to placebo, ALLN-177 treatment reduced urinary oxalate by 11.6 ± 2.7 mg/day, p = 0.0002 (least squares mean ± SD). CONCLUSIONS In healthy volunteers, with diet-induced hyperoxaluria treatment with ALLN-177, when compared to placebo, significantly reduced urinary oxalate excretion by degrading dietary oxalate in the gastrointestinal tract and thereby reducing its absorption. ALLN-177 may represent a new approach for managing secondary hyperoxaluria and its complications.
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Affiliation(s)
- Craig B Langman
- Division of Kidney Diseases, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, and Lurie Children's Hospital of Chicago, Chicago, Ill., USA
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Affiliation(s)
- Shrikant R Mulay
- From Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig Maximilian University of Munich, Munich, Germany
| | - Hans-Joachim Anders
- From Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig Maximilian University of Munich, Munich, Germany
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Acute oxalate nephropathy due to pancreatic atrophy in newly diagnosed pancreatic carcinoma. Hum Pathol 2015; 48:163-6. [PMID: 26614399 DOI: 10.1016/j.humpath.2015.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 08/23/2015] [Accepted: 09/16/2015] [Indexed: 11/22/2022]
Abstract
Acute oxalate nephropathy can occur due to primary hyperoxaluria and secondary hyperoxaluria. The primary hyperoxalurias are a group of autosomal recessive disorders of endogenous oxalate overproduction. Secondary hyperoxaluria may occur as a result of excess dietary intake, poisoning with oxalate precursors (ethylene glycol), or enteric hyperoxaluria. The differential diagnosis of enteric hyperoxaluria includes inflammatory bowel disease, short bowel syndrome, bariatric surgery (with jejunoileal bypass or Roux-en-Y gastric bypass), celiac disease, partial colectomy, and chronic pancreatitis. The common etiology in all these processes is fat malabsorption, steatorrhea, saponification of calcium, and absorption of free oxalate. Hyperoxaluria causes increased urinary oxalate excretion, urolithiasis (promoted by hypovolemia, decreased urinary pH caused by metabolic acidosis, and decreased citrate and magnesium concentrations in urine), tubulointerstitial oxalate deposits, and tubulointerstitial nephritis. We report a rare case of acute oxalate nephropathy due to pancreatic atrophy and exocrine insufficiency caused by newly diagnosed pancreatic cancer.
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Oxalate nephropathy in systemic sclerosis: Case series and review of the literature. Semin Arthritis Rheum 2015; 45:315-20. [PMID: 26239907 DOI: 10.1016/j.semarthrit.2015.06.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 06/08/2015] [Accepted: 06/30/2015] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To increase awareness of oxalate nephropathy as a cause of acute kidney injury (AKI) among systemic sclerosis patients with small intestinal dysmotility and malabsorption, and to prompt consideration of dietary modification and early treatment of predisposing causes of oxalate nephropathy in this population. METHODS Two cases of biopsy-proven oxalate nephropathy were identified among systemic sclerosis patients in the course of direct clinical care. Subsequently, a retrospective search of the Johns Hopkins Pathology databases identified a third patient with systemic sclerosis who developed oxalate nephropathy. RESULTS Among the three patients with qualifying biopsies, all three had systemic sclerosis with lower gastrointestinal involvement. All three presented with diarrhea, malabsorption, and AKI. In two of the three patients, diarrhea was present for at least 2 years before the development of AKI; in the third, incidental oxalate nephropathy was noted 3 years before she developed AKI and extensive oxalate nephropathy in the setting of a prolonged mycobacterium avium-intracellulare enteritis. In the first case, oxalate crystals were present by urinalysis months before diagnosis by biopsy; in the second, hyperoxaluria was diagnosed by urine collection immediately after; and in the third, oxalate crystals had been noted incidentally on post-transplant renal biopsy 3 years before the development of fulminant oxalate nephropathy. All three patients died within a year after diagnosis. CONCLUSIONS Patients with systemic sclerosis and bowel dysmotility associated with chronic diarrhea and malabsorption may be at risk for an associated oxalate nephropathy. Regular screening of systemic sclerosis patients with small bowel malabsorption syndromes through routine urinalysis or 24-h urine oxalate collection, should be considered. Further studies defining the prevalence of this complication in systemic sclerosis, the benefit of dietary modification on hyperoxaluria, the effect of treating small intestinal bowel overgrowth with antibiotics, and the effectiveness of probiotics, calcium supplements, or magnesium supplements to prevent hyperoxaluria-associated renal disease in these patients, are warranted.
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Bhasin B, Ürekli HM, Atta MG. Primary and secondary hyperoxaluria: Understanding the enigma. World J Nephrol 2015; 4:235-244. [PMID: 25949937 PMCID: PMC4419133 DOI: 10.5527/wjn.v4.i2.235] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 08/29/2014] [Accepted: 02/09/2015] [Indexed: 02/05/2023] Open
Abstract
Hyperoxaluria is characterized by an increased urinary excretion of oxalate. Primary and secondary hyperoxaluria are two distinct clinical expressions of hyperoxaluria. Primary hyperoxaluria is an inherited error of metabolism due to defective enzyme activity. In contrast, secondary hyperoxaluria is caused by increased dietary ingestion of oxalate, precursors of oxalate or alteration in intestinal microflora. The disease spectrum extends from recurrent kidney stones, nephrocalcinosis and urinary tract infections to chronic kidney disease and end stage renal disease. When calcium oxalate burden exceeds the renal excretory ability, calcium oxalate starts to deposit in various organ systems in a process called systemic oxalosis. Increased urinary oxalate levels help to make the diagnosis while plasma oxalate levels are likely to be more accurate when patients develop chronic kidney disease. Definitive diagnosis of primary hyperoxaluria is achieved by genetic studies and if genetic studies prove inconclusive, liver biopsy is undertaken to establish diagnosis. Diagnostic clues pointing towards secondary hyperoxaluria are a supportive dietary history and tests to detect increased intestinal absorption of oxalate. Conservative treatment for both types of hyperoxaluria includes vigorous hydration and crystallization inhibitors to decrease calcium oxalate precipitation. Pyridoxine is also found to be helpful in approximately 30% patients with primary hyperoxaluria type 1. Liver-kidney and isolated kidney transplantation are the treatment of choice in primary hyperoxaluria type 1 and type 2 respectively. Data is scarce on role of transplantation in primary hyperoxaluria type 3 where there are no reports of end stage renal disease so far. There are ongoing investigations into newer modalities of diagnosis and treatment of hyperoxaluria. Clinical differentiation between primary and secondary hyperoxaluria and further between the types of primary hyperoxaluria is very important because of implications in treatment and diagnosis. Hyperoxaluria continues to be a challenging disease and a high index of clinical suspicion is often the first step on the path to accurate diagnosis and management.
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