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

Resveratrol inhibits calcium oxalate crystal growth, reduces adhesion to renal cells and induces crystal internalization into the cells, but promotes crystal aggregation

Resveratrol is a natural phenolic compound that belongs to stilbenoid group found in diverse plants. Health benefits and therapeutic potentials of resveratrol have been widely recognized in various diseases. In kidney stone disease, it can alleviate oxalate-induced hyperproduction of free radicals in renal epithelial cells. Nevertheless, its direct effects on calcium oxalate (CaOx) crystal, which is the major stone component, remained unclear. This study therefore addressed the direct effects of resveratrol (at 1, 10 or 100 μM) on each step of CaOx kidney stone formation. The results revealed that resveratrol had no significant effects on CaOx crystallization. However, resveratrol significantly decreased CaOx crystal growth and adhesion to renal epithelial cells at all concentrations, and induced crystal internalization into the cells (a process related to crystal degradation by endolysosomes) in a concentration-dependent manner. On the other hand, resveratrol promoted crystal aggregation. These data indicate that resveratrol serves as a dual modulator on CaOx stone formation. While it inhibits CaOx stone development by reducing crystal growth and adhesion to renal cells and by inducing crystal internalization into the cells, resveratrol promotes crystal aggregation, which is one of the mechanisms leading to kidney stone formation.

Sulfated Undaria pinnatifida Polysaccharide Promotes Endocytosis of Nano-Calcium Oxalate Dihydrate by Repairing Subcellular Organelles in HK-2 Cells

The clinical manifestation of primary hyperoxaluria includes hyperoxaluria and recurrent urinary calculi. In this study, an oxidative damage model was constructed based on oxalate damage to the human renal proximal tubular epithelial cells (HK-2), and a comparative study was carried out on four different sulfated levels of Undaria pinnatifida polysaccharides (UPP0, UPP1, UPP2, and UPP3 with sulfate group [-OSO₃^-] contents of 1.59%, 6.03%, 20.83%, and 36.39%, respectively) on the repair of oxidatively damaged HK-2 cells. The results showed that after repair by UPPs, cell viability was enhanced, healing ability was improved, the intracellular superoxide dismutase level and mitochondrial membrane potential were increased, malondialdehyde, reactive oxygen species, and intracellular Ca²⁺ levels were reduced, cellular autophagy was reduced; lysosomal integrity was improved, and cytoskeleton and cell morphology were restored. The ability of repaired cells to endocytose nano-calcium oxalate dihydrate crystals (nano-COD) was enhanced. The activity of UPPs was closely related to their -OSO₃^- content. A too high or too low -OSO₃^- content was not conducive to polysaccharide activity, and only UPP2 exhibited the best cell repair ability and strongest ability to promote the cell endocytosis of crystals. UPP2 may be used as a potential agent to inhibit CaOx crystal deposition caused by high oxalate concentration.

Inflammatory Cells in Nephrectomy Tissue from Patients without and with a History of Urinary Stone Disease

BACKGROUND AND OBJECTIVES

Urinary stone disease has been associated with inflammation, but the specific cell interactions that mediate events remain poorly defined. This study compared calcification and inflammatory cell patterns in kidney tissue from radical nephrectomy specimens of patients without and with a history of urinary stone disease.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Nontumor parenchyma of biobanked radical nephrectomy specimens from age- and sex-matched stone formers (n=44) and nonstone formers (n=82) were compared. Calcification was detected by Yasue staining and inflammatory cell populations by immunohistochemistry for CD68 (proinflammatory M1 macrophages), CD163 and CD206 (anti-inflammatory M2 macrophages), CD3 (T lymphocytes), and tryptase (mast cells). Calcifications and inflammatory cells were quantified in cortex and medulla using Image-Pro analysis software.

RESULTS

Calcification in the medulla of stone formers was higher than in nonstone formers (P<0.001). M1 macrophages in the cortex and medulla of stone formers were greater than in nonstone formers (P<0.001), and greater in stone former medulla than stone former cortex (P=0.02). There were no differences in age, sex, body mass index, tumor characteristics (size, stage, or thrombus), vascular disease status, or eGFR between the groups. M2 macrophages, T lymphocytes, and mast cells did not differ by stone former status. There was a correlation between M1 macrophages and calcification in the medulla of stone formers (rho=0.48; P=0.001) and between M2 macrophages and calcification in the medulla of nonstone formers (rho=0.35; P=0.001). T lymphocytes were correlated with calcification in the cortex of both nonstone formers (rho=0.27; P=0.01) and stone formers (rho=0.42; P=0.004), whereas mast cells and calcification were correlated only in the cortex of stone formers (rho=0.35; P=0.02).

CONCLUSIONS

Higher medullary calcification stimulated accumulation of proinflammatory rather than anti-inflammatory macrophages in stone formers.

Regulatory Effects of Damaged Renal Epithelial Cells After Repair by Porphyra yezoensis Polysaccharides with Different Sulfation Degree on the Calcium Oxalate Crystal-Cell Interaction

BACKGROUND

The interaction between urinary microcrystals and renal epithelial cells is closely related to kidney stone formation. However, the mechanism of cell state changes that affect crystal-cell interaction remains unclear.

METHODS

This study investigated the relationship between the sulfate group (-OSO3 -) content in Porphyra yezoensis polysaccharide (PYP) and the ability to repair damaged cells, as well as the changes in cell adhesion and endocytosis of nano-calcium oxalate monohydrate (COM) crystals before and after PYP repair of damaged renal tubular epithelial cells. The sulfur trioxide-pyridine method was used to sulfate PYP (-OSO3 - content of 14.14%), and two kinds of sulfated PYPs with -OSO3 - content of 20.28% (SPYP1) and 27.14% (SPYP2) were obtained. The above three PYPs were used to repair oxalate-damaged human proximal tubular epithelial cells (HK-2), and the changes in the biochemical indicators of the cells before and after the repair and the changes in cell adhesion and endocytosis of nano-COM crystals were detected.

RESULTS

After repair by PYPs, the cell viability increased, the number of reactive oxygen species decreased, and the reduction of mitochondrial membrane potential and the release of intracellular Ca2+ were suppressed. The cells repaired by PYPs inhibited the adhesion of nano-COM crystals while promoting the endocytosis of the adhered crystals. The endocytosed crystals mainly accumulated in the lysosome. The ability of PYPs to repair cell damage, inhibit crystal adhesion, and promote crystal endocytosis was enhanced when the -OSO3 - content increased. Among them, SPYP2 with the highest -OSO3 - content showed the best biological activity.

CONCLUSION

SPYP2 showed the best ability to repair damaged cells, followed by SPYP1 and PYP. SPYP2 may become a potential green drug that inhibits the formation and recurrence of calcium oxalate stones.

Human kidney stones: a natural record of universal biomineralization

GeoBioMed - a new transdisciplinary approach that integrates the fields of geology, biology and medicine - reveals that kidney stones composed of calcium-rich minerals precipitate from a continuum of repeated events of crystallization, dissolution and recrystallization that result from the same fundamental natural processes that have governed billions of years of biomineralization on Earth. This contextual change in our understanding of renal stone formation opens fundamentally new avenues of human kidney stone investigation that include analyses of crystalline structure and stratigraphy, diagenetic phase transitions, and paragenetic sequences across broad length scales from hundreds of nanometres to centimetres (five Powers of 10). This paradigm shift has also enabled the development of a new kidney stone classification scheme according to thermodynamic energetics and crystalline architecture. Evidence suggests that ≥50% of the total volume of individual stones have undergone repeated in vivo dissolution and recrystallization. Amorphous calcium phosphate and hydroxyapatite spherules coalesce to form planar concentric zoning and sector zones that indicate disequilibrium precipitation. In addition, calcium oxalate dihydrate and calcium oxalate monohydrate crystal aggregates exhibit high-frequency organic-matter-rich and mineral-rich nanolayering that is orders of magnitude higher than layering observed in analogous coral reef, Roman aqueduct, cave, deep subsurface and hot-spring deposits. This higher frequency nanolayering represents the unique microenvironment of the kidney in which potent crystallization promoters and inhibitors are working in opposition. These GeoBioMed insights identify previously unexplored strategies for development and testing of new clinical therapies for the prevention and treatment of kidney stones.

Protective Effect of Degraded Porphyra yezoensis Polysaccharides on the Oxidative Damage of Renal Epithelial Cells and on the Adhesion and Endocytosis of Nanocalcium Oxalate Crystals

The protective effects of Porphyra yezoensis polysaccharides (PYPs) with molecular weights of 576.2 (PYP1), 105.4 (PYP2), 22.47 (PYP3), and 3.89 kDa (PYP4) on the oxidative damage of human kidney proximal tubular epithelial (HK-2) cells and the differences in adherence and endocytosis of HK-2 cells to calcium oxalate monohydrate crystals before and after protection were investigated. Results showed that PYPs can effectively reduce the oxidative damage of oxalic acid to HK-2 cells. Under the preprotection of PYPs, cell viability increased, cell morphology improved, reactive oxygen species levels decreased, mitochondrial membrane potential increased, S phase cell arrest was inhibited, the cell apoptosis rate decreased, phosphatidylserine exposure reduced, the number of crystals adhered to the cell surface reduced, but the ability of cells to endocytose crystals enhanced. The lower the molecular weight, the better the protective effect of PYP. The results in this article indicated that PYPs can reduce the risk of kidney stone formation by protecting renal epithelial cells from oxidative damage and reducing calcium oxalate crystal adhesion, and PYP4 with the lowest molecular weight may be a potential drug for preventing kidney stone formation.

Effects of Selenized Astragalus Polysaccharide on the Adhesion and Endocytosis of Nanocalcium Oxalate Dihydrate after the Repair of Damaged HK-2 Cells

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.

Pseudoxanthoma Elasticum, Kidney Stones and Pyrophosphate: From a Rare Disease to Urolithiasis and Vascular Calcifications

Pseudoxanthoma elasticum is a rare disease mainly due to ABCC6 gene mutations and characterized by ectopic biomineralization and fragmentation of elastic fibers resulting in skin, cardiovascular and retinal calcifications. It has been recently described that pyrophosphate (a calcification inhibitor) deficiency could be the main cause of ectopic calcifications in this disease and in other genetic disorders associated to mutations of ENPP1 or CD73. Patients affected by Pseudoxanthoma Elasticum seem also prone to develop kidney stones originating from papillary calcifications named Randall’s plaque, and to a lesser extent may be affected by nephrocalcinosis. In this narrative review, we summarize some recent discoveries relative to the pathophysiology of this mendelian disease responsible for both cardiovascular and renal papillary calcifications, and we discuss the potential implications of pyrophosphate deficiency as a promoter of vascular calcifications in kidney stone formers and in patients affected by chronic kidney disease.

Beginnings of nephrolithiasis: insights into the past, present and future of Randall's plaque formation research

PURPOSE OF REVIEW

Kidney stones form as a result of heterogeneous nucleation on a calcium phosphate lesion in the renal papilla known as Randall's plaque. Stone disease has plagued humans for millennia with relatively little progress made in the realm of prevention. An understanding of the historical aspects of research into Randall's plaque is necessary to interpret novel correlative imaging discoveries. Focus for the past several decades has been on the distal papillary tip, and the overlooked Anderson-Carr-Randall progression is revitalized with novel supporting evidence.

RECENT FINDINGS

Novel correlative techniques of three-dimensional micro-XCT imaging combined with electron and light microscopy techniques have revealed that the earliest mineralization event in the papilla is a distinct event that occurs proximal to the region where Randall's plaque has traditionally been identified.

SUMMARY

The history of Randall's plaque research and the Anderson-Carr-Randall progression is reviewed. Proximal intratubular mineral deposits in normal and Randall's plaque affected papillae may be a target for future therapeutic interventions for nephrolithiasis. Further collaboration between nephrologists and urologists is necessary to cure this debilitating disease.

Geobiology reveals how human kidney stones dissolve in vivo

More than 10% of the global human population is now afflicted with kidney stones, which are commonly associated with other significant health problems including diabetes, hypertension and obesity. Nearly 70% of these stones are primarily composed of calcium oxalate, a mineral previously assumed to be effectively insoluble within the kidney. This has limited currently available treatment options to painful passage and/or invasive surgical procedures. We analyze kidney stone thin sections with a combination of optical techniques, which include bright field, polarization, confocal and super-resolution nanometer-scale auto-fluorescence microscopy. Here we demonstrate using interdisciplinary geology and biology (geobiology) approaches that calcium oxalate stones undergo multiple events of dissolution as they crystallize and grow within the kidney. These observations open a fundamentally new paradigm for clinical approaches that include in vivo stone dissolution and identify high-frequency layering of organic matter and minerals as a template for biomineralization in natural and engineered settings.

Protective Effects of Pistacia lentiscus L. fruit extract against calcium oxalate monohydrate induced proximal tubular injury

ETHNOPHARMACOLOGICAL RELEVANCE

The world prevalence of kidney stones is increasing and plants are frequently used to treat urolithiasis. Pistacia lentiscus L, a plant which freely grows around the Mediterranean basin areas, is widely used for various pathologies. P. lentiscus has an important impact as it has economical value on top of its pharmacological interest. Decoctions of its aerial parts and/or resin are used to treat kidney stones.

AIM OF THE STUDY

To in vitro assess the potential nephroprotective effect of Pistacia lentiscus ethanolic fruit extract (PLEF) on proximal tubular cells in response to the adhesion of calcium oxalate monohydrate (COM) crystals.

MATERIALS AND METHODS

Human Kidney [HK]-2 cells were incubated with and without COM in the presence or absence of PLEF. Cell viability was measured by the resazurin assay. The expression of E-cadherin was analyzed by PCR. The extracellular production of H₂O₂ was measured by Amplex® Red H₂O₂ Assay. The numbers of detached or non-adherent COM crystals in the presence of PLEF were microscopically captured and counted using ImageJ software. The interaction of PLEF with COM and the effect of PLEF on crystal size were analyzed by flow cytometry. The spectrophotometric measurement of turbidity was performed for assessing the COM concentration.

RESULTS

PLEF incubated with COM was able to increase the cell viability. The decrease of E-cadherin expression after incubation with COM was counteracted by PLEF. Overproduction of H₂O₂ induced by COM was also inhibited by PLEF. Observations using flow cytometry showed that interactions between PLEF and the COM crystals occurred. PLEF was also effective in reducing the particles size and in lowering COM concentration.

CONCLUSION

Our data show that COM tubulotoxicity can be significantly reversed by PLEF -at least in part- via an inhibition of COM crystals adhesion onto the apical membrane. This early beneficial effect of PLEF needs to be further investigated as a useful strategy in nephrolithiasis prevention.

Papillary Ductal Plugging is a Mechanism for Early Stone Retention in Brushite Stone Disease

PURPOSE

Mechanisms of early stone retention in the kidney are under studied and poorly understood. To date attachment via Randall's plaque is the only widely accepted theory in this regard, which is best described in idiopathic calcium oxalate stone formers. Brushite stone formers are known to have distinct papillary morphology relative to calcium oxalate stone formers. As such we sought to determine whether stone attachment mechanisms in such patients may be similarly unique.

MATERIALS AND METHODS

Patients undergoing percutaneous and or ureteroscopic procedures for stone removal consented to endoscopic renal papillary examination and individual stone collection. Each removed stone was processed using micro computerized tomography to assess the 3-dimensional microstructure and the minerals contained, and search for common structural features indicative of novel mechanisms of early growth and attachment to renal tissue.

RESULTS

A total of 25 intact brushite stones were removed from 8 patients and analyzed. Video confirmed attachment of 13 of the 25 stones with the remainder believed to have been accidently dislodged during the procedure. Microscopic examination by light and computerized tomography failed to show evidence of Randall's plaque associated with any stone containing brushite. Conversely each brushite stone demonstrated microstructural evidence of having grown attached to a ductal plug formed of apatite.

CONCLUSIONS

Three-dimensional analysis of small brushite stones suggests overgrowth on ductal apatite plugs as a mechanism of early stone growth and retention. Such findings represent what is to our knowledge the initial supporting evidence for a novel mechanism of stone formation which has previously been hypothesized but never verified.

Size-dependent cellular uptake mechanism and cytotoxicity toward calcium oxalate on Vero cells

Urinary crystals with various sizes are present in healthy individuals and patients with kidney stone; however, the cellular uptake mechanism of calcium oxalate of various sizes has not been elucidated. This study aims to compare the internalization of nano-/micron-sized (50 nm, 100 nm, and 1 μm) calcium oxalate monohydrate (COM) and dihydrate (COD) crystals in African green monkey renal epithelial (Vero) cells. The internalization and adhesion of COM and COD crystals to Vero cells were enhanced with decreasing crystal size. Cell death rate was positively related to the amount of adhered and internalized crystals and exhibited higher correlation with internalization than that with adhesion. Vero cells mainly internalized nano-sized COM and COD crystals through clathrin-mediated pathways as well as micron-sized crystals through macropinocytosis. The internalized COM and COD crystals were distributed in the lysosomes and destroyed lysosomal integrity to some extent. The results of this study indicated that the size of crystal affected cellular uptake mechanism, and may provide an enlightenment for finding potential inhibitors of crystal uptake, thereby decreasing cell injury and the occurrence of kidney stones.

Probiotics for prevention of urinary stones

BACKGROUND

Urinary supersaturation is one key determinant of calcium oxalate (CaOx) urinary stone formation, and urinary excretions of oxalate and citrate are two key determinants. Each is influenced by gastrointestinal processes.

METHODS

Open label and randomized placebo studies have examined the effect of oral probiotic preparations on urinary supersaturation and oxalate excretion. Cross sectional studies in humans have studied the association of Oxalobacter formigenes colonization status and urinary oxalate excretion and prevalence of urinary stones. The intestinal microbiome of representative animals adapted to a high oxalate diet has been defined.

RESULTS

The fecal content of O. formigenes, the best studied oxalate-degrader, varies depending on stone status. However, trials with probiotics designed to degrade oxalate including those containing O. formigenes, Lactobacillus, and/or Bifidobacterium spp., have been disappointing. Multiple intestinal segments of animals on a high oxalate diet contains diverse communities of microorganisms that can function together to degrade and detoxify a large oxalate load.

CONCLUSIONS

Although the intestinal microbiome seems likely to play a role to modify gastrointestinal absorption of lithogenic substances and hence urinary stone risk, whether we can develop tools to manipulate it and decrease this kidney stone risk remains to be determined.

Protective Effects of Degraded Soybean Polysaccharides on Renal Epithelial Cells Exposed to Oxidative Damage

This study aimed to investigate the protective effects of degraded soybean polysaccharides (DSP) on oxidatively damaged African green monkey kidney epithelial (Vero) cells. Low DSP concentration (10 μg/mL) elicited an evident protective effect on H₂O₂-induced cell injury (0.3 mmol/L). The cell viabilities of the H₂O₂-treated group and the DSP-protected group were 57.3 and 93.1%, respectively. The cell viability decreased to 88.3% when the dosage was increased to 100 μg/mL. DSP protected Vero cells from H₂O₂-mediated oxidative damage by enhancing cellular superoxide dismutase activity and total antioxidant capacity and by decreasing malonaldehyde content and lactate dehydrogenase release. The H₂O₂-treated cells stimulated the aggregation of calcium oxalate monohydrate crystals. DSP could also reduce the crystal size, decrease the attached crystal content, and prevent the cell aggregation by alleviating oxidative injury and lipid peroxidation, enhancing antioxidant capacity, and decreasing hyaluronan expression on cellular surfaces. The internalization ability of the injured cells was improved after these cells were exposed to DSP solution. The regulation ability of DSP-repaired cells on calcium oxalate dihydrate formation, crystal attachment, aggregation, and internalization was lower than that of normal cells but was higher than that of the injured cells. DSP may be a potential green drug to prevent calcium oxalate (CaOx) stone formation because DSP could protect cells from oxidative damage and inhibit CaOx crystal formation.

Reinjury risk of nano-calcium oxalate monohydrate and calcium oxalate dihydrate crystals on injured renal epithelial cells: aggravation of crystal adhesion and aggregation

BACKGROUND

Renal epithelial cell injury facilitates crystal adhesion to cell surface and serves as a key step in renal stone formation. However, the effects of cell injury on the adhesion of nano-calcium oxalate crystals and the nano-crystal-induced reinjury risk of injured cells remain unclear.

METHODS

African green monkey renal epithelial (Vero) cells were injured with H2O2 to establish a cell injury model. Cell viability, superoxide dismutase (SOD) activity, malonaldehyde (MDA) content, propidium iodide staining, hematoxylin-eosin staining, reactive oxygen species production, and mitochondrial membrane potential (Δψm) were determined to examine cell injury during adhesion. Changes in the surface structure of H2O2-injured cells were assessed through atomic force microscopy. The altered expression of hyaluronan during adhesion was examined through laser scanning confocal microscopy. The adhesion of nano-calcium oxalate monohydrate (COM) and calcium oxalate dihydrate (COD) crystals to Vero cells was observed through scanning electron microscopy. Nano-COM and COD binding was quantitatively determined through inductively coupled plasma emission spectrometry.

RESULTS

The expression of hyaluronan on the cell surface was increased during wound healing because of Vero cell injury. The structure and function of the cell membrane were also altered by cell injury; thus, nano-crystal adhesion occurred. The ability of nano-COM to adhere to the injured Vero cells was higher than that of nano-COD crystals. The cell viability, SOD activity, and Δψm decreased when nano-crystals attached to the cell surface. By contrast, the MDA content, reactive oxygen species production, and cell death rate increased.

CONCLUSION

Cell injury contributes to crystal adhesion to Vero cell surface. The attached nano-COM and COD crystals can aggravate Vero cell injury. As a consequence, crystal adhesion and aggregation are enhanced. These findings provide further insights into kidney stone formation.

The protective effects of an herbal agent tutukon on ethylene glycol and zinc disk induced urolithiasis model in a rat model

To evaluate protective effects of Tutukon^®, a plant derived herbal product, on the development of rat urolithiasis model. A total of 45 rats were divided into three groups namely; Group 1 (control group; drinking water + zinc disk), Group 2 (0.5 % ethylene glycol [EG] to drinking water + zinc disk) and Group 3 (study group-0.5 % EG + Tutukon + zinc disk). Moreover, zinc disks were placed into bladder of rats to serve as a nidus for stone development. Five rats from each group were killed at the end of the 1st, 2nd and 4th week. The level of bladder inflammation, the disk weights and the urine oxalate, calcium and pH values and were evaluated and compared. The inflammation scores of the pathological evaluation were not significantly different among three groups. At the end of the 28th day, weights of the zinc disks were significantly higher in Group 2 (394.4 ± 41.2) when compared to Group 1 (1517.5 ± 367.3) and Group 3 (386.2 ± 26.9) (p = 0.016). The disk weights increased gradually at 7th, 14th and 28th days in Group 1 (p = 0.018) and Group 2 (p = 0.009) while remained stable in Group 3 (p = 0.275). Urine calcium levels were not affected among three groups throughout the study period. At the end of the 28th day, while the urine oxalate levels of rats in Group 1 was lower than that of both Group 2 (p = 0.046) and Group 3 (p = 0.008); Group 2 and Group 3 had similar oxalate excretion levels (p = 0.701). However, the difference was not significant. Tutukon seems to decrease stone deposition on zinc disks implanted in the bladder of rats. The exact mechanism of this preventive effect is, however, not well understood.

Topography, Composition and Structure of Incipient Randall Plaque at the Nanoscale Level

PURPOSE

Randall identified calcium phosphate plaques in renal papillae as the origin of kidney stones. However, little is known about the early steps of Randall plaque formation preceding the onset of urolithiasis. Our objective was to characterize the composition and the initial formation site of incipient Randall plaque in nonstone forming, living patients.

MATERIALS AND METHODS

Median patient age was 67.7 years. A total of 54 healthy papillae from kidneys removed for cancer and without stones were analyzed by immunohistochemistry and von Kossa staining, field emission-scanning electron microscopy with energy dispersive x-ray analysis, μ-Fourier transform infrared spectroscopy, cryo-transmission electron microscopy coupled to selected area electron diffraction and electron energy loss spectroscopy.

RESULTS

Incipient Randall plaque was observed in 72.7% of kidneys. As expected, carbonated apatite was the main component of microcalcifications but amorphous calcium phosphate and whitlockite were identified in 80% and 40% of papillae, respectively. Incipient plaques were noted in the deepest part of the papillae around the loop of Henle tip as well as around the vasa recta, representing 62.4% and 37.2% of microcalcifications, respectively. Plaques were rarely close to collecting ducts. At the nanoscale level incipient calcifications were often composed of several nanocrystals in organic material that looked like microvesicles.

CONCLUSIONS

Incipient Randall plaque is frequent. It appears not only at the extreme tip of the renal papillae around the hairpin structure of the loop of Henle but also around the vasa recta. Nanoscale analyses suggest a local nucleation process promoting nanocrystal growth in a supersaturated milieu. In addition, plaques contain various calcium and magnesium phosphates, and not only carbonated apatite.

Calcium oxalate toxicity in renal epithelial cells: the mediation of crystal size on cell death mode

The cytotoxicity of calcium oxalate (CaOx) in renal epithelial cells has been studied extensively, but the cell death mode induced by CaOx with different physical properties, such as crystal size and crystal phase, has not been studied in detail. In this study, we comparatively investigated the differences of cell death mode induced by nano-sized (50 nm) and micron-sized (10 μm) calcium oxalate monohydrate (COM) and calcium oxalate dihydrate (COD) to explore the cell death mechanism. The effect of the exposure of nano-/micron-sized COM and COD crystals toward the African green monkey renal epithelial (Vero) cells were investigated by detecting cell cytoskeleton changes, lysosomal integrity, mitochondrial membrane potential (Δψm), apoptosis and/or necrosis, osteopontin (OPN) expression, and malondialdehyde (MDA) release. Nano-/micron-sized COM and COD crystals could cause apoptosis and necrosis simultaneously. Nano-sized crystals primarily caused apoptotic cell death, leading to cell shrinkage, phosphatidylserine ectropion, and nuclear shrinkage, whereas micron-sized crystals primarily caused necrotic cell death, leading to cell swelling and cell membrane and lysosome rupture. Nano-sized COM and COD crystals induced much greater cell death (sum of apoptosis and necrosis) than micron-sized crystals, and COM crystals showed higher cytotoxicity than the same-sized COD crystals. Both apoptosis and necrosis could lead to mitochondria depolarization and elevate the expression of OPN and the generation of lipid peroxidation product MDA. The amount of expressed OPN and generated MDA was positively related to cell injury degree. The physicochemical properties of crystals could affect the cell death mode. The results of this study may provide a basis for future studies on cell death mechanisms.

Limitation of apoptotic changes and crystal deposition by Tutukon following hyperoxaluria-induced tubular cell injury in rat model

This study aimed at evaluating the protective effects of a herbal medication (Tutukon) on the hyperoxaluria induced apoptotic changes and crystal deposition in renal tubular epithelium in rat model. 60 male wistar rats were divided into three different groups (each group n: 20). In Group I severe hyperoxaluria was induced by ethylene glycol (EG) (0.75%) administration for 28 days. In Group II, in addition to hyperoxaluria induction, animals were treated with Tutukon for 28 days. Group III animals constituted the controls without any specific medication and/or intervention. While the presence and degree of crystal deposition in the tubular lumen were examined histopathologically under light microscopy, tubular apoptotic changes were evaluated using immunohistochemical staining for cysteine-aspartic acid protease-3 (Caspase-3) and tumor necrosis factor alpha (TNF-α) positivity on days 14 and 28, respectively. Evaluation of apoptotic changes by Caspase-3 positivity showed that while the majority of animals undergoing EG only showed evident apoptotic changes (n: 9), Tutukon application demonstrated a significant limitation with limited or no apoptosis (n: 7) in these animals. Similar data were noted for TNF alpha expression; while apoptotic changes were evident in 8 (80%) in Group I animals, limited changes were noted in Tutukon Group (n: 2). Regarding crystal deposition despite evident changes in Group I (9 animals), like apoptotic alterations, it was again significantly limited in animals receiving Tutukon (4 animals). Renal tubular crystal deposition and apoptotic changes induced by hyperoxaluria play a role in the pathogenesis of urolithiasis and the limitation of these changes might be instituted by Tutukon as a result of its antioxidant and antiinflammatory effects.

Randall's plaque as the origin of calcium oxalate kidney stones

Eight decades ago, Alexander Randall identified calcium phosphate deposits at the tip of renal papillae as the origin of renal calculi. The awareness that these "Randall's plaque" promote renal stone formation has been amplified during the past years by the development of endoscopic procedures allowing the in situ visualization of these plaques. Recent studies based upon kidney biopsies evidenced that apatite deposits at the origin of these plaque originate from the basement membranes of thin loops of Henle and then spread in the surrounding interstitium. In addition, scanning electron microscopy examination of calcium oxalate stones developed on Randall's plaque evidenced that plaque may also be made of tubules obstructed by calcium phosphate plugs. Hypercalciuria has been associated to Randall's plaque formation. However, several additional mechanisms may be involved resulting in increased tissular calcium phosphate supersaturation and the role of macromolecules in plaque formation remains elusive. At last, apatite crystals are the main mineral phase identified in plaques, but other calcium phosphates and various chemical species such as purines have been evidenced, revealing thereby that several mechanisms may be responsible for plaque formation.

Androgen receptor enhances kidney stone-CaOx crystal formation via modulation of oxalate biosynthesis & oxidative stress

Males develop kidney stones far more frequently than females with a ratio of 2–3:1, suggesting that androgen receptor (AR) signaling might play a key role in the development of nephrolithiasis. Using the cre-loxP system to selectively knock out AR in glyoxylate-induced calcium oxalate (CaOx) crystal mouse models, we found that the mice lacking hepatic AR had less oxalate biosynthesis, which might lead to lower CaOx crystal formation, and that the mice lacking kidney proximal or distal epithelial AR also had lower CaOx crystal formation. We found that AR could directly up-regulate hepatic glycolate oxidase and kidney epithelial NADPH oxidase subunit p22-PHOX at the transcriptional level. This up-regulation might then increase oxalate biosynthesis and oxidative stress that resulted in induction of kidney tubular injury. Targeting AR with the AR degradation enhancer ASC-J9 led to suppression of CaOx crystal formation via modulation of oxalate biosynthesis and oxidative stress in both in vitro and in vivo studies. Taken together, these results established the roles of AR in CaOx crystal formation.

Genetic modulation of nephrocalcinosis in mouse models of ectopic mineralization: the Abcc6(tm1Jfk) and Enpp1(asj) mutant mice

Ectopic mineralization of renal tissues in nephrocalcinosis is a complex, multifactorial process. The purpose of this study was to examine the role of genetic modulation and the role of diet in nephrocalcinosis using two established mouse models of ectopic mineralization, Abcc6(tm1Jfk) and Enpp1(asj) mice, which serve as models for pseudoxanthoma elasticum and generalized arterial calcification of infancy, two heritable disorders, respectively. These mutant mice, when on standard rodent diet, develop nephrocalcinosis only at a very late age. In contrast, when placed on an 'acceleration diet' composed of increased phosphate and reduced magnesium content, they showed extensive mineralization of the kidneys affecting primarily the medullary tubules as well as arcuate and renal arteries, as examined by histopathology and quantitated by chemical assay for calcium. Mineralization could also be detected noninvasively by micro computed tomography. Whereas the heterozygous mice did not develop nephrocalcinosis, compound heterozygous mice carrying both mutant alleles, Abcc6(tm1Jfk/+) and Enpp1(+/asj), developed ectopic mineralization similar to that noted in homozygous mice for either gene, indicating that deletion of one Abcc6 allele along with Enpp1 haploinsufficiency resulted in renal mineralization. Thus, synergistic genetic defects in the complex mineralization/antimineralization network can profoundly modulate the degree of ectopic mineralization in nephrocalcinosis.

Role of TNF-associated cytokines in renal tubular cell apoptosis induced by hyperoxaluria

Crystal-cell interaction has been reported as one of the most crucial steps in urinary stone formation. Hyperoxaluria-induced apoptotic changes in renal tubular epithelial cells is the end-stage of this interaction. We aimed to evaluate the possible pathways responsible in the induction of apoptosis within the involved cells by assessing the receptoral expression of three different pathways. 16 male Spraque-Dowley rats were divided into two groups: Group 1 (n:8) received only distilled water; Group 2 (n:8) received 0.75 % ethylene glycol (EG) in their daily water to induce hyperoxaluria for 2 weeks. After 24 h urine collection, all animals were euthenized and right kidneys were removed and fixed for immunohistochemical evaluation. Oxalate and creatinine levels (in 24 h-urine) and FAS, tumor necrosis factor (TNF), TNF-related apoptosis-inducing ligand (TRAIL) and TRAIL receptor-2 expressions (in tissue) have been assessed. In addition to TNF (p = 0.0007) expression; both FAS (p = 0.0129 ) and FASL (p = 0.032) expressions significantly increased in animals treated with EG. The expressions of TRAIL (p = 0.49) and TRAIL-R2 (p = 0.34) receptors did not change statistically after hyperoxaluria induction. Although a positive correlation with cytokine expression density and 24 h-urinary oxalate expression (mg oxalate/mg creatinine) has been assessed with TNF (p = 0.04, r = 0.82), FAS (p = 0.05, r = 0.80), FAS-L (p = 0.04, r = 0.82); no correlation could be demonstrated between TRAIL and TRAIL R2 expressions. Our results indicate that apoptosis induced by oxalate is possibly mediated via TNF and FAS pathways. However, TRAIL and TRAIL-R2 seemed to have no function in the cascade. Correlation with urinary oxalate levels did further strengthen the findings.

Molecular mechanisms involved in the protective effect of the chloroform extract of Selaginella lepidophylla (Hook. et Grev.) Spring in a lithiasic rat model

Urolithiasis is a multifaceted process, progressing from urine supersaturation to the formation of mature renal calculi. Calcium oxalate, the main component of kidney stones, has toxicological effects on renal epithelial cells. Some medicinal plants have shown pharmacological effects against renal lithiasis, such as Selaginella lepidophylla (Hook. et Grev) Spring, a plant empirically used in Mexico for its diuretic and antilithiasic activity. The plant was identified and ground, and a chloroform extract (CE) was obtained. Urolithiasis was induced in Wistar female rats by administration of ethylene glycol and ammonium chloride for 21 days. Urolithiasis rats were treated with the CE (50 mg/kg) for 21 days. Osmolality, creatinine, sodium and potassium concentrations were measured in blood and urine. Glomerular filtration rate (GFR), and electrolytic and water balances were calculated. Urinary oxalic acid concentration was measured. Apoptosis, lipoperoxidation, ROS and p-amino hippuric acid were determined in cortical tissue. Urolithiasis rats showed a decrease of urinary flow, GFR, electrolytic balance, renal tubular secretion and ATP concentration and increase of urinary oxalic acid, lipoperoxidation, oxidative stress and apoptosis in cortical tissue. After treatment with the CE, urinary flow rate, GFR and renal tubular secretion levels were recovered; on the other hand, serum creatinine and urinary oxalic acid decreased on day 21. CE of Selaginella lepidophylla prevented the damage caused by lithiasic process by improving the active secretion in the proximal tubules, counteracting the ROS and lipoperoxidation effects by oxalate and decreased the OAT3 expression on kidney.

Aluminum citrate prevents renal injury from calcium oxalate crystal deposition

Calcium oxalate monohydrate crystals are responsible for the kidney injury associated with exposure to ethylene glycol or severe hyperoxaluria. Current treatment strategies target the formation of calcium oxalate but not its interaction with kidney tissue. Because aluminum citrate blocks calcium oxalate binding and toxicity in human kidney cells, it may provide a different therapeutic approach to calcium oxalate-induced injury. Here, we tested the effects of aluminum citrate and sodium citrate in a Wistar rat model of acute high-dose ethylene glycol exposure. Aluminum citrate, but not sodium citrate, attenuated increases in urea nitrogen, creatinine, and the ratio of kidney to body weight in ethylene glycol-treated rats. Compared with ethylene glycol alone, the addition of aluminum citrate significantly increased the urinary excretion of both crystalline calcium and crystalline oxalate and decreased the deposition of crystals in renal tissue. In vitro, aluminum citrate interacted directly with oxalate crystals to inhibit their uptake by proximal tubule cells. These results suggest that treating with aluminum citrate attenuates renal injury in rats with severe ethylene glycol toxicity, apparently by inhibiting calcium oxalate's interaction with, and retention by, the kidney epithelium.

The effect of intracrystalline and surface-bound osteopontin on the degradation and dissolution of calcium oxalate dihydrate crystals in MDCKII cells

In vivo, urinary crystals are associated with proteins located within the mineral bulk as well as upon their surfaces. Proteins incarcerated within the mineral phase of retained crystals could act as a defence against urolithiasis by rendering them more vulnerable to destruction by intracellular and interstitial proteases. The aim of this study was to examine the effects of intracrystalline and surface-bound osteopontin (OPN) on the degradation and dissolution of urinary calcium oxalate dihydrate (COD) crystals in cultured Madin Darby canine kidney (MDCK) cells. [(14)C]-oxalate-labelled COD crystals with intracrystalline (IC), surface-bound (SB) and IC + SB OPN, were generated from ultrafiltered (UF) urine containing 0, 1 and 5 mg/L human milk OPN and incubated with MDCKII cells, using UF urine as the binding medium. Crystal size and degradation were assessed using field emission scanning electron microscopy (FESEM) and dissolution was quantified by the release of radioactivity into the culture medium. Crystal size decreased directly with OPN concentration. FESEM examination indicated that crystals covered with SB OPN were more resistant to cellular degradation than those containing IC OPN, whose degree of disruption appeared to be related to OPN concentration. Whether bound to the crystal surface or incarcerated within the mineral interior, OPN inhibited crystal dissolution in direct proportion to its concentration. Under physiological conditions OPN may routinely protect against stone formation by inhibiting the growth of COD crystals, which would encourage their excretion in urine and thereby perhaps partly explain why, compared with calcium oxalate monohydrate crystals, COD crystals are more prevalent in urine, but less common in kidney stones.

Hyperoxaluria-induced tubular ischemia: the effects of verapamil and vitamin E on apoptotic changes with an emphasis on renal papilla in rat model

An experimental study in rats was performed to evaluate the presence and the degree of both tubular apoptotic changes and crystallization at cortical, medullar and papillary regions of the kidney during hyperoxaluric phase and assess the possible protective effects of vitamin E and verapamil on these pathologic changes (particularly in papillary part of the affected kidneys). A total of 32 rats have been included into the study program. Hyperoxaluria was induced by continuous administration of ethylene glycol (0.75%). In addition to hyperoxaluria induction, animals in Groups 2 and 3 did receive a calcium channel-blocking agent (verapamil) and vitamin E, respectively. Histologic alterations of the kidneys including crystal formation together with apoptotic changes were evaluated on days 1, 14 and 28, respectively. Both apoptotic changes and the presence and degree of crystallization were assessed separately in renal cortical region, medulla and particularly papillary parts of the removed kidneys. Although verapamil did well limit the degree of crystal formation and apoptosis and brought it to the same levels observed in control group animals in all parts of the kidneys during intermediate phase, addition of vitamin E was failed to show the same protective effect during both intermediate and late phase evaluations. As demonstrated in our study, the limitation of both crystal deposition and apoptotic changes might be instituted by calcium channel-blocking agents. Clinical application of such agents in the prophylaxis of stone disease might limit the formation of urinary calculi, especially in recurrent stone formers.

Percutaneous and transureteral biopsies of renal papillae: safe and appropriate procedures for in vivo histologic analysis in stone formers

BACKGROUND AND PURPOSE

According to the Randall plaque theory, urinary crystals may attach to focal interstitial deposits of calcium phosphate (CaP), localized in the tip of the renal papillae. The aim of this prospective study was to evaluate the feasibility and safety of papillary biopsy, performed during ureterorenoscopy (URS) or percutaneous nephrolithotomy (PCNL), to obtain, in vivo, appropriate samples to investigate interstitial CaP deposits that represent Randall's plaques precursors.

PATIENTS AND METHODS

Twenty-eight patients who were affected by recurrent renal stones, 13 males and 15 females, with a median age of 42.5 years (range 17-76 y), underwent rigid and/or flexible URS (8 patients) or PCNLs (20 patients). In all cases, endoscopic biopsies from renal papillae were performed. Papillary samples were obtained by means of 3F or 4F cup biopsy forceps if semirigid and flexible ureterorenoscopes were used. During percutaneous procedures, with rigid and flexible instruments, 5F or 10F cup forceps were used. The same pathologist analyzed all the histologic specimens.

RESULTS

All patients underwent successful biopsy procedures. The quality of the obtained tissue allowed for an accurate histochemical analysis in 27 of 28 (96.4%) biopsies. One biopsy was inadequate because of some important regressive phenomena. No specific complications had to be attributed to biopsy procedures.

CONCLUSIONS

Percutaneous or transureteral biopsies of renal papillae resulted in being safe and appropriate procedures to obtain papillary samples to identify the presence of interstitial calcium deposits. In the light of the low number of inadequate biopsies, it can be concluded that no difference was found between the percutaneous and transureteral bioptic approach.

A comparison of the binding of urinary calcium oxalate monohydrate and dihydrate crystals to human kidney cells in urine

OBJECTIVE

To compare the binding kinetics of urinary calcium oxalate monohydrate (COM) and dihydrate (COD) crystals to human kidney (HK-2) cells in ultra-filtered (UF), and centrifuged and filtered (CF) human urine; and to quantify the binding of COM and COD crystals to cultured HK-2 cells in UF and CF urine samples collected from different individuals.

MATERIALS AND METHODS

Urine was collected from healthy subjects, pooled, centrifuged and filtered. (14) C-oxalate-labelled COM and COD crystals were precipitated from the urine by adding oxalate after adjustment of two aliquots of the urine to 2 and 8 mm Ca(2+), respectively. For the kinetic study, the crystals were incubated with HK-2 cells for up to 120 min in pooled CF urine adjusted to 2 and 8 mm Ca(2+). Identical experiments were also carried out in UF urine samples collected from the same individuals. For the quantitative study, the same radioactively labelled COM and COD crystals were incubated with HK-2 cells for 50 min in separate CF and UF urines collected from eight healthy individuals at the native Ca(2+) concentrations of the urines. Field emission electron microscopy and Fourier transform-infrared spectroscopy were used to confirm crystal morphology.

RESULTS

COM and COD crystals generally bound more strongly at 8 mm than at 2 mm Ca(2+). The kinetic binding curves of COM were smooth, while those of COD were consistently biphasic, suggesting that the two crystal types induce different cellular metabolic responses: HK-2 cells crystals appear to possess a transitory mechanism for detaching COD, but not COM crystals. In UF urine, COM binding was significantly greater than that of COD at 2 mm Ca(2+), but at 8 mm Ca(2+) the binding of COD was greater at early and late time points. COD also bound significantly more strongly at early time points in CF urine at both 2 and 8 mm Ca(2+). In both CF and UF urine, there was no difference between the binding affinity of urinary COM and COD crystals.

CONCLUSION

Binding of both COM and COD crystals to cultured human renal epithelial cells is influenced by urinary macromolecules and ambient Ca(2+) concentration. HK-2 cells appear to possess a mechanism for the rapid detachment of bound COD crystals, making it difficult to show any unambiguous overall difference between the binding affinity of COM and COD crystals.

The tubular epithelium in the initiation and course of intratubular nephrocalcinosis

Intratubular nephrocalcinosis is defined as the histological observation of calcium oxalate and/or calcium phosphate deposits retained within the lumen of the renal tubules. As the tubular epithelium is the primary interaction partner of crystals formed in the tubular fluid, the role of the epithelial cells in nephrocalcinosis has been investigated intensively. This review summarizes our current understanding on how the tubular epithelium mechanistically appears to be involved both in the initiation and in the course of nephrocalcinosis, with emphasis on in vivo observations.

Origin and types of calcium oxalate monohydrate papillary renal calculi

OBJECTIVES

Subepithelial hydroxyapatite calcification of renal papilla is thought to be involved in the formation of calcium oxalate monohydrate (COM) papillary calculi. To assess the mechanism of formation, we sought to correlate the fine structure of papillary renal calculi with specific pathophysiologic conditions and urinary alterations.

METHODS

The study included 831 COM papillary renal calculi with established fine inner structures. A total of 24 patients with chronic stone formation were randomly selected, and their urine was collected and analyzed. The case history and lifestyle habits of these patients were obtained.

RESULTS

The 831 papillary calculi could be classified into 1 of 4 main groups. Type I included small calculi in which COM columnar crystals begin to develop in the concave zone in close contact with papillary tissue. Type II calculi contained a hydroxyapatite core located in or near the concave zone. Type III consisted of calculi that developed on the tip of the papillae and in the concave zone, containing hydroxyapatite, calcified tissue, and calcified tubules. Type IV consisted of papillary calculi in which the core, which is situated near, but not in, the concave zone, is formed by intergrown COM crystals and organic matter. Many factors, including urinary alterations (eg, hyperoxaluria), associated diseases (eg, hypertension, diabetes), and consumption or exposure to cytotoxic substances (eg, analgesic abuse) were associated with these types of calculi.

CONCLUSIONS

Our findings have indicated that injury is the first cause of papillary COM calculus formation, with the location of the injury determining the morphology of the resulting calculus.

Renal toxicity of ethylene glycol results from internalization of calcium oxalate crystals by proximal tubule cells

Ethylene glycol exposure can lead to the development of renal failure due to the metabolic formation of calcium oxalate monohydrate (COM) crystals. The renal damage is closely linked to the degree of COM accumulation in the kidney and most likely results from a COM-induced injury to proximal tubule (PT) cells. The present studies have measured the binding and internalization of COM by primary cultures of normal PT cells from humans and from Wistar and Fischer-344 rats in order to examine the roles of these uptake processes in the resulting cytotoxicity. Internalization was determined by incubation of cells with [(14)C]-COM at 37 degrees C, removal of bound COM with an EDTA incubation, followed by solubilization of cells, as well as by transmission electron microscopy of COM-exposed cells. COM crystals were internalized by PT cells in time- and concentration-dependent manners. COM crystals were bound to and internalized by rat cells about five times more than by human cells. Binding and internalization values were similar between PT cells from Wistar and Fischer-344 rats, indicating that a differential uptake of COM does not explain the known strain difference in sensitivity to ethylene glycol renal toxicity. Internalization of COM correlated highly with the degree of cell death, which is greater in rat cells than in human cells. Thus, surface binding and internalization of COM by cells play critical roles in cytotoxicity and explain why rat cells are more sensitive to COM crystals. At the same level of COM accumulation after ethylene glycol exposure or hyperoxaluria in vivo, rats would be more susceptible than humans to COM-induced damage.

Are calcium oxalate crystals involved in the mechanism of acute renal failure in ethylene glycol poisoning?

INTRODUCTION

Ethylene glycol (EG) poisoning often results in acute renal failure, particularly if treatment with fomepizole or ethanol is delayed because of late presentation or diagnosis. The mechanism has not been established but is thought to result from the production of a toxic metabolite.

METHODS

A literature review utilizing PubMed identified papers dealing with renal toxicity and EG or oxalate. The list of papers was culled to those relevant to the mechanism and treatment of the renal toxicity associated with either compound. ROLE OF METABOLITES: Although the "aldehyde" metabolites of EG, glycolaldehyde, and glyoxalate, have been suggested as the metabolites responsible, recent studies have shown definitively that the accumulation of calcium oxalate monohydrate (COM) crystals in kidney tissue produces renal tubular necrosis that leads to kidney failure. In vivo studies in EG-dosed rats have correlated the severity of renal damage with the total accumulation of COM crystals in kidney tissue. Studies in cultured kidney cells, including human proximal tubule (HPT) cells, have demonstrated that only COM crystals, not the oxalate ion, glycolaldehyde, or glyoxylate, produce a necrotic cell death at toxicologically relevant concentrations. COM CRYSTAL ACCUMULATION: In EG poisoning, COM crystals accumulate to high concentrations in the kidney through a process involving adherence to tubular cell membranes, followed by internalization of the crystals. MECHANISM OF TOXICITY: COM crystals have been shown to alter membrane structure and function, to increase reactive oxygen species and to produce mitochondrial dysfunction. These processes are likely to be involved in the mechanism of cell death.

CONCLUSIONS

Accumulation of COM crystals in the kidney is responsible for producing the renal toxicity associated with EG poisoning. The development of a pharmacological approach to reduce COM crystal adherence to tubular cells and its cellular interactions would be valuable as this would decrease the renal toxicity not only in late treated cases of EG poisoning, but also in other hyperoxaluric diseases such as primary hyperoxaluria and kidney stone formation.

Modulation of calcium oxalate dihydrate growth by selective crystal-face binding of phosphorylated osteopontin and polyaspartate peptide showing occlusion by sectoral (compositional) zoning

Calcium oxalate dihydrate (COD) mineral and the urinary protein osteopontin/uropontin (OPN) are commonly found in kidney stones. To investigate the effects of OPN on COD growth, COD crystals were grown with phosphorylated OPN or a polyaspartic acid-rich peptide of OPN (DDLDDDDD, poly-Asp(86-93)). Crystals grown with OPN showed increased dimensions of the {110} prismatic faces attributable to selective inhibition at this crystallographic face. At high concentrations of OPN, elongated crystals with dominant {110} faces were produced, often with intergrown, interpenetrating twin crystals. Poly-Asp(86-93) dose-dependently elongated crystal morphology along the {110} faces in a manner similar to OPN. In crystal growth studies using fluorescently tagged poly-Asp(86-93) followed by imaging of crystal interiors using confocal microscopy, sectoral (compositional) zoning in COD was observed resulting from selective binding and incorporation (occlusion) of peptide exclusively into {110} crystal sectors. Computational modeling of poly-Asp(86-93) adsorption to COD {110} and {101} surfaces also suggests increased stabilization of the COD {110} surface and negligible change to the natively stable {101} surface. Ultrastructural, colloidal-gold immunolocalization of OPN by transmission electron microscopy in human stones confirmed an intracrystalline distribution of OPN. In summary, OPN and its poly-Asp(86-93) sequence similarly affect COD mineral growth; the {110} crystallographic faces become enhanced and dominant attributable to {110} face inhibition by the protein/peptide, and peptides can incorporate into the mineral phase. We, thus, conclude that the poly-Asp(86-93) domain is central to the OPN ability to interact with the {110} faces of COD, where it binds to inhibit crystal growth with subsequent intracrystalline incorporation (occlusion).

Intracrystalline urinary proteins facilitate degradation and dissolution of calcium oxalate crystals in cultured renal cells

We have previously proposed that intracrystalline proteins would increase intracellular proteolytic disruption and dissolution of calcium oxalate (CaOx) crystals. Chauvet MC, Ryall RL. J Struct Biol 151: 12-17, 2005; Fleming DE, van Riessen A, Chauvet MC, Grover PK, Hunter B, van Bronswijk W, Ryall RL. J Bone Miner Res 18: 1282-1291, 2003; Ryall RL, Fleming DE, Doyle IR, Evans NA, Dean CJ, Marshall VR. J Struct Biol 134: 5-14, 2001. The aim of this investigation was to determine the effect of increasing concentrations of intracrystalline protein on the rate of CaOx crystal dissolution in Madin-Darby canine kidney (MDCKII) cells. Crystal matrix extract (CME) was isolated from urinary CaOx monohydrate (COM) crystals. Cold and [14C]oxalate-labeled COM crystals were precipitated from ultrafiltered urine containing 0-5 mg/l CME. Crystal surface area was estimated from scanning electron micrographs, and synchrotron X-ray diffraction was used to determine nonuniform strain and crystallite size. Radiolabeled crystals were added to MDCKII cells and crystal dissolution, expressed as radioactive label released into the medium, was measured. Increasing CME content did not significantly alter crystal surface area. However, nonuniform strain increased and crystallite size decreased in a dose-response manner, both reaching saturation at a CME concentration of 3 mg/ and demonstrating unequivocally the inclusion of increasing quantities of proteins in the crystals. This was confirmed by Western blotting. Crystal dissolution also followed saturation kinetics, increasing proportionally with final CME concentration and reaching a plateau at a concentration of approximately 2 mg/l. These findings were complemented by field emission scanning electron microscopy, which showed that crystal degradation also increased relative to CME concentration. Intracrystalline proteins enhance degradation and dissolution of CaOx crystals and thus may constitute a natural defense against urolithiasis. The findings have significant ramifications in biomineral metabolism and pathogenesis of renal stones.

The importance of a clean face: the effect of different washing procedures on the association of Tamm-Horsfall glycoprotein and other urinary proteins with calcium oxalate crystals

This study was undertaken to determine whether the use of different washing procedures could explain dissident findings in published studies examining the role of urinary macromolecules in urolithiasis. Calcium oxalate monohydrate (COM) crystals were deposited from or added to the same sieved urine, washed with copious or limited amounts of distilled water, or with methanol, and examined by field emission scanning electron microscopy (FESEM). Demineralized extracts were analysed by SDS-PAGE and Western blotting for Tamm-Horsfall glycoprotein (THG), human serum albumin (HSA), osteopontin (OPN) and prothrombin fragment 1 (PTF1). Synchrotron X-ray diffraction (SXRD) with Rietveld whole-pattern peak fitting and profile analysis was used to determine non-uniform crystal strain and crystallite size in crystals generated from inorganic solutions in the presence of increasing concentrations of THG and prothrombin (PT). HSA and PTF1 were present in all demineralized crystal extracts, confirming their inclusion within COM. OPN was present in all extracts except those derived from pure inorganic COM crystals, because of its occlusion within small numbers of calcium oxalate dihydrate (COD) crystals contaminating the COM population. THG was absent from the demineralized extracts of all crystals washed copiously with water, but present in those washed with methanol or limited amounts of water. FESEM showed extraneous organic material associated only with crystals whose extracts contained THG, confirming that the protein does not bind permanently to the COM crystal surface and is not occluded within the mineral bulk. This was confirmed by SXRD, which showed that non-uniform strain and crystallite size remained unaltered in crystals grown in the presence of increasing THG concentrations. However, non-uniform strain increased and crystallite size decreased with increasing PT concentrations, demonstrating unambiguously that PT is included in COM crystals. It was concluded that scrupulous care must be taken to ensure the complete removal of extraneous THG adventitiously associated with CaOx crystals in order to avoid inaccurate analysis of crystal matrix protein content and possible misinterpretation of experimental data.

Effect of urine fractionation on attachment of calcium oxalate crystals to renal epithelial cells: implications for studying renal calculogenesis

Our aim was to determine whether fractionation of human urine affects the attachment of calcium oxalate monohydrate (COM) crystals to renal cells. Urine collected from six healthy subjects was fractionated into sieved (S), centrifuged (C), centrifuged and filtered (CF), or ultrafiltered (UF). Attachment of [(14)C]COM crystals to Madin-Darby canine kidney (MDCK) cells was studied after precoating the crystals or the cells with the urine fractions and by using the same fractions as the binding medium. Protein content of the fractions and precoated crystals was analyzed with SDS-PAGE and Western blotting. All urine fractions inhibited crystal attachment. When fractions from the six urine samples were used to precoat the cells, the median inhibitions of crystal adhesion ( approximately 40%) were not significantly different. Median inhibition after preincubation of crystals was the same for the S, C, and CF fractions ( approximately 40%) but significantly greater than for the UF fraction ( approximately 28%). When fractions were used as the binding medium, median inhibitions decreased from 64% in the S fraction to 47 (C), 42 (CF), and to 29% (UF). SDS-PAGE analysis showed that centrifugation and filtration reduced the amount of Tamm-Horsfall glycoprotein (THG), which was confirmed by Western blotting. Human serum albumin, urinary prothrombin fragment 1, and osteopontin, but not THG, were present in demineralized extracts of the precoated crystals. Fractionation of human urine affects the attachment of COM crystals to MDCK cells. Hence future studies investigating regulation of crystal-cell interactions should be carried out in untreated urine as the binding medium.

Hypercalciuria in patients with CLCN5 mutations

Hypercalciuria is regarded as a characteristic symptom of Dent disease, an X-linked recessive tubulopathy characterized by low molecular weight (LMW) proteinuria, nephrocalcinosis/nephrolithiasis, and progressive renal failure due to mutations in the CLCN5 gene. As the presence of hypercalciuria may affect the decision to consider a CLCN5 mutation in the differential diagnosis, the phenotypic spectrum and the relative frequency of hypercalciuria in patients with CLCN5 mutations was determined. We assessed renal calcium excretion in 34 male patients with proven CLCN5 mutations, who had been referred because of LMW proteinuria and at least one additional symptom of Dent disease. Hypercalciuria was defined as renal calcium excretion exceeding 0.1 mmol/kg per day. Data obtained were compared with all series of CLCN5-positive patients identified by a systematic literature survey. In 7 of our 19 families, at least 1 affected male had normal calcium excretion. Hypercalciuria was observed in 22 of 31 patients tested (71%) compared to 85 of 90 (94.4%) in series from Europe and North America and 74.4% from Japan. LMW proteinuria was present in all CLCN5-positive patients; 25% of the patients in European and North American series, 45% of the Japanese, and 41% in the present series had only two of the four principal symptoms of Dent disease. Therefore, a CLCN5 mutation should be considered irrespective of the presence of hypercalciuria in a patient with LMW proteinuria and one additional symptom of Dent disease.

Protein regulation of intrarenal crystallization

PURPOSE OF REVIEW

In this review we discuss the key role renal proteins appear to play during initiation and growth of renal stones.

RECENT FINDINGS

Specific macromolecules have been identified in urine that can regulate crystal nucleation, growth, aggregation, and adhesion to renal cells. Many are incorporated into the matrix of crystals while they grow, including urinary prothrombin fragment 1, thereby increasing crystal susceptibility to degradation by cellular proteases. None of these macromolecular inhibitors appears to be quantitatively decreased in the urine of stone formers, although functional deficiencies thought due to abnormal glycosylation have been implicated, especially in the case of Tamm Horsfall protein. Increasing information is available on the nature and expression of crystal binding molecules on the renal cell surface, and they appear to be maximally expressed in response to stressful stimuli. Studies that employ atomic force microscopy and knockout mice are now being used to further clarify macromolecule-crystal interactions.

SUMMARY

The exact series of events that transform supersaturation to crystal formation and renal stones are poorly defined. Multiple anchored and soluble renal proteins potentially modulate or even regulate these events. A combination of proteomics and molecular biology seems likely to unravel these critical mediators in the coming years.

Crystal Retention in Renal Stone Disease: A Crucial Role for the Glycosaminoglycan Hyaluronan?

The mechanisms that are involved in renal stone disease are not entirely clear. In this article, the various concepts that have been proposed during the past century are reviewed briefly and integrated into current insights. Much attention is dedicated to hyaluronan (HA), an extremely large glycosaminoglycan that may play a central role in renal stone disease. The precipitation of poorly soluble calcium salts (crystal formation) in the kidney is the inevitable consequence of producing concentrated urine. HA is a major constituent of the extracellular matrix in the renal medullary interstitium and the pericellular matrix of mitogen/stress-activated renal tubular cells. HA is an excellent crystal-binding molecule because of its size, negative ionic charge, and ability to form hydrated gel-like matrices. Crystal binding to HA leads to crystal retention in the renal tubules (nephrocalcinosis) and to the formation of calcified plaques in the renal interstitium (Randall's plaques). It remains to be determined whether one or both forms of renal crystal retention are involved in the development of kidney stones (nephrolithiasis).

Characterization of glycosaminoglycans in tubular epithelial cells: calcium oxalate and oxalate ions effects

BACKGROUND

The interaction between tubular epithelial cells and calcium oxalate crystals or oxalate ions is a very precarious event in the lithogenesis. Urine contains ions, glycoproteins and glycosaminoglycans that inhibit the crystallization process and may protect the kidney against lithogenesis. We examined the effect of oxalate ions and calcium oxalate crystals upon the synthesis of glycosaminoglycans in distal [Madin-Darby canine kidney (MDCK)] and proximal (LLC-PK1) tubular cell lines.

METHODS

Glycosaminoglycan synthesis was analyzed by metabolic labeling with (35)S-sulfate and enzymatic digestion with specific mucopolysaccharidases. Cell death was assessed by fluorescent dyes and crystal endocytosis was analised by flow cytometry.

RESULTS

The main glycosaminoglycans synthesized by both cells were chondroitin sulfate and heparan sulfate most of them secreted to the culture medium or present at cellular surface. Exposition of MDCK cells to oxalate ions increased apoptosis rate and the incorporation of (35)S-sulfate in chondroitin sulfate and heparan sulfate, while calcium oxalate crystals were endocyted by LLC-PK1, induced necrotic cell death, and increased (35)S-sulfate incorporation in glycosaminoglycans. These effects seem to be specific and due to increased biosynthesis, since hydroxyapatite and other carboxylic acid did not induced cellular death or glycosaminoglycan synthesis and no changes in sulfation degree or molecular weight of glycosaminoglycans could be detected. Thapsigargin inhibited the glycosaminoglycan synthesis induced by calcium oxalate in LLC-PK1, suggesting that this effect was sensitive to the increase in cytosolic calcium.

CONCLUSION

Tubular cells may increase the synthesis of glycosaminoglycans to protect from the toxic insult of calcium oxalate crystals and oxalate ions, what could partially limit the lithogenesis.