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Garg N, Nguyen TT, Astor BC, Zhong W, Parajuli S, Aziz F, Mohamed M, Djamali A, Norby SM, Mandelbrot DA. Oxalate Nephropathy After Kidney Transplantation: Risk Factors and Outcomes of Two Phenotypes. Clin Transplant 2024; 38:e15368. [PMID: 39031705 DOI: 10.1111/ctr.15368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/07/2024] [Accepted: 05/19/2024] [Indexed: 07/22/2024]
Abstract
Describing risk factors and outcomes in kidney transplant recipients with oxalate nephropathy (ON) may help elucidate the pathogenesis and guide treatment strategies. We used a large single-center database to identify patients with ON and categorized them into delayed graft function with ON (DGF-ON) and late ON. Incidence density sampling was used to select controls. A total of 37 ON cases were diagnosed between 1/2011 and 1/2021. DGF-ON (n = 13) was diagnosed in 1.05% of the DGF population. Pancreatic atrophy on imaging (36.4% vs. 2.9%, p = 0.002) and gastric bypass history (7.7% vs. 0%; p = 0.06) were more common in DGF-ON than with controls with DGF requiring biopsy but without evidence of ON. DGF-ON was not associated with worse graft survival (p = 0.98) or death-censored graft survival (p = 0.48). Late ON (n = 24) was diagnosed after a mean of 78.2 months. Late ON patients were older (mean age 55.1 vs. 48.4 years; p = 0.02), more likely to be women (61.7% vs. 37.5%; p = 0.03), have gastric bypass history (8.3% vs. 0.8%; p = 0.02) and pancreatic atrophy on imaging (38.9% vs. 13.3%; p = 0.02). Late ON was associated with an increased risk of graft failure (HR 2.0; p = 0.07) and death-censored graft loss (HR 2.5; p = 0.10). We describe two phenotypes of ON after kidney transplantation: DGF-ON and late ON. Our study is the first to our knowledge to evaluate DGF-ON with DGF controls without ON. Although limited by small sample size, DGF-ON was not associated with adverse outcomes when compared with controls. Late ON predicted worse allograft outcomes.
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Affiliation(s)
- Neetika Garg
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Thanh Thanh Nguyen
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Brad C Astor
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Sandesh Parajuli
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Fahad Aziz
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Maha Mohamed
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Arjang Djamali
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Suzanne M Norby
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Didier A Mandelbrot
- Division of Nephrology, Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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Mejia C, Tariq A, Alotaibi M, Lakhani L, Greenspan W, Naqvi F, Alasfar S, Brennan DC. Prospective Assessment of the Prevalence of Enter Hyperoxalosis in Kidney Transplant Candidates. Transplant Direct 2023; 9:e1464. [PMID: 37009166 PMCID: PMC10065837 DOI: 10.1097/txd.0000000000001464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/07/2023] [Indexed: 04/01/2023] Open
Abstract
Enteric hyperoxalosis (EH) is an emerging cause of kidney transplantation (KT) dysfunction. We sought to determine the prevalence of EH and factors that affect plasma oxalate (POx) among at-risk KT candidates. Methods We prospectively measured POx among KT candidates evaluated at our center from 2017 to 2020 with risk factors for EH namely bariatric surgery, inflammatory bowel disease, or cystic fibrosis. EH was defined by a POx ≥10 μmol/L. Period-prevalence of EH was calculated. We compared mean POx across 5 factors: underlying condition, chronic kidney disease (CKD) stage, dialysis modality, phosphate binder type, and body mass index. Results Of 40 KT candidates screened, 23 had EH for a 4-y period prevalence of 58%. Mean POx was 21.6 ± 23.5 μmol/L ranging from 0 to 109.6 μmol/L. 40% of screened had POx >20 μmol/L. Sleeve gastrectomy was the most common underlying condition associated with EH. Mean POx did not differ by underlying condition (P = 0.27), CKD stage (P = 0.17), dialysis modality (P = 0.68), phosphate binder (P = 0.58), and body mass index (P = 0.56). Conclusions Bariatric surgery and inflammatory bowel disease were associated with a high prevalence of EH among KT candidates. Contrary to prior studies, sleeve gastrectomy was also associated with hyperoxalosis in advanced CKD. POx concentrations observed in EH reached levels associated with tissue and potentially allograft deposition. Concentrations can be as high as that seen in primary hyperoxaluria. More studies are needed to assess if POx is indeed a modifiable factor affecting allograft function in patients with EH.
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Fong P, Wusirika R, Rueda J, Raphael KL, Rehman S, Stack M, de Mattos A, Gupta R, Michels K, Khoury FG, Kung V, Andeen NK. Increased Rates of Supplement-Associated Oxalate Nephropathy During COVID-19 Pandemic. Kidney Int Rep 2022; 7:2608-2616. [PMID: 36120391 PMCID: PMC9464307 DOI: 10.1016/j.ekir.2022.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/05/2022] [Accepted: 09/05/2022] [Indexed: 11/07/2022] Open
Abstract
Introduction Causes of secondary oxalate nephropathy include enteric dysfunction and excessive intake of oxalate or oxalate precursors. During the COVID-19 pandemic, there has been a dramatic rise in sales of supplements and vitamin C, during which time we observed an apparent increase in the proportion of ingestion-associated oxalate nephropathy. Methods We retrospectively reviewed secondary oxalate nephropathy and compared pre-pandemic (2018–2019) and pandemic (2020–early 2022) time periods. Results We identified 35 patients with kidney biopsy proven (30 native, 5 allograft) oxalate nephropathy at a single academic institution. Supplement-associated oxalate nephropathy comprised a significantly higher proportion of cases during COVID-19 pandemic compared with the preceding 2 years (44% vs. 0%, P = 0.002), and was associated with use of vitamin C, dietary changes, and supplements. Oxalate nephropathy in the kidney allograft, in contrast, remained associated with enteric hyperoxaluria, antibiotic use, and dehydration. Many patients had diabetes mellitus (57%), hypertension (40%) and/or pre-existing chronic kidney disease (CKD, 49%). Of 9 patients in which the potentially causative ingestion was identified and removed, 8 experienced improvement in kidney function. Conclusion There was a shift toward supplements rather than enteric hyperoxaluria as a leading cause of secondary oxalate nephropathy during the COVID-19 pandemic. Kidney outcomes are better than those observed for enteric hyperoxaluria, if the offending agent is identified and removed.
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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: 62] [Impact Index Per Article: 20.7] [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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Geraghty R, Wood K, Sayer JA. Calcium oxalate crystal deposition in the kidney: identification, causes and consequences. Urolithiasis 2020; 48:377-384. [PMID: 32719990 PMCID: PMC7496019 DOI: 10.1007/s00240-020-01202-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/17/2020] [Indexed: 02/06/2023]
Abstract
Calcium oxalate (CaOx) crystal deposition within the tubules is often a perplexing finding on renal biopsy of both native and transplanted kidneys. Understanding the underlying causes may help diagnosis and future management. The most frequent cause of CaOx crystal deposition within the kidney is hyperoxaluria. When this is seen in native kidney biopsy, primary hyperoxaluria must be considered and investigated further with biochemical and genetic tests. Secondary hyperoxaluria, for example due to enteric hyperoxaluria following bariatric surgery, ingested ethylene glycol or vitamin C overdose may also cause CaOx deposition in native kidneys. CaOx deposition is a frequent finding in renal transplant biopsy, often as a consequence of acute tubular necrosis and is associated with poorer long-term graft outcomes. CaOx crystal deposition in the renal transplant may also be secondary to any of the causes associated with this phenotype in the native kidney. The pathophysiology underlying CaOx deposition is complex but this histological phenotype may indicate serious underlying pathology and should always warrant further investigation.
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Affiliation(s)
- R Geraghty
- Renal Services, The Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - K Wood
- Histopathology Department, The Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - J A Sayer
- Renal Services, The Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK. .,Translational and Clinical Research Institute, Faculty of Medical Sciences, International Centre for Life, Newcastle University, Central Parkway, Newcastle upon Tyne, NE1 3BZ, UK. .,NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne, UK.
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Palsson R, Chandraker AK, Curhan GC, Rennke HG, McMahon GM, Waikar SS. The association of calcium oxalate deposition in kidney allografts with graft and patient survival. Nephrol Dial Transplant 2020; 35:888-894. [PMID: 30165691 PMCID: PMC7849934 DOI: 10.1093/ndt/gfy271] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/24/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Whether calcium oxalate (CaOx) deposition in kidney allografts following transplantation (Tx) adversely affects patient outcomes is uncertain, as are its associated risk factors. METHODS We performed a retrospective cohort study of patients who had kidney allograft biopsies performed within 3 months of Tx at Brigham and Women's Hospital and examined the association of CaOx deposition with the composite outcome of death or graft failure within 5 years. RESULTS Biopsies from 67 of 346 patients (19.4%) had CaOx deposition. In a multivariable logistic regression model, higher serum creatinine [odds ratio (OR) = 1.28 per mg/dL, 95% confidence interval (CI) 1.15-1.43], longer time on dialysis (OR = 1.11 per additional year, 95% CI 1.01-1.23) and diabetes (OR = 2.26, 95% CI 1.09-4.66) were found to be independently associated with CaOx deposition. CaOx deposition was strongly associated with delayed graft function (DGF; OR = 11.31, 95% CI 5.97-21.40), and with increased hazard of the composite outcome after adjusting for black recipient race, donor type, time on dialysis before Tx, diabetes and borderline or acute rejection (hazard ratio 1.90, 95% CI 1.13-3.20). CONCLUSIONS CaOx deposition is common in allografts with poor function and portends worse outcomes up to 5 years after Tx. The extent to which CaOx deposition may contribute to versus result from DGF, however, cannot be determined based on our retrospective and observational data. Future studies should examine whether reducing plasma and urine oxalate prevents CaOx deposition in the newly transplanted kidney and whether this has an effect on clinical outcomes.
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Affiliation(s)
- Ragnar Palsson
- Renal Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Gary C Curhan
- Renal Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Helmut G Rennke
- Renal Pathology Service, Brigham and Women's Hospital, Boston, MA, USA
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Lumlertgul N, Siribamrungwong M, Jaber BL, Susantitaphong P. Secondary Oxalate Nephropathy: A Systematic Review. Kidney Int Rep 2018; 3:1363-1372. [PMID: 30450463 PMCID: PMC6224620 DOI: 10.1016/j.ekir.2018.07.020] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 07/22/2018] [Accepted: 07/23/2018] [Indexed: 01/16/2023] Open
Abstract
Introduction Little is known of the clinical outcomes of secondary oxalate nephropathy. To inform clinical practice, we performed a systematic review of case reports and case series to examine the clinical characteristics and outcomes of patients with secondary oxalate nephropathy. Methods Electronic databases were searched for case reports and case series of individual cases or cohorts of patients with biopsy-proven oxalate nephropathy in native or transplanted kidneys from 1950 until January 2018. Results Fifty-seven case reports and 10 case series met the inclusion criteria, totaling 108 patients. The case series were meta-analyzed. Mean age was 56.4 years old, 59% were men, and 15% were kidney transplant recipients. Fat malabsorption (88%) was the most commonly attributed cause of oxalate nephropathy, followed by excessive dietary oxalate consumption (20%). The mean baseline serum creatinine was 1.3 mg/dl and peaked at 4.6 mg/dl. Proteinuria, hematuria, and urinary crystals was reported in 69%, 32%, and 26% of patients, respectively. Mean 24-hour urinary oxalate excretion was 85.4 mg/d. In addition to universal oxalate crystal deposition in tubules and/or interstitium, kidney biopsy findings included acute tubular injury (71%), tubular damage and atrophy (69%), and interstitial mononuclear cell infiltration (72%); 55% of patients required dialysis. None had complete recovery, 42% had partial recovery, and 58% remained dialysis-dependent. Thirty-three percent of patients died. Conclusion Secondary oxalate nephropathy is a rare but potentially devastating condition. Renal replacement therapy is required in >50% of patients, and most patients remain dialysis-dependent. Studies are needed for effective preventive and treatment strategies in high-risk patients with hyperoxaluria-enabling conditions.
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Affiliation(s)
- Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Monchai Siribamrungwong
- Department of Medicine, Lerdsin Hospital, College of Medicine, Rangsit University, Bangkok, Thailand
| | - Bertrand L. Jaber
- Department of Medicine, St. Elizabeth’s Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Paweena Susantitaphong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
- Correspondence: Paweena Susantitaphong, Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, 10330.
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Selistre LDS, Cochat P, Rech DL, Parant F, de Souza VC, Dubourg L. Association between glomerular filtration rate (measured by high-performance liquid chromatography with iohexol) and plasma oxalate. J Bras Nefrol 2018; 40:73-76. [PMID: 29738022 PMCID: PMC6533971 DOI: 10.1590/1678-4685-jbn-3743] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 08/31/2017] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Secondary hyperoxalemia is a multifactorial disease that affects several organs and tissues in patients with native or transplanted kidneys. Plasma oxalate may increase during renal failure because it is cleared from the body by the kidneys. However, there is scarce evidence about the association between glomerular filtration rate and plasma oxalate, especially in the early stages of chronic kidney disease (CKD). METHODS A case series focuses on the description of variations in clinical presentation. A pilot study was conducted using a cross-sectional analysis with 72 subjects. The glomerular filtration rate (GFR) and plasma oxalate levels were measured for all patients. Results: Median (IQR) GFR was 70.50 [39.0; 91.0] mL/min/1.73 m2. Plasma oxalate was < 5.0 µmol/L in all patients with a GFR > 30 mL/min/1.73m2. Among the 14 patients with severe CKD (GFR < 30 mL/min/1.73 m2) only 4 patients showed a slightly increased plasma oxalate level (between 6 and 12 µmol/L). CONCLUSION In non-primary hyperoxaluria, plasma oxalate concentration increases when GFR < 30mL/min/1.73 m2 and, in our opinion, values greater than 5 µmol/L with a GFR > 30 mL/min/1.73 m2 are suggestive of primary hyperoxaluria. Further studies are necessary to confirm plasma oxalate increase in patients with low GFR levels (< 30mL/min/1.73 m2).
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Affiliation(s)
| | - Pierre Cochat
- Université Claude-Bernard Lyon, Centre de Référence des Maladies
Rénales Rares Nephrogones, Service de Néphrologie et Rhumatologie Pédiatriques,
Lyon, France
| | | | - François Parant
- Hospices Civils de Lyon, GHS - Centre de Biologie Sud, UM
Pharmacologie - Toxicologie, F-69495, Pierre Bénite, France
| | | | - Laurence Dubourg
- Université Claude-Bernard, Groupement Hospitalier Edouard Herriot,
Hospices Civils de Lyon, UMR 5305, Rhone-Alpes, Lyon, France
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9
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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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Demoulin N, Issa Z, Crott R, Morelle J, Danse E, Wallemacq P, Jadoul M, Deprez PH. Enteric hyperoxaluria in chronic pancreatitis. Medicine (Baltimore) 2017; 96:e6758. [PMID: 28489752 PMCID: PMC5428586 DOI: 10.1097/md.0000000000006758] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Chronic pancreatitis may lead to steatorrhea, enteric hyperoxaluria, and kidney damage. However, the prevalence and determinants of hyperoxaluria in chronic pancreatitis patients as well as its association with renal function decline have not been investigated.We performed an observational study. Urine oxalate to creatinine ratio was assessed on 2 independent random urine samples in consecutive adult patients with chronic pancreatitis followed at the outpatient clinic from March 1 to October 31, 2012. Baseline characteristics and annual estimated glomerular filtration rate (eGFR) change during follow-up were compared between patients with hyper- and normo-oxaluria.A total of 48 patients with chronic pancreatitis were included. The etiology of the disease was toxic (52%), idiopathic (27%), obstructive (11%), autoimmune (6%), or genetic (4%). Hyperoxaluria (defined as urine oxalate to creatinine ratio >32 mg/g) was found in 23% of patients. Multivariate regression analysis identified clinical steatorrhea, high fecal acid steatocrit, and pancreatic atrophy as independent predictors of hyperoxaluria. Taken together, a combination of clinical steatorrhea, steatocrit level >31%, and pancreatic atrophy was associated with a positive predictive value of 100% for hyperoxaluria. On the contrary, none of the patients with a fecal elastase-1 level >100 μg/g had hyperoxaluria. Longitudinal evolution of eGFR was available in 71% of the patients, with a mean follow-up of 904 days. After adjustment for established determinants of renal function decline (gender, diabetes, bicarbonate level, baseline eGFR, and proteinuria), a urine oxalate to creatinine ratio >32 mg/g was associated with a higher risk of eGFR decline.Hyperoxaluria is highly prevalent in patients with chronic pancreatitis and associated with faster decline in renal function. A high urine oxalate to creatinine ratio in patients with chronic pancreatitis is best predicted by clinical steatorrhea, a high acid steatocrit, and pancreatic atrophy. Further studies will need to investigate the mechanisms of renal damage in chronic pancreatitis and the potential benefits of therapies reducing oxaluria.
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Affiliation(s)
- Nathalie Demoulin
- Division of Nephrology, Cliniques universitaires Saint-Luc
- Institut de Recherche Expérimentale et Clinique
| | - Zaina Issa
- Division of Nephrology, Cliniques universitaires Saint-Luc
| | - Ralph Crott
- Institut de Recherche Santé et Société, Université catholique de Louvain
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc
- Institut de Recherche Expérimentale et Clinique
| | - Etienne Danse
- Institut de Recherche Expérimentale et Clinique
- Department of Radiology
| | - Pierre Wallemacq
- Institut de Recherche Expérimentale et Clinique
- Department of Clinical Chemistry
| | - Michel Jadoul
- Division of Nephrology, Cliniques universitaires Saint-Luc
- Institut de Recherche Expérimentale et Clinique
| | - Pierre H. Deprez
- Institut de Recherche Expérimentale et Clinique
- Department of Hepato-Gastroenterology, Cliniques universitaires Saint-Luc, Brussels, Belgium
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Ermer T, Eckardt KU, Aronson PS, Knauf F. Oxalate, inflammasome, and progression of kidney disease. Curr Opin Nephrol Hypertens 2016; 25:363-71. [PMID: 27191349 PMCID: PMC4891250 DOI: 10.1097/mnh.0000000000000229] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Oxalate is an end product of metabolism excreted via the kidney. Excess urinary oxalate, whether from primary or enteric hyperoxaluria, can lead to oxalate deposition in the kidney. Oxalate crystals are associated with renal inflammation, fibrosis, and progressive renal failure. It has long been known that as the glomerular filtration rate becomes reduced in chronic kidney disease (CKD), there is striking elevation of plasma oxalate. Taken together, these findings raise the possibility that elevation of plasma oxalate in CKD may promote renal inflammation and more rapid progression of CKD independent of primary cause. RECENT FINDINGS The inflammasome has recently been identified to play a critical role in oxalate-induced renal inflammation. Oxalate crystals have been shown to activate the NOD-like receptor family, pyrin domain containing 3 inflammasome (also known as NALP3, NLRP3, or cryopyrin), resulting in release of IL-1β and macrophage infiltration. Deletion of inflammasome proteins in mice protects from oxalate-induced renal inflammation and progressive renal failure. SUMMARY The findings reviewed in this article expand our understanding of the relevance of elevated plasma oxalate levels leading to inflammasome activation. We propose that inhibiting oxalate-induced inflammasome activation, or lowering plasma oxalate, may prevent or mitigate progressive renal damage in CKD, and warrants clinical trials.
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Affiliation(s)
- Theresa Ermer
- Department of Nephrology und Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology und Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Peter S. Aronson
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, U.S.A
| | - Felix Knauf
- Department of Nephrology und Hypertension, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, U.S.A
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Humayun Y, Ball KC, Lewin JR, Lerant AA, Fülöp T. Acute oxalate nephropathy associated with orlistat. J Nephropathol 2016; 5:79-83. [PMID: 27152294 PMCID: PMC4844913 DOI: 10.15171/jnp.2016.14] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 03/21/2016] [Indexed: 11/09/2022] Open
Abstract
Background: Obesity is a major world-wide epidemic which has led to a surge of various weight loss-inducing medical or surgical treatments. Orlistat is a gastrointestinal lipase inhibitor used as an adjunct treatment of obesity and type 2 diabetes mellitus to induce clinically significant weight loss via fat malabsorption.
Case Presentation: We describe a case of a 76-year-old female with past medical history of chronic kidney disease (baseline serum creatinine was 1.5-2.5 mg/dL), hypertension, gout and psoriatic arthritis, who was admitted for evaluation of elevated creatinine, peaking at 5.40 mg/dL. She was started on orlistat 120 mg three times a day six weeks earlier. Initial serologic work-up remained unremarkable. Percutaneous kidney biopsy revealed massive calcium oxalate crystal depositions with acute tubular necrosis and interstitial inflammation. Serum oxalate level returned elevated at 45 mm/l (normal <27). Timed 24-hour urine collection documented increased oxalate excretion repeatedly (54-96 mg/24 hour). After five renal dialysis sessions in eighth days she gradually regained her former baseline kidney function with creatinine around 2 mg/dL. Given coexisting proton-pump inhibitor therapy, only per os calcium-citrate provided effective intestinal oxalate chelation to control hyperoxaluria.
Conclusions: Our case underscores the potential of medically induced fat malabsorption to lead to an excessive oxalate absorption and acute kidney injury (AKI), especially in subjects with pre-existing renal impairment. Further, it emphasizes the importance of kidney biopsy to facilitate early diagnosis and treatment.
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Affiliation(s)
- Youshay Humayun
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Kenneth C Ball
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Jack R Lewin
- Department of Pathology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Anna A Lerant
- Department of Anesthesiology, University of Mississippi Medical Center, Jackson, Mississippi, USA ; Simulation and Interprofessional Education Center, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Tibor Fülöp
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
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14
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Taheri D, Gheissari A, Shaabani P, Tabibian SR, Mortazavi M, Seirafian S, Merrikhi A, Fesharakizadeh M, Dolatkhah S. Acute oxalate nephropathy following kidney transplantation: Report of three cases. JOURNAL OF RESEARCH IN MEDICAL SCIENCES 2015; 20:818-23. [PMID: 26664431 PMCID: PMC4652317 DOI: 10.4103/1735-1995.168408] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Calcium oxalate (CaOx) crystal deposition is a common finding immediately after kidney transplantation. However, small depositions of CaOx could be benign while extensive depositions lead to poor graft outcome. Here we report three cases with end-stage renal disease (ESRD), bilateral nephrolithiasis, and unknown diagnosis of primary hyperoxaluria (PH) who underwent a renal transplant and experienced an early-onset graft failure. Although an acute rejection was suspected, renal allograft biopsies and subsequent allograft nephrectomies showed extensive CaOx deposition, which raised a suspicion of PH. Even though increased urinary excretion of CaOx was found in all patients, this diagnosis could be confirmed with further tests including genetic study and metabolic assay. In conclusion, massive CaOx deposition in kidney allograft is an important cause of poor allograft survival and needs special management. Furthermore, our cases suggest patients with ESRD and a history of nephrolithiasis should be screened for elevated urinary oxalate excretion and rule out of PH.
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Affiliation(s)
- Diana Taheri
- Department of Pathology, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran ; Department of Nephrology, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alaleh Gheissari
- Department of Pediatric Nephrology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Pooria Shaabani
- Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Mojgan Mortazavi
- Department of Nephrology, Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shiva Seirafian
- Department of Nephrology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Merrikhi
- Department of Pediatric Nephrology, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Fesharakizadeh
- Department of Surgery, School of Medicine, Islamic Azad University, Najaf Abad Branch, Isfahan, Iran
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15
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Escudero-Sánchez R, Villacorta-Pérez J, Fernández-Juarez GM, Guerrero-Márquez MC, Fernández Gil M. Acute oxalate nephropathy and chronic pancreatitis. Rev Clin Esp 2015; 215:352-4. [PMID: 25796468 DOI: 10.1016/j.rce.2015.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 02/15/2015] [Indexed: 10/23/2022]
Affiliation(s)
- R Escudero-Sánchez
- Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España.
| | - J Villacorta-Pérez
- Nefrología, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | | | - M C Guerrero-Márquez
- Anatomía Patológica, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - M Fernández Gil
- Servicio de Aparato Digestivo, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
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16
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Nazzal L, Puri S, Goldfarb DS. Enteric hyperoxaluria: an important cause of end-stage kidney disease. Nephrol Dial Transplant 2015; 31:375-82. [PMID: 25701816 DOI: 10.1093/ndt/gfv005] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Accepted: 12/21/2014] [Indexed: 12/11/2022] Open
Abstract
Hyperoxaluria is a frequent complication of inflammatory bowel diseases, ileal resection and Roux-en-Y gastric bypass and is well-known to cause nephrolithiasis and nephrocalcinosis. The associated prevalence of chronic kidney disease and end-stage kidney disease (ESKD) is less clear but may be more consequential than recognized. In this review, we highlight three cases of ESKD due to enteric hyperoxaluria following small bowel resections. We review current information on the pathophysiology, complications and treatment of this complex disease.
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Affiliation(s)
- Lama Nazzal
- Nephrology Section, New York Harbor VA Healthcare System and Nephrology Division, NYU Langone Medical Center, New York, NY, USA
| | - Sonika Puri
- Nephrology Section, New York Harbor VA Healthcare System and Nephrology Division, NYU Langone Medical Center, New York, NY, USA
| | - David S Goldfarb
- Nephrology Section, New York Harbor VA Healthcare System and Nephrology Division, NYU Langone Medical Center, New York, NY, USA
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17
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Abstract
Diarrhea is a frequent but overlooked complication of kidney transplantation. Diarrhea is repeatedly neglected, often considered by patients and clinicians an unavoidable side effect of immunosuppressive regimens. It is, however, associated with a significant impairment in life quality. Severe and chronic posttransplant diarrhea may lead to dehydration, malabsorption, rehospitalization, immunosuppression, noncompliance, and a greater risk of graft loss and death. There is thus a need to optimize and standardize the management of posttransplant diarrhea with consistent diagnostic and therapeutic strategies. A recent study has suggested that the increased sensitivity of molecular tools might help in early pathogen identification and guidance of antimicrobial treatment. Most bacterial and protozoan infections are readily curable with appropriate antimicrobial agents; cryptosporidiosis and C. difficile infections may however be complicated by relapsing courses. In addition, identification of enteric viral genomes in stool has further reduced posttransplant diarrhea of unknown origin. Chronic norovirus-related posttransplant diarrhea, arising from the interplay of the virus and immunosuppressive drugs, has emerged as a new challenge in the field. Prospective and controlled studies are necessary to evaluate the efficacy and safety of innovative anti-norovirus therapeutics, as well as optimal immunosuppressive regimens, to enable viral clearance while preventing rejection and donor-specific antibody formation. This review seeks to provide a basis for the design of future clinical prospective studies.
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18
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Glew RH, Sun Y, Horowitz BL, Konstantinov KN, Barry M, Fair JR, Massie L, Tzamaloukas AH. Nephropathy in dietary hyperoxaluria: A potentially preventable acute or chronic kidney disease. World J Nephrol 2014; 3:122-142. [PMID: 25374807 PMCID: PMC4220346 DOI: 10.5527/wjn.v3.i4.122] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 06/12/2014] [Accepted: 08/29/2014] [Indexed: 02/06/2023] Open
Abstract
Hyperoxaluria can cause not only nephrolithiasis and nephrocalcinosis, but also renal parenchymal disease histologically characterized by deposition of calcium oxalate crystals throughout the renal parenchyma, profound tubular damage and interstitial inflammation and fibrosis. Hyperoxaluric nephropathy presents clinically as acute or chronic renal failure that may progress to end-stage renal disease (ESRD). This sequence of events, well recognized in the past in primary and enteric hyperoxalurias, has also been documented in a few cases of dietary hyperoxaluria. Estimates of oxalate intake in patients with chronic dietary hyperoxaluria who developed chronic kidney disease or ESRD were comparable to the reported average oxalate content of the diets of certain populations worldwide, thus raising the question whether dietary hyperoxaluria is a primary cause of ESRD in these regions. Studies addressing this question have the potential of improving population health and should be undertaken, alongside ongoing studies which are yielding fresh insights into the mechanisms of intestinal absorption and renal excretion of oxalate, and into the mechanisms of development of oxalate-induced renal parenchymal disease. Novel preventive and therapeutic strategies for treating all types of hyperoxaluria are expected to develop from these studies.
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19
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Abstract
: The cutaneous deposition disorders are a group of unrelated conditions characterized by the accumulation of either endogenous or exogenous substances within the skin. These cutaneous deposits are substances that are not normal constituents of the skin and are laid down usually in the dermis, but also in the subcutis, in a variety of different circumstances. There are 5 broad categories of cutaneous deposits. The first group includes calcium salts, bone, and cartilage. The second category includes the hyaline deposits that may be seen in the dermis in several metabolic disorders, such as amyloidosis, gout, porphyria, and lipoid proteinosis. The third category includes various pigments, heavy metals, and complex drug pigments. The fourth category, cutaneous implants, includes substances that are inserted into the skin for cosmetic purposes. The fifth category includes miscellaneous substances, such as oxalate crystals and fiberglass. In this article, the authors review the clinicopathologic characteristics of cutaneous deposition diseases, classify the different types of cutaneous deposits, and identify all the histopathologic features that may assist in diagnosing the origin of a cutaneous deposit.
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20
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Karaolanis G, Lionaki S, Moris D, Palla VV, Vernadakis S. Secondary hyperoxaluria: a risk factor for kidney stone formation and renal failure in native kidneys and renal grafts. Transplant Rev (Orlando) 2014; 28:182-7. [PMID: 24999029 DOI: 10.1016/j.trre.2014.05.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 05/18/2014] [Accepted: 05/21/2014] [Indexed: 12/22/2022]
Abstract
Secondary hyperoxaluria is a multifactorial disease affecting several organs and tissues, among which stand native and transplanted kidneys. Nephrocalcinosis and nephrolithiasis may lead to renal insufficiency. Patients suffering from secondary hyperoxaluria, should be promptly identified and appropriately treated, so that less renal damage occurs. The aim of this review is to underline the causes of hyperoxaluria and the related pathophysiologic mechanisms, which are involved, along with the description of seven cases of irreversible renal graft injury due to secondary hyperoxaluria.
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Affiliation(s)
- Georgios Karaolanis
- Transplantation Unit, Laiko General Hospital, Medical School of Athens, Athens, Greece.
| | - Sophia Lionaki
- Nephrology and Transplantation Unit, Laiko Hospital, Athens, Greece
| | - Demetrios Moris
- Transplantation Unit, Laiko General Hospital, Medical School of Athens, Athens, Greece
| | | | - Spiridon Vernadakis
- Transplantation Unit, Laiko General Hospital, Medical School of Athens, Athens, Greece
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21
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Abstract
Oxalate arthropathy is a rare cause of arthritis characterized by deposition of calcium oxalate crystals within synovial fluid. This condition typically occurs in patients with underlying primary or secondary hyperoxaluria. Primary hyperoxaluria constitutes a group of genetic disorders resulting in endogenous overproduction of oxalate, whereas secondary hyperoxaluria results from gastrointestinal disorders associated with fat malabsorption and increased absorption of dietary oxalate. In both conditions, oxalate crystals can deposit in the kidney leading to renal failure. Since oxalate is primarily renally eliminated, it accumulates throughout the body in renal failure, a state termed oxalosis. Affected organs can include bones, joints, heart, eyes, and skin. Since patients can present with renal failure and oxalosis before the underlying diagnosis of hyperoxaluria has been made, it is important to consider hyperoxaluria in patients who present with unexplained soft tissue crystal deposition. The best treatment of oxalosis is prevention. If patients present with advanced disease, treatment of oxalate arthritis consists of symptom management and control of the underlying disease process.
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Affiliation(s)
- Elizabeth C Lorenz
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
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22
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Cohen-Bucay A, Garimella P, Ezeokonkwo C, Bijol V, Strom JA, Jaber BL. Acute oxalate nephropathy associated with Clostridium difficile colitis. Am J Kidney Dis 2013; 63:113-8. [PMID: 24183111 DOI: 10.1053/j.ajkd.2013.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 09/06/2013] [Indexed: 01/05/2023]
Abstract
We report the case of a 69-year-old man who presented with acute kidney injury in the setting of community-acquired Clostridium difficile-associated diarrhea and biopsy-proven acute oxalate nephropathy. We discuss potential mechanisms, including increased colonic permeability to oxalate. We conclude that C difficile-associated diarrhea is a potential cause of acute oxalate nephropathy.
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Affiliation(s)
- Abraham Cohen-Bucay
- Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA.
| | | | - Chukwudi Ezeokonkwo
- Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Vanesa Bijol
- Kidney Pathology Service, Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - James A Strom
- Division of Nephrology, Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
| | - Bertrand L Jaber
- Division of Nephrology, Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA
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23
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Getting JE, Gregoire JR, Phul A, Kasten MJ. Oxalate nephropathy due to 'juicing': case report and review. Am J Med 2013; 126:768-72. [PMID: 23830537 DOI: 10.1016/j.amjmed.2013.03.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Revised: 03/11/2013] [Accepted: 03/11/2013] [Indexed: 02/08/2023]
Abstract
A patient presented with oxalate-induced acute renal failure that was attributable to consumption of oxalate-rich fruit and vegetable juices obtained from juicing. We describe the case and also review the clinical presentation of 65 patients seen at Mayo Clinic (Rochester, MN) from 1985 through 2010 with renal failure and biopsy-proven renal calcium oxalate crystals. The cause of renal oxalosis was identified for all patients: a single cause for 36 patients and at least 2 causes for 29 patients. Three patients, including our index patient, had presumed diet-induced oxalate nephropathy in the context of chronic kidney disease. Identification of calcium oxalate crystals in a kidney biopsy should prompt an evaluation for causes of renal oxalosis, including a detailed dietary history. Clinicians should be aware that an oxalate-rich diet may potentially precipitate acute renal failure in patients with chronic kidney disease. Juicing followed by heavy consumption of oxalate-rich juices appears to be a potential cause of oxalate nephropathy and acute renal failure.
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Affiliation(s)
- Jane E Getting
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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24
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Ceulemans LJ, Nijs Y, Nuytens F, De Hertogh G, Claes K, Bammens B, Naesens M, Evenepoel P, Kuypers D, Vanrenterghem Y, Monbaliu D, Pirenne J. Combined kidney and intestinal transplantation in patients with enteric hyperoxaluria secondary to short bowel syndrome. Am J Transplant 2013; 13:1910-4. [PMID: 23730777 DOI: 10.1111/ajt.12305] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 03/25/2013] [Accepted: 04/10/2013] [Indexed: 01/25/2023]
Abstract
Kidney transplantation is the treatment of choice for end-stage renal disease whereas indications for intestinal transplantation are currently restricted to patients with irreversible small bowel failure and severe complications of total parenteral nutrition (mostly shortage and infection of venous accesses, major electrolyte disturbances and liver failure). Enteric hyperoxaluria is secondary to certain intestinal diseases like intestinal resections, chronic inflammatory bowel disease and other malabsorption syndromes and can lead to end-stage renal disease requiring kidney transplantation. We report two patients suffering from renal failure due to enteric hyperoxaluria (secondary to extensive intestinal resection) in whom we elected to replace not only the kidney but also the intestine to prevent recurrence of hyperoxaluria in the transplanted kidney.
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Affiliation(s)
- L J Ceulemans
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
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25
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Schleich A, Fehr T, Gaspert A, Wüthrich RP, Mohebbi N. Unexpected deterioration of graft function after combined kidney and pancreas transplantation. Clin Kidney J 2013; 6:228-30. [PMID: 26019854 PMCID: PMC4432450 DOI: 10.1093/ckj/sft012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 01/21/2013] [Indexed: 11/12/2022] Open
Affiliation(s)
- Andreas Schleich
- Division of Nephrology , University Hospital Zurich , Zurich , Switzerland
| | - Thomas Fehr
- Division of Nephrology , University Hospital Zurich , Zurich , Switzerland
| | - Ariana Gaspert
- Department of Surgical Pathology , University Hospital Zurich , Zurich , Switzerland
| | - Rudolf P Wüthrich
- Division of Nephrology , University Hospital Zurich , Zurich , Switzerland
| | - Nilufar Mohebbi
- Division of Nephrology , University Hospital Zurich , Zurich , Switzerland
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26
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Troxell ML, Houghton DC, Hawkey M, Batiuk TD, Bennett WM. Enteric oxalate nephropathy in the renal allograft: an underrecognized complication of bariatric surgery. Am J Transplant 2013; 13:501-9. [PMID: 23311979 DOI: 10.1111/ajt.12029] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 10/18/2012] [Accepted: 10/31/2012] [Indexed: 02/06/2023]
Abstract
Enteric hyperoxalosis is a recognized complication of bariatric surgery, with consequent oxalate nephropathy leading to chronic kidney disease and occasionally end-stage renal failure. In patients with prior gastrointestinal bypass surgery, renal allografts are also at risk of oxalate nephropathy. Further, transplant recipients may be exposed to additional causes of hyperoxalosis. We report two cases of renal allograft oxalate nephropathy in patients with remote histories of bariatric surgery. Conservative management led to improvement of graft function in one patient, while the other patient returned to dialysis. Interpretation of serologic, urine and biopsy studies is complicated by oxalate accumulation in chronic renal failure, and heightened excretion in the early posttransplant period. A high index of suspicion and careful clinicopathologic correlation on the part of transplant nephrologists and renal pathologists are required to recognize and treat allograft oxalate nephropathy. As the incidence of obesity and pretransplant bariatric surgery increases in the transplant population, allograft oxalate nephropathy is likely to be an increasing cause of allograft dysfunction.
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Affiliation(s)
- M L Troxell
- Department of Pathology, Oregon Health & Science University, Portland, OR, USA.
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27
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Beloncle F, Sayegh J, Duveau A, Besson V, Croue A, Subra JF, Augusto JF. An unexpected cause of progressive renal failure in a 66-year-old male after liver transplantation: secondary hyperoxaluria. Int Urol Nephrol 2012; 45:1209-13. [PMID: 22395848 DOI: 10.1007/s11255-012-0140-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Accepted: 02/06/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperoxaluria is a rare metabolic disorder characterized by calcium oxalate deposition in different tissues. It is caused either by an inherited disease of oxalate metabolism [primary hyperoxalurias (PH)] or by an acquired disturbance (secondary hyperoxaluria). CASE We report here an atypical presentation of enteric hyperoxaluria-induced renal failure that occurred after liver transplantation. Despite adapted treatment and intensive haemodialysis, the patient did not recover. This case allows the reviewing of the multiple pathophysiological mechanisms involved in this disease. CONCLUSION Oxalate nephropathy should be considered in the differential diagnosis of acute renal failure, especially when previous renal impairment and fat malabsorption are present. We suggest performing renal biopsy early to allow a prompt diagnosis and therapeutic intervention.
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Affiliation(s)
- François Beloncle
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, 4 rue Larrey, 49933, Angers cedex 9, France
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28
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Primary nonfunction of renal allograft secondary to acute oxalate nephropathy. Case Rep Transplant 2011; 2011:876906. [PMID: 23213607 PMCID: PMC3504227 DOI: 10.1155/2011/876906] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 07/26/2011] [Indexed: 11/17/2022] Open
Abstract
Primary nonfunction (PNF) accounts for 0.6 to 8% of renal allograft failure, and the focus on causes of PNF has changed from rejection to other causes. Calcium oxalate (CaOx) deposition is common in early allograft biopsies, and it contributes in moderate intensity to higher incidence of acute tubular necrosis and poor graft survival. A-49-year old male with ESRD secondary to polycystic kidney disease underwent extended criteria donor kidney transplantation. Posttransplant, patient developed delayed graft function (DGF), and the biopsy showed moderately intense CaOx deposition that persisted on subsequent biopsies for 16 weeks, eventually resulting in PNF. The serum oxalate level was 3 times more than normal at 85 μmol/L (normal <27 μmol/L). Allograft nephrectomy showed massive aggregates of CaOx crystal deposition in renal collecting system. In conclusion, acute oxalate nephropathy should be considered in the differential diagnosis of DGF since optimal management could change the outcome of the allograft.
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29
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Impact of norovirus/sapovirus-related diarrhea in renal transplant recipients hospitalized for diarrhea. Transplantation 2011; 92:61-9. [PMID: 21555974 DOI: 10.1097/tp.0b013e31821c9392] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Diarrhea of unspecified cause frequently occurs after renal transplantation and is usually ascribed to mycophenolic acid toxicity. Norovirus (NoV) and sapovirus (SaV) have been sporadically reported to cause chronic diarrhea in immunocompromised patients. METHODS We undertook a retrospective study (2008-2009) to examine the clinical and epidemiologic significance of NoV and SaV infections in adult renal transplant recipients hospitalized for acute or chronic diarrhea. RESULTS Ninety-six renal transplant recipients were hospitalized for diarrhea at our institution during a 16-month period, 87 of whom were included in the study, including 46 patients with chronic diarrhea. Among 41 patients with unexplained diarrhea, 20 patients were screened for NoV/SaV, 16 of whom were positive. Fifteen of them (94%) had chronic diarrhea. When compared with bacterial and parasitic infections, NoV/SaV infections were associated with a greater weight loss at the time of admission, a 8.7-fold longer duration of symptoms and a more frequent need for mycophenolic acid dosage reduction. Eighty-one percent of patients hospitalized for NoV/SaV-associated diarrhea experienced acute renal failure. Five and one patients subsequently had biopsy-diagnosed active graft rejection and oxalate nephropathy, respectively. Ten of the 14 patients who underwent a longitudinal study of NoV/SaV stool's clearance exhibited a prolonged viral shedding period with a median time of 289 days (107-581 days). CONCLUSIONS Our study indicates that NoV/SaV infection causes posttransplant chronic diarrhea potentially complicated by severe kidney graft impairment.
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30
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Cartery C, Faguer S, Karras A, Cointault O, Buscail L, Modesto A, Ribes D, Rostaing L, Chauveau D, Giraud P. Oxalate nephropathy associated with chronic pancreatitis. Clin J Am Soc Nephrol 2011; 6:1895-902. [PMID: 21737848 DOI: 10.2215/cjn.00010111] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Enteric overabsorption of oxalate may lead to hyperoxaluria and subsequent acute oxalate nephritis (AON). AON related to chronic pancreatitis is a rare and poorly described condition precluding early recognition and treatment. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We collected the clinical characteristics, treatment, and renal outcome of 12 patients with chronic pancreatitis-associated AON followed in four French renal units. RESULTS Before AON, mild to moderate chronic kidney disease was present in all patients, diabetes mellitus in eight (insulin [n = 6]; oral antidiabetic drugs [n = 2]), and known chronic pancreatitis in only eight. At presentation, pancreas imaging showed gland atrophy/heterogeneity, Wirsung duct dilation, calcification, or pseudocyst. Renal findings consisted of rapidly progressive renal failure with tubulointerstitial profile. Acute modification of glomerular filtration preceded the AON (i.e., diarrhea and diuretics). Increase in urinary oxalate excretion was found in all tested patients and hypocalcemia in nine (<1.5 mmol/L in four patients). Renal biopsy showed diffuse crystal deposits, highly suggestive of oxalate crystals, with tubular necrosis and interstitial inflammatory cell infiltrates. Treatment consisted of pancreatic enzyme supplementation, oral calcium intake, and an oxalate-free diet in all patients and renal replacement therapy in five patients. After a median follow-up of 7 months, three of 12 patients reached end-stage renal disease. CONCLUSION AON is an under-recognized severe crystal-induced renal disease with features of tubulointerstitial nephritis that may occur in patients with a long history of chronic pancreatitis or reveal the pancreatic disease. Extrinsic triggering factors should be prevented.
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Affiliation(s)
- Claire Cartery
- Service de Néphrologie et Immunologie Clinique, Hôpital de Rangueil, 1 avenue Jean Poulhès, TSA 50032, 31059 Toulouse Cedex 9, France
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