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Ganesan C, Thomas I, Montez‐Rath ME, Chertow GM, Leppert JT, Pao AC. Hypocitraturia and Risk of Bone Disease in Patients With Kidney Stone Disease. JBMR Plus 2023; 7:e10786. [PMID: 37701146 PMCID: PMC10494504 DOI: 10.1002/jbm4.10786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/24/2023] [Accepted: 06/01/2023] [Indexed: 09/14/2023] Open
Abstract
Patients with kidney stone disease are at higher risk for bone disease. Hypocitraturia is common in patients with kidney stone disease and a key risk factor for stone recurrence. In this retrospective cohort study, we sought to determine whether hypocitraturia is also a risk factor for incident bone disease in patients with kidney stone disease. We used nationwide data from the Veterans Health Administration and identified 9025 patients with kidney stone disease who had a 24-hour urine citrate measurement between 2007 and 2015. We examined clinical characteristics of patients by level of 24-hour urine citrate excretion (<200, 200-400, and >400 mg/d) and the time to osteoporosis or fracture according to 24-hour urine citrate excretion level. Almost one in five veterans with kidney stone disease and a 24-hour urine citrate measurement had severe hypocitraturia, defined as <200 mg/d. Patients with severe hypocitraturia were at risk for osteoporosis or fracture (hazard ratio [HR] = 1.23; confidence interval [CI] 1.03-1.48), but after adjustment for demographic factors, comorbid conditions, and laboratory abnormalities associated with hypocitraturia, the association was no longer statistically significant (HR = 1.18; CI 0.98-1.43). Our results in a predominantly male cohort suggest a modest association between hypocitraturia and osteoporosis or fracture; there are likely to be other explanations for the potent association between kidney stone disease and diminished bone health. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Calyani Ganesan
- Department of Medicine, Division of NephrologyStanford UniversityPalo AltoCAUSA
| | - I‐Chun Thomas
- Division of Nephrology and Department of UrologyVeterans Affairs Palo Alto Health Care SystemPalo AltoCAUSA
| | - Maria E Montez‐Rath
- Department of Medicine, Division of NephrologyStanford UniversityPalo AltoCAUSA
| | - Glenn M Chertow
- Department of Medicine, Division of NephrologyStanford UniversityPalo AltoCAUSA
| | - John T Leppert
- Department of Medicine, Division of NephrologyStanford UniversityPalo AltoCAUSA
- Division of Nephrology and Department of UrologyVeterans Affairs Palo Alto Health Care SystemPalo AltoCAUSA
- Department of UrologyStanford UniversityPalo AltoCAUSA
| | - Alan C Pao
- Department of Medicine, Division of NephrologyStanford UniversityPalo AltoCAUSA
- Division of Nephrology and Department of UrologyVeterans Affairs Palo Alto Health Care SystemPalo AltoCAUSA
- Department of UrologyStanford UniversityPalo AltoCAUSA
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Adomako EA, Li X, Sakhaee K, Moe OW, Maalouf NM. Urine pH and Citrate as Predictors of Calcium Phosphate Stone Formation. KIDNEY360 2023; 4:1123-1129. [PMID: 37307531 PMCID: PMC10476682 DOI: 10.34067/kid.0000000000000184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/28/2023] [Indexed: 06/14/2023]
Abstract
Key Points The occurrence of calcium phosphate stones has increased over the past five decades, and this is most notable in female stone formers. High urine pH and hypocitraturia are the most discriminatory urine parameters between calcium phosphate and calcium oxalate stone formers. High urine pH in calcium phosphate stone formers is independent of the effect of dietary alkali and acid. Background Urinary parameters, including urine pH and citrate, are recognized as critical in the pathophysiology of calcium-based stones. The factors contributing to variation in these parameters between calcium oxalate (CaOx) and calcium phosphate (CaP) stone formers (SFs) are, however, not well-understood. In this study, using readily available laboratory data, we explore these differences to delineate the odds of forming CaP versus CaOx stones. Methods In this single-center retrospective study, we compared serum and urinary parameters between adult CaP SFs, CaOx SFs, and non–stone formers. Results Urine pH was higher and urine citrate lower in CaP SFs compared with same-sex CaOx SFs and non–stone formers. In CaP SFs, higher urine pH and lower citrate were independent of markers of dietary acid intake and gastrointestinal alkali absorption, suggesting abnormal renal citrate handling and urinary alkali excretion. In a multivariable model, urine pH and urine citrate were most discriminatory between CaP SFs and CaOx SFs (receiver-operating characteristic area under the curve of 0.73 and 0.65, respectively). An increase in urine pH by 0.35, a decrease in urine citrate by 220 mg/d, a doubling of urine calcium, and female sex all independently doubled the risk of CaP stone formation compared with CaOx stones. Conclusions High urine pH and hypocitraturia are two clinical parameters that distinguish the urine phenotype of CaP SFs from CaOx SFs. Alkalinuria is due to intrinsic differences in the kidney independent of intestinal alkali absorption and is accentuated in the female sex.
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Affiliation(s)
- Emmanuel A. Adomako
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, UT Southwestern Medical Center, Dallas, Texas
| | - Xilong Li
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, UT Southwestern Medical Center, Dallas, Texas
- Peter O'Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, Texas
| | - Khashayar Sakhaee
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, UT Southwestern Medical Center, Dallas, Texas
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Orson W. Moe
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, UT Southwestern Medical Center, Dallas, Texas
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
- Department of Physiology, UT Southwestern Medical Center, Dallas, Texas
| | - Naim M. Maalouf
- Charles and Jane Pak Center for Mineral Metabolism and Clinical Research, UT Southwestern Medical Center, Dallas, Texas
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
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LaFavers KA, Gaddy AR, Micanovic R, Lingeman J, Williams JC, Coe FL, El-Achkar TM, Worcester E. Water Loading and Uromodulin Secretion in Healthy Individuals and Idiopathic Calcium Stone Formers. Clin J Am Soc Nephrol 2023; 18:1059-1067. [PMID: 37256909 PMCID: PMC10564375 DOI: 10.2215/cjn.0000000000000202] [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: 12/19/2022] [Accepted: 05/24/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Uromodulin is a protein made only by the kidney and released in urine, circulating in polymerizing and nonpolymerizing forms. This protein's multiple functions include inhibition of stone formation in the urine. The physiological determinants of uromodulin production are incompletely understood. METHODS We investigated changes in uromodulin levels and key factors governing its production and release in urine and serum. We performed an experiment to determine whether water loading, a common intervention to prevent stone formation, will alter the rate of uromodulin production. During a 2-day period, 17 stone forming participants and 14 control participants were subjected to water loading (day 1) and normal fluid intake (day 2). Uromodulin levels were measured on timed hourly collections in urine and plasma during the period of the study. RESULTS Water loading increased urinary uromodulin secretion (33±4 versus 10±4 μ g/min at baseline, P < 0.0001) in stone formers and control participants. Despite high urine volumes, most participants maintained relatively stable urinary uromodulin concentrations. Native Western blots for polymerizing and nonpolymerizing uromodulin suggest that polymerizing uromodulin was the predominant form at higher urinary flow volumes. Urine flow rates and sodium excretion were significant correlates of urinary uromodulin production. Water loading did not affect serum uromodulin levels, which were also not associated with urinary uromodulin. CONCLUSIONS Water loading increases the secretion of polymerizing urinary uromodulin. This increased secretion reduces the variability of urinary uromodulin concentrations despite high urine volumes. Serum uromodulin levels were not affected by this treatment.
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Affiliation(s)
- Kaice A. LaFavers
- Division of Nephrology and Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Anna R. Gaddy
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Radmila Micanovic
- Division of Nephrology and Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - James Lingeman
- Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana
| | - James C. Williams
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Fredric L. Coe
- Section of Nephrology, Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Tarek M. El-Achkar
- Division of Nephrology and Hypertension, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana
- Roudebush VA Medical Center, Indianapolis, Indiana
| | - Elaine Worcester
- Section of Nephrology, Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
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Hou B, Lin C, Hao Z. Chronic hepatitis B virus infection increases the risk of upper urinary calculi. BMC Urol 2022; 22:82. [PMID: 35668522 PMCID: PMC9169271 DOI: 10.1186/s12894-022-01038-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/27/2022] [Indexed: 11/23/2022] Open
Abstract
Background Although hepatitis B virus (HBV) is a recognized risk factor for renal diseases, little is known about HBV infection in individuals with upper urinary calculi (UUC). We investigated the relationship between chronic HBV infection and UUC. Methods We retrospectively analysed data from 1399 patients who were discharged from the Department of Urology (2017–2018). The diagnosis of UUC was determined using urinary tract ultrasonography or computed tomography, and HBV infection was evaluated by a positive hepatitis B surface antigen (HBsAg) test. Data on patients with and without UUC and HBsAg-positive and HBsAg-negative patients were compared by univariate and multivariate analyses. Results Data on chronic HBV infection and UUC were available for 1062 patients, including 514 who presented with UUC and 548 who did not. Overall, 5.8% of total patients, 8.0% of UUC patients and 3.8% of non-UUC patients had chronic HBV infection. UUC patients (41/514) had a significantly higher prevalence of HBsAg positivity (OR 2.175; 95% CI 1.267–3.734; P = 0.004) than non-UUC patients (21/548). After stratifying by sex, the relative odds of HBsAg positivity were statistically significant in men (OR 2.156; 95% CI 1.162–4.003; P = 0.015) but not in women (OR 2.947; 95% CI 0.816–10.643; P = 0.099). The incidence of urinary pH > 6 and staghorn stones was significantly higher in HBsAg-positive UUC patients than in HBsAg-negative UUC patients. Conclusion This is the first study to demonstrate that chronic HBV infection is strongly associated with UUC, at least in men. The urinary pH > 6 and staghorn stones were more common in UUC patients with chronic HBV infection. Supplementary Information The online version contains supplementary material available at 10.1186/s12894-022-01038-z.
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Affiliation(s)
- Bingbing Hou
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, 230032, China.,Institute of Urology, Anhui Medical University, Hefei, China.,Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, China
| | - Changming Lin
- Department of Urology, The Fourth Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zongyao Hao
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, No. 218 Jixi Road, Hefei, 230032, China. .,Institute of Urology, Anhui Medical University, Hefei, China. .,Anhui Province Key Laboratory of Genitourinary Diseases, Anhui Medical University, Hefei, China.
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Abstract
A significant increase in the prevalence of kidney stones has been observed worldwide. In the past decades, this expansion was more pronounced among women than men. The precise mechanisms involved in the differences in the risk profile of stone disease between men and women have not been fully elucidated. Diet and lifestyle only partially can explain the differences, and the combination of factors such as the influence of sex hormones, genetics, and disorders in acid-base handling and urine pH, as well as differences in calcium tubular reabsorption and stone composition in men and women, may contribute to differences in the risk profile. In this review, we summarize the sex differences in the pathophysiologic basis of kidney stones, which may contribute to a more focused approach.
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Affiliation(s)
- Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
| | | | - Gary C Curhan
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Betz MV, Coe FL, Chapman AB. Agreement of Food Records and 24-Hour Urine Studies in Clinical Practice. J Ren Nutr 2021; 32:51-57. [PMID: 34429244 DOI: 10.1053/j.jrn.2021.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 06/21/2021] [Accepted: 07/19/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The objective of this study was to determine the level of agreement between 3-day food records obtained as part of clinical care with 24-hour urine collections specifically assessing sodium, potassium, phosphorus, calcium, protein, and fluid intake. DESIGN AND METHODS Data were collected from patients at a nephrology clinic in a metropolitan, academic medical center. Patients who completed both a 3-day food record and a 24-hour urine collection were analyzed. Food record and urine collection measurements were compared using a simple ratio, Pearson's correlation, and general linear models. RESULTS Patients (n = 85) were 47.9 ± 15.2 years of age, 54% were female, with a mean serum creatinine of 1.3 ± 0.7 mg/dL and estimated glomerular filtration rate of 64.2 ± 25.6 mL/min. Patients had autosomal-dominant polycystic kidney disease (48.2%), nephrolithiasis (31.1%), chronic kidney disease (4.7%), or other genetic or cystic conditions impacting the kidney (12.9%). Nutrient intake was measured utilizing a 3-day food record. Food records and urine collections were compared using the values, correlations, and general linear models. Fluid intake demonstrated the highest agreement (ratio 1.01) and calcium demonstrated the least agreement (ratio 6.30). Significant correlations were demonstrated for phosphorus (r = 0.321, P = .003), magnesium (r = 0.256, P = .018), protein (r = 0.555, P < .000), and fluid (r = 0.277, P = .010) intake. Food record intake of potassium (P = .046), protein (P = .004), and fluid (P = .010) were significant predictors of 24-hour urine excretion. CONCLUSION 3-day food records are useful tools to determine patient dietary patterns, but should be used with caution when assessing specific nutrient intake in clinical settings.
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Affiliation(s)
- Melanie V Betz
- Chronic Kidney Disease Nutrition & Education Specialist, Section of Nephrology, University of Chicago Medicine, Chicago, Illinois.
| | - Fredric L Coe
- Professor of Medicine, Section of Nephrology, University of Chicago Medicine, Chicago, Illinois
| | - Arlene B Chapman
- Chief of Section of Nephrology & Professor of Medicine, Section of Nephrology, University of Chicago Medicine, Chicago, Illinois
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