Isolation from human calcium oxalate renal stones of nephrocalcin, a glycoprotein inhibitor of calcium oxalate crystal growth. Evidence that nephrocalcin from patients with calcium oxalate nephrolithiasis is deficient in gamma-carboxyglutamic acid

Current Status of Protein Biomarkers in Urolithiasis-A Review of the Recent Literature

Urolithiasis is an increasingly common clinical problem worldwide. The formation of stones is a combination of metabolic status, environmental factors, family history and many other aspects. It is important to find new ways to quickly detect and assess urolithiasis because it causes sudden, severe pain and often comes back. One way to do this is by exploring new biomarkers. Current advances in proteomic studies provide a great opportunity for breakthroughs in this field. This study focuses on protein biomarkers and their connection to kidney damage and inflammation during urolithiasis.

Vitamins as regulators of calcium-containing kidney stones - new perspectives on the role of the gut microbiome

Calcium-based kidney stone disease is a highly prevalent and morbid condition, with an often complicated and multifactorial aetiology. An abundance of research on the role of specific vitamins (B6, C and D) in stone formation exists, but no consensus has been reached on how these vitamins influence stone disease. As a consequence of emerging research on the role of the gut microbiota in urolithiasis, previous notions on the contribution of these vitamins to urolithiasis are being reconsidered in the field, and investigation into previously overlooked vitamins (A, E and K) was expanded. Understanding how the microbiota influences host vitamin regulation could help to determine the role of vitamins in stone disease.

Kidney stone matrix proteins: Role in stone formation

Stone formation is induced by an increased level of urine crystallization promoters and reduced levels of its inhibitors. Crystallization inhibitors include citrate, magnesium, zinc, and organic compounds such as glycosaminoglycans. In the urine, there are various proteins, such as uromodulin (Tamm-Horsfall protein), calgranulin, osteopontin, bikunin, and nephrocalcin, that are present in the stone matrix. The presence of several carboxyl groups in these macromolecules reduces calcium oxalate monohydrate crystal adhesion to the urinary epithelium and could potentially protect against lithiasis. Proteins are the most abundant component of kidney stone matrix, and their presence may reflect the process of stone formation. Many recent studies have explored the proteomics of urinary stones. Among the stone matrix proteins, the most frequently identified were uromodulin, S100 proteins (calgranulins A and B), osteopontin, and several other proteins typically engaged in inflammation and immune response. The normal level and structure of these macromolecules may constitute protection against calcium salt formation. Paradoxically, most of them may act as both promoters and inhibitors depending on circumstances. Many of these proteins have other functions in modulating oxidative stress, immune function, and inflammation that could also influence stone formation. Yet, the role of these kidney stone matrix proteins needs to be established through more studies comparing urinary stone proteomics between stone formers and non-stone formers.

Understanding the link between kidney stones and cancers of the upper urinary tract and bladder

Kidney stones are one of the most common renal pathologies. While emerging evidence has implicated a potential association between kidney stones and upper urinary tract cancers (including renal cancer), there is limited understanding as to the common underlying biological pathways functionally linking the etiology of kidney stone formation and the incidence, development, and progression of urinary tract cancers. From a clinical perspective, kidney stone disease can be a barrier to oncologic care due to renal obstruction. From the epidemiological perspective, risk factors associated with both conditions include smoking, alcohol consumption, diet, and gender. Herein, we review the association between renal calculi and malignancy of the upper urinary tract and discuss the current understanding of (a) potential shared mechanisms, and (b) the impact this has on shared therapeutic management of both conditions.

Vitamin K - sources, physiological role, kinetics, deficiency, detection, therapeutic use, and toxicity

Vitamin K is traditionally connected with blood coagulation, since it is needed for the posttranslational modification of 7 proteins involved in this cascade. However, it is also involved in the maturation of another 11 or 12 proteins that play different roles, encompassing in particular the modulation of the calcification of connective tissues. Since this process is physiologically needed in bones, but is pathological in arteries, a great deal of research has been devoted to finding a possible link between vitamin K and the prevention of osteoporosis and cardiovascular diseases. Unfortunately, the current knowledge does not allow us to make a decisive conclusion about such a link. One possible explanation for this is the diversity of the biological activity of vitamin K, which is not a single compound but a general term covering natural plant and animal forms of vitamin K (K₁ and K₂) as well as their synthetic congeners (K₃ and K₄). Vitamin K₁ (phylloquinone) is found in several vegetables. Menaquinones (MK₄–MK₁₃, a series of compounds known as vitamin K₂) are mostly of a bacterial origin and are introduced into the human diet mainly through fermented cheeses. Current knowledge about the kinetics of different forms of vitamin K, their detection, and their toxicity are discussed in this review.

Do "inhibitors of crystallisation" play any role in the prevention of kidney stones? A critique

A critical examination of data in the literature and in as yet unpublished laboratory records on the possible role of so-called inhibitors of crystallisation in preventing the formation of calcium-containing kidney stones leads to the following conclusions. So-called inhibitors of spontaneous "self-nucleation" are unlikely to play any role in the initiation of the crystallisation of CaOx or CaP in urine because excessive urinary supersaturation of urine with respect to these salts dominates the onset of "self-nucleation" within the normal time frame of the transit of tubular fluid through the nephron (3-4 min). Inhibitors of the crystal growth of CaOx crystals may or may not play a significant role in the prevention of CaOx stone-formation since once again excessive supersaturation of urine can overwhelm any potential effect of the inhibitors on the growth process. However, they may play a role as inhibitors of crystal growth at lower levels of metastable supersaturation when the balance between supersaturation and inhibitors is more equal. Inhibitors of CaOx crystal aggregation may play a significant role in the prevention of stones, since they do not appear to be strongly affected by excessive supersaturation, either in vitro or in vivo. Inhibitors of CaOx crystal binding to renal tubular epithelium may exist but further studies are necessary to elucidate their importance in reducing the risk of initiating stones in the renal tubules. Inhibitors of CaOx crystal binding to Randall's Plaques and Randall's Plugs may exist but further studies are necessary to elucidate their importance in reducing the risk of initiating stones on renal papillae. There may be an alternative explanation other than a deficiency in the excretion of inhibitors for the observations that there is a difference between CaOx crystal size and degree of aggregation in the fresh, warm urines of normal subjects compared those in urine from patients with recurrent CaOx stones. This difference may depend more on the site of "self-nucleation" of CaOx crystals in the renal tubule rather than on a deficiency in the excretion of so-called inhibitors of crystallisation by patients with CaOx stones. The claim that administration of potassium citrate, potassium magnesium citrate or magnesium hydroxide reduces the rate of stone recurrence may be due to the effect of these forms of medication on the supersaturation of urine with respect to CaOx and CaP rather than to any increase in "inhibitory activity" attributed to these forms of treatment. In summary, there is a competition between supersaturation and so-called inhibitors of crystallisation which ultimately determines the pattern of crystalluria in stone-formers and normals. If the supersaturation of urine with respect to CaOx reaches or exceeds the 3-4 min formation product of that salt, then it dominates the crystallisation process both in terms of "self-nucleation" and crystal growth but appears to have little or no effect on the degree of aggregation of the crystals produced. At supersaturation levels of urine with respect to CaOx well below the 3-4 min formation product of that salt, the influence of inhibitors increases and some may affect not only the degree of aggregation but also the crystal growth of any pre-formed crystals of CaOx at these lower levels of metastability.

Mechanistic Insights into the Antilithiatic Proteins from Terminalia arjuna: A Proteomic Approach in Urolithiasis

Kidney stone formation during hyperoxaluric condition is inherently dependent on the interaction between renal epithelial cells and calcium oxalate (CaOx) crystals. Although modern medicine has progressed in terms of removal of these stones, recurrence and persistent side effects restricts their use. Strategies involving plant based agents which could be used as adjunct therapy is an area which needs to be explored. Plant proteins having antilithiatic activity is a hitherto unexplored area and therefore, we conducted a detailed identification and characterization of antilithiatic proteins from Terminalia arjuna (T. arjuna). Proteins were isolated from the dried bark of T. arjuna and those having molecular weights > 3 kDa were subjected to anion exchange chromatography followed by gel filtration chromatography. Four proteins were identified exhibiting inhibitory activity against CaOx crystallization and crystal growth kinetics The cytoprotective and anti-apoptotic efficacy of these purified proteins was further investigated on oxalate injured renal epithelial cells (MDCK and NRK-52E) wherein, injury due to oxalate was significantly attenuated and led to a dose dependent increase in viability of these cells. These proteins also prevented the interaction of the CaOx crystals to the cell surface and reduced the number of apoptotic cells. Identification of these 4 anionic proteins from the bark of T. arjuna was carried out by Matrix-assisted laser desorption/ionization-time of flight Mass spectrometry (MALDI-TOF MS). This was followed by database search with the MASCOT server and sequence similarity was found with Nuclear pore anchor, DEAD Box ATP-dependent RNA helicase 45, Lon protease homolog 1 and Heat shock protein 90–3. These novel proteins isolated from T. arjuna have the potential to inhibit CaOx crystallization and promote cell survival and therefore, offer novel avenues which need to be explored further for the medical management of urolithiasis.

Kidney stones

Kidney stones are mineral deposits in the renal calyces and pelvis that are found free or attached to the renal papillae. They contain crystalline and organic components and are formed when the urine becomes supersaturated with respect to a mineral. Calcium oxalate is the main constituent of most stones, many of which form on a foundation of calcium phosphate called Randall's plaques, which are present on the renal papillary surface. Stone formation is highly prevalent, with rates of up to 14.8% and increasing, and a recurrence rate of up to 50% within the first 5 years of the initial stone episode. Obesity, diabetes, hypertension and metabolic syndrome are considered risk factors for stone formation, which, in turn, can lead to hypertension, chronic kidney disease and end-stage renal disease. Management of symptomatic kidney stones has evolved from open surgical lithotomy to minimally invasive endourological treatments leading to a reduction in patient morbidity, improved stone-free rates and better quality of life. Prevention of recurrence requires behavioural and nutritional interventions, as well as pharmacological treatments that are specific for the type of stone. There is a great need for recurrence prevention that requires a better understanding of the mechanisms involved in stone formation to facilitate the development of more-effective drugs.

Inhibitory potency of crystal matrix protein on the crystallization of calcium oxalate

The presence of macromolecular substances is among the multiple factors that may influence the complex process of urinary stone formation. The aim of this study was to evaluate the inhibitory potency of crystal matrix protein (CMP). Purification of CMP consisted of calcium oxalate crystal formation, dissolution of crystals, electrodialysis and high-performance liquid chromatography (HPLC). The inhibitory potency of crystal aggregation was examined by the seed crystal method, the undiluted urine method, and the use of scanning electron microscopy (SEM). CMP showed the protein band of 31 kDa in SDS-PAGE. Anti-CMP polyclonal antibody and antihuman prothrombin antibody cross-reacted well with human prothrombin and CMP in Western blotting. CMP and human prothrombin had high inhibitory potency by the seed crystal method and undiluted urine method. Using SEM, we were able to observe the high inhibitory potency of human prothrombin and undiluted CMP on the aggregation of calcium oxalate crystals.

Nephrolithiasis: molecular mechanism of renal stone formation and the critical role played by modulators

Urinary stone disease is an ailment that has afflicted human kind for many centuries. Nephrolithiasis is a significant clinical problem in everyday practice with a subsequent burden for the health system. Nephrolithiasis remains a chronic disease and our fundamental understanding of the pathogenesis of stones as well as their prevention and cure still remains rudimentary. Regardless of the fact that supersaturation of stone-forming salts in urine is essential, abundance of these salts by itself will not always result in stone formation. The pathogenesis of calcium oxalate stone formation is a multistep process and essentially includes nucleation, crystal growth, crystal aggregation, and crystal retention. Various substances in the body have an effect on one or more of the above stone-forming processes, thereby influencing a person's ability to promote or prevent stone formation. Promoters facilitate the stone formation while inhibitors prevent it. Besides low urine volume and low urine pH, high calcium, sodium, oxalate and urate are also known to promote calcium oxalate stone formation. Many inorganic (citrate, magnesium) and organic substances (nephrocalcin, urinary prothrombin fragment-1, osteopontin) are known to inhibit stone formation. This review presents a comprehensive account of the mechanism of renal stone formation and the role of inhibitors/promoters in calcium oxalate crystallisation.

Effects of a urolith prevention diet on urine compositions of glycosaminoglycans, Tamm-Horsfall glycoprotein, and nephrocalcin in cats with calcium oxalate urolithiasis

OBJECTIVE

To evaluate urine concentrations of glycosaminoglycans, Tamm-Horsfall glycoprotein, and nephrocalcin in cats fed a diet formulated to prevent calcium oxalate uroliths.

ANIMALS

10 cats with calcium oxalate urolithiasis.

PROCEDURES

In a previous study conducted in accordance with a balanced crossover design, cats were sequentially fed 2 diets (the diet each cat was consuming prior to urolith detection and a diet formulated to prevent calcium oxalate uroliths). Each diet was fed for 8 weeks. At the end of each 8-week period, a 72-hour urine sample was collected. Concentrations of glycosaminoglycans, Tamm-Horsfall glycoprotein, and the 4 isoforms of nephrocalcin in urine samples collected during that previous study were measured in the study reported here. RESULTS; Diet had no effect on the quantity of Tamm-Horsfall glycoprotein and nephrocalcin in urine. However, the urine concentration of glycosaminoglycans was significantly higher during consumption of the urolith prevention diet.

CONCLUSIONS AND CLINICAL RELEVANCE

Feeding a urolith prevention diet increased the urine concentration of glycosaminoglycans, which are glycoprotein inhibitors of growth and aggregation of calcium oxalate crystals.

A hypothesis of calcium stone formation: an interpretation of stone research during the past decades

An interpretation of previous and recent observation on calcium salt crystallization and calcium stone formation provide the basis for formulation of a hypothetical series of events leading to calcium oxalate (CaOx) stone formation in the urinary tract. The various steps comprise a primary precipitation of calcium phosphate (CaP) at high nephron levels, establishment of large intratubular and/or interstitial (sub-epithelial) aggregates of CaP. These crystal masses subsequently might be dissolved during periods with low urine pH. On the denuded surface of subepithelial or intratubularly trapped CaP, release of calcium ions can result in very high ion-activity products of CaOx, particularly during simultaneous periods with peaks of CaOx supersaturation. Crystals of CaOx may result from nucleation in the macromolecular environment surrounding the apatite crystal phase. In the presence of low pH, low citrate and high ion-strength of urine, formation of large CaOx crystal masses can be accomplished by self-aggregation of Tamm-Horsfall mucoprotein. Following dislodgment of the initially fixed CaOx stone embryo, the further development into to clinically relevant stone is accomplished by CaOx crystal growth and CaOx crystal aggregation of the retained stone material. The latter process is modified by a number of inhibitors and promoters present in urine. The retention of the stone is a consequence of anatomical as well as hydrodynamic factors.

Urinary tract stones

Urinary tract stone disease is one of the most common urologic conditions in the US, with a lifetime prevalence of about 13% for men and 7% for women. In this article we review the management of urinary tract stones and discuss when to seek urologic consultation. We cover epidemiologic data, stone types, presenting symptoms, imaging, metabolic evaluation and risk factors, and medical management strategies. We also discuss the indications for surgical intervention and the common operative procedures currently available.

Involvement of urinary proteins in the rat strain difference in sensitivity to ethylene glycol-induced renal toxicity

Ethylene glycol (EG) exposure is a common model for kidney stones, because animals accumulate calcium oxalate monohydrate (COM) in kidneys. Wistar rats are more sensitive to EG than Fischer 344 (F344) rats, with greater COM deposition in kidneys. The mechanisms by which COM accumulates differently among strains are poorly understood. Urinary proteins inhibit COM adhesion to renal cells, which could alter COM deposition in kidneys. We hypothesize that COM accumulates more in Wistar rat kidneys because of lower levels of inhibitory proteins in urine. Wistar and F344 rats were treated with 0.75% EG in drinking water for 8 wk. Twenty-four-hour urine was collected every 2 wk for analysis of urinary proteins. Similar studies were conducted for 2 wk using 2% hydroxyproline (HP) as an alternative oxalate source. Total urinary protein was higher in F344 than Wistar rats at all times. Tamm-Horsfall protein was not different between strains. Osteopontin (OPN) levels in Wistar urine and kidney tissue were higher and were further increased by EG treatment. This increase in OPN occurred before renal COM accumulation. Untreated F344 rats showed greater CD45 and ED-1 staining in kidneys than untreated Wistars; in contrast, EG treatment increased CD45 and ED-1 staining in Wistars more than in F344 rats, indicating macrophage infiltration. This increase occurred in parallel with the increase in OPN and before COM accumulation. Like EG, HP induced markedly greater oxalate concentrations in the plasma and urine of Wistar rats compared with F344 rats. These results suggest that OPN upregulation and macrophage infiltration do not completely protect against COM accumulation and may be a response to crystal retention. Because the two oxalate precursors, EG and HP, produced similar elevations of oxalate, the strain difference in COM accumulation may result more so from metabolic differences between strains than from differences in urinary proteins or inflammatory responses.

Red blood cell membrane fragments but not intact red blood cells promote calcium oxalate monohydrate crystal growth and aggregation

PURPOSE

Cell membranes are thought to promote calcium oxalate kidney stone formation but to our knowledge the modulating effect of red blood cell membranes on calcium oxalate crystals has not been previously investigated. Thus, we examined the effects of red blood cell membrane fragments on calcium oxalate monohydrate and calcium oxalate dihydrate crystal growth and aggregation.

MATERIALS AND METHODS

Calcium oxalate monohydrate and calcium oxalate dihydrate crystals were treated with red blood cell membrane fragments or intact red blood cells from a healthy donor. Phase contrast microscopy was performed to evaluate crystal morphology and aggregation. We used ImageMaster 2D Platinum software to evaluate crystal size and spectrophotometric oxalate depletion assay to monitor crystal growth.

RESULTS

Red blood cell membrane fragments had significant promoting activity on calcium oxalate monohydrate crystal growth with an approximately 75% increase in size and aggregation with an approximately 2.5-fold increase in aggregate number compared to the control without membrane fragments or cells. Approximately 50% of calcium oxalate monohydrate crystals were adhered by red blood cell membrane fragments. Intact red blood cells had no significant effect on calcium oxalate monohydrate crystal growth or aggregation but they could transform calcium oxalate monohydrate to calcium oxalate dihydrate crystals. Red blood cell membrane fragments and intact red blood cells had no effect on calcium oxalate dihydrate crystals. The promoting activity of red blood cell membrane fragments on calcium oxalate monohydrate crystal growth was successfully confirmed by spectrophotometric oxalate depletion assay.

CONCLUSIONS

To our knowledge our data provide the first direct evidence that red blood cell membrane fragments are a promoting factor for calcium oxalate monohydrate crystal growth and aggregation. Thus, they may aggravate calcium oxalate stone formation.

A HindIII polymorphism of fibronectin gene is associated with nephrolithiasis

OBJECTIVES

To evaluate the association between fibronectin gene (FN1) polymorphisms and calcium oxalate nephrolithiasis as a genetic risk factor.

METHODS

Genomic DNA of 143 patients with calcium oxalate nephrolithiasis and 154 healthy controls were screened for polymorphisms (HaeIII b, MspI, and HindIII) of the FN1 gene, using polymerase chain reaction-restriction fragments length polymorphism method. Allele and genotype frequencies were compared between the groups.

RESULTS

Although the observed differences between distribution of genotypes of AA, AB, and BB (for HaeIII b), as well as CC, CD, and DD (MspI) were not significant, FF genotype for HindIII showed significant difference when compared with both EF and EE + EF genotype (P = .00202 and P = .00203, respectively).

CONCLUSIONS

The results of our study revealed that HindIII polymorphism of the FN1 gene is highly associated with calcium oxalate stone disease. This association makes FN a good candidate for further studies about the etiology of stone disease, and in the future it could be a candidate marker for evaluating the genetic risks in patients with nephrolithiasis.

Characterizations of urinary sediments precipitated after freezing and their effects on urinary protein and chemical analyses

One of the obstacles in analyzing frozen urine samples is the formation of uncharacterized precipitates. Frequently, these precipitates are discarded before analysis. Some laboratory data may be erroneous if these precipitates contain important compounds. In the present study, we examined urinary sediments precipitated after overnight storage at -20 degrees C. Although cells and debris were removed before freezing, the precipitates remained, whereas storing the centrifuged urine overnight at 4 degrees C did not result in precipitate formation. There were no significant differences observed among 10 healthy individuals (5 men and 5 women). EDTA (5 mM) could efficiently reduce the amount of precipitates to approximately 25% of the initial amount. The addition of exogenous CaCl2, but not sodium oxalate and NaCl, significantly increased the amount of precipitates in a dose-dependent manner. Linear regression analysis revealed a significant correlation between endogenous urinary calcium level and the amount of precipitates (r = 0.894; P < 0.001). Urine pH also had some effects on the type and amount of precipitates. These precipitates were composed mainly of calcium oxalate dihydrate and amorphous calcium crystals. The results also showed that these precipitates could deplete urinary proteins and calcium ions (23.6 +/- 1.1% decrease). Therefore, these freezer-induced urinary sediments significantly affect protein analysis and measurement of calcium levels in the urine. However, vigorous shaking of the sample at room temperature could redissolve these precipitates. Our data strongly indicate that these freezer-induced precipitates must be taken into account when the frozen urine samples are analyzed.

Heparan sulfate gene polymorphism in calcium oxalate nephrolithiasis

Calcium oxalate (CaOx) nephrolithiasis has a complex pathogenic mechanism. Besides environmental factors, genetic factors also have influence on stone formation. This study represents the effects of heparan sulfate (HSPG2) gene polymorphism for determining the risk of urolithiasis. We investigated 143 CaOx stone formers with 158 healthy individuals for the BamHI restriction site polymorphism located in intron 6 of the HSPG gene using the polymerase chain reaction, restriction fragments length polymorphism method. After digestion with BamHI, the polymorphism was assumed to cause three genotypes according to the banding types as GG (242 bp), GT (242, 144, and 98 bp) and TT (144 and 98 bp). According to the genotype frequencies between the groups, TT genotype showed significantly increased risk for urolithiasis than TG and GG genotypes. We concluded that HSPG2 gene polymorphism might be one of the genetic factors affecting the CaOx stone formation.

Urinary trefoil factor 1 is a novel potent inhibitor of calcium oxalate crystal growth and aggregation

PURPOSE

Crystal growth and aggregation are the important mechanisms of calcium oxalate stone formation in the kidney. Recently we successfully purified trefoil factor 1 from human urine and used an oxalate depletion assay to indirectly infer its inhibitory activity against calcium oxalate crystal growth. We searched for direct evidence to define the inhibitory activity of urinary trefoil factor 1 against calcium oxalate crystal growth. Moreover, we also evaluated whether urinary trefoil factor 1 has any effects on calcium oxalate crystal aggregation and transformation.

MATERIALS AND METHODS

Isolated and aggregated forms of calcium oxalate monohydrate crystals were produced in the absence or presence of 7, 70 and 700 ng/ml urinary trefoil factor 1, nephrocalcin as a positive control or lysozyme (Sigma-Aldrich) as a negative control.

RESULTS

The data clearly indicated that urinary trefoil factor 1 and nephrocalcin at physiological levels could effectively inhibit calcium oxalate monohydrate crystal growth and aggregation, whereas lysozyme did not affect the growth and aggregation of calcium oxalate monohydrate crystals. At a supraphysiological concentration of 4 microg/ml urinary trefoil factor 1 and nephrocalcin could transform calcium oxalate monohydrate crystals to the dihydrate type, which has much less adsorptive capability.

CONCLUSIONS

To our knowledge these data provide the first direct evidence that urinary trefoil factor 1 is a novel potent inhibitor of calcium oxalate crystal growth and aggregation, and can transform calcium oxalate monohydrate crystals to the dihydrate type.

Glycosylation of prothrombin fragment 1 governs calcium oxalate crystal nucleation and aggregation, but not crystal growth

Urinary glycoproteins play an important role in the modulation of calcium oxalate crystallisation. In several cases, this has been attributed to glycosylation of the proteins as evidenced by urinary prothrombin fragment 1 where there is a correlation between sialylation and calcium oxalate kidney stone disease. In the present study, plasma-derived prothrombin fragment 1 (PTF1) was enzymatically modified in order to generate its asialo and aglyco forms. The parent glycoprotein and its two glycoforms were used in calcium oxalate crystallisation studies to assess the role of the carbohydrate moeity in PTF1's potent inhibitory activity. The glycans inhibited crystal aggregation and promoted crystal nucleation, but had no effect on crystal growth. The terminal sialic acid residues had a small effect on inhibition of crystal aggregation whereas they contributed significantly to promotion of nucleation. These results indicate that glycosylation of PTF1 governs calcium oxalate crystal nucleation and aggregation but it does not affect the protein's role in inhibiting crystal growth. Since promotion of nucleation and inhibition of aggregation are both regarded as protective mechanisms against calcium oxalate urinary stone formation, the kringle domain on which the glycans are located is implicated in PTF1's inhibitory activity. It is speculated that modifications in the glycosylation of urinary PTF1 in stone-formers may regulate its capacity to protect against calcium urolithiasis.

How does bovine serum albumin prevent the formation of kidney stone? A kinetics study

To attain a better understanding of the crystallization of calcium oxalate crystals under the influence of the protein bovine serum albumin, we examined not only the nucleation kinetics but also the structural synergy between the biomineral and the biosubstrate. It follows that during the crystallization process of calcium oxalate crystals bovine serum albumin inhibits the nucleation of calcium oxalate by increasing the kink kinetics barrier. The results of scanning electron microscopy and X-ray diffraction show, however, that bovine serum albumin promotes the formation of calcium oxalate dihydrate. Apart from this, bovine serum albumin facilitates the ordered calcium oxalate crystal assembly by suppressing the supersaturation-driven interfacial structure mismatch. The physics questions behind the mentioned effects have been addressed from the kinetics point of view. This may explain why bovine serum albumin plays an important role in suppressing urine stone formation.

Models for protein binding to calcium oxalate surfaces

It is widely believed that proteins rich in Asp, Glu or Gla (gamma carboxyglutamic acid) interact strongly with calcium oxalate surfaces and inhibit calcium oxalate crystal growth. An alternative hypothesis would be that the interaction of Asp, Glu and Gla residues with surfaces could facilitate nucleation and crystal aggregation. Prothrombin fragment 1 and bikunin have been studied extensively as inhibitors, beta-microglobulin, transferrin and antitrypsin have been found in stone matrix and tubulin has been observed in the attachment of crystals to cell surfaces. The aim of this study is to examine how well carboxylate groups in proteins found either in stone matrix, or proposed as inhibitors, could fit with the calcium ion sub-lattice of both calcium oxalate monohydrate and dihydrate surfaces. The carboxylate groups in the acidic Asp, Glu and Gla residues were marked in the Protein Data Bank structures and matched to calcium oxalate surfaces using the Cerius 3D molecular modeling program. A contact was defined if a carboxylate oxygen atom approached a surface calcium atom in such a way that the separation was less than 6 Angstrom but greater than 2.4 Angstrom, the sum of the ionic radii. If the proteins maintain their 3D structure, the number of contacts was no more than 3 or 4 for all the proteins studied, irrespective of the calcium oxalate surface.

Defective urinary crystallization inhibition and urinary stone formation

INTRODUCTION

Nephrocalcin (NC) is a glycoprotein produced in the kidney and inhibits calcium oxalate crystal formation. It has been separated into 4 isoforms (A, B, C, and D) and found that (A + B) are more abundant than (C + D) in urine of healthy subjects, but the reverse is seen in human urine of kidney stone patients. To further examine the role of this protein in inhibition of urinary crystallization, nephrocalcin isoforms were purified from 2 genetically pure dog species.

MATERIALS AND METHODS

We studied healthy Beagles, known to be non-stone forming dogs, and Mini-Schnauzers, known to be calcium oxalate stone formers. NC was isolated and purified from each group. Urinary biochemistry and calcium oxalate crystal growth inhibition were measured.

RESULTS

Specific crystal growth inhibition activity was significantly higher in non-stone forming dogs (9.79 +/- 2.25 in Beagles vs. 2.75 +/- 1.34 of Mini-Schnauzers, p < 0.005). Dissociation constants toward calcium oxalate monohydrate were 10-fold different, with Beagles' isoforms being 10 times stronger inhibitors compare to those of Mini-Schnauzers'. Isoforms C + D of NC were the main isoforms isolated in stone-forming dogs.

CONCLUSION

NC of these two species of dogs differently affects calcium oxalate crystallization and might have a role in determining ulterior urinary stone formation.

Protein profiling of organic stone matrix and urine from dogs with urolithiasis

Two-thirds of the organic matrix in urinary stones consists of proteins. Their relationship to calculogenesis remains controversial with regard to their effect as inhibitors or promoters during stone formation. The purpose of the present study was to determine the differences in peptide and protein pattern between the urine of stone formers (n = 23) and control dogs (n = 12), as well as between organic matrix of different urinary stones (struvite n = 11, calcium oxalate n = 8, uric acid n = 4) using surface-enhanced laser desorption/ionization time-of-flight mass spectrometry. Specific differences in protein and peptide profiles were found in the organic matrix of different mineral compositions. Characteristic differences were also found in urinary peptide and protein pattern especially in molecular masses below 20 kDa between affected and healthy dogs. Based on the obtained molecular masses they were in some cases tentatively identified as proteins that are known to be involved in stone formation in humans. The study shows that in dogs, specific-urinary peptides and proteins might be associated with urolithiasis. It indicates the importance to further characterize those proteins for possible diagnostic purposes in prognosis and therapy.

Lithogenesis: induction of renal calcifications by nanobacteria

Nanobacteria have been isolated from kidney stones and it has been suggested that they may act as a nucleus for the initiation of the renal stones. In the present study, we examine their role in biocrystallization and their in vivo effects on kidney pathology. Calcium oxalate monohydrate (COM) assay was carried out in the presence of nanobacteria to study biocrystallization. Wistar rats were given an intravenous injection of nanobacteria and the kidneys were examined for pathological changes. The COM assay showed accelerated biocrystallization of (14)C-oxalate in the presence of nanobacteria, indicating them to be efficient candidates for biomineralization. Histopathological studies revealed bacteria induced renal tubular calcifications and various manifestations of infection. Our studies confirm that nanobacteria may be involved in the pathogenesis of renal tubular calcification.

Identification of human urinary trefoil factor 1 as a novel calcium oxalate crystal growth inhibitor

Previous research on proteins that inhibit kidney stone formation has identified a relatively small number of well-characterized inhibitors. Identification of additional stone inhibitors would increase understanding of the pathogenesis and pathophysiology of nephrolithiasis. We have combined conventional biochemical methods with recent advances in mass spectrometry (MS) to identify a novel calcium oxalate (CaOx) crystal growth inhibitor in normal human urine. Anionic proteins were isolated by DEAE adsorption and separated by HiLoad 16/60 Superdex 75 gel filtration. A fraction with potent inhibitory activity against CaOx crystal growth was isolated and purified by anion exchange chromatography. The protein in 2 subfractions that retained inhibitory activity was identified by matrix-assisted laser desorption/ionization-time-of-flight MS and electrospray ionization-quadrupole-time-of-flight tandem MS as human trefoil factor 1 (TFF1). Western blot analysis confirmed the mass spectrometric protein identification. Functional studies of urinary TFF1 demonstrated that its inhibitory potency was similar to that of nephrocalcin. The inhibitory activity of urinary TFF1 was dose dependent and was inhibited by TFF1 antisera. Anti-C-terminal antibody was particularly effective, consistent with our proposed model in which the 4 C-terminal glutamic residues of TFF1 interact with calcium ions to prevent CaOx crystal growth. Concentrations and relative amounts of TFF1 in the urine of patients with idiopathic CaOx kidney stone were significantly less (2.5-fold for the concentrations and 5- to 22-fold for the relative amounts) than those found in controls. These data indicate that TFF1 is a novel potent CaOx crystal growth inhibitor with a potential pathophysiological role in nephrolithiasis.

A simple procedure for isolating microgram quantities of biologically active bikunin from human urine

OBJECTIVE

To report a simple, relatively rapid protocol to isolate biologically active bikunin from human urine using ion-exchange-trypsin affinity chromatography. Bikunin is a protease inhibitor which has been shown to play a role in various processes, including inhibition of calcium oxalate crystallization, the regulation of proliferation and modulation of carcinogenesis. The unavailability of the purified protein has hampered studies on bikunin's expanding role in these processes.

MATERIALS AND METHODS

Female human urine was dialysed (15 kDa threshold) and crudely fractionated with a double-saturated ammonium sulphate precipitation. The first precipitation was with 35% saturated ammonium sulphate, and the supernatant was harvested, and the second with 90% saturated ammonium sulphate, and the precipitate collected. The protein mixture was then passed over Sepharose SP-fast-flow cation exchange and Sepharose Q-fast-flow anion exchange columns connected in series. The final purification was with a trypsin-affinity column which selectively bound bikunin.

RESULTS

This procedure could recover 1 microg of bikunin per 2 mL of urine, and the final product was essentially free of contaminating inter-alpha-trypsin inhibitor heavy chains or bikunin-heavy chain conjugates. Product purity was confirmed by two-dimensional polyacrylamide gel electrophoresis combined with silver staining or Western blot. All isolations contained the 17 kDa minimally glycoslyated/sulphated form of bikunin and the 28 kDa form of bikunin. Some preparations also contained 33-48 kDa forms of bikunin. The protein cores of all three proteins were confirmed to be bikunin by mass spectrometry and Western blot. Harvested bikunin retained its trypsin inhibitory activity (L-benzoylarginine-p-nitroanilide assay). Preparations containing the 33-45 kDa form had two to three times more trypsin inhibitory activity than preparations without this band.

CONCLUSIONS

This novel ion exchange-trypsin affinity chromatography protocol uses only two chromatographic steps. The product consists of three isomers of biologically active bikunin, free of contaminating heavy chains or bikunin-heavy chain conjugates. The ready availability of purified bikunin should facilitate future studies of bikunin's emerging role in urolithiasis, proliferation and carcinogenesis.

Evaluation of the association between sex and risk of forming urate uroliths in Dalmatians

OBJECTIVE

To test the hypothesis that urate uroliths are uncommonly detected in female Dalmatians, compared with males.

DESIGN

Case-control study.

SAMPLE POPULATION

Medical records of dogs evaluated at veterinary teaching hospitals in North America from 1981 to 2002 and compiled by the Veterinary Medical Database, and records of dogs with uroliths submitted for quantitative analyses to the Minnesota Urolith Center from 1981 to 2002.

PROCEDURES

Crude odds ratios (ORs) and 95% confidence intervals were calculated to assess whether sex (male vs female) was a risk factor for urate urolithiasis.

RESULTS

In Dalmatians evaluated by veterinary teaching hospitals in North America, males were more likely (OR, 13.0) to form uroliths, compared with females. In Dalmatians that formed uroliths analyzed by the Minnesota Urolith Center, males were more likely (OR, 14.0) to form urate uroliths, compared with females. In all dogs (Dalmatian and non-Dalmatian) that formed uroliths analyzed by the Minnesota Urolith Center, males were also more likely (OR, 48.0) to form urate uroliths, compared with females.

CONCLUSIONS AND CLINICAL RELEVANCE

When conducting studies and formulating generalities about urate urolithiasis in Dalmatians, it is important to consider sex-related differences in urolith occurrence. Long-term dietary or drug protocols designed to minimize formation of urate uroliths in male Dalmatians may not be warranted in female Dalmatians.

Update: management of calcium oxalate uroliths in dogs and cats

Calcium oxalate has become the most common mineral occurring in canine and feline uroliths. Although calcium oxalate urolith formation may be a consequence of metabolic disease, the underlying cause is not identified in many dogs and cats. Currently, there is no successful medical dissolution protocol, and calcium oxalate uroliths must be removed physically if causing problems. Effective preventative protocols are available for dogs and cats, although they are not uniformly successful.

Morphological and immunological characteristics of nanobacteria from human renal stones of a north Indian population

The aim of this study was to detect, isolate and characterize the nanobacteria from human renal stones from a north Indian population, and to determine their role in biomineralization. Renal stones retrieved from the kidneys of 65 patients were processed and subjected to mammalian cell culture conditions. The isolated bacteria were examined using scanning (SEM) and transmission electron microscopy (TEM). They were characterized for the presence of DNA, proteins and antigenicity. The role of these bacteria in biomineralization was studied by using the (14)C-oxalate based calcium oxalate monohydrate (COM) crystallization assay. We observed the presence of apatite forming, ultrafilterable gram negative, coccoid microorganisms in 62% of the renal stones. SEM studies revealed 60-200 nm sized organisms with a distinct cell wall and a capsule. TEM images showed needle like apatite structures both within and surrounding them. They were heat sensitive, showed antibiotic resistance and accelerated COM crystallization. A potent signal corresponding to the presence of DNA was observed in demineralized nanobacterial cells by flow cytometry. The protein profile showed the presence of several peptide bands of which those of 18 kDa and 39kDa were prominent. Apatite forming nanosized bacteria are present in human renal stones and may play a role in the pathophysiology of renal stone formation by facilitating crystallization and biomineralization. However, further studies are required to establish the exact mechanism by which nanobacteria are involved in the causation of renal stones.

Kidney stone inhibitors in patients with renal stones and endemic renal tubular acidosis in northeast Thailand

Distal renal tubular acidosis (dRTA) is generally associated with hypercalciuria, hypocitraturia, and nephrolithiasis. Our intention was to study glycosaminoglycans (GAGS) and nephrocalcin (NC), two well-known crystal growth inhibitors, in a population with endemic dRTA and nephrolithiasis in northeast (NE) Thailand. We studied 13 patients, six with dRTA and seven with nephrolithiasis with normal or undefined acidification function. Six healthy adults living in the same area as the patients and another six from the Bangkok (BKK) area were used as controls. We measured urinary pH, ammonia, calcium, citrate, magnesium, oxalate, potassium, sodium and uric acid. GAGS were determined by an Alcian blue precipitation method and were qualitated by agarose gel electrophoresis after being isolated using 5% cetyltrimethylammonium bromide at pH 6.0. NC isoforms were isolated as previously described by Nakagawa et al. Citrate was higher in BKK controls ( p<0.04). There was a striking difference among GAGS from BKK when compared with other groups (103.85+/-10.70 vs. 23.52+/-8.11 for dRTA, 22.36+/-14.98 for kidney stone patients and 14.73+/-2.87 mg/ml in controls from the NE region, ( p<0.0001). dRTA and stone-forming patients excrete proportionally more (C+D) than (A+B) NC isoforms ( p<0.05). Also, their NC showed a 100-fold weaker binding capacity of calcium oxalate monohydrate crystals. The ratio of chondroitin sulfate/heparin sulfate in GAGS was approximately 9/1. In addition to the traditional risk factors for nephrolithiasis in dRTA, GAGS and NC might play an important role in the pathogenesis of stone formation in this population.

The role of osteopontin on calcium oxalate crystal formation

OBJECTIVE

We evaluated whether osteopontin (OPN) and other proteins with the RGD sequence as in OPN (RGD family proteins) that are present in renal tubular cells (fibronectin [FN], Tamm-Horsfall glycoprotein [THP], vitronectin [VN], and laminin [LN]) inhibit the aggregation and growth of calcium oxalate (CaOx) crystals by a novel seed crystal method using collagen granules (CG) with and without OPN adhered on the surface. We also evaluated the effect of solid phase OPN, FN and THP in which the relationship between their proteins and CaOx crystallization was reported. Moreover, the state and time-course changes in CaOx crystals adhered to CG were observed under scanning electron microscopy (SEM).

METHODS

The inhibitory activity (IA) on the aggregation and growth of CaOx crystals was measured in vitro by the conventional seed crystal method using isotopes. In this study, the following nine samples were used: OPN alone; FN alone; THP alone; VN alone; LN alone; CG alone; and CG with OPN, FN, or THP adhered on the surface (OPN/FN/THP-immobilized CG). In addition, the state and time-course changes in CaOx crystals adhered to CG were evaluated by SEM.

RESULTS

Using the conventional seed crystal method, the following values of IA were obtained: 91.7% (37.5 micro g/ml) for OPN, 5.0% (100 micro g/ml) for FN, 2.0% (100 micro g/ml) for THP, 3.0% (100 micro g/ml) for VN, and 1.0% (100 micro g/ml) for LN. However, the value of IA obtained by our seed crystal method using CG was 92.1% (180cm(2)/5ml PBS) when CG alone was used. Although the value of IA was decreased by 33.6% when OPN-immobilized CG was used, it did not significantly change when FN/THP-immobilized CG was used. When CG alone was used, the evaluation of CaOx crystallization by SEM demonstrated mild adherence and aggregation of CaOx crystal suspension (seed crystals) on the CG surface, although newly formed crystals only slightly adhered to the CG surface. When OPN-immobilized CG was used, marked adherence and aggregation of seed crystals were observed, in addition to the relatively increased adherence of newly formed crystals. When FN/THP-immobilized CG was used, newly formed crystals only slightly adhered to the CG surface, although the degree of seed crystal adherence and aggregation did not significantly change.

CONCLUSIONS

These findings suggest that the immobilization of OPN to the CG surface enhances the adherence and aggregation of seed crystals, as well as enhancing the adherence of newly formed crystals, resulting in decreased IA of CG (overall promotion of crystal deposition). Therefore, the results of this study clarified that OPN enhances the formation and aggregation of CaOx crystals in this experimental system.

Molecular cloning and characterization of a novel carboxylesterase-like protein that is physiologically present at high concentrations in the urine of domestic cats (Felis catus)

Normal mammals generally excrete only small amounts of protein in the urine, thus avoiding major leakage of proteins from the body. Proteinuria is the most commonly recognized abnormality in renal disease. However, healthy domestic cats ( Felis catus ) excrete proteins at high concentrations (about 0.5 mg/ml) in their urine. We investigated the possible cause of proteinuria in healthy cats, and discovered a 70 kDa glycoprotein, which was excreted as a major urinary protein in cat urine, irrespective of gender. To elucidate the biochemical functions and the excretion mechanism of this protein, we cloned the cDNA for this protein from a cat kidney cDNA library. The deduced amino acid sequence shared 47% identity with the rat liver carboxylesterase (EC 3.1.1.1), and both the serine hydrolase active site and the carboxylesterase-specific sequence were conserved. Therefore we named this protein cauxin (carboxylesterase-like urinary excreted protein). In contrast to the mammalian carboxylesterases, most of which are localized within the cells of various organs, cauxin was expressed specifically in the epithelial cells of the distal tubules, and was secreted efficiently into the urine, probably because it lacked the endoplasmic reticulum retention sequence (HDEL). Based on our finding that cauxin is not expressed in the immature cat kidney, we conclude that cauxin is involved in physiological functions that are specific for mature cats. Recently, cauxin-like cDNAs were found from human brain and teratocarcinoma cells. These data suggest that cauxin and cauxin-like human proteins are categorized as a novel group of carboxylesterase multigene family.

Urinary analysis of nephrolithiasis markers

Renal stone disease is an ancient and common affliction, common in industrialised nations. The causes and incidence of nephrolithiasis are presented. Afterwards, the promoters and inhibitors of renal stone formation analysis in urine are described including enzymatic methods, chromatography, capillary electrophoresis and other techniques. Aspects such as sample collection and storage are also included. The review article includes referenced tables that provide summaries of methodology for the analysis of nephrolithiasis related compounds.

Polarized calcium and calmodulin signaling in secretory epithelia

This review examines polarized calcium and calmodulin signaling in exocrine epithelial cells. The calcium ion is a simple, evolutionarily ancient, and universal second messenger. In exocrine epithelial cells, it regulates essential functions such as exocytosis, fluid secretion, and gene expression. Exocrine cells are structurally polarized, with the apical region usually dedicated to secretion. Recent advances in technology, in particular the development of videoimaging and confocal microscopy, have led to the discovery of polarized, subcellular calcium signals in these cell types. The properties of a rich variety of local and global calcium signals have now been described in secretory epithelial cells. Secretagogues stimulate apical-to-basal waves of calcium in many exocrine cell types, but there are some interesting exceptions to this rule. The shapes of intracellular calcium signals are determined by the distribution of calcium-releasing channels and mechanisms that limit calcium elevation. Polarized distribution of calcium-handling mechanisms also leads to transcellular calcium transport in exocrine epithelial cells. This transport can deliver considerable amounts of calcium into secreted fluids. Multicellular polarized calcium signals can coordinate the activity of many individual cells in epithelial secretory tissue. Certain particularly sensitive cells serve as pacemakers for initiation of intercellular calcium waves. Many calcium signaling pathways involve activation of calmodulin. This ubiquitous protein regulates secretion in exocrine cells and also activates interesting feedback interactions with calcium channels and transporters. Very recently it became possible to directly study polarized calcium-calmodulin reactions and to visualize the process of hormone-induced redistribution of calmodulin in live cells. The structural and functional polarity of secretory epithelia alongside the polarity of its calcium and calmodulin signaling present an interesting lesson in tissue organization.

Reduced crystallization inhibition by urine from women with nephrolithiasis

BACKGROUND

Human urine is known to inhibit growth, aggregation, nucleation, and cell adhesion of calcium oxalate monohydrate (COM) crystals, the main solid phase of human kidney stones. This study tested the hypothesis that low levels of inhibition are present in women with calcium oxalate stones and, therefore, could promote stone production.

METHODS

In 17 stone-forming women and 17 normal women matched in age within five years, inhibition by dialyzed urine proteins of COM growth and aggregation was examined, as well as whole urine upper limits of metastability (ULM) for COM and calcium phosphate (CaP) in relation to the corresponding supersaturation (SS).

RESULTS

Compared to normals, patient urine showed a reduced ULM in relation to SS. In contrast to men, there was no difference in growth inhibition.

CONCLUSIONS

Reduced CaP and CaOx ULM values in relation to SS are a characteristic of female stone formers. This defect could promote stones by facilitating crystal nucleation. Abnormal inhibition may well be a very important cause of human nephrolithiasis.

Phosphorylated osteopontin peptides suppress crystallization by inhibiting the growth of calcium oxalate crystals

BACKGROUND

Osteopontin isolated from human urine [uropontin (uOPN)] is a potent inhibitor of calcium oxalate (CaOx) monohydrate (COM) crystallization. However, specific structural features responsible for its effects on CaOx crystallization were not previously known. The present studies were designed to define molecular features responsible for interactions of uOPN with COM crystals and the inhibition of crystallization.

METHODS

Peptides and phosphopeptides with sequences corresponding to potential crystal binding domains within the protein sequence of osteopontin were synthesized. Then the effects of these peptides on COM crystal growth and crystal aggregation were investigated and their secondary structures analyzed.

RESULTS

Growth of COM crystals was inhibited by approximately 50% at 1000 nmol/L concentrations by the two unmodified peptides with the closest clustering of aspartic acid residues. Growth was not inhibited by the other two unmodified peptides, with aspartic residues more evenly distributed within their sequences. Phosphorylation markedly increased inhibition of COM crystal growth, so that each of the four phosphorylated peptides inhibited growth by at least 50% at concentrations of < or =200 nmol/L. Phosphorylation of these peptides did not cause changes in secondary structure that would favor interaction with COM crystal surfaces.

CONCLUSIONS

These studies of synthetic peptides identify molecular features within the osteopontin molecule that contribute to the inhibition of one aspect of COM crystallization. The inhibition of crystal growth induced by phosphorylation appears to result from altered local patterns of charge density, since conformational changes favoring interaction with crystals were not caused by phosphorylation.

Cholesterol crystal binding of biliary immuno-globulin A: visualization by fluorescence light microscopy

AIM: To assess potential contributions of biliary IgA for crystal agglomeration into gallstones, we visualized cholesterol crystal binding of biliary IgA.

METHODS: Crystal binding biliary proteins were extracted from human gallbladder bile using lectin affinity chromatography. Biliary IgA was isolated from the bound protein fraction by immunoaffinity chromatography. Pure cholesterol monohydrate crystals were incubated with biliary IgA and fluoresceine isothiocyanate (FITC)conjugated anti IgA at 37 °C. Samples were examined under polarizing and fluorescence light microscopy with digital image processing.

RESULTS: Binding of biliary IgA to cholesterol monohydrate crystals could be visualized with FITC conjugated anti IgA antibodies. Peak fluorescence occurred at crystal edges and dislocations. Controls without biliary IgA or with biliary IgG showed no significant fluorescence.

CONCLUSION: Fluorescence light microscopy provided evidence for cholesterol crystal binding of biliary IgA. Cholesterol crystal binding proteins like IgA might be important mediators of crystal agglomeration and growth of cholesterol gallstones by modifying the evolving crystal structures in vivo.

Reduced crystallization inhibition by urine from men with nephrolithiasis

BACKGROUND

Human urine is known to inhibit growth, aggregation, nucleation, and cell adhesion of calcium oxalate monohydrate (COM) crystals, the main solid phase of human kidney stones. This study tests the hypothesis that low levels of inhibition are present in men with calcium oxalate stones and could therefore promote stone production.

METHODS

In 17 stone-forming men and 17 normal men that were matched in age to within five years, we studied the inhibition by dialyzed urine proteins of COM growth, aggregation, and binding to cultured BSC-1 renal cells, as well as whole urine upper limits of metastability (ULM) for COM and calcium phosphate (CaP) in relationship to the corresponding supersaturation (SS).

RESULTS

Compared with normals, patient urine showed reduced COM growth inhibition and reduced ULM in relationship to SS. When individual defects were considered, 15 of the 17 patients were abnormal in one or more inhibition measurements. ULM and growth inhibition defects frequently coexisted.

CONCLUSIONS

Reduced COM growth and CaP and CaOx ULM values in relationship to SS are a characteristic of male stone formers. Both defects could promote stones by facilitating crystal nucleation and growth. Abnormal inhibition may be a very important cause of human nephrolithiasis.