Orthophosphate therapy decreases urinary calcium excretion and serum 1,25-dihydroxyvitamin D concentrations in idiopathic hypercalciuria

Re-evaluation of phosphoric acid-phosphates - di-, tri- and polyphosphates (E 338-341, E 343, E 450-452) as food additives and the safety of proposed extension of use

The Panel on Food Additives and Flavourings added to Food (FAF) provided a scientific opinion re-evaluating the safety of phosphates (E 338-341, E 343, E 450-452) as food additives. The Panel considered that adequate exposure and toxicity data were available. Phosphates are authorised food additives in the EU in accordance with Annex II and III to Regulation (EC) No 1333/2008. Exposure to phosphates from the whole diet was estimated using mainly analytical data. The values ranged from 251 mg P/person per day in infants to 1,625 mg P/person per day for adults, and the high exposure (95th percentile) from 331 mg P/person per day in infants to 2,728 mg P/person per day for adults. Phosphate is essential for all living organisms, is absorbed at 80-90% as free orthophosphate excreted via the kidney. The Panel considered phosphates to be of low acute oral toxicity and there is no concern with respect to genotoxicity and carcinogenicity. No effects were reported in developmental toxicity studies. The Panel derived a group acceptable daily intake (ADI) for phosphates expressed as phosphorus of 40 mg/kg body weight (bw) per day and concluded that this ADI is protective for the human population. The Panel noted that in the estimated exposure scenario based on analytical data exposure estimates exceeded the proposed ADI for infants, toddlers and other children at the mean level, and for infants, toddlers, children and adolescents at the 95th percentile. The Panel also noted that phosphates exposure by food supplements exceeds the proposed ADI. The Panel concluded that the available data did not give rise to safety concerns in infants below 16 weeks of age consuming formula and food for medical purposes.

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A critical examination of data in the literature and in as yet unpublished laboratory records on the possible role of so-called inhibitors of crystallisation in preventing the formation of calcium-containing kidney stones leads to the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.

Dietary recommendations and treatment of patients with recurrent idiopathic calcium stone disease

This review describes the various dietary regimens that have been used to advise patients on how to prevent the recurrence of their calcium-containing kidney stones. The conclusion is that although there is some general advice that may be useful to many patients, it is more efficacious to screen each patient individually to identify his/her main urinary, metabolic, nutritional, environmental, and lifestyle risk factors for stone-formation and then tailor specific advice for that particular patient based on the findings from these investigations. If the patient can be motivated to adhere strictly to this conservative approach to the prophylactic management of their stone problem over a long time period, then it is possible to prevent them from forming further stones. This approach to stone management is considerably less expensive than any of the procedures currently available for stone removal or disintegration. In the UK, for each new stone episode prevented by this conservative approach to prophylaxis it is calculated to save the Health Authority concerned around £2000 for every patient treated successfully. In the long term, this accumulates to a major saving within each hospital budget if most stone patients can be prevented from forming further stones and when the savings are totalled up country-wide saves the National Exchequer considerable sums in unclaimed Sick Pay and industry a significant number of manpower days which would otherwise be lost from work. It is also of immense relief and benefit to the patients not to have to suffer the discomfort and inconvenience of further stone episodes.

Clinical review. Kidney stones 2012: pathogenesis, diagnosis, and management

CONTEXT

The pathogenetic mechanisms of kidney stone formation are complex and involve both metabolic and environmental risk factors. Over the past decade, major advances have been made in the understanding of the pathogenesis, diagnosis, and treatment of kidney stone disease.

EVIDENCE ACQUISITION AND SYNTHESIS

Both original and review articles were found via PubMed search reporting on pathophysiology, diagnosis, and management of kidney stones. These resources were integrated with the authors' knowledge of the field.

CONCLUSION

Nephrolithiasis remains a major economic and health burden worldwide. Nephrolithiasis is considered a systemic disorder associated with chronic kidney disease, bone loss and fractures, increased risk of coronary artery disease, hypertension, type 2 diabetes mellitus, and the metabolic syndrome. Further understanding of the pathophysiological link between nephrolithiasis and these systemic disorders is necessary for the development of new therapeutic options.

Evidence for a signaling axis by which intestinal phosphate rapidly modulates renal phosphate reabsorption

The mechanisms by which phosphorus homeostasis is preserved in mammals are not completely understood. We demonstrate the presence of a mechanism by which the intestine detects the presence of increased dietary phosphate and rapidly increases renal phosphate excretion. The mechanism is of physiological relevance because it maintains plasma phosphate concentrations in the normal range after ingestion of a phosphate-containing meal. When inorganic phosphate is infused into the duodenum, there is a rapid increase in the renal fractional excretion of phosphate (FE Pi). The phosphaturic effect of intestinal phosphate is specific for phosphate because administration of sodium chloride does not elicit a similar response. Phosphaturia after intestinal phosphate administration occurs in thyro-parathyroidectomized rats, demonstrating that parathyroid hormone is not essential for this effect. The increase in renal FE Pi in response to the intestinal administration of phosphate occurs without changes in plasma concentrations of phosphate (filtered load), parathyroid hormone, FGF-23, or secreted frizzled related protein-4. Denervation of the kidney does not attenuate phosphaturia elicited after intestinal phosphate administration. Phosphaturia is not elicited when phosphate is instilled in other parts of the gastrointestinal tract such as the stomach. Infusion of homogenates of the duodenal mucosa increases FE Pi, which demonstrates the presence of one or more substances within the intestinal mucosa that directly modulate renal phosphate reabsorption. Our experiments demonstrate the presence of a previously unrecognized phosphate gut-renal axis that rapidly modulates renal phosphate excretion after the intestinal administration of phosphate.

Hyperoxaluric calcium nephrolithiasis

Hyperoxaluria leads to increased calcium oxalate supersaturation and calcium oxalate stone formation. Excess oxalate can arise from endogenous overproduction as in primary hyperoxaluria or from dietary sources. In the last 15 years great strides have been made in the diagnosis and treatment of primary hyperoxaluria. However options still seem limited in treating the mild hyperoxaluria found in many stone formers. Inadequate knowledge of food oxalate content, the effect of dietary oxalate precursors on oxalate excretion, and the factors affecting handling of oxalate by the intestine prevent development of rational therapies for treatment of hyperoxaluria. Recent studies of oxalate degrading bacteria and renewed interest in the role of diet calcium in oxalate absorption may lead to better therapeutic strategies for hyperoxaluric calcium nephrolithiasis.

A medical hypothesis: phosphorus balance and prostate cancer

Over the last three decades the mortality rate for prostatic carcinoma has steadily increased. Carcinoma of prostate (CaP), the most common malignancy in men, is also the second most common cause of cancer deaths in men. However, few epidemiologic studies have been done, and there are scant clues to the etiology/pathogenesis of CaP. As treatment failures for advanced carcinoma continue to frustrate clinicians, more emphasis has recently been focused on strategies to prevent invasive CaP. Prostatic hyperplasia is a universal phenomenon in aging men. Mechanism and signals causing this growth are not understood. Thus, prostatic diseases affect men over the age of 45 and increase in frequency with age so that by the eighth decade more than 90% of men have benign prostatic hyperplasia, of which some progress to CaP. Data from several studies support that higher levels of active metabolite of vitamin D, 1,25-(OH)2-D, reduce the risk of prostatic hyperplasia and CaP. Men with high serum levels of 1,25-(OH)2-D have a reduced risk of poorly differentiated and clinically advanced CaP. Receptor for vitamin D has been reported in both normal and cancer prostate cells. 1,25-(OH)2-D inhibits proliferation and induces differentiation of normal and neoplastic cells. Hypercalcemic activity of 1,25-(OH)2-D or its analogues, however, thwart their use for therapy in humans. 1,25-(OH)2-D also has an established role in phosphorus homeostasis. Low dietary intake of phosphorus leads to an increase in serum concentration of 1,25-(OH)2-D. In addition, dietary fructose reduces plasma phosphate levels by 30 to 50% for more than 3 hr due to a rapid shift of phosphate from extracellular to intracellular compartment. Fruit intake has been shown to be associated with reduced risk of CaP, particularly the advanced type. Put together, these observations support that dietary determinants of hypophosphatemia, leading to increased plasma levels of 1,25-(OH)2-D, could reduce the risk of aging men to develop prostatic diseases, both benign prostatic hyperplasia and CaP.

Role of diet in the therapy of urolithiasis

The data reviewed in this paper indicate that there is compelling direct and indirect evidence that certain dietary modifications can limit the risk for stone formation. Fluid therapy should be a front-line approach for all stone formers, because it is safe, cheap, and effective. Restricting sodium and animal-protein consumption produces changes in the urinary environment that should benefit the majority of stone formers, including a decrease in calcium and increase in citrate excretion. Minimizing the intake of processed goods limits sodium gluttony. These dietary modifications also reduce cardiovascular risks. Indiscriminant calcium restriction should be avoided, because it could accelerate stone formation and violate skeletal integrity. Oxalate restriction should be considered for calcium oxalate stone formers, especially those with hyperoxaluria. Specific recommendations for modifying the consumption of other nutrients cannot be made at this time because of the limited available information about the resultant effects. The aforementioned goals can be achieved within the context of a nutritionally balanced diet providing adequate sources of fruits and vegetables. There is a definite need for better designed studies of the nutritional effects on stone disease. This would promote a better understanding of the interplay between the genetic and environmental components of this disorder.

Serum calcitriol and dietary protein intake in idiopathic calcium stone patients

In kidney stone patients, high protein intake and calcitriol overproduction are factors leading to hypercalciuria, but there are conflicting reports on the effects of dietary protein on calcitriol production. To investigate the relationships between serum calcitriol, dietary protein intake, and urinary calcium excretion, 33 male idiopathic calcium stone formers (aged 20-60 years), with normal renal function and on unrestricted diet, have been studied. Dietary protein intake was estimated by the protein catabolic rate determination. Abnormally elevated calcitriol levels were found in 16 patients (48.5%) who had similar levels of serum intact parathyroid hormone and phosphate, creatinine clearance, and calcium and phosphate urinary excretion, but lower protein catabolic rate (82+/-16 vs. 97+/-20 g/day, P<0.05) than the patients with normal calcitriol levels. The calcitriol to intact parathyroid hormone ratio was higher in hypercalciuric than in normocalciuric patients (2.4+/-1.1 vs. 1.6+/-0.8, P<0.05). Calcitriol was positively correlated with plasma calcium (r=0.41, P<0.01) and inversely with protein catabolic rate (r=-0.42, P<0.01). Protein catabolic rate was positively correlated with creatinine clearance (r=0.69, P<0.001) and urinary phosphate excretion (r=0.72, P<0.001). No relationship was observed between calcitriol and creatinine clearance. These results confirm the calcitriol overproduction in calcium stone disease and that the high calcitriol to intact parathyroid hormone ratio is the main feature associated with hypercalciuria. Calcitriol serum levels appear to be unrelated to creatinine clearance, whereas there is an inverse relationship with protein catabolic rate. This suggests that low rather than high dietary protein intake may favor the increase of calcitriol synthesis in male calcium stone formers with normal renal function.

Physiological effects of slow release potassium phosphate for absorptive hypercalciuria: a randomized double-blind trial

PURPOSE

We examined the physiological effects and tolerance of UroPhos-K, a slow release neutral form of potassium phosphate (155 mg. phosphate and 8 mEq. potassium per tablet) in patients with absorptive hypercalciuria.

MATERIALS AND METHODS

A total of 31 patients with absorptive hypercalciuria were studied at baseline and after 3 months of treatment with 4 tablets twice daily of UroPhos-K or placebo (identical in appearance) in a prospective randomized, placebo controlled, double-blind trial during a 4-day inpatient study with a daily constant metabolic diet containing 400 mg. calcium, 100 mEq. sodium and 800 mg. phosphate.

RESULTS

Treatment with UroPhos-K did not cause significant gastrointestinal side effects, increase fasting serum potassium or phosphorus, or reduce hemoglobin or creatinine clearance. It reduced urinary calcium excretion from 277 +/- 72 to 166 +/- 43 mg. per day (p < 0.001), associated with a reduction in serum 1,25-dihydroxyvitamin D concentration from 50 +/- 11 to 42 +/- 9 pg./ml. (p < 0.001). Indexes of intestinal calcium absorption and markers of bone turnover also decreased modestly. None of these changes was seen in the placebo group.

CONCLUSIONS

In patients with absorptive hypercalciuria UroPhos-K seems to correct hypercalciuria by a combination of reduced intestinal absorption, bone resorption and improved renal calcium reabsorption. The drug is well tolerated compared to placebo.

Physiological effects of slow release potassium phosphate for absorptive hypercalciuria: a randomized double-blind trial

PURPOSE

We examined the physiological effects and tolerance of UroPhos-K, a slow release neutral form of potassium phosphate (155 mg. phosphate and 8 mEq. potassium per tablet) in patients with absorptive hypercalciuria.

MATERIALS AND METHODS

A total of 31 patients with absorptive hypercalciuria were studied at baseline and after 3 months of treatment with 4 tablets twice daily of UroPhos-K or placebo (identical in appearance) in a prospective randomized, placebo controlled, double-blind trial during a 4-day inpatient study with a daily constant metabolic diet containing 400 mg. calcium, 100 mEq. sodium and 800 mg. phosphate.

RESULTS

Treatment with UroPhos-K did not cause significant gastrointestinal side effects, increase fasting serum potassium or phosphorus, or reduce hemoglobin or creatinine clearance. It reduced urinary calcium excretion from 277 +/- 72 to 166 +/- 43 mg. per day (p < 0.001), associated with a reduction in serum 1,25-dihydroxyvitamin D concentration from 50 +/- 11 to 42 +/- 9 pg./ml. (p < 0.001). Indexes of intestinal calcium absorption and markers of bone turnover also decreased modestly. None of these changes was seen in the placebo group.

CONCLUSIONS

In patients with absorptive hypercalciuria UroPhos-K seems to correct hypercalciuria by a combination of reduced intestinal absorption, bone resorption and improved renal calcium reabsorption. The drug is well tolerated compared to placebo.

Hyperresponsiveness of vitamin D receptor gene expression to 1,25-dihydroxyvitamin D3. A new characteristic of genetic hypercalciuric stone-forming rats

Hypercalciuria in genetic hypercalciuric stone-forming (GHS) rats is accompanied by intestinal Ca hyperabsorption with normal serum 1,25-dihydroxyvitamin D3 [1,25(OH)2D3] levels, elevation of intestinal, kidney, and bone vitamin D receptor (VDR) content, and greater 1,25(OH)2D3-induced bone resorption in vitro. To test the hypothesis that hyperresponsiveness of VDR gene expression to 1,25(OH)2D3 may mediate these observations, male GHS and wild-type Sprague- Dawley normocalciuric control rats were fed a normal Ca diet (0.6% Ca) and received a single intraperitoneal injection of either 1,25(OH)2D3 (10-200 ng/100 g body wt) or vehicle. Total RNAs were isolated from both duodenum and kidney cortex, and the VDR and calbindin mRNA levels were determined by Northern blot hybridization using specific cDNA probes. Under basal conditions, VDR mRNA levels in GHS rats were lower in duodenum and higher in kidney compared with wild-type controls. Administration of 1,25(OH)2D3 increased VDR gene expression significantly in GHS but not normocalciuric animals, in a time- and dose-dependent manner. In vivo half-life of VDR mRNA was similar in GHS and control rats in both duodenum and kidney, and was prolonged significantly (from 4-5 to > 8 h) by 1,25(OH)2D3 administration. Neither inhibition of gene transcription by actinomycin D nor inhibition of de novo protein synthesis with cycloheximide blocked the upregulation of VDR gene expression stimulated by 1,25(OH)2D3 administration. No alteration or mutation was detected in the sequence of duodenal VDR mRNA from GHS rats compared with wild-type animals. Furthermore, 1,25(OH)2D3 administration also led to an increase in duodenal and renal calbindin mRNA levels in GHS rats, whereas they were either suppressed or unchanged in wild-type animals. The results suggest that GHS rats hyperrespond to minimal doses of 1,25(OH)2D3 by an upregulation of VDR gene expression. This hyperresponsiveness of GHS rats to 1,25(OH)2D3 (a) occurs through an increase in VDR mRNA stability without involving alteration in gene transcription, de novo protein synthesis, or mRNA sequence; and (b) is likely of functional significance, and affects VDR-responsive genes in 1, 25(OH)2D3 target tissues. This unique characteristic suggests that GHS rats may be susceptible to minimal fluctuations in serum 1, 25(OH)2D3, resulting in increased VDR and VDR-responsive events, which in turn may pathologically amplify the actions of 1,25(OH)2D3 on Ca metabolism that thus contribute to the hypercalciuria and stone formation.

Sustained reduction in urinary calcium during long-term treatment with slow release neutral potassium phosphate in absorptive hypercalciuria

PURPOSE

We tested whether UroPhos-K, a new slow release neutral form of potassium phosphate (155 mg. phosphate, 8 mEq. potassium per tablet) in a dose of 4 tablets twice daily would produce a sustained hypocalciuric response and maintain bone mass in patients with absorptive hypercalciuria, a major cause of nephrolithiasis characterized by excessive intestinal calcium absorption accompanied in some patients by excessive bone loss.

MATERIALS AND METHODS

A total of 25 patients with absorptive hypercalciuria were studied in a 4-year, prospective, open trial with UroPhos-K at yearly intervals during a 4-day inpatient physiological study with a constant metabolic diet containing 400 mg. calcium, 100 mEq. sodium and 800 mg. phosphate daily.

RESULTS

Treatment with UroPhos-K caused a sustained, marked reduction in urinary calcium (264 to 181 mg. daily). Fractional 47calcium absorption decreased modestly (74.0 to 64.6%) commensurate with a reduction in serum 1,25-dihydroxyvitamin D (42 to 34 pg./ml.). Intact parathyroid hormone increased within the normal range (30 to 42 pg./ml.). Bone mineral density was stable at the lumbar spine, femoral neck and distal third of the radius.

CONCLUSIONS

UroPhos-K may provide a long-term alternative for hypercalciuric patients in whom thiazide therapy fails.

Medical therapy, calcium oxalate urolithiasis

The development of diagnostic protocols that identify specific risk factors for calcium oxalate nephrolithiasis has led to the formulation of directed medical regimens that are aimed at correcting the underlying metabolic disturbances. Initiation of these treatment programs has reduced markedly the rate of stone formation in the majority of patients who form stones. This article discusses the rationale that underlies the choice of medical therapy for the various pathophysiologic causes of calcium oxalate nephrolithiasis and the appropriate use of available medications.

Physicochemical effects of a new slow-release potassium phosphate preparation (UroPhos-K) in absorptive hypercalciuria

A new slow-release, neutral potassium phosphate salt (UroPhos-K) has been formulated in order to minimize gastrointestinal side effects and avoid sodium-induced calciuria. It was tested in a prospective randomized, double-blind trial in a group of 21 kidney stone patients with absorptive hypercalciuria type I (AH). Twelve patients allocated to the UroPhos-K group received four tablets twice daily with breakfast and an evening snack providing 1240 mg of phosphorus and 63.5 mEq of potassium daily. Nine patients assigned to the placebo group received placebo tablets of the same appearance containing excipient only. Subjects were studied during a 3-day period in the hospital while consuming a constant metabolic diet containing 400 mg Ca, 100 mEq Na, and 800 mg P per day before and after 3 months of treatment. Treatment with UroPhos-K did not cause any significant gastrointestinal side effects; nor did it raise fasting serum K or phosphorus, or reduce hemoglobin or creatinine clearance. It was associated with a rise in urinary K from 46 +/- 7 to 98 +/- 9 mEq per day and phosphorus from 744 +/- 185 to 1535 +/- 112 mg per day (p < 0.001 each). UroPhos-K treatment reduced urinary Ca from 288 +/- 63 to 171 +/- 49 mg/day (p < 0.001), without altering oxalate excretion. It reduced the urinary saturation of calcium oxalate without altering that of brushite. Moreover, by increasing urinary excretion of inhibitors (citrate and pyrophosphate), it reduced the propensity for spontaneous nucleation of brushite (increased formation product of brushite) and inhibited crystal agglomeration of calcium oxalate.(ABSTRACT TRUNCATED AT 250 WORDS)

The effects of high phosphorus intake on calcium homeostasis

Survey data confirm that the dietary pattern of many American women who are at high risk of developing osteoporosis is typically high in phosphorus and low in calcium. The imbalance between calcium and phosphorus intake may become more pronounced with continued changes in food preferences and the growing use of phosphorus-containing food additives. Recent studies in young women have shown that a high phosphorus diet moderately low in calcium results in a mild secondary hyperparathyroidism that persists over 4 weeks. Plasma levels of calcitriol did not change despite changes in PTH and serum ionized calcium. Studies on men have shown that dietary phosphorus at levels within the normal range of intakes can affect the renal production and serum concentration of calcitriol. High phosphorus intakes for ten days reduced their plasma calcitriol levels; a 70% reduction in phosphate intake significantly increased their plasma calcitriol. Thus, several lines of evidence indicate that prolonged high phosphorus intake may impair the usual homeostatic mechanisms that come into play when dietary calcium is limited. This, in turn, could impair achievement of maximal bone mass or accelerate bone loss. Although no clinical studies have linked high phosphorus intake with lower bone mass or higher rates of bone loss in humans, this relationship has been demonstrated in animal models. For example, young beagles fed high phosphorus, moderately low calcium diets showed a significant reduction in vertebral bone mass. Current dietary patterns of high phosphorus, low calcium consumption result in persistent changes in calcium regulating hormones that are not conducive to maximizing peak bone mass during growth or slowing the rate of aging bone loss. The net effect of the present dietary pattern on bone status, particularly in teenage and young adult women, needs to be determined. Optimal nutrition early in life, which may include higher calcium and lower phosphorus intakes, together with adequate exercise, may be the most cost-effective approach to the prevention of osteoporotic fractures.

Etiology and treatment of urolithiasis

Nephrolithiasis is a heterogeneous disorder, with varying chemical composition and pathophysiologic background. Although kidney stones are generally composed of calcium oxalate or calcium phosphate, they may also consist of uric acid, magnesium-ammonium phosphate, or cystine. Stones develop from a wide variety of metabolic or environmental disturbances, including varying forms of hypercalciuria, hypocitraturia, undue urinary acidity, hyperuricosuria, hyperoxaluria, infection with urease-producing organisms, and cystinuria. The cause of stone formation may be ascertained in most patients using the reliable diagnostic protocols that are available for the identification of these disturbances. Effective medical treatments, capable of correcting underlying derangements, have been formulated. They include sodium cellulose phosphate, thiazide, and orthophosphate for hypercalciuric nephrolithiasis; potassium citrate for hypocitraturic calcium nephrolithiasis; acetohydroxamic acid for infection stones; and D-penicillamine and alpha-mercaptopropionylglycine for cystinuria. Using these treatments, new stone formation can now be prevented in most patients.

Calcium metabolism

In normal individuals, 1,25-dihydroxyvitamin D (1,25-D) levels regulate calcium (Ca) absorption according to Ca intake; its synthesis is stimulated by low Ca intake, probably via increased parathyroid hormone (PTH) secretion, to increase Ca absorption, and suppressed during high intake to reduce Ca absorption. The body also adapts Ca absorption in response to renal Ca excretion, and phosphate absorption in response to phosphate intake. These adaptations may fail or be impaired in certain diseases. In disorders of overadaptation, the intestinal tract absorbs excessive amounts of Ca due to overproduction of 1,25-D, as in absorptive hypercalciuria, sarcoidosis, primary hyperparathyroidism, and tumoral calcinosis. Intestinal hyperabsorption and hypercalciuria may occur on both low- and high-Ca diets. Primary hyperparathyroidism and hypoparathyroidism are bihormonal, related to over- and underproduction, respectively, of both 1,25-D and PTH. Underadaptation disorders are typically related to low 1,25-D synthesis or resistance to this metabolite; examples include postmenopausal osteoporosis, chronic renal failure, and osteomalacia. Many of these adaptational disorders can be relieved or improved by manipulating Ca, phosphate, sodium, or protein intake or by administering exogenous 1,25-D. Overabsorption of Ca and other substances, such as oxalate, may be responsible for Ca nephrolithiasis. Hypocitraturia (which may be a complication of certain diseases or the result of unbalanced diet or excessive exercise), diets high in readily metabolizable sugars and purine-rich proteins (meat, poultry, and fish), and low fluid intake can all contribute to stone formation. Various regimens may reduce the risk of Ca nephrolithiasis.

Physiologic regulation of the serum concentration of 1,25-dihydroxyvitamin D by phosphorus in normal men

We asked this question: in normal humans, is either a normal dietary intake or normal serum concentration of phosphorus a determinant of the serum concentration of 1,25(OH)2D? In seven normal men whose dietary phosphorus was decreased from 2,300 to 625 mg/d, each intake for 8-9 d, under strictly controlled, normal metabolic conditions, we measured serum concentrations of 1,25(OH)2D daily, and concentrations of phosphorus hourly throughout a 24-h period, before and after restriction. Decreasing dietary phosphorus induced: (a) a 58% increase in serum levels of 1,25(OH)2D; (b) a 35% decrease in serum levels of phosphorus measured in the afternoon; (c) a 12% decrease in the 24-h mean serum level of phosphorus; but, (d) no decrease in morning fasting levels of phosphorus. Serum concentrations of 1,25(OH)2D varied inversely and significantly with 24-h mean concentrations of phosphorus (r = -0.77, P less than 0.001). When these data are combined with those of our prior study in which dietary phosphorus was varied over an extreme range, the relationship between serum levels of 1,25(OH)2D and 24-h mean serum levels of phosphorus is even stronger (r = -0.90, P less than 0.001). In the aggregate, the results demonstrate that in normal men, dietary phosphorus throughout a normal range and beyond, can finely regulate the renal production and serum concentration of 1,25(OH)2D, and provide evidence that this regulation is mediated by fine modulation of the serum concentration of phosphorus.

Clinical and laboratory approaches for evaluation of nephrolithiasis

A medical history and laboratory investigation of patients with recurrent stones serve as the cornerstone for preventive and therapeutic treatment. Identifiable risk factors can be discovered in 90 per cent of the patients. More sophisticated analyses of urinary supersaturation can be helpful in resistant cases.

Trichlormethiazide and oral phosphate therapy in patients with absorptive hypercalciuria

In a short-term prospective study 36 patients with absorptive hypercalciuria were initially treated with diet alone followed by either trichlormethiazide (4 mg. per day) or oral neutral phosphate (1,500 mg. of elemental phosphorus per day) for 6 weeks. Study subjects were then crossed over to the second drug for an additional 6 weeks. In response to dietary treatment urinary calcium decreased from a pre-treatment value of 346 +/- 63 mg. per 24 hours to 308 +/- 90 mg. per 24 hours. Oral phosphate therapy caused a further decrease in urinary calcium to 218 +/- 85 mg. per 24 hours, an over-all decrease of 37 per cent. Parathyroid function did not change significantly with phosphate administration but circulating levels of 1,25-dihydroxyvitamin D decreased by 22 per cent (73 +/- 12 to 57 +/- 16 pg. per ml., p less than 0.001). Pre-treatment renal phosphate threshold did not correlate with the response to oral phosphate administration. Trichlormethiazide treatment led to a 34 per cent decrease in urinary calcium with a mean value on treatment of 228 +/- 80 mg. per 24 hours. 1,25-Dihydroxyvitamin D levels decreased by 10 per cent. Pre-treatment fasting calcium excretion, parathyroid function and 1,25-dihydroxyvitamin D levels did not correlate with the response to trichlormethiazide. We conclude that both drugs by pharmacological means improve the biochemical abnormalities in absorptive hypercalciuria and should be efficacious in its treatment.

Effect of dietary protein and minerals on calcium and zinc utilization

The utilization of most minerals can be altered not only by varying the dietary levels of protein, carbohydrate, fiber, fat, and vitamins but also by varying the forms of macronutrients fed. Interactions among minerals are frequent and sometimes complex. Thus, all assessments of mineral requirements should include discussions of the effects of interactions on mineral bioavailability. Some of these interactions occur in the gut and affect the absorption of minerals. Other interactions affect the metabolism, transport and storage of minerals, and ultimately their excretion in urine or in endogenous gut secretions.

Normal and abnormal regulation of 1,25-(OH)2D synthesis

1,25-Dihydroxyvitamin D (1,25-(OH)2D) plays a crucial role in the maintenance of blood calcium and phosphorus levels and in normal skeletal mineralization. The concentration of this metabolite in the blood is, by necessity, tightly regulated. The most important stimuli for renal 1,25-(OH)2D synthesis include parathyroid hormone (PTH), its second messenger cyclic adenosine monophosphate (cAMP) and phosphate deprivation. Hypocalcemia and calcitonin, initially thought to act via stimulation of PTH release, have now been shown to directly stimulate 1-hydroxylation. Estrogens also increase 1,25-(OH)2D production, probably by upregulating renal PTH receptors. Inhibitors of the renal 25-(OH)D 1 alpha-hydroxylase include 1,25-(OH)2D itself, hypercalcemia, and phosphate loading. The PTH-vitamin D axis as modulated by the serum ionized calcium level controls adaptation to alterations in dietary calcium and sodium intake and to changes in skeletal turnover based on the level of physical activity. Although normally the renal production of 1,25-(OH)2D is tightly regulated and changes little in response to vitamin D challenge, there are certain conditions in which 1,25-(OH)2D appears to be substrate-dependent. These include hypoparathyroidism, hyperparathyroidism, vitamin D deficiency, sarcoidosis and the anephric state, conditions in which PTH is not well-modulated by alterations in serum ionized calcium or in which extrarenal synthesis of 1,25-(OH)2D occurs. In several disorders, including absorptive hypercalciuria, pseudohypoparathyroidism, hypophosphatemic rickets, and tumoral calcinosis, the regulation of the renal 1 alpha-hydroxylase appears to be altered.

Effect of calcium intake on serum levels of 25-hydroxyvitamin D3

The effects of high calcium intake on vitamin D metabolism were investigated. To the normal diet of 14 healthy men, 2 g calcium were added daily for 6-7 weeks. The mean serum concentration of 25-hydroxyvitamin D3 increased from 73 +/- 7 to 94 +/- 6 nmol l-1 (P less than 0.05, Student's unpaired t-test; P less than 0.01, paired t-test) in the subjects receiving calcium, whereas there was only a minimal increase, from 67 +/- 5 to 71 +/- 4 nmol l-1 in a control group on a normal diet. At the end of the study the difference between the test group and the controls was highly significant (P less than 0.005). The calcium loading caused a statistically significant depression of the serum levels of 1,25-dihydroxyvitamin D. The results obtained are in agreement with previous studies in rats and indicate that calcium intake is of some importance for the serum level of 25-hydroxyvitamin D3. The findings are discussed in relation to our previous finding that there is a relationship between high 25-hydroxyvitamin D3 levels and hypercalciuria in renal-stone formers.

Dietary intake of phosphorus modulates the circadian rhythm in serum concentration of phosphorus. Implications for the renal production of 1,25-dihydroxyvitamin D

We recently reported that in healthy men, changes in the production rate (PR) of 1,25-dihydroxyvitamin D [1,25-(OH)2D] accounted for the 80% increase and the 30% decrease in its serum concentration that was induced by restriction and supplementation, respectively, of dietary phosphorus. These changes in PR and serum concentration of 1,25-(OH)2D could be mediated by changes in serum concentrations of phosphorus that occur after the morning fasting period. To examine this hypothesis, we measured serum concentrations of phosphorus in blood drawn at hourly intervals for 24 h in six healthy men in whom dietary phosphorus was initially maintained at 1,500 mg/70 kg body weight per day for 9 d, then restricted to 500 mg/d (coupled with orally administered aluminum hydroxide) for 10 d, and then supplemented to 3,000 mg/d for 10 d. When dietary phosphorus was normal, the serum concentration of phosphorus exhibited the normal circadian rhythm: a rapid decrease in early morning to a nadir at 1100, followed by an increase to plateau at 1600 h and a further increase to an acrophase (peak) at 0030 h. The variation in serum levels of phosphorus can be described as the sum of sinusoidal functions with periodicities of 24 and 12 h. Phosphorus restriction for 10 d induced a 40% reduction in the 24-h mean serum level of phosphorus, abolished the early afternoon rise in its serum level (i.e., the 12-h periodic component of the time series), and delayed the acrophase by 3 h to 0330 h. Phosphorus supplementation for 10 d induced a 14% increase in the 24-h mean serum level of phosphorus but no significant change in its morning fasting level, exaggerated the early afternoon rise in serum phosphorus, and advanced the acrophase by 9 h to 1530 h. The changes in the PR of 1,25-(OH)2D induced by restriction and supplementation of dietary phosphorus varied inversely and significantly with those induced in the 24-h mean serum level of phosphorus (R = -0.88, P less than 0.001). These data demonstrate that in healthy men, dietary phosphorus is an important determinant of the serum concentration of phosphorus throughout most of the day. The data suggest that diet-induced changes in serum levels of phosphorus mediate the changes in PR and serum concentration of 1,25(OH)2D.

Noncalculi urinary tract disorders secondary to idiopathic hypercalciuria in children

Pediatricians frequently have faced one or more of an array of lower urinary tract symptoms without obvious cause. Now, with increasing recognition, many of these diagnostic enigmas have been ascribed to idiopathic hypercalciuria. This article reviews this "new" clinical syndrome, attempts to clarify pathophysiology, and selects patients for therapeutic intervention.

"Idiopathic" hypercalciuria and hereditary hypophosphatemic rickets. Two phenotypical expressions of a common genetic defect

Among 59 closely related members of one Bedouin tribe, we identified 9 who had the characteristic features of hereditary hypophosphatemic rickets with hypercalciuria (HHRH). We found "idiopathic" hypercalciuria in 21 of the 50 asymptomatic members. The biochemical abnormalities observed in these 21 subjects were qualitatively similar to those in the 9 with HHRH, but were quantitatively milder. The urinary calcium concentration was 0.43 +/- 0.14 mg per milligram of creatinine (mean +/- SD) in the patients with HHRH, 0.34 +/- 0.07 in the subjects with idiopathic hypercalciuria, and 0.14 +/- 0.05 in normal subjects from the same tribe. Tubular reabsorption of phosphorus and serum phosphorus concentrations were 3.0 and 4.3 SD units below the age-related mean, respectively, in HHRH, and 1.1 SD units below the normal mean for both variables in idiopathic hypercalciuria. Mean serum levels of 1,25-dihydroxyvitamin D (1,25-(OH)2D) were 303 pg per milliliter in HHRH and 145 pg per milliliter in idiopathic hypercalciuria (upper normal limit, 110). We conclude that the subjects with hypercalciuria and the patients with HHRH shared a hereditary renal phosphate leak that led to hypophosphatemia, elevated serum concentrations of 1,25-(OH)2D, increased intestinal calcium absorption, and hypercalciuria. The magnitude of the hypophosphatemia, which regulates 1,25-(OH)2D levels, appears to determine which subjects will have hypercalciuria alone and which will also have bone disease.

Studies on the relationship between vitamin D3 status and urinary excretion of calcium in healthy subjects: effects of increased levels of 25-hydroxyvitamin D3

The metabolic consequences of a rapid increase in vitamin D status in healthy subjects were investigated. Circulating levels of 25-hydroxyvitamin D3 were increased by 224% in 12 healthy men by giving oral vitamin D3 for 7 weeks and by 200% in 15 healthy women by UVB irradiation for 7 weeks. No statistically significant effects on the serum levels of calcium, phosphate, creatinine, urate, albumin, PTH, basal urinary excretion of calcium, fasting urinary excretion of cAMP, or urinary excretion of calcium after calcium load tests were observed with the unpaired t-test. With the paired t-test the small stimulatory effects (about 25%) on basal urinary excretion of calcium became statistically significant in both experiments. The ratio between calcium and creatinine in fasting urine was significantly elevated following UVB irradiation (from 0.11 +/- 0.02 to 0.21 +/- 0.04, p less than 0.025 unpaired t-test, p less than 0.02 paired t-test) but not after oral intake of vitamin D3. The level of 1,25-dihydroxyvitamin D in serum was not affected to a statistically significant degree by oral vitamin D3, whereas there was a slight decrease from 48 +/- 3 to 39 +/- 3 pmol/l following UVB irradiation. It is concluded that an increase in the concentration of 25-hydroxyvitamin D3 up to about 125 nmol/l has small and negligible effects on calcium homeostasis in healthy subjects. This finding is discussed in relation to our previous finding that hypercalciuric renal stone formers have elevated serum levels of 25-hydroxyvitamin D3 as compared with normocalciuric stone formers and healthy subjects.

The metabolism and mechanism of action of 1,25-dihydroxyvitamin D3

Much has been learned about the formation of the active metabolite of vitamin D3, 1,25-dihydroxyvitamin D3. Information concerning its formation and catabolism has allowed a clear understanding of factors involved in the maintenance of plasma concentrations of the hormone. The effects of 1,25-dihydroxyvitamin D3 on calcium transporting cells in the intestine are marked and well defined. The tissue (intestinal tissue) is easily isolated and manipulated and hence, this is an ideal tissue in which to examine the mechanism of divalent cation transport. The mechanism by which 1,25-dihydroxyvitamin D3 brings about this effect should help in understanding sterol hormone action.

The effect of oral phosphate administration on major indices of skeletal metabolism in normal subjects

The effect of brief periods of phosphate administration on indices of human skeletal metabolism was investigated. Thirteen subjects (8 women, 5 men; 19-36 years old) received 2 g of oral phosphate daily for 5 days. Serum phosphorus rose 26% (3.8 +/- 0.1 mg/dl to 4.8 +/- 0.1 mg/dl; p less than .01) while total calcium fell (9.3 +/- 0.1 mg/dl to 8.9 +/- 0.1 mg/dl; p less than .01). Parathyroid hormone levels increased by 50% (14.1 +/- 2.0 pg/ml to 21.5 +/- 1.7 pg/ml; p less than .05) although values remained within the normal range. A persistent phosphaturia (0.64 +/- 0.10 g/g Cr to 1.8 +/- 0.4 g/g Cr; p less than .05) and a 69% fall in urinary calcium (80.8 +/- 10.0 mg/g Cr to 24.6 +/- 6.0 mg/g Cr; p less than .001) were observed. 1,25-dihydroxyvitamin D3 and urinary hydroxyproline concentrations did not change significantly but the bone gamma-carboxyglutamic acid protein (BGP) concentration rose 41% by day 2 (9.6 +/- 1.3 mg/ml to 13.5 +/- 2.2 mg/ml; p less than .005) and remained elevated throughout the study period. These results support the possibility that brief periods of phosphate administration may be useful in the therapy of disorders associated with low bone turnover, such as osteoporosis.

High circulating levels of 25-hydroxyvitamin D3 in renal stone formers with hyperabsorptive hypercalciuria

Normocalcaemic male stone formers, 31-51 years old (n = 108) on a free diet, were divided into a hypercalciuric group (n = 47) with calcium excretion rates higher than 8.0 mmol/24 h, a normocalciuric group (n = 32) with calcium excretion rates below 6.1 mmol/24 h and an intermediate group (n = 29). There were no statistically significant differences between the hypercalciuric and the normocalciuric groups with respect to serum levels of calcium, phosphate, creatinine, urate, ALAT, albumin, PTH, 1,25-dihydroxyvitamin D or urinary excretion of cAMP. The group of patients with high calcium excretion had significantly higher serum levels of 25-hydroxyvitamin D3 (75 +/- 4 nmol/l) than the group with low calcium excretion (57 +/- 4 nmol/l) (p less than 0.002), while the group of patients with intermediate calcium excretion had 25-hydroxyvitamin D3 levels between the other two groups (69 +/- 4 nmol/l). A highly accurate method based on isotope dilution-mass spectrometry was used to assay 25-hydroxyvitamin D3. Of the patients with hypercalciuria (n = 47), seven were classified as hyperabsorbers on the basis of calcium load tests. These patients were found to have even higher serum levels of 25-hydroxyvitamin D3 (108 +/- 10 nmol/l)--significantly higher than that of the hypercalciuric patients as a whole. The above study was carried out in March 1983. In September, the group of patients with high urinary calcium excretion also had significantly higher levels of 25-hydroxyvitamin D3 than the group of patients with low calcium excretion.(ABSTRACT TRUNCATED AT 250 WORDS)

Oral intake of phosphorus can determine the serum concentration of 1,25-dihydroxyvitamin D by determining its production rate in humans

Changes in the oral intake of phosphorus could induce the reported changes in the serum concentration of 1,25-dihydroxyvitamin D (1,25-(OH)2D) by inducing changes in its production rate (PR) or metabolic clearance rate (MCR), or both. To investigate these possibilities, we employed the constant infusion equilibrium technique to measure the PR and MCR of 1,25-(OH)2D in six healthy men in whom the oral intake of phosphorus was initially maintained at 1,500 mg/70 kg body weight per d for 9 d, then restricted to 500 mg/d (coupled with oral administration of aluminum hydroxide) for 10 d, and then supplemented to 3,000 mg/d for 10 d. With phosphorus restriction, the serum concentration of 1,25-(OH)2D increased by 80% from a mean of 38 +/- 3 to 68 +/- 6 pg/ml, P less than 0.001; the PR increased from 1.8 +/- 0.2 to 3.8 +/- 0.6 micrograms/d, P less than 0.005; the MCR did not change significantly. The fasting serum concentration of phosphorus decreased from 3.5 +/- 0.2 to 2.6 +/- 0.2 mg/dl, P less than 0.01. With phosphorus supplementation, the serum concentration of 1,25-(OH)2D decreased abruptly, reaching a nadir within 2 to 4 d; after 10 d of supplementation, the mean concentration of 27 +/- 4 pg/ml was lower by 29%, P less than 0.01, than the value measured when phosphorus intake was normal. The PR decreased to 1.3 +/- 0.2 micrograms/d, P less than 0.05; the MCR did not change significantly. The fasting serum concentration of phosphorus increased significantly, but only initially. These data demonstrate that in healthy men, reductions and increases in the oral intake of phosphorus can induce rapidly occurring, large, inverse, and persisting changes in the serum concentration of 1,25-(OH)2D. Changes in the PR of 1,25-(OH)2D account entirely for the phosphorus-induced changes in serum concentration of this hormone.

Investigation and treatment of renal calculi

We have investigated and treated 176 patients who were suffering from renal calculi. The stones contained calcium in 87% of patients, predominantly urate in 11%, and rarely contained magnesium ammonium phosphate or cystine. Of the patients with calcium stones, hypercalciuria was present in 75% and was identified in 57% by the measurement of the 24-hour urinary calcium excretion, and in a further 18% by a standardization calcium "fast-and-load" test. Nine patients were found to have primary hyperparathyroidism and were treated surgically. A further 21% were suspected to have normocalcaemic hyperparathyroidism, and metabolic studies are being developed to clarify this. The treatment of hypercalciuria included a low-calcium diet, and various combinations of a thiazide diuretic, phosphate supplements and sodium cellulose phosphate. Hypercalciuria was controlled in all compliant patients, and only two developed further stones. Hyperuricosuria was rarely the sole metabolic abnormality in patients with calcium stones, though this might reflect the referral pattern of the Unit. Uric acid stones were frequently, but not invariably, associated with hyperuricosuria and acid urine, and even large uric acid calculi dissolved with a combined therapy of high fluid intake, allopurinol and an alkalinizing agent. Surgical treatment was rarely required in these patients. A stone in the renal pelvis of one patient was removed percutaneously and did not require ultrasonic fragmentation. Modern methods of investigation and treatment have greatly improved the outlook for patients with recurrent renal calculi.

Oral phosphate load unmasks underlying renal phosphate leak in symptomatic and asymptomatic members of family with idiopathic hypercalciuria

The effects of a 2 Gm oral phosphorus load in a family with idiopathic hypercalciuria (IH) consisting of 3 symptomatic (DT, CS, DS) and 2 asymptomatic (MS, PD) members were compared with 12 normal control subjects. Biochemical parameters measured included: total and ionized calcium, phosphorus, intact and carboxyl-terminal parathyroid hormone, urinary calcium, phosphorus, and sodium. Water loading had no effect on these parameters. After the phosphorus load, serum phosphorus rose 1.60 mg/dl in the control subjects but only 1.34 mg/dl in the IH family at the end of one hour. Basal tubular reabsorption of phosphate (TRP) were comparable in the control subjects and the IH family. After the phosphorus load, the TRP in the control subjects fell (average 9.2%) accompanied by a significant (P less than 0.02) rise in the carboxyl-terminal parathyroid hormone. Except for DT who had been taking hydrochlorothiazide, the TRP fell dramatically in the rest of the IH family (DS 25%, CS 12%, PD 26%, MS 50%) in the absence of any perturbations in either the intact or carboxyl-terminal parathyroid hormone. A hypocalciuric effect was observed in the IH family but not in the control subjects after phosphorus loading. The oral phosphorus challenge unmasked a parathyroid hormone independent renal phosphate leak in both symptomatic and asymptomatic members in a family with idiopathic hypercalciuria.

Development of hypercalcemic hyperparathyroidism after long-term phosphate supplementation in hypophosphatemic osteomalacia. Report of two cases

Orally administered phosphate supplements are the mainstay of therapy for hypophosphatemic osteomalacia of diverse causes and are generally believed to be free from harmful side effects. Two cases are reported, however, in which long-term therapy (14 and 10 years, respectively) resulted in hypercalcemic hyperparathyroidism associated with surgically proved adenomatous hyperplasia. This complication occurred despite concomitant treatment with pharmacologic doses of vitamin D. Thus, long-term oral phosphate therapy can produce tertiary hyperparathyroidism in susceptible patients.

Effect of dietary phosphorus on circulating concentrations of 1,25-dihydroxyvitamin D and immunoreactive parathyroid hormone in children with moderate renal insufficiency

The hyperparathyroidism characteristic of patients with moderate renal insufficiency could be caused by decreases in the plasma concentration of ionized calcium (Ca++) evoked by: (a) recurring increases in the plasma concentration of inorganic phosphorus that may be detectable only in the post-prandial period; (b) a reversible, phosphorus-mediated suppression of renal 25-hydroxyvitamin D-1 alpha-hydroxylase that decreases the plasma concentration of 1,25-dihydroxyvitamin D (1,25-(OH)2D) enough to decrease both gut absorption and bone resorption of Ca++; (c) both of these. In a group of eight children with moderate renal insufficiency, mean glomerular filtration rate (GFR) 45 +/- 4 (SE) ml/min per 1.73 M2, ages 6-17 yr, we tested these hypotheses by determining the effect of short term (5 d) restriction and supplementation of dietary intake of phosphorus on the plasma concentration of 1,25-(OH)2D, the serum concentrations of immunoreactive parathyroid hormone (iPTH) and phosphorus, and the fractional renal excretion of phosphorus ( FEPi ). When dietary phosphorus was normal, 1.2 g/d, the serum concentrations of phosphorus throughout the day were not greater than those of normal control children, and the serum concentrations of carboxyl-terminal iPTH (C-iPTH) were greater, 59 +/- 9 vs. 17 +/- 3 mu leq/ml, and unchanging; the serum concentration of intact-iPTH was also greater, 198 +/- 14 vs. 119 +/- 8 pg/ml. The plasma concentration of 1,25-(OH)2D was lower than that of age-matched controls, 27 +/- 3 vs. 36 +/- 2 pg/ml (P less than 0.01). When dietary phosphorus was restricted to 0.35 g/d, the plasma concentration of 1,25-(OH)2D increased by 60% to a mean value not different from that of normal controls, while serum concentrations of C-iPTH and intact-iPTH decreased by 25%, the latter concentration to a mean value not different from that of controls. FEPi decreased from 31 to 9%. When dietary phosphorus was supplemented to 2.4 g/d, the plasma concentration of 1,25-(OH)2D decreased 32%, while those of C-iPTH and intact-iPTH increased by 131 and 45%, respectively; FEPi increased from 27 to 53%. Plasma concentrations of 25-hydroxyvitamin D remained normal and unchanged, and GFR did not change when dietary phosphorus was manipulated. The data demonstrate that in children with moderate renal insufficiency: (a) A normal dietary intake of phosphorus in attended by a decreased circulating concentration of 1,25-(OH)2D and an increased concentration of iPTH, but not by recurring increases in the serum concentration of phosphorus at any time of the day; (b) Dietary phosphorus is, however, a major determinant of the circulating concentrations of both 1,25-(OH)2D and iPTH, which vary inversely and directly, respectively, with dietary intake of phosphorus, and increase and decrease, respectively, to normal values when phosphorus is restricted for 5 d; (c) Restriction and supplementation of dietary phosphorus induces changes in the serum concentration of iPTH that correlate strongly but inversely with those induced in the plasma concentration of 1,25-(OH)2D (r = -0.88, P < 0.001); and (d) The physiologic responsiveness of the renal tubule to changes in dietary phosphorus is to a substantial extent intact. The data provide support for the second hypothesis stated.

Evidence for disordered control of 1,25-dihydroxyvitamin D production in absorptive hypercalciuria

In previous studies, we observed increases in the circulating concentration and production rate of 1,25-dihydroxyvitamin D (1,25-(OH)2D) in a large majority of patients with the syndrome of absorptive hypercalciuria. In the present study, the hypothesis that 1,25-(OD)2D production might be relatively autonomous in this syndrome was tested by fashioning a suppression test in which patients were challenged with a short-term increase in dietary calcium intake. We found that contrary to our hypothesis, the circulating concentration of 1,25-(OH)2D was remarkably sensitive to calcium intake in 15 patients with absorptive hypercalciuria (mean decrease, from 74 to 49 pg per milliliter, P less than 0.001). When this challenge was prolonged for two weeks, however, patients with absorptive hypercalciuria had evidence of an apparent "escape" phenomenon, in which the circulating concentration of 1,25-(OH)2D rebounded toward its initial level and the renal tubular phosphate threshold fell markedly. These findings provide evidence for disordered control of renal phosphate handling and 1,25-(OH)2D production in absorptive hypercalciuria and suggest a linked rather than a cause-and-effect relation between these two abnormalities.