Idiopathic calcium oxalate urolithiasis and endogenous oxalate production

Oxalate Flux Across the Intestine: Contributions from Membrane Transporters

Epithelial oxalate transport is fundamental to the role occupied by the gastrointestinal (GI) tract in oxalate homeostasis. The absorption of dietary oxalate, together with its secretion into the intestine, and degradation by the gut microbiota, can all influence the excretion of this nonfunctional terminal metabolite in the urine. Knowledge of the transport mechanisms is relevant to understanding the pathophysiology of hyperoxaluria, a risk factor in kidney stone formation, for which the intestine also offers a potential means of treatment. The following discussion presents an expansive review of intestinal oxalate transport. We begin with an overview of the fate of oxalate, focusing on the sources, rates, and locations of absorption and secretion along the GI tract. We then consider the mechanisms and pathways of transport across the epithelial barrier, discussing the transcellular, and paracellular components. There is an emphasis on the membrane-bound anion transporters, in particular, those belonging to the large multifunctional Slc26 gene family, many of which are expressed throughout the GI tract, and we summarize what is currently known about their participation in oxalate transport. In the final section, we examine the physiological stimuli proposed to be involved in regulating some of these pathways, encompassing intestinal adaptations in response to chronic kidney disease, metabolic acid-base disorders, obesity, and following gastric bypass surgery. There is also an update on research into the probiotic, Oxalobacter formigenes, and the basis of its unique interaction with the gut epithelium. © 2021 American Physiological Society. Compr Physiol 11:1-41, 2021.

Combined kidney and intestinal transplantation in patients with enteric hyperoxaluria secondary to short bowel syndrome

Kidney transplantation is the treatment of choice for end-stage renal disease whereas indications for intestinal transplantation are currently restricted to patients with irreversible small bowel failure and severe complications of total parenteral nutrition (mostly shortage and infection of venous accesses, major electrolyte disturbances and liver failure). Enteric hyperoxaluria is secondary to certain intestinal diseases like intestinal resections, chronic inflammatory bowel disease and other malabsorption syndromes and can lead to end-stage renal disease requiring kidney transplantation. We report two patients suffering from renal failure due to enteric hyperoxaluria (secondary to extensive intestinal resection) in whom we elected to replace not only the kidney but also the intestine to prevent recurrence of hyperoxaluria in the transplanted kidney.

Intestinal permeability in subjects from two different race groups with diverse stone-risk profiles

It is well established that calcium oxalate stones may be caused by colonic or ileum oxalate (Ox) hyperabsorption (secondary to intestinal dysfunction). Studies have reported that increased intestinal permeability (IP) can cause hyperabsorption of nutrients culminating in passive diffusion of Ox. In South Africa, renal stones occur in the white population (W) but are extremely rare in the black population (B). Previous studies have shown that despite B having a hyperoxalurogenic diet relative to W, urinary Ox in the former is not higher. It has been suggested that different Ox handling mechanisms in the groups are the cause of this disparity. The present study was undertaken to examine whether the IP index, a reliable and accurate measure of intestinal integrity, plays a role in this anomaly. Ten healthy males from each group ingested a dual-sugar isotonic solution containing 5 g lactulose (LA) and 2 g mannitol (MA). IP was assessed by comparing the LA:MA ratio in 5 h urine samples using high performance anion exchange chromatography coupled with pulse amperometric detection to measure the concentration of each sugar. 24 h dietary intake and urine composition were also determined. LA excretion was identical in both groups (0.03 %) while MA excretion was 8.3 % in B and 11.3 % in W. IP index was 0.004 for B and 0.003 for W. It is concluded that IP is not a contributory factor in the apparent different handling of dietary Ox in B and W South Africans. It is speculated that differences in renal transporters may play a role.

Sodium restriction as initial conservative treatment for urinary stone disease

PURPOSE

Sodium restriction is widely recommended to prevent urinary stone recurrence. However, the effect of urinary sodium excretion has not been fully evaluated. We investigated the relationship between urinary sodium, urinary metabolite excretion and the risk of recurrence in urinary stone formers.

MATERIALS AND METHODS

Selected for study were 798 stone formers with no evidence of metabolic disorders as the cause of abnormal urinary solutes. We analyzed the relationship between urinary sodium and other metabolic parameters by gender. Values were adjusted by covariates according to correlation status. Patients were divided into stone formers with hypernatriuresis or normal natriuresis (less than 220 mEq daily) and urinary parameters were compared. Kaplan-Meier analysis was done to determine the cumulative incidence of recurrent stones by urinary sodium. Patients were considered recurrence-free at a minimum followup of 3 years without incidence.

RESULTS

In the 492 men and 306 women mean ± SD age was 40.0 ± 11.4 and 45.4 ± 12.7 years, and mean body mass index was 23.9 ± 3.1 and 23.0 ± 3.0 kg/m(2), respectively. Using covariate adjusted partial correlation coefficients urinary sodium was noted to influence volume, pH, calcium, uric acid, oxalate and citrate in men, and volume, pH, calcium, uric acid and citrate in women (each p <0.05). At a median followup of 56.1 months 46 of 98 stone formers (46.9%) with normal natriuresis experienced stone recurrence vs 60 of 93 (64.5%) with hypernatriuresis. Patients with hypernatriuresis also had significantly decreased time to recurrence than those with normal natriuresis (log rank test p = 0.043).

CONCLUSIONS

Results show that urinary sodium is an important determinant of other stone forming parameters and of the risk of recurrent stones. These findings suggest that a sodium restricted diet should be the initial step when treating stone formers.

Diet to reduce mild hyperoxaluria in patients with idiopathic calcium oxalate stone formation: a pilot study

OBJECTIVES

To assess whether a normal-calcium, low-animal protein, low-salt diet is effective in reducing hyperoxaluria in idiopathic calcium oxalate nephrolithiasis compared with a traditional low-oxalate diet, routinely recommended by clinicians

METHODS

We treated 56 patients with idiopathic calcium oxalate stone formation who presented with mild hyperoxaluria (>40 mg/d) while consuming a free diet with a normal-calcium, low-animal protein, low-salt diet for a 3-month period. We compared the results obtained with this diet with those of a historical control group of 20 hyperoxaluric patients treated in the traditional way with a low-oxalate diet

RESULTS

After 3 months of therapy, the mean oxaluria level had decreased from 50.2 to 35.5 mg/d with the normal-calcium, low-animal protein, low-salt diet and from 45.9 to 40.2 mg/d with the traditional diet (adjusted difference between post-treatment mean value -7.3 mg/d, 95% confidence interval -12.3 to -2.2, P = .005)

CONCLUSIONS

The results suggest that a normal-calcium, low-animal protein, low-salt diet can reduce oxalate excretion in hyperoxaluric patients. This should encourage the undertaking of a randomized-control study to confer more solid evidence in support of our findings.

Monosaccharide-H2O2 reactions as a source of glycolate and their stimulation by hydroxyl radicals

An analysis of the H(2)O(2)-induced breakdown and transformation of different keto-monosaccharides at physiological concentrations reveals that glycolate and other short-chained carbohydrates and organic acids are produced. Depletion of monosaccharides and glycolate synthesis occurs at increased rates as the length of the carbohydrate chain is decreased, and is significantly increased in the presence of trace amounts of Fe(2+) ions (10 microM). Rates of monosaccharide depletion (initial concentration of 3 mM) observed were up to 1.55 mmol h(-1) in the case of fructose, and 2.59 mmol h(-1) in the case of dihydroxyacetone, depending upon pH, H(2)O(2) concentration, temperature and the presence or absence of catalytic amounts of Fe(2+). Glycolate was produced by dihydroxyacetone cleavage at rates up to 0.45 mmol h(-1) in the absence, and up to 1.88 mmol h(-1) in the presence of Fe(2+) ions (pH 8). Besides glycolate, other sugars (ribose, glyceraldehyde, glucose), glucitol (sorbitol) and organic acids (formic and 2-oxogluconic acid) were produced in such H(2)O(2)-induced reactions with fructose or dihydroxyacetone. EPR measurements demonstrated the participation of the OH radical, especially at higher pH. Presence of metal ions at higher pH values, resulting in increased glycolate synthesis, was accompanied by enhanced hydroxyl radical generation. Observed changes in intensity of DEPMPO-OH signals recorded from dihydroxyacetone and fructose reactions demonstrate a strong correlation with changes in glycolate yield, suggesting that OH radical formation enhances glycolate synthesis. The results presented suggest that different mechanisms are responsible for the cleavage or other reactions (isomerisation, auto- or free-radical-mediated oxidation) of keto-monosaccharides depending of experimental conditions.

Conjugated bile acid replacement therapy reduces urinary oxalate excretion in short bowel syndrome

BACKGROUND

Patients with short bowel syndrome (SBS) have steatorrhea, in part because of bile acid malabsorption that causes decreased bile acid secretion into the duodenum and consequent fat maldigestion. In SBS patients with colon in continuity, luminal calcium forms calcium fatty acid soaps rather than precipitating as insoluble calcium oxalate. Soluble oxalate is hyperabsorbed by the colon leading to hyperoxaluria and an increased risk for renal calcium oxalate stones and deposits. The authors hypothesized that oral ingestion of conjugated bile acids would increase fat absorption and thereby decrease calcium fatty acid soap formation and oxalate hyperabsorption.

METHODS

The effect of conjugated bile acid replacement therapy (9 g/d) on fecal fat excretion and urine oxalate excretion was measured in an appropriate patient, utilizing the metabolic balance technique. The effects of chronic bile acid replacement therapy on oxalate excretion and nutritional status also were measured in a 3-month outpatient study.

RESULTS

Natural conjugated bile acid replacement therapy reduced fecal fat excretion from 119 to 79 g/d (Delta40 g/d), and urinary oxalate excretion from 87 to 64 mg/d (966 to 710 micromol/d; Delta23 mg/d). Cholylsarcosine, a synthetic conjugated bile acid, had similar but less powerful effects. During a 3-month outpatient trial of natural conjugated bile acids (9 g/d), urine oxalate decreased to normal levels (27 mg/d) in association with weight gain, decreased hunger, and decreased hyperphagia.

CONCLUSION

Conjugated bile acid replacement therapy reduced fecal fat excretion, reduced urinary oxalate excretion, and improved nutritional status in a patient with SBS with colon in continuity, hyperoxaluria, and oxalate nephrolithiasis.

Comparison of urine composition of healthy Labrador retrievers and miniature schnauzers

OBJECTIVE

To compare urine composition in Labrador Retrievers (LR) and Miniature Schnauzers (MS) fed the same dog food.

ANIMALS

8 healthy LR (mean [+/- SD] age, 3.1+/-1.7 years) and 8 healthy MS (mean age, 3.7+/-1.3 years).

PROCEDURE

A nutritionally complete dry dog food was fed to the dogs for 24 days. Urinary pH, volume, specific gravity, frequency of urination, and urinary concentrations of 12 analytes were measured for each dog; urinary relative supersaturation (RSS) with calcium oxalate and brushite (calcium hydrogen phosphate dihydrate) were calculated from these values.

RESULTS

MS urinated significantly less often and had a lower urine volume (ml/kg of body weight per d) and a significantly higher urine pH, compared with LR. Urinary calcium concentration and brushite RSS were significantly higher in the urine of MS. As a result of a high calorie requirement, primarily as a result of high surface area to volume ratio, MS had significantly higher intake (per kg body weight) of dietary minerals, compared with LR.

CONCLUSIONS AND CLINICAL RELEVANCE

Differences in urine composition exist between breeds fed the same diet, some of which, including lower urine volume, higher calcium concentration, and higher brushite RSS, may contribute to the high prevalence of calcium oxalate uroliths observed in MS. Differences between breeds should be considered when evaluating strategies for controlling calcium oxalate stone formation.

Extraction of glyceric and glycolic acids from urine with tetrahydrofuran: utility in detection of primary hyperoxaluria

Primary hyperoxaluria (PH) is an autosomal recessive metabolic abnormality characterized by excessive oxalate excretion leading to nephrocalcinosis and progressive renal dysfunction. Type I primary hyperoxaluria (PH I) results from a deficiency of alanine:glyoxylate aminotransferase, whereas type II disease has been traced to a deficiency of d-glycerate dehydrogenase. The two syndromes are often distinguished on the basis of organic acids that are coexcreted with oxalate: glycolate and l-glycerate in type I and type II disease, respectively. Routine organic acid analysis with diethyl ether extraction followed by gas chromatographic analysis failed to detect normal and increased concentrations of these diagnostic metabolites. Subsequent extraction of urine with tetrahydrofuran (THF), however, extracted 75% of added glycerate, 42% of added glycolate, and 75% of added ethylphosphonic acid (internal calibrator). THF extraction was analytically sensitive enough to allow determination of normal excretion of glycolate (14–72 μg/mg creatinine) and glycerate (0–5 years, 12–177 μg/mg creatinine and &gt;5 years, 19–115 μg/mg creatinine). Four of five patients with PH I and both patients with type II disease were correctly identified. Thus, THF extraction is a convenient adjunct to routine organic acid analysis and facilitates the detection of PH.