History Of Nephrolithiasis Research Articles

Chronic Kidney Disease in the U.S. Hemophilia Population: A Cohort Study

Chronic Kidney Disease in the U.S. Hemophilia Population: A Cohort Study

Young Male With Penile Pain

A 27-year-old man with a history of nephrolithiasis presented to the emergency department with dysuria and penile pain. He reported a foreign body sensation and pain at the distal tip of his penis. One week prior, he had experienced transient left-sided flank pain. The patient also endorsed a small amount of hematuria and a weakened urinary stream. Given these symptoms, a bedside ultrasound was performed (Figure 1).

Safety and Tolerability of Vitamin D Supplementation in the Vitamin D and Type 2 Diabetes (D2d) Study – A Randomized Trial in Persons With Prediabetes

ObjectivesThe routine use of vitamin D supplements has increased substantially in the United States. However, the safety and tolerability of long-term use of high-dose vitamin D are unknown. We assessed the safety and tolerability of vitamin D3 at a dose of 4000 IU daily in the vitamin D and type 2 diabetes (D2d) trial. MethodsPersons with overweight/obesity and prediabetes without a recent history of nephrolithiasis, hypercalcemia, hypercalciuria, or other conditions potentially associated with vitamin D use, were randomized to either daily 4000 IU of vitamin D3 or placebo. Participants were allowed to take vitamin D up to 1000 IU/day and calcium up to 600 mg/day, in addition to study medication. Incident adverse events (AE), defined as any untoward or unfavorable medical occurrence, were ascertained in both groups at in-person visits and interim phone or email encounters four times a year. Serious AEs (SAE) were defined as those AEs that resulted in death, new or prolonged hospitalization, persistent or significant disability, or congenital anomaly or birth defect, or were life threatening or represented another significant hazard. ResultsA total of 8,304 AEs occurred during three years of follow-up. AEs were less frequent in the vitamin D group compared to placebo [4039 (116.1 events per 100 person-years) vs. 4265 (123.8 events per 100 person-years) (Incidence Rate Ratio [IRR] = 0.94; 95% Confidence Interval (CI) 0.90, 0.98)]. The overall frequency of protocol-specified AEs of interest was low, including nephrolithiasis, hypercalcemia, hypercalciuria, and low estimated glomerular filtration rate (eGFR) with no significant between-group differences. There were also no significant differences between the vitamin D and placebo groups in SAEs (IRR = 0.95; 95% CI 0.81, 1.13). ConclusionsVitamin D3 supplementation at 4,000 IU per day was safe and well-tolerated and did not increase risk of AEs or SAEs, including those typically associated with vitamin D excess such as hypercalciuria or nephrolithiasis. Funding SourcesNational Institute of Diabetes and Digestive and Kidney Diseases, Office of Dietary Supplements of the National Institutes of Health, the American Diabetes Association.

MO048PATHOGENIC VARIANTS IN CHLORIDE VOLTAGE-GATED CHANNEL 5 (CLCN5), ASSOCIATED WITH DENT DISEASE TYPE 1, SHOULD BE CONSIDERED IN END-STAGE KIDNEY DISEASE OF UNKNOWN AETIOLOGY

Abstract Background and Aims Hemizygous variants in chloride voltage-gated channel 5 (CLCN5) on chromosome Xp11.22 cause Dent disease type 1, characterised by low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis, nephrolithiasis, and progressive renal failure. We describe a truncating pathogenic variant in two brothers presenting with end-stage kidney disease (ESKD) and no evidence of nephrolithiasis or nephrocalcinosis. Method Two white British brothers presented to a different regional centre over 20 years ago with ESKD of unknown aetiology. The UK 100,000 Genomes Project provided a unique opportunity to make a molecular diagnosis using whole-genome sequencing linked to clinical records. Results The older brother presented with ESKD aged 23 with bilateral small kidneys and no evidence of nephrolithiasis or nephrocalcinosis on ultrasound. He had various musculoskeletal pains, 'cutaneous ectopic calcification' and secondary hyperparathyroidism, all of which improved post parathyroidectomy. Investigation of his 17-year-old brother for consideration of kidney transplant donation revealed progressive chronic kidney disease (CKD), microscopic haematuria, proteinuria (3g/24hours) and hypokalaemia. There was no nephrocalcinosis or renal calculi on ultrasound or cystoscopy. Renal biopsy showed tubulointerstitial changes with patchy fibrosis and marked chronic inflammatory cell infiltrates. He had a history of enuresis, polydipsia, delayed bone age and general developmental delay. ESKD by the age of 22 was complicated by hypertension and hyperparathyroidism requiring parathyroidectomy. Right knee pain with 'unusual osteochondral abnormality' on MRI resulted in a supracondylar femoral osteotomy. Early serum and urine biochemistry results were not available. A hemizygous nonsense variant p.Arg417Ter in CLCN5 was identified by whole-genome sequencing via the 100,000 Genomes Project. Sanger sequencing at the Wessex Regional Genetics Laboratory confirmed this. This variant was predicted to be protein-truncating, was absent in the genome aggregation database (gnomAD) and equivalent to a variant associated with Dent disease in other patients therefore classified as a class 5 pathogenic variant according to ACMG guidelines. Three male children with Dent disease have previously been reported with the pathogenic variant p.Arg347Ter. A seven and a twelve year old from two different families in Japan had microscopic haematuria, proteinuria, elevated β2-microglobulin and normal renal function. The twelve-year-old had mild hypercalciuria, but neither had a history of nephrolithiasis or nephrocalcinosis. A four-year-old Turkish boy manifested hypophosphataemia, nephrolithiasis and nephrocalcinosis. Unusually for Dent disease, he also had hypokalaemic hypochloraemic metabolic alkalosis and hyper-reninaemic hyperaldosteronism more characteristic of Bartter syndrome, but with elevated β2-microglobulin more typical of Dent disease. None of these cases had CKD but were all reported at a very young age. Conclusion Approximately 15% of patients with ESKD in Europe have an unknown aetiology. Dent disease has a variable phenotype and screening of patients for low molecular weight proteinuria such as β2-microglobulin is not routinely performed. Dent disease type 1 should be considered in patients presenting with unexplained renal failure even without typical clinical features.

Spontaneous Resolution of Primary Hyperparathyroidism Following COVID-19 Infection

Background: Spontaneous resolution of primary hyperparathyroidism (PHPT) is extremely rare, and has previously been reported exclusively in the setting of apoplexy (auto-infarction) of a large parathyroid adenoma outgrowing its blood supply. We report an unusual case of spontaneous PHPT resolution after Covid-19 infection. Clinical Case: A 38-year-old Hispanic woman was seen in clinic for evaluation of hypercalcemia first noted on routine bloodwork in 2018. She had a history of nephrolithiasis (1 episode) but no other symptom associated with hypercalcemia. She was not on medications associated with hypercalcemia, and had no family history of Ca disorder. Serum biochemistry was notable for hypercalcemia (Ca: 10.9, 10.5, and 10.8 mg/dL, nl 8.4–10.2), normal albumin and Cr, elevated PTH (106 and 70 pg/mL, nl 15–65), with low phosphate (2.3 mg/dL, nl 2.4–4.5) and 25-OH-Vit. D (14 ng/mL, nl 20–80). 24-hr urinary studies showed elevated urine Ca (285 and 375 mg/day, nl 100–250), with urine Cr of 1.3 and 1.5 g/day, respectively. Findings of hypercalcemia, hypercalciuria, and elevated serum PTH, led to the diagnosis of PHPT. Neck ultrasound and sestamibi scan of the parathyroids with SPECT-CT did not localize any abnormal parathyroid gland. A month after PHPT diagnosis, and prior to surgical evaluation, patient presented with a 9-day history of fever, cough, and shortness of breath. She tested positive for Covid-19 infection by SARS-CoV-2 PCR on nasal swab, and was quarantined at home with symptomatic treatment. No glucocorticoids were given. Serum Ca was normal (9.5 mg/dL) at the time of Covid-19 diagnosis. All Covid-19 symptoms subsided 14 days after onset. Repeat labs 1 and 3 months after Covid-19 infection showed persistently normal serum Ca (10.0 and 9.8 mg/dL), with low then normal PTH (13 and 43 pg/mL), compatible with spontaneous resolution of PHPT. Patient denied any neck discomfort before, during, or after Covid-19 infection. Spontaneous resolution of PHPT is rare and follows apoplexy of a large parathyroid adenoma. In our patient, imaging failed to localize a large parathyroid adenoma, making it less likely that resolution of her PHPT was caused by apoplexy. Resolution of PHPT temporally coincided with Covid-19 infection, although the link between the two conditions is unclear at this time. Hypothesized mechanisms include an imbalance in the normal PTH-Ca axis caused by SARS-CoV-2 mediated release of inflammatory cytokines (e.g. interferon, previously reported to lower serum calcium), or development of antibodies against the parathyroid or CaSR. RNA and protein expression of ACE2, the SARS-CoV-2 cell receptor gene, is not detected in normal parathyroid tissue. Conclusion: To our knowledge, this is the first reported case of spontaneous resolution of PHPT after Covid-19 infection. Further studies are needed to understand the frequency of this occurrence, and the underlying mechanism.

A Case of Parathyroid Adenoma Three Decades Post Radioactive Iodine Therapy: Is It Just a Coincidence or Real Risk?

Abstract Background: External radiation to the head and neck is a known risk factor for the development of parathyroid adenoma. But the incidence is very rare in internal radiation recipients. Here we describe a case of parathyroid adenoma after 30 years of radioactive iodine therapy for Graves’ disease. Clinical Case: A 50-year-old female presented during an annual visit with progressive fatigue, polyuria, polydipsia, nocturia, muscle weakness, and some memory impairment. She had a past medical history of Graves’ disease treated with radioactive iodine therapy 30 years ago with subsequent hypothyroidism, controlled essential hypertension, asthma, and obesity BMI 32.5 kg/m2. There was no history of nephrolithiasis, fractures, pituitary tumor, or acid reflux. Family history was noted for thyroid diseases, no calcium issues or hyperparathyroidism. Neck examination did not reveal any thyromegaly or palpable nodule. Laboratory tests showed calcium 11.4 mg/dL (8.6-10.3), ionized calcium 6.1 mg/dL (4.2-5.4), parathyroid hormone 213.9 pg/mL (12-88), total vitamin D 22 ng/mL (31-100), TSH 0.47 uIU/mL (0.34-3.00), Free T4 1.1 ng/dL (0.6-1.6), creatinine 0.7 mg/dL (0.6-1.2), eGFR >60 ml/min/1.73 m2, 24-hr urine calcium 405 mg (40-350). Bone density revealed T-score -4.9 at the lumbar spine, -2.8 at the total hip, -3.1 at the femoral neck, and -2.9 at distal 1/3 radius. Neck ultrasound showed atrophy of the thyroid gland with a lobulated hypoechoic area measuring up to 1.3 x 0.9 x 0.9 cm without internal blood flow at posterior inferior to the right lobe of the thyroid gland. Parathyroid SPECT/CT scan revealed no evidence of parathyroid adenoma. The hypoechoic lesion was suspected to be a lymph node according to imaging studies. However, according to laboratory and bone density results, we suspected primary hyperparathyroidism in which the patient required surgery due to current symptoms. The patient underwent surgery with an intraoperative finding of a nodule at the superior of the right parathyroid gland. A frozen section of the nodule was sent which confirmed parathyroid adenoma. The gland, weighted 483 mg, was removed with subsequent improvement of intraoperative parathyroid hormone level from 238.5 pg/mL to 26.5 pg/mL. Follow up calcium was at 9.5 mg/dL. The patient was supplemented with calcium and vitamin D afterward. Her symptoms improved significantly. Conclusion: Hypercalcemia in a patient with prior history of radioactive iodine therapy should raise concern for parathyroid adenoma. Imaging of the parathyroid gland should be cautiously interpreted with laboratory tests as it could be a false negative. Due to patient met criteria for surgery, the surgical approach should be pursued for both diagnostic confirmation and definite treatment. Intraoperative parathyroid hormone monitoring is beneficial in equivocal imaging and in reflecting successful resection of uniglandular disease.

A Case Report of Calcium-Sensing Receptor Gene Variant and Primary Hyperparathyroidism

Introduction: Primary hyperparathyroidism (PHPT) is an endocrinopathy that results from excessive production of parathyroid hormone from one or more overactive parathyroid gland(s). An estimated 90% of PHPT cases are sporadic, and 10% are inherited, comprising familial hyperparathyroidism (FHP). In FHP syndromes, variable clinical features are partly attributed to genetic heterogeneity. While there is not a consensus whether Familial hypocalciuric hypercalcemia (FHH) is a distinct entity or a form of FHP, accurate diagnosis is critical in guiding proper decision-making. The utility of genetic testing is multi-fold: help inform most likely diagnosis, guide prognosis and management, and inform familial recurrence risk. We report a patient with early-onset hypercalcemia, post subtotal parathyroidectomy, notable family history, with a likely pathogenic variant in the calcium-sensing receptor gene, CASR. Case Presentation: A 42 yo, female with history of nephrolithiasis and hypercalcemia diagnosed in her 20’s with PHPT was referred to our endocrinology clinic. Preoperative work up showed calcium of 11.1mg/dL, albumin 4.2g/dL, PTH of 177pg/mL, creatinine 0.92mg/dL. Sestamibi showed persistent activity in the mid to inferior aspect of right thyroid lobe suspicious for parathyroid adenoma. She underwent 3 gland parathyroidectomy and pathology showed mildly hypercellular parathyroid in left superior & right superior gland, normocellular left inferior gland. PTH levels normalized post-surgery. PTH levels normalized post surgery. Genetic evaluation was done, given her early-onset hypercalcemia, multi-gland involvement, and notable family history (maternal grandfather with parathyroidectomy for hypercalcemia and mother reportedly undergoing a hyperparathyroidism workup). Invitae hyperparathyroidism genetic panel revealed a likely pathogenic variant in CASR (c.659G>A; p.R220Q). Discussion: To date, our case with PHPT is the second report of the likely pathogenic variant CASR (c.659G>A; p.R220Q), which affects a conserved extracellular domain residue, thought to be important in sensing extracellular calcium. This variant has been previously reported in another family with FHH with 5 affected relatives. The reported 29-year old proband also had recurrent pancreatitis, which resolved with subtotal parathyroidectomy, but remained hypercalcemic. Despite the marked phenotypic heterogeneity in our patient and the case with FHH in terms of clinical presentation and response to treatment with surgery; both shared a history of hyperparathyroidism and a family history of hypercalcemia, suggesting contributions from the same CASR gene variant. With limited existing data about the variable expressivity of variants in genes implicated in the pathogenesis of both FHH and FHP; our case adds value to the existing evidence that supports its possible genetic contribution to PHPT

A Unique Case of Primary Hyperparathyroidism

Background: Primary hyperparathyroidism is the most common cause of hypercalcemia. It is more commonly seen in postmenopausal women, but can develop in younger individuals. Brown Tumors are an uncommon finding that can be seen in sever hyperparathyroidism. These bone findings are most often seen in the maxilla or mandible, though can affect any bone. Bone changes are reversible after parathyroidectomy.Clinical Case: An 18 year old male with a PMH of nephrolithiasis presented with a two day history of flank pain and hematuria. Endocrinology was consulted for hypercalcemia and elevated PTH. He had a family history of nephrolithiasis in his maternal uncle and grandfather, but no known family history of hypercalcemia or thyroid cancer. He was not on any medications or supplements. His initial labs were significant for a calcium of 15.0, PTH of 644, and a Vitamin D 25 of 11.7. He had no known history of hypercalcemia. He was treated with aggressive hydration, 4mg of zometa, 30mg of sensipar and two doses of 200mg calcitonin, with improvement in his calcium levels. Imaging of the abdomen and pelvis revealed multifocal solid-cystic lesions in the right superior pubic ramus and the distal femur, with smaller enhancing lesions in the left subtrochanteric, consistent with Brown Tumors. SpectCT was obtained and significant for a 2.1 by 1.4cm lesion in the anterior superior mediastinum. His overall presentation was consistent with primary hyperparathyroidism secondary to an ectopic parathyroid adenoma. Due to his relative young age at presentation and degree of primary hyperparathyroidism, there was concern for MEN1 or possible parathyroid carcinoma. MRI of the pituitary was obtained and showed a 4mm microadenoma in the right side of the pituitary. Prolactin, thyroid hormones, IGF-1, plasma metanephrines and calcitonin were all within normal limits. CDC73, a genetic marker for parathyroid carcinoma, was negative. Genetic work up for MEN1 was also negative. Endocrine surgery was consulted and he underwent a resection of the ectopic parathyroid adenoma.Discusion: Though most patients with primary hyperparathyroidism are asymptomatic, nephrolithiasis and Brown Tumors can be seen with more severe cases. It is important to rule out possible genetic causes for primary hyperthyroidism in patients with abnormal presentations, as it will change the overall long term management.

86. Unilateral Ovarian Agenesis: A Systematic Review of the Literature and Report of Two Cases

<h3>Background</h3> Ovarian agenesis (OA) is a rare and often incidental finding. Noncompeting embryological, vascular, and mechanical hypotheses comprise possible etiologies, though exact predisposing factors remain unknown. Here, we report two cases of unilateral OA (UOA) and results from the first systematic review. <h3>Case</h3> A 15-year-old girl with history of nephrolithiasis and pelvic pain presented for diagnostic laparoscopy due to suspected endometriosis. Three prior ultrasounds demonstrated normal-appearing ovaries with right corpus luteum cyst. Surgery revealed normal round ligaments, normal postpubertal uterus, right fallopian tube with paratubal cyst and enlarged right ovary. The left ovary, left distal fallopian tube, and left uteroovarian ligament were absent. Multiple peritoneal biopsies were positive for endometriosis. Right paratubal cyst was removed. Postoperative MRI did not identify a heterotopic left ovary. The second patient is a 30-year-old G3P1011 with a history of genital chlamydia, prior laparotomy to retrieve a foreign body, and right tubal ectopic pregnancy treated medically two years prior. She presented with severe abdominal pain and positive pregnancy test. An ultrasound demonstrated normal bilateral ovaries and a cystic right adnexal structure concerning for ectopic pregnancy. Patient elected for unilateral salpingectomy. Operative findings were significant for bleeding gestational sac extruding from the broad ligament. The left ovary and round ligaments were normal, but the right ovary, distal fallopian tube and infundibulopelvic ligament were absent. In both cases a second attending physician was consulted intraoperatively to confirm the absent ovary. <h3>Comments</h3> We conducted a systematic literature review on OA on 6/29/20 using Cochrane Library, Medline, Embase, Google Scholar, Scopus, and Web of Science databases, resulting in 66 relevant articles with 85 cases of OA. Descriptive statistics and univariate analysis were performed in SAS and Excel. The average age of diagnosis was 23.8 years. Ultrasound was the most common imaging technique (49%), and the majority of cases had laparoscopic surgery (65%). Of the cases that mentioned pre-operative imaging results, 13/51 did not mention ovarian anomalies. Abdominal/pelvic pain (27%), and infertility/subfertility (21%) were the most common presenting symptoms. UOA was the most common type of OA (96%) with both sides equally affected. Some ipsilateral fallopian tube absence was present in 81% cases. Approximately 26% of cases had concomitant uterine abnormalities, while 20% had renal abnormalities. These findings are important as they may guide workup and follow-up for females if ovarian agenesis or heterotopic ovarian location is diagnosed.

Sodium-glucose cotransporter 2 inhibitors and risk of nephrolithiasis.

Sodium-glucose cotransporter 2 inhibitors (SGLT2Is) may reduce nephrolithiasis risk by increasing urine flow. We aimed to investigate whether initiation of SGLT2I was associated with reduced nephrolithiasis risk. We conducted an active-comparator new-user cohort study using the Danish health registries in the period 11 November 2012 to 31 December 2018. Individuals aged ≥40years initiating SGLT2Is or glucagon-like peptide-1 receptor agonists (GLP1 RAs) were followed from treatment initiation until an inpatient or outpatient diagnosis of nephrolithiasis, death, emigration or end of study. New users of SGLT2Is were matched 1:1 on propensity scores to new users of GLP1 RAs. In supplementary analyses, risk of recurrent nephrolithiasis was assessed in individuals with a history of nephrolithiasis before treatment initiation. We identified 24,290 and 19,576 eligible users of SGLT2Is and GLP1 RAs, respectively. After matching, 12,325 patient pairs remained. The median age was 61years and median follow-up was 2.0years. The nephrolithiasis rate was 2.0 per 1000 person-years in SGLT2I initiators compared with 4.0 per 1000 person-years in GLP1 RA initiators, with a rate difference of -1.9 per 1000 person-years (95% CI -2.8, -1.0) and an HR of 0.51 (95% CI 0.37, 0.71). For recurrent nephrolithiasis (n = 731 patient pairs), the rate difference was -17 per 1000 person-years (95% CI -33, -1.5) and the HR was 0.68 (95% CI 0.48, 0.97). Initiation of treatment with SGLT2Is was associated with a clinically significant reduced risk of incident and recurrent nephrolithiasis.

Tired of Being Ignored: Fatigue as a Presenting Symptom in Primary Hyperparathyroidism

BackgroundFatigue is a common presenting symptom in primary hyperparathyroidism (PHPT). Although fatigue alone is not currently an indication for parathyroidectomy, it can have a significant detrimental effect on quality of life. The purpose of this study was to determine if there are underlying differences in demographic or disease characteristics in patients with PHPT who present with fatigue compared with those who do not. MethodsWe reviewed a prospective database of 2197 patients undergoing parathyroidectomy for PHPT by three endocrine surgeons from 2001 to 2019. Patients were divided into two groups based on the presence or absence of fatigue as a presenting symptom. Objective measures of disease severity were then compared between groups. ResultsA total of 1379 (63%) patients presented with fatigue. Patients presenting with fatigue were more likely to be female and to have a prior fracture, lower preoperative serum calcium (Ca), and normocalcemic PHPT. There were no statistically significant differences between groups in age, body mass index, history of nephrolithiasis, or preoperative serum parathyroid hormone levels. Patients presenting with fatigue were also more likely to have smaller parathyroid glands and multiglandular disease. No statistically significant differences were detected in postoperative serum Ca and parathyroid hormone levels, or cure or recurrence rates. ConclusionsPatients with PHPT who report fatigue as a presenting symptom present with more complex disease as manifested by a higher incidence of multiglandular disease and normocalcemic PHPT. Despite this, surgical cure is equivalent to other patients. Therefore, fatigue should be a discrete indication for parathyroidectomy in PHPT.

Living Donor Gifted Lithiasis: Long-Term Outcomes in Recipients

ObjectivesPresence of nephrolithiasis in a living donor has been at least a relative contraindication to living donor nephrectomy. The concern for stone recurrence and outcomes has been one of the reasons for reluctance to consider these medically complex donors. We evaluate long-term outcomes in recipients of kidney grafts from donors with nephrolithiasis, or history of nephrolithiasis, and provide results from our experience at Indiana University. Materials and MethodsWe retrospectively reviewed 57 donor-recipient pairs, where the allograft was received from a living donor with symptomatic calculi, or with imaging evidence of kidney stones, between 2003 and 2018. This research study was done in compliance with the ethical standards set forth in the Helsinki Congress. ResultsThe mean age of recipients was 46±19 years and 58% were male. Kidney recipients were followed for a median of 3.5 years and 59.6% of patients had follow-up imaging studies. None of the recipients had obstructing renal calculi or related infections. None of the recipients required any interventions for recurrent calculi and no stone episode lead to adverse event to the graft. Hyperoxaluria and hypercalciuria were the most common risk factors in 24-hour urine collections obtained from donors. ConclusionsOur findings from a single large center looking at kidney recipient outcomes over a long follow-up period found that gifted lithiasis is a safe procedure. Careful selection of “medically complex donors” with kidney stones based on appropriate guidelines is a key step. Further studies are needed to help develop consensus guidelines.

Beyond Prevalence: Annual Cumulative Incidence of Kidney Stones in the United States.

It is well documented that the prevalence of nephrolithiasis is increasing in adults in the United States over time. Approximately 11% of men and 7% of women have reported a lifetime history of nephrolithiasis in cross-sectional studies. However, the burden of acute management may be better assessed from annual cumulative incidence. This accounting of new stone occurrences, however, is not well described on a national scale. The Medical Expenditure Panel Survey is a set of large-scale health care utilization surveys of families, individuals, their health care providers and employers, with surveys administered every 6 months for the duration of each individual's 2-year panel. We queried the survey data of adult participants between 2005 and 2015, with analysis conducted with provided weights and strata to allow our findings to be representative of the civilian noninstitutionalized U.S. adult population. Those with diagnosed renal or ureteral calculi as noted by ICD-9 codes were included as our incident stone formers. In 2005, the mean age of stone formers was 45 years. Of stone formers 52.2% were male, 91% were White and 47.6% were in the Southern U.S. The incidence of stone occurrences was 0.6% (177/33,961 individuals, weighted to represent population of 1,923,322/296,185,002 individuals). By 2015, the mean age was 51.7 years, with 52% male, 83% White and 38.2% residing in the Southern U.S. Between 2005 and 2015, the overall incidence increased from 0.6% to 0.9% (p <0.001). Based on this large-scale, nationally representative analysis of adults in the United States, the estimated annual cumulative incidence of stone occurrence is approaching 1%. Moreover, this incidence appears to be increasing over time, rising from 0.6% in 2005 to 0.9% in 2015. These data may help to better anticipate the need for urological care for stone disease and direct resource distribution.

Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism

Parathyroidectomy provides definitive management for primary hyperparathyroidism (PHPT), reducing the risk of subsequent fracture, nephrolithiasis, and chronic kidney disease (CKD), but its use among older adults in the US is unknown. To identify patient characteristics associated with the use of parathyroidectomy for the management of PHPT in older adults. This population-based, retrospective cohort study used 100% Medicare claims from beneficiaries with an initial diagnosis of PHPT from January 1, 2006, to December 31, 2016. Patients were considered to meet consensus guideline criteria for parathyroidectomy based on diagnosis codes indicating osteoporosis, nephrolithiasis, or stage 3 CKD. Multivariable logistic regression was used to identify patient characteristics associated with parathyroidectomy. Data were analyzed from February 11, 2020, to October 8, 2020. The primary outcome was parathyroidectomy within 1 year of diagnosis. Among 210 206 beneficiaries with an incident diagnosis of PHPT (78.8% women; mean [SD] age, 75.3 [6.8] years), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Among the subset of patients who met consensus guideline criteria for operative management (n = 131 723), 38 983 (29.6%) were treated with parathyroidectomy. Patients treated operatively were younger (mean [SD] age, 73.5 [5.7] vs 76.0 [7.1] years) and more likely to be White (90.1% vs 86.0%), to be robust or prefrail (92.1% vs 85.7%), and to have fewer comorbidities (Charlson Comorbidity Index score of 0 or 1, 54.6% vs 44.1%), in addition to being more likely to live in socioeconomically disadvantaged (46.9% vs 40.3%) and rural (18.1% vs 13.6%) areas (all P < .001). On multivariable analysis, increasing age had a strong inverse association with parathyroidectomy among patients aged 76 to 85 years (unadjusted rate, 25.9%; odds ratio [OR], 0.68 [95% CI, 0.67-0.70]) and older than 85 years (unadjusted rate, 11.2%; OR, 0.27 [95% CI, 0.26-0.29]) compared with those aged 66 to 75 years (unadjusted rate, 35.6%), as did patients with moderate to severe frailty (unadjusted rate, 18.9%; OR, 0.60 [95% CI, 0.56-0.64]) compared with robust patients (unadjusted rate, 36.1%) and those with a Charlson Comorbidity Index score of 2 or greater (unadjusted rate, 25.9%; OR, 0.77 [95% CI, 0.75-0.79]) compared with a Charlson Comorbidity Index score of 0 (unadjusted rate, 37.0%). With regard to operative guidelines, a history of nephrolithiasis increased the odds of parathyroidectomy (OR, 1.43 [95% CI, 1.39-1.47]); stage 3 CKD decreased the odds of parathyroidectomy (OR, 0.71 [95% CI, 0.68-0.74]); and osteoporosis showed no association (OR, 1.01 [95% CI, 0.99-1.03]). In this cohort study, most older adults with PHPT did not receive definitive treatment with parathyroidectomy. Older age, frailty, and multimorbidity were associated with nonoperative management, and guideline recommendations had minimal effect on treatment decisions. Further research is needed to identify barriers to surgical care and develop tools to target parathyroidectomy to older adults most likely to benefit.

Bariatric Surgery in Patients with a History of Nephrolithiasis: 24-h Urine Profiles and Radiographic Changes After Roux-en-Y Gastric Bypass Versus Sleeve Gastrectomy.

To evaluate the differences in 24-h urine profiles, radiographic imaging, and stone events post-Roux-en-Y gastric bypass versus sleeve gastrectomy in patients with a history of nephrolithiasis. A retrospective review was conducted on 102 patients with a history of nephrolithiasis who then underwent bariatric surgery at our tertiary academic center. Computed tomography imaging and 24-h urine profile values were performed pre-operatively and at 1-year follow-up. A total of 60 patients underwent Roux-en-Y gastric bypass and 42 had sleeve gastrectomy. The Roux-en-Y gastric bypass group had significant increases in oxalate and decreases in citrate (p = 0.009 and 0.003, respectively), while the sleeve gastrectomy group had decreases in oxalate and stable citrate (p = 0.013 and 0.906, respectively). Roux-en-Y gastric bypass was the only significant predictor of post-operative hyperoxaluria (OR 7.1 [95% CI 2.3-21.3], p = 0.001). Radiographically, 38.3% of the Roux-en-Y gastric bypass group and 26.2% of the sleeve gastrectomy group had an increase in stone burden, and post-operative stone procedure rate was 10.0% and 7.1%, respectively. At 1-year post-bariatric surgery, patients who underwent Roux-en-Y gastric bypass had exacerbated lithogenic urinary profiles, while those in sleeve gastrectomy patients improved. Although not statistically significant, stone burden increase and stone procedure rate were higher post-Roux-en-Y gastric bypass and will likely worsen at a longer follow-up due to the group's lithogenic 24-h urine profiles. These findings support pre-bariatric counseling and urinary monitoring in patients with a history of kidney stones who undergo RYGB, with a multi-disciplinary approach between urologists and general surgeons.

S3576 Mesenteric Panniculitis: Case Report and Literature Review

INTRODUCTION: Mesenteric panniculitis, also known as sclerosing mesenteritis, belongs to a spectrum of rare diseases of the fatty (adipose) tissue of the mesentery. It is most commonly associated with abdominal surgery, autoimmune disorders and malignancy. Here we present a rare case of mesenteric panniculitis in a young woman who recently diagnosed with mesenteric panniculitis with no predisposing factors. CASE DESCRIPTION/METHODS: The patient is a 29-year-old female with a past medical history of nephrolithiasis who presented to our emergency department (ED) complaining of generalized nausea, fever, and generalized abdominal pain, which was more severe in the right flank region. Notable workup in the ED included a urinalysis with elevated white blood cell count and many bacteria present. The patient was then started on intravenous antibiotics and was admitted under impression of urinary tract infection. Upon admission a computed tomography (CT) scan of the abdomen was done which showed non-obstructing calculi in the lower pole of the right kidney. Additionally it showed lower abdominal mesenteric fat stranding consistent with mesenteric panniculitis (Figure 1, 2). These findings were most prominent in the lower abdomen and pelvis. The gastroenterology service was consulted and recommended no treatment given the patients abdominal pain being attributed to nephrolithiasis. During her hospitalization the patients abdominal pain resolved with intravenous fluid hydration and antibiotics. She was then discharged home with follow up appointments scheduled. DISCUSSION: Mesenteric panniculitis is a chronic and benign condition caused by fat degeneration and necrosis within mesentery. The exact mechanism of pathogenesis is not clear but a non-specific immune response to various stimuli has been suggested to trigger the inflammation of the adipose tissue. The disease has been associated with inflammatory conditions, autoimmune disorders, malignancies, tuberculosis and abdominal trauma or surgery. Patients can have a variety of symptoms including abdominal pain, nausea, vomiting, diarrhea, constipation, or intestinal obstruction. The main goal of treatment is the relief of symptoms by addressing inflammation. Corticosteroids are the treatment of choice, but colchicine, azathioprine, cyclophosphamide, infliximab have shown success. This case is unique as patient did not have any contributing factors such as abdominal surgeries, autoimmune disorders, family history of auto immune diseases and malignancy.Figure 1.: CT scan (axial view) showing omental fat stranding consistent with mesenteric panniculitis (blue arrow).Figure 2.: CT scan (coronal view) showing omental fat stranding consistent with mesenteric panniculitis (blue arrow).

Ectopic biomineralization in kidney stone formers compared to non-stone formers.

BackgroundKidney stone formers (SFs) are at increased risk of stroke, myocardial infarction, and atherosclerosis of the carotid and coronary arteries. These cardiovascular and urologic pathologies can result from ectopic biomineral deposition. The objectives of this study are: (I) to evaluate risk factors for ectopic biomineralization, and (II) to characterize the overall burden of ectopic minerals in known SFs compared to non-stone formers (NSFs) matched for these risk factors.MethodsPresence and quantity of biominerals at eight anatomic locations (abdominal aorta, common iliac arteries, pelvic veins, prostate or uterus, mesentery, pancreas, and spleen) were determined in a case control study by retrospective analysis of clinical non-contrast computed tomography scans obtained from 190 SFs and 190 gender- and age-matched NSFs (renal transplant donors). Predictors of biomineralization were determined using negative binomial regression. A subgroup of 140 SFs and 140 NSFs were matched for risk factors for systemic biomineralization, and mineralization was compared between these matched SFs and NSFs using ordinal logistic regression.ResultsHypertension, hyperlipidemia, diabetes mellitus, and smoking were more common amongst SFs. Risk factors for increased systemic biomineralization included history of nephrolithiasis, male gender, older age, and history of hyperlipidemia. When controlling for these comorbidities, SFs had significantly increased biomineralization systemically and at the abdominal aorta, iliac arteries, prostate, mesentery, pancreas, and spleen compared to NSFs.ConclusionsThe current study provides evidence that SFs are at increased risk of biomineralization systemically, independent of common risk factors of atherosclerosis.

Role of core body temperature in nephrolithiasis

To assess the role of core body temperature in urinary stone formation using a large clinical dataset. We retrospectively collected 14519039 individual temperature measurements from 580416 patients with medical history, laboratory values and medication history between 2013 and 2018 at a single institution. After exclusions and matching 2:1 (controls:cases) to account for confounding variables, 7104 patients with a history of urinary stones were identified. Patients with a history of urinary stones (cases) had an elevated mean (SD) oral temperature compared to matched controls, at 36.666(0.17) vs 36.659(0.20)°C (P=0.012). Logistic regression of matched samples showed that higher core body temperature was predictive of a history of nephrolithiasis (odds ratio 1.21, 95% confidence interval 1.04-1.4; P=0.015). Core body temperature was significantly higher in patients with a history of urinary stones compared to matched controls, contrary to the anticipated thermodynamic considerations leading to crystal aggregation. Given that the core body temperature is elevated, rather than decreased, thermodynamic process driving stone formation is unlikely.

Opiates prescribed for acute renal colic are associated with prolonged use.

Patients presenting with acute renal colic may be at risk of opiate abuse. We sought to analyze prescribing patterns and identify risk factors associated with prolonged opiate use during episodes of acute renal colic. Retrospective study of patients presenting with both a stone confirmed on imaging and an acute pain episode from 6/2017-2/2020. Opiate prescription data was obtained from a statewide prescribing database. Primary outcome was an opiate refill or new opiate prescription prior to resolution of the stone episode (either passage or surgery). Univariate and multivariate linear regression analysis was performed. A total of 271 patients met inclusion criteria. Mean age was 52years and 48% had a history of nephrolithiasis. 180 (66%) patients filled a new opiate prescription during their acute stone episode. Thirty-eight (14%) patients had an existing opiate prescription within 3months of their stone episode. Seventy-four (27%) patients refilled an opiate prescription prior to stone passage or surgery. Larger stone size, need for surgery, prolonged time to treatment, existing opiate prescription, new opiate prescription at presentation, and greater initial number of pills prescribed were associated with increased risk of requiring a refill prior to stone resolution. Patients prescribed new opiates for acute nephrolithiasis and those with an existing opioid prescription are likely to require refills before resolution of the stone episode. Larger stones that require surgery (not spontaneous passage) also increase the risk. Timely treatment of these patients and initial treatment with non-narcotics may reduce the risk of prolonged opiate use.

Late onset primary hyperoxaluria after kidney transplantation in a 36-year-old woman

Primary hyperoxaluria is a rare congenital autosomal recessive disorder disrupting the glyoxylate metabolism pathway in the liver. Type1 primary hyperoxaluria is caused by a deficiency in a specific liver enzyme namely, alanine glyoxylate-aminotransferase which catalyzes the conversion of glyoxylate to glycine. By the absence of this enzyme, glyoxylate is converted to oxalate and high oxalate level causes deposition of insoluble calcium oxalate crystals in different organs specifically kidneys. The disease usually manifested by recurrent nephrolithiasis and/or nephrocalcinosis leads to renal failure. This report describes an end-stage renal disease case of a 36-year-old Iranian woman without any history of nephrolithiasis who underwent kidney transplantation. She developed an early onset transplant kidney failure. The patient underwent kidney biopsy, which revealed oxalate nephropathy, accordingly the genetic study confirmed diagnosis of primary hyperoxaluria. This rare case shows how type 1 primary hyperoxaluria can develop after kidney transplantation without having any manifestation prior to transplantation