History Of Urolithiasis Research Articles

Nocardia prostatitis in a small intestine transplant recipient

A 37-year-old small bowel transplant recipient with a history of urolithiasis was admitted for dysuria after passing a urinary stone. His laboratory evaluation showed increased blood urea nitrogen and creatinine. Urinalysis showed increased white blood cells and positive leukocyte esterase. A computed tomography scan revealed signs of urinary tract obstruction and prostatic enlargement. He failed to respond initially to empiric antibiotic treatment with ciprofloxacin and ampicillin sulbactam while waiting for culture results. The pathogen recovered from both urine and blood culture was subsequently identified as Nocardia asteroides complex. The isolate was sensitive to ceftriaxone and sulfa but resistant to ciprofloxacin. The patient improved on ceftriaxone and trimethoprim-sulfamethoxazole and completed a 6-month course without any relapse. Nocardia prostatitis is an uncommon infection and must be treated with a long course of antibiotics guided by susceptibility testing.

Urinary Calculi

<h2>Abstract</h2> Stones in the urinary collecting system are among the most common of medical problems. In industrialized countries, the lifetime incidence is more than 10% in men and 5% in women. Stones occur when urinary chemistry results in concentrations of stone salts that exceed the limit of metastability for that salt in solution. This most often reflects excessive excretion of one or more stone constituents, deficient inhibitory activity in urine, or simply a low urine volume resulting in excessively concentrated urine. Such conditions can occur transiently. About 50% of patients who form a first stone suffer no recurrence in the subsequent 8 years. Recurrent episodes, bilateral stones and a family history of urolithiasis are predictors of a higher likelihood of recurrence, and full metabolic evaluation is warranted in such patients.

Intestinal Oxalobacter formigenes colonization in calcium oxalate stone formers and its relation to urinary oxalate.

Oxalobacter formigenes is an anaerobic commensal colonic bacterium capable of degrading oxalate through the enzyme oxalyl-CoA decarboxylase. It has been theorized that individuals who lack this bacterium have higher intestinal oxalate absorption, leading to a higher urinary oxalate concentration and an increased risk of calcium oxalate urolithiasis. We performed a prospective, controlled study to evaluate O. formigenes colonization in calcium oxalate stone formers and to correlate colonization with urinary oxalate and other standard urinary stone risk factors. Thirty-five first-time calcium oxalate stone formers were compared with 10 control subjects having no history of urolithiasis and a normal renal ultrasound scan. All subjects underwent standard metabolic testing by submitting serum and 24-hour urine specimens. In addition, all subjects submitted stool samples for culture and detection of O. formigenes by Xentr(ix) O. formigenes Monitor. Intestinal Oxalobacter was detected in only 26% of the stone formers compared with 60% of the controls (p < 0.05). Overall, the average urinary oxalate excretion by the two groups was similar (38.6 mg/day v 40.8 mg/day). Among stone formers, however, there were statistically higher urinary oxalate concentrations in O. formigenes-negative patients compared with those testing positive (41.7 mg/day v 29.4 mg/day) (p = 0.03). Furthermore, all 10 stone formers with hyperoxaluria (>44 mg/day) tested negative for O. formigenes (p < 0.05). Calcium oxalate stone formers have a low rate of colonization with O. formigenes. Among stone formers, absence of intestinal Oxalobacter correlates with higher urinary oxalate concentration and an increased risk of hyperoxaluria. Introduction of the Oxalobacter bacterium or an analog of its enzyme oxalyl-CoA decarboxylase into the intestinal tract may be a treatment for calcium oxalate stone disease.

Urinary calcium excretion in children with vesicoureteral reflux.

Renal malformations including vesico-ureteral reflux (VUR) are associated with urolithiasis. However, studies on urinary calcium excretion in children with VUR have not been reported. This study was conducted to find out whether children with VUR have a higher prevalence of hypercalciuria and whether their family members are affected by hypercalciuria and/or urolithiasis. We studied the prevalence of hypercalciuria and urolithiasis in 46 children (12 males and 34 females) with VUR and in their parents. Three out of 46 children had renal colic and nine out of 46 exhibited calyceal microlithiasis in the renal sonography. According to Stapleton's criteria, we found that 27 out of 46 children (58.6%) had hypercalciuria. These children were significantly shorter than children with normal calciuria and showed lower values of maximal urinary osmolality. We found no differences in urinary calcium excretion values related to the VUR grading, or to the presence or absence of renal scars, or to whether VUR was still unresolved or already resolved at the time of study. Seventeen out of 27 children with hypercalciuria (63%) had one or both parents affected by hypercalciuria, and there was a history of urolithiasis in six first-degree relatives and in four second-degree relatives (37%). Besides, 10 out of 19 children without hypercalciuria (52.6%) had one or both parents affected by hypercalciuria and there was a history of urolithiasis in three first-degree relatives and in three second-degree relatives (31.6%). Among the 27 children whose parents had hypercalciuria, four had both parents affected, 19 had only the mother affected and in four patients only the father was affected. Our results showed that the prevalence of hypercalciuria was greater in paediatric patients with VUR than in the general population. Urolithiasis in patients with VUR had a metabolic origin. Hypercalciuria was inherited as an autosomal dominant trait although with a higher probability to be inherited from the mother.

The Use of Ultrasonography in Evaluating Adults with Febrile Urinary Tract Infection

Background. Urinary tract infection (UTI) is a common disease. Controversy exists about the role of radiological evaluation in the patient with urinary tract infection. Materials and Methods. From 04 2001 to 12 2001, patients with febrile UTI admitted to Chang Gung Memorial Hospital, Chiayi were prospectively evaluated by ultrasonography. The inclusion criteria of febrile UTI was a body temperature of more than 38°C with a bacterial count of 103 or more per mL in a freshly voided midstream or catheterized urine. Results. A total of 94 patients were evaluated and all patients recovered. Major abnormal sonograms were present in 17 (18%) of the patients. A history of urolithiasis and a duration of fever ≥ 3 days after admission were statistically significant clinical parameters in predicting major abnormal sonogram. Although diabetes mellitus was not statistically significant in predicting major abnormal sonogram, diabetic patients had 2.5 times the likelihood of major structural abnormalities than nondiabetic patients. Conclusion. Ultrasonographic study of patients with febrile UTI should be limited only to those with a duration of fever ≥ 3 days and a history of urolithiasis. Ultrasonographic study should also be considered in febrile UTI patients with diabetes mellitus

Prevalencia y factores de riesgo en Yucatán, México, para litiasis urinaria

To measure the prevalence of urolithiasis in Yucatan, and to establish a possible association of the disease with family history and water hardness. During 1996, a survey was conducted on the population over one year of age in the State of Yucatan. Subjects were classified as having definite lithiasis (DL), probable lithiasis (PL), or no lithiasis (NL). Total hardness, calcium hardness, and magnesium hardness, were determined in drinking water samples. From a total of 5 832 questionnaires, 323 subjects (5.5%) were found to have DL, and 282 (4.8%) PL. The prevalence of lithiasis increased sharply with age, ranging from 1% in the population 18 years or younger, to 11.3% in those over 50 years. A family history of urolithiasis was positive in 44% of subjects with DL and in 34 % of those with PL, compared to 28% of those with NL (OR=2.8, 95% CI=2.2-3.4, p<0.0001, and OR=1.8, 95% CI=1.4-2.4, p<0.0001, respectively). Water hardness above 400 ppm was associated with a higher prevalence of urolithiasis (OR=1.9, 95% CI=1.21-2.94, p=0.003). The prevalence of urolithiasis in Yucatan is higher than that reported elsewhere in the scientific literature. A family history of the disease and high water hardness are risk factors that need to be investigated in future studies.

16-Year-Old Boy With Gross Hematuria

16-Year-Old Boy With Gross Hematuria

THE ASSOCIATION OF AN INCREASED URINARY CALCIUM-TO- CREATININE RATIO, AND ASYMPTOMATIC GROSS AND MICROSCOPIC HEMATURIA IN CHILDREN

The role of hypercalciuria for the evaluation of unexplained asymptomatic gross and microscopic hematuria in children remains unclear, as evidenced by conflicting reports in the literature. We study the function of hypercalciuria in these patients, and determine whether routine evaluation of urine for hypercalciuria and treatment with thiazide diuretics, based on the results of a urinary calcium-to-creatinine ratio, is necessary. We also wanted to compare the yield of a urinary calcium-to-creatinine ratio in patients with gross and microscopic hematuria subgroups. Between 1991 and 1998 we treated 96 patients with microscopic hematuria (group 1) and 46 with gross hematuria (group 2). All patients had isolated unexplained hematuria. Patients with organic and anatomical causes, including urinary tract infection and other urinary symptoms, were excluded from the study. Nephrological urine and serum analyses in patients with hematuria were otherwise normal, as were all imaging studies. Group 1 included 50 males and 46 females, with a mean age of 7.6 years (range 1 to 14), and a spot urinary calcium-to-creatinine ratio was done in 79. Group 2 included 35 males and 11 females, with a mean age of 8.5 years (range 8 months to 14 years), and a spot urinary calcium-to-creatinine ratio was done in 43. A ratio of 0.2 or greater was considered hypercalciuria. The season of presentation was noted to determine any pattern. There were no seasonal variations regarding presentation. Followup of 34 patients in group 1 and 15 group 2, with a mean followup of 10.6 months (range 1 month to 8 years), was available. A total of 28 (82.3%) patients in group 1 and 15 (71.4%) group 2 had complete resolution of hematuria. However, there were 6 patients in both groups who had persistent hematuria but remained totally asymptomatic. Hydrochlorothiazide was used in only 2 patients in group 1 and 1 group 2 due to intractable hematuria on expectant management, a markedly increased urinary calcium-to-creatinine ratio and positive family history of urolithiasis. Although we cannot establish a direct cause and effect relationship, hypercalciuria is detected in a substantial number of cases of unexplained gross and microscopic hematuria. However, based on our study we do not recommend treatment with thiazide diuretics in all patients diagnosed with hypercalciuria, as hematuria resolved in a majority with observation or expectant treatment and minor dietary modification. We reserve treatment with thiazide diuretics only for those patients with intractable hematuria, a markedly increased urine calcium-to-creatinine ratio and family history of urolithiasis

Recurrent abdominal and flank pain in children with idiopathic hypercalciuria

To evaluate the role of idiopathic hypercalciuria (IH) as a cause of recurrent abdominal pain (RAP) in children. We retrospectively reviewed the medical records of 124 children referred for various complaints who had 24-h urine calcium excretion greater than 2 mg/kg/d or random urine calcium-creatinine ratio greater than 0.18 mg/mg. Fifty-two children with various clinical complaints had RAP or flank pain. These comprised of 22 males and 30 females, 9 mo to 15.9 y of age, mean 6.7 +/- 3.5 y. A family history of urolithiasis was present in 50% of all the children. Only 6 of the 52 children with abdominal pain had renal stones. In addition to abdominal pain, 27 children had hematuria and 10 had urinary incontinence. Mild metabolic acidosis was present in three children, parathyroid hormone activity elevated in two and serum vitamin D activity was increased in nine. All children were treated with increased fluid intake and a reduction in dietary sodium and oxalate and some required treatment with thiazide and antispasmodics. Forty-five cases responded to treatment, 5 failed to improve from therapy, and 2, which were not followed up as patients, were not available. We describe 52 children with RAP or back pain due to IH and recommend that IH be considered in the differential diagnosis of RAP in childhood.

Recurrent abdominal and flank pain in children with idiopathic hypercalciuria

Objective: To evaluate the role of idiopathic hypercalciuria (IH) as a cause of recurrent abdominal pain (RAP) in children. Patients and methods: We retrospectively reviewed the medical records of 124 children referred for various complaints who had 24-h urine calcium excretion greater than 2mg/kg/d or random urine calcium-creatinine ratio greater than 0.18mg/mg. Results: Fifty-two children with various clinical complaints had RAP or flank pain. These comprised of 22 males and 30 females, 9 mo to 15.9 y of age, mean 6.7 3.5 y. A family history of urolithiasis was present in 50% of all the children. Only 6 of the 52 children with abdominal pain had renal stones. In addition to abdominal pain, 27 children had hematuria and 10 had urinary incontinence. Mild metabolic acidosis was present in three children, parathyroid hormone activity elevated in two and serum vitamin D activity was increased in nine. All children were treated with increased fluid intake and a reduction in dietary sodium and oxalate and some required treatment with thiazide and antispasmodics. Forty-five cases responded to treatment, 5 failed to improve from therapy, and 2, which were not followed up as patients, were not available. Conclusion: We describe 52 children with RAP or back pain due to IH and recommend that IH be considered in the differential diagnosis of RAP in childhood.

Asymptomatic hypercalciuria: prevalence and metabolic characteristics.

Hypercalciuria is of continuing interest as a risk factor for kidney stones in children. We screened 592 healthy Turkish children (308 boys, 284 girls, aged 3 month-16 years) for hypercalciuria by measurement of urinary calcium/creatinine (UCa/Cr) ratio in the second-morning urine samples. Hypercalciuria was noted in 17 children (2.9%), 9 of them were boy and 8 of them were girl. Oral calcium-loading test could only be done in 7 children who were diagnosed as having hypercalciuria, and it revealed absorptive hypercalciuria in 2 cases and renal hypercalciuria in no cases. The frequency of a family history of urolithiasis in asymptomatic hypercalciuric children was 50%. Median UCa/Cr ratios and urinary magnesium/creatinine (UMg/Cr) ratios were 0.11 and 0.10 and the 97th percentiles were 0.32 and 0.23 respectively. The UCa/Cr ratio in second-morning urine samples was correlated with the UMg/Cr ratio (r = 0.44) and was independent of age and sex.

Hyperuricosuria in children: clinical presentation and natural history.

Idiopathic hyperuricosuria (HU) was previously reported in only a limited number of children with hematuria. We aimed to outline the clinical presentation and natural history of HU not only in children with hematuria, but also in those with dysuria and/or recurrent abdominal/flank pain and a family history of urolithiasis. Retrospective analysis of data at diagnosis from 102 consecutive children with HU and outcome analysis of 26 of them who were followed >/=1 years (mean: 3.1) with no specific therapy. Sixty-one participants had HU and 41 had HU + hypercalciuria. Fifty-two patients had no hematuria among the presenting symptoms, more than one third had normal urinalysis at our first examination, one half had microcalculi (<3 mm in diameter) at renal sonography, and 12% had stones (4-18 mm). Thirty participants of the 39 with no hematuria at our first examination (77%) showed microcalculi or calculi at renal sonography. The patients with microcalculi were significantly older than were those without microcalculi. During the follow-up, 4 of 26 children never had hematuria and 8 had no hematuria during most of the follow-up period. Two patients who had a calculus at first visit and 3 who formed calculi 4 to 12 mm in diameter, after 1 to 3.5 years subsequently passed them in the urine. The lack of hematuria is not predictive of absence of urolithiasis. Therefore, it may be misleading to judge on the efficacy of a given therapy only based on disappearance of hematuria. HU and hypercalciuria have to be suspected in children with dysuria and those with recurrent abdominal/flank pain and familial history of urolithiasis, although they have no hematuria.

Proteus syndrome: a case report and review of the literature

Proteus syndrome is a rare hamartomatous condition comprising overgrowth of some part of the body in association with various cutaneous, neurovascular, musculoskeletal, and other organ systems. In some cases, there is a family history. The case presented is that of a 6-year-old boy with left hemihypertrophy, widespread capillary hemangiomatosis in the extremities, a pigmented nevus on the right forearm, macrosyndactyly of the second and third fingers, together with a history of urolithiasis. The literature on this rare syndrome is reviewed.

Analysis of urolithiasis in patients with gout and hyperuricemia using ultrasonography

The number of patients with gout and hyperuricemia is increasing in Japan. Urolithiasis is one of the important complications in this disease and early diagnosis of urolithiasis is necessary in disease management. Therefore, we expected to find an exact incidence of urolithiasis in Japanese gouty and hyperuricemic patients in our study. We examined 208 patients using ultrasonography (US) of the abdomen at our hospital (171 primary gout and 37 asymptomatic hyperuricemia). We examined the incidence of urolithiasis in US of the abdomen, past history and urine occult blood reaction in gouty and hyperuricemic patients. We also examined the duration of the current illness. The total number of ‘positive findings’ in US of the abdomen was 64 among 208 cases (30.8%). For these 64 with ‘positive findings’, 51.6% had ‘calcification’ or ‘stone formation’ in bilateral kidneys and 48.4% showed ‘positive findings’ before the onset of gouty arthritis. Among the 208 cases, 16.3% had a history of urolithiasis. Of the 59 cases with ‘stone formation’ among the 64 with ‘positive findings’ in US of the abdomen, 10.2% showed a positive urine occult blood reaction. The frequency of detecting a ‘positive findings’ was evidently proportional to the detection of this illness. In conclusion, the incidence of urolithiasis in gouty and hyperuricemic patients was examined by US of the abdomen. The value of this diagnostic modality was highly appreciated in this instance. The following were suggested as important approaches for the management of gouty or hyperuricemic patients: correction of the serum uric acid levels, early diagnoses of urolithiasis by US of the abdomen, proper alkalization of urine and sufficient diuresis.

Analysis of urolithiasis in patients with gout and hyperuricemia using ultrasonography

The number of patients with gout and hyperuricemia is increasing in Japan. Urolithiasis is one of the important complications in this disease and early diagnosis of urolithiasis is necessary in disease management. Therefore, we expected to find an exact incidence of urolithiasis in Japanese gouty and hyperuricemic patients in our study. We examined 208 patients using ultrasonography (US) of the abdomen at our hospital (171 primary gout and 37 asymptomatic hyperuricemia). We examined the incidence of urolithiasis in US of the abdomen, past history and urine occult blood reaction in gouty and hyperuricemic patients. We also examined the duration of the current illness. The total number of ‘positive findings’ in US of the abdomen was 64 among 208 cases (30.8%). For these 64 with ‘positive findings’, 51.6% had ‘calcification’ or ‘stone formation’ in bilateral kidneys and 48.4% showed ‘positive findings’ before the onset of gouty arthritis. Among the 208 cases, 16.3% had a history of urolithiasis. Of the 59 cases with ‘stone formation’ among the 64 with ‘positive findings’ in US of the abdomen, 10.2% showed a positive urine occult blood reaction. The frequency of detecting a ‘positive findings’ was evidently proportional to the detection of this illness. In conclusion, the incidence of urolithiasis in gouty and hyperuricemic patients was examined by US of the abdomen. The value of this diagnostic modality was highly appreciated in this instance. The following were suggested as important approaches for the management of gouty or hyperuricemic patients: correction of the serum uric acid levels, early diagnoses of urolithiasis by US of the abdomen, proper alkalization of urine and sufficient diuresis.

Renal calyceal microlithiasis: clinical presentation may precede sonographic evidence.

Calyceal microlithiasis (CM) is characterized by the sonographic finding of hyperechogenic spots less than 3 mm in diameter in renal calyces, and it may be the first step in calculus formation. From January 1992 to January 1998, we have observed 216 children with CM. The present report deals with 34 of them in whom renal sonography was negative at first observation and the diagnosis of CM was made only on repeated sonographic examinations. The presenting symptoms were recurrent abdominal pain, dysuria, and hematuria occurring alone or in combination. Half of the patients had hypercalciuria. A history of urolithiasis in at least one first- or second-degree relative was present in 85% of patients. Renal sonography was repeated after 6-22 months (mean 11) and showed unilateral CM in 16 subjects and bilateral in 18. The finding of CM may be preceded by a period of time when symptoms and/or signs are present while microcalculi are not yet detectable. Repeated ultrasound examinations may be needed not only in patients with hypercalciuria but also in those with recurrent abdominal pain, dysuria, and/or hematuria not associated with hypercalciuria.

Lithogenic risk factors in normal black volunteers, and black and white recurrent stone formers.

To compare lithogenic risk factors in normal black volunteer men (BN), male black stone formers (BSF) and male white recurrent stone formers (WSF); in addition, the differential diagnoses in the stone formers were compared to determine if the causes of renal stones differed in the two groups. The study included 22 BN, 22 consecutive BSF and 122 consecutive WSF seen over a 10-year period. Each subject was assessed by a thorough medical history, dietary analysis and a full serum and urinary biochemical evaluation. Although the WSF were significantly more overweight (P<0.001) and obese (P<0.001) than the BSF, neither group had values significantly different from those of their respective normal populations. There was no significant difference in serum levels of Ca, phosphorus, ionised Ca, calcitriol and alkaline phosphatase in BSF and WSF, but levels of parathyroid hormone tended to be (P<0.1) and calcitriol was significantly higher in BSF than WSF (P<0.03). The BSF urinary excretion levels tended to be more like that of the WSF, with the following pattern present; BN<BSF<WSF, except for citrate, where BSF< BN<WSF. No dietary or metabolic abnormality was found in 9% of BSF and 5% of WSF. Pure dietary lithogenic risk factors were present in 9% of BSF and 21% of WSF. The prevalence of metabolic risk factors was similar in the two groups but the distribution differed. Renal hypercalciuria, absorptive hypercalciuria and mild metabolic hyperoxaluria were 2.5-3 times more prevalent in the WSF. Although the urine of BSF tends to be more like that of WSF, the lithogenic risk factors present differed and were less severe. The increase in urinary calcium excretion, coupled with a lower citrate excretion, may be the most important reason for stone formation in the black population. An increased protein intake may also play a role. In this small group of BSF there was no family history of urolithiasis, supporting the view that there may be a more prominent genetic influence in WSF.

Fate of residual fragments after successful extracorporeal shock wave lithotripsy.

The aim of the present study was to investigate the reason residual fragments from upper urinary tract calculi failed to clear after successful extracorporeal shock wave lithotripsy (ESWL). Risk factors were analyzed in 161 patients with residual fragments (< or = 4 mm) that had remained for more than 3 months after ESWL. The factors examined in the present study were gender, a history of urolithiasis, the number, location and size of stones, hydronephrosis 3 months after ESWL and bacteriuria before ESWL. The mean follow-up period was 20.0 months (range 6-69 months). The overall stone-free rate was 14.3%. The stone-free rate in patients with multiple stones or hydronephrosis 3 months after ESWL was significantly lower than that in patients without these conditions (P < 0.05 and P < 0.01, respectively). The cumulative non-clearance rate in patients with hydronephrosis was significantly higher than in patients without this condition (P < 0.05). Results of Cox's proportional hazards model indicated that hydronephrosis was the most important and only significant factor for failure to clear of the seven factors investigated (P < 0.05). Hydronephrosis was most highly correlated with the fate of residual fragments after ESWL.

Risk of Urinary Tract Cancers Following Kidney or Ureter Stones

pelvidureter cancer (SIR = 2.5; 95% GI = 1.8-3.3) and bladder cancer (SIR = 1.4; 95% CI = 1.3-1.6) were observed, but the SIRS for women were more than twice those for men. Risks varied little by age or duration of follow-up. Risks of renal pelvidureter cancer and bladder cancer among patients with an associated diagnosis of urinary tract infection were more than double those among patients without such infection, although the risks were significantly elevated in both groups. Conclusions: Individuals hospitalized for kidney or ureter stones are at increased risk of developing renal pelvidureter or bladder cancer, even beyond 10 years of follow-up. Chronic irritation and infection may play a role, since kidney or ureter stones were located on the same side of the body as the tumors in most patients with renal pelvidureter cancer evaluated in our study. Editorial Comment: First, it was vasectomy and its possible association with subsequent coronary artery disease, and now it is urolithiasis leading to urothelial cancer. While the former raised a furor later calmed by additional studies, this most recent finding remains unchallenged. Although squamous cell cancer of the renal pelvis has been related to a history of urolithiasis, this study is possibly the first to link stone disease and transitional cell cancer. The data hold up even if one were to eliminate all patients with tumors discovered during the first year after a stone episode, that is concurrent disease states, or patients with tumors found only at autopsy, that is clinically silent tumors. Notably, there was no increase in renal cell or lung cancer in this patient group, suggesting that the findings cannot be attributed to a generalized renal problem or other confounding problems, such as smoking or job related risks. Also of interest, in 75% of the patients the tumor and stone were located on the same side, again invoking the argument that tumor formation was possibly due to local irritation from the stone. Lastly, the risk of urothelial tumor formation remained as long as 10 years after the initial stone event. The bottom line question is whether radiographic or cystoscopidcytology surveillance is indicated in all patients with stones to detect renal pelvidureteral or bladder tumors in 0.14 and 0.62%, respectively. This article has made me more aware but I am not planning to expand my followup of urolithiasis beyond that of urinalysis and a plain radiograph of the abdomen at routine intervals. Ralph V. Clayman, M.D.

Consultation with the Specialist

Consultation with the Specialist