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Diagnosis and management of hypercalciuria in children

Srivastava, Taraka; Schwaderer, Andrewb

Current Opinion in Pediatrics: April 2009 - Volume 21 - Issue 2 - p 214–219
doi: 10.1097/MOP.0b013e3283223db7
Nephrology: Edited by Michel Baum

Purpose of review In this review, recent advances in the epidemiology, genetics, clinical associations and management of idiopathic hypercalciuria will be discussed.

Recent findings A significant genetic contribution exists in the pathophysiology of hypercalciuria. Although several candidate genes and genetic alterations have been proposed, identification of precise gene(s) responsible remains elusive. Decreased bone density has been increasingly associated with hypercalciuria. Recent publications have suggested that bisphosphonates may play a role in the management in patients in whom both hypercalciuria and decreased bone density are present.

Summary Idiopathic hypercalciuria is a common disorder in children and can present with a range of clinical presentations such as hematuria, voiding dysfunction, flank pain, abdominal pain, nephrolithiasis, urinary tract infection and decreased bone mineral density. Dietary modifications are often sufficient in the management of hypercalciuria. If the symptoms persist or a rare monogenic disorder is present, consideration should be given to medical treatment with a thiazide diuretic and/or citrate therapy.

aSection of Nephrology, The Children's Mercy Hospital and Clinics, University of Missouri, Kansas City, USA

bDivision of Nephrology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA

Correspondence to Tarak Srivastava, MD, Section of Nephrology, The Children's Mercy Hospital, 2401Gillham Road, Kansas City, MO 64108, USA Tel: +1 816 234 3010; fax: +1 816 234 3494; e-mail:

The authors have no conflicts of interest.

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Idiopathic hypercalciuria, that is elevated urinary calcium excretion without concomitant hypercalcemia, is a common disorder seen in 3–6% of children [1,2]. Hypercalciuria has been defined in children on a ‘statistical’ basis as urinary calcium excretion of more than 4 mg/kg/day as opposed to the ‘outcome’-based value of more than 250 mg/day in women and more than 300 mg/day in men. In children presenting symptoms may include hematuria, voiding dysfunction, flank pain, abdominal pain and urolithiasis. Additionally hypercalciuria has been associated with recurrent urinary tract infections (UTIs) and decreased bone mineral density. In this review, the different aspects of hypercalciuria that are relevant to clinical practice will be discussed.

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Genetics of hypercalciuria

Hypercalciuria is linked to development of urolithiasis. In children with hypercalciuria, the prevalence of urolithiasis in the family is 46–69% [3,4•]. A positive family history appears to be the single most important risk factor [5]. The frequently observed familial clustering of calcium urolithiasis is most compatible with an autosomal dominant transmission [6]. A number of candidate genes have been suggested in pathogenesis of hypercalciuria, such as soluble adenylate cyclase, calcium sensing receptor (CASR), vitamin D receptor, chloride channel-5, sodium phosphate cotransporter-2 and claudin-16 [7••]. Reed et al. [8,9] mapped the defect in three families with severe absorptive hypercalciuria to 1q23.3–q24 and sequenced a putative gene that increases the relative risk by 2.2–3.5-fold. Vezzoli et al. [10] identified a single nucleotide polymorphism, Arg990Gly, in the CASR gene, which accounted for 4.1% of total variance in calcium excretion. Imamura et al. [11] and Giuffre et al. [12] have described three unrelated children with hypercalciuria who have 4q33-qter and 4q31.3-qter deletion, respectively, which raises the potential for a putative gene for hypercalciuria in that region. Currently the hypercalciuric trait is suspected to be polygenic and requires the interaction of genetic and environmental factors [13,14]. The role of environment has been well substantiated by Trinchieri [15], who showed that with change in dietary habits both the incidence and chemical composition of calculi have changed. At the beginning of the last century, bladder calculus from ammonium urate was relatively frequent in Europe. At present, as our diets have become rich in protein, refined carbohydrates and sodium, calcium stones predominate in ureter or kidney.

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Classification of hypercalciuria

The development of hypercalciuria involves interactions between the gastrointestinal tract, bone and kidney, and a complex interplay of hormones, such as parathyroid hormone (PTH), calcitonin, and 1,25-dihydroxyvitamin D. Pak et al. [16] introduced a classification of absorptive, renal and resorptive hypercalciuria for idiopathic hypercalciuria. Over the years, investigators have further modified the classification based on urine calcium excretion, serum phosphate, and serum PTH secretion during fasting and after a calcium load [17]. Idiopathic hypercalciuria results from either a combination of increased gastrointestinal calcium absorption from a direct increase in calcium absorption (type 1 absorptive hypercalciuria) or through excess 1,25-dihydroxyvitamin D-mediated calcium absorption (type II absorptive hypercalciuria); decreased renal absorption of either calcium (renal hypercalciuria) or phosphorus (type III absorptive hypercalciuria); or enhanced bone resorption (resorptive hypercalciuria) [18–20]. Renal and absorptive hypercalciuria may not be distinct entities, as indicated by the lack of increased bone turnover in hypercalciuric children [21]. Children initially diagnosed with having either renal or absorptive hypercalciuria had a different result when tested 3–7 years later [22]. Additionally no major alterations in intestinal calcium absorption were identified when children with hypercalciuria were given an oral strontium load [23•]. It is possible that absorptive and renal hypercalciuria may represent a continuum of a single disease [24,25]. Thus, we do not suggest formal assessments for subtypes of hypercalciuria in children on a regular basis, but it can be utilized as a reasonable framework to methodically approach an evaluation of a medically complex child with hypercalciuria.

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Clinical features of hypercalciuria

The pathological role for hypercalciuria has been attributed in nonglomerular hematuria (gross or microscopic), dysuria, urinary frequency, abdominal pain, back pain or nephrolithiasis as these symptoms improve with normalization of urine calcium. In a retrospective review of 288 hypercalciuric children, presenting symptoms included voiding symptoms and gross hematuria (28%), voiding symptoms and microscopic hematuria (30%), urinary frequency (21%), dysuria (22%) and combined urgency-frequency and dysuria (28%) [26].

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Twenty-six to 36% of children have no identifiable basis for hematuria other than hypercalciuria; inversely, 31% of children with hypercalciuria have hematuria [27–30]. The prevalence of hypercalciuria is similar for both gross and microscopic hematuria, with the type of hematuria not related to the severity of hypercalciuria [27–30]. Although the association between hematuria and hypercalciuria has been noted in multiple studies, the underlying mechanism is not known, but likely results from injury to the urinary tract [31].

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Voiding symptoms, abdominal pain and flank pain

Hypercalciuria presents in 8–30% of children with voiding symptoms [3,30]. These symptoms can range from urinary urgency, frequency, dysuria, enuresis or suprapubic pain and are believed to occur from injury to urinary epithelium from calcium microcrystals [26]. In addition to voiding symptoms, idiopathic hypercalciuria without nephrolithiasis has been associated with recurrent flank and/or abdominal pain [3,32].

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Hypercalciuria is found in 28–79% of children with urolithiasis and nephrocalcinosis [33,34]. In a recent study, hypercalciuria (40%) and hypocitraturia (38%) were the most common risk factors for the development of urolithiasis in children [4•]. Although urolithiasis occurs in only 5% of children with hypercalciuria, microcalculi (i.e. hyperechogenic spots <3 mm in renal calyces) are much more common (57%) [3]. The risk of urolithiasis in children with idiopathic hypercalciuria has varied between studies from 0/33 (0%) developing stones with a 4–11-year follow-up [35], to 9/58 (16%) with a 1–6-year follow-up [36], to 4/30 (13%) with a 1–3-year follow-up [3] and 8/60 (13%) with a 1–4-year follow-up [28]. The presence of gross hematuria, a family history of urolithiasis and greater levels of hypercalciuria increase the risk for progression to urolithiasis [36,37].

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Urinary tract infection

Stojanović et al. [38••] found 21% of children with UTI had hypercalciuria compared with 7% in normal children; of these hypercalciuria was seen in 10% of children with first UTI and in 44% with recurrent UTI. Similarly, Biyikli et al. [39] found 43% of children with recurrent UTI had hypercalciuria. On the contrary, in children with symptomatic idiopathic hypercalciuria, Vachvanichsanong et al. [40] found 40% to have a UTI, of which 78% were recurrent. A reduction in urinary calcium excretion with increased fluid intake, reduction of dietary sodium and oxalate and thiazide diuretic (in 36%) resulted in no further UTIs in 61% of children with recurrent UTIs [40]. In another study of children with recurrent UTIs [41], normal urinary tracts and idiopathic hypercalciuria, no further UTIs occurred in 95% following normalization of urinary calcium excretion.

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Decreased bone density

In children, Penido et al. [42,43] identified a low bone mineral density in 35% of children with idiopathic hypercalciuria, and this was more marked in hypercalciuric children with hypocitraturia. Schwaderer et al. [44••] recently have shown that children with hypercalciuria have decreased bone mineral content, and this is more marked in children with stones. Gomes et al. [45•] found a high expression of receptor activator of nuclear factor KB ligand (RANKL) and a low expression of transforming growth factor-β in transiliac bone biopsies from patients with idiopathic hypercalciuria compared with controls, suggesting a role of increased bone resorption and delayed mineralization in hypercalciuria. Garcia-Nieto et al. [46] made the observation of a negative linear correlation between age and bone mineral content in children with idiopathic hypercalciuria. Freundlich et al. [47] showed reduced bone mineral density in children with hypercalciuria, and also identified a high incidence of both hypercalciuria and reduced bone mineral density in their asymptomatic mothers. These two studies raise the possibility that adult osteoporosis might have its origin in childhood. The natural course of hypercalciuria-associated low bone density warrants further evaluation.

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Management of hypercalciuria

In children with symptomatic hypercalciuria it is important to conduct a formal evaluation for assessment of cause and severity of hypercalciuria, which will guide subsequent dietary and pharmacological therapy.

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In clinical situations in which hypercalciuria can be attributed to play a pathological role, a timed urine collection should be obtained for creatinine, calcium, sodium, potassium and citrate. In cases in which it is difficult to collect timed urine samples, random urine samples may be used. The urine samples should ideally be evaluated when the child is free of stones and infection and is on his usual diet. One must be cognizant of two facts: traditional statistical cut-offs of more than 4 mg/kg/day or urine calcium/creatinine ratio more than 0.21 are influenced by diet, ethnicity, age and region, and this has been critically addressed by Butani and Kalia [48], and random urine samples do not always correlate strongly with a 24-h urine collection as shown by Koyun et al. [49•]. Before hypercalciuria is labeled as idiopathic, one must consider the possibility of a secondary cause. The rare monogenic disorders and the underlying mechanism for development of secondary hypercalciuria have been recently reviewed in two reviews (Table 1) [13,50••]. An evaluation for secondary disorders should be considered in the presence of positive family history, failure to thrive, growth retardation, rickets, acid–base disturbances, renal dysfunction, proteinuria, electrolyte imbalance, dysmorphic features or poor response to therapy.

Table 1

Table 1

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Diet in hypercalciuria

Urinary calcium excretion is significantly affected by sodium, protein, potassium, phosphorus and calcium in the diet. There is a reproducible linear positive correlation between urinary sodium and calcium excretion in both stone formers and normal individuals [51]. One excretes ∼1 mmol (or 40 mg) calcium for every 100 mmol (or 2.3 g) of sodium [52]. Studies have shown urinary calcium increases when dietary sodium intake is increased from 50 to 300 mmol/day [51]. Breslau et al. [53] found mean urinary calcium excretion to increase from 110 to 167 mg/day by daily supplementation of 240 mEq of sodium. In contrast, potassium supplementation at 1 mEq/kg/day has been shown to decrease calcium excretion in children with hypercalciuria [54]. Dietary potassium exists as potassium salts of organic anions in vegetables and fruits [55]. Thus, limiting excessive sodium and supplementing potassium in diet is important in management of hypercalciuria, when normal renal function is present. We recommend a diet that is not excessive in salt (2.0–2.4 g sodium/day) and supplemented with at least the recommended daily allowance of five to six servings of fruits and vegetables (3.0–3.5 g potassium/day). Compliance with these dietary recommendations can be assessed by measuring urine Na/K ratio, which should be less than 2.5.

An increase in dietary protein intake increases net acid excretion, which in turn increases urinary calcium excretion [55]. Urinary calcium excretion has been shown to correlate directly with the level of dietary protein intake [56]. The increment in urinary calcium excretion is ∼0.04 mmol (∼1.6 mg) Ca/g protein. The increase in calcium excretion with dietary protein is more marked in calcium stone formers than in healthy individuals [18,57]. Polito et al. [58•] found a significant interaction between urinary urea (protein intake) and sodium (salt intake) in increasing urinary calcium in hypercalciuric children. Protein restriction is not suggested in children as it could impair growth. A dietary restriction of calcium is not recommended in children with hypercalciuria, as it puts the growing child at risk for negative calcium balance and poor bone mineralization, and also increases urinary excretion of oxalate from increased gastrointestinal absorption of oxalate.

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Anticalciuric diuretics

Thiazide diuretics that decrease urinary calcium excretion have been widely used in children with hypercalciuria. Medications should be used once dietary modifications have failed to normalize urinary calcium excretion and/or symptoms attributable to hypercalciuria persist. Chlorothiazide 15–25 mg/kg/day or hydrochlorothiazide 1.5–2.5 mg/kg/day can be used. Although the precise mechanism for thiazides is not known, it is proposed that thiazide-induced volume contraction increases paracellular calcium absorption in proximal tubules, though a transcellular calcium transport in distal tubule is also suspected [59]. Recently Jiang et al. [60••] showed that WNK4 enhances TRPV5-mediated Ca2+ uptake and inhibits thiazide-sensitive Na+–Cl cotransporter (NCC), and the positive effect of WNK4 on TRPV5 could be blocked by increasing NCC in a dose-dependent fashion. Children on long-term thiazide diuretics need to be monitored for dyselectrolytemia, hyperlipidemia and hyperglycemia. Thiazides are the drug of choice in monogenic disorders associated with severe hypercalciuria such as Dent's disease, Bartter type 5 from activating mutations in CASR, pseudohypoaldosteronism type II with WNK4 gene mutation, familial hypomagnesemia with hypercalciuria and nephrocalcinosis, and others [60••,61–63].

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Potassium citrate

Citrate in urine is well known to have an inhibitory role in calcium stone formation [64,65]. In randomized controlled studies, citrate therapy has been shown to be beneficial in adults with stones [66–68]. In children, citrate therapy has been shown to decrease recurrence of new stones, growth of residual stone fragments following lithotripsy and in stone-forming children with hypocitraturia [69,70]. In a preliminary study in nine healthy children, treatment with potassium citrate at 0.5 or 1 mEq K/kg/day resulted in an increase in urinary citrate excretion, but the higher dose also caused a significant increase in urine pH [71]. Indeed there is a concern that the increase in urine pH observed with citrate therapy may promote urinary supersaturation of calcium phosphate, thus defeating the purpose of treatment. It appears that urinary citrate is important in protecting hypercalciuric children from stone formation [72]. Potassium citrate is being used more often as the first line of drugs, given fewer adverse effects, although it has not been examined sufficiently to date, but should be the drug of choice in children with renal tubular acidosis.

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Neutral phosphate salts are to be used in children in whom hypercalciuria is secondary to severe tubular phosphate leak in rare disorders involving phosphate reabsorption in the proximal tubule, such as hypophosphatemic rickets with hypercalciuria, Lowe syndrome, and other disorders [73]. Drugs such as sodium cellulose phosphate, a nonabsorbable ion-exchange resin, used for complexing intestinal calcium are not to be used in children as they increase the risk for negative calcium balance. Alendronate, a bisphosphonate drug, decreases urine calcium excretion in genetic hypercalciuric stone-forming rats on a low calcium diet, suggesting a role for bone in development of hypercalciuria [74]. Bisphosphonates were shown to be beneficial in adults with hypercalciuria [75–77]. Freundlich and Alon [78••] published the first case series of seven children with osteopenia and hypercalciuria in whom bisphosphonates normalized urinary calcium excretion, improved bone mineral content and urinary symptoms.

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Our understanding of calcium handling by the kidney and development of hypercalciuria has much improved over the past decade from studying rare inherited renal tubular disorders, and hopefully large population-based genetic studies will allow us to better understand the ‘polygenic’ trait of idiopathic hypercalciuria. Hypercalciuria can be controlled in most cases with dietary modifications and/or drug therapy with potassium citrate and/or thiazides. It is our belief that for now drug therapy should be reserved for children with symptomatic hypercalcuria and/or rare monogenic disorders. At present anticalciuric therapy in children is not based on strong evidence-based medicine but more on clinical observation, and needs to be studied prospectively.

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References and recommended reading

Papers of particular interest, published within the annual period of review, have been highlighted as:

• of special interest

•• of outstanding interest

Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 277–278).

1 Moore ES, Coe FL, McMann BJ, Favus MJ. Idiopathic hypercalciuria in children: prevalence and metabolic characteristics. J Pediatr 1978; 92:906–910.
2 Bercem G, Cevit O, Toksoy HB, et al. Asymptomatic hypercalciuria: prevalence and metabolic characteristics. Indian J Pediatr 2001; 68:315–318.
3 Polito C, La Manna A, Cioce F, et al. Clinical presentation and natural course of idiopathic hypercalciuria in children. Pediatr Nephrol 2000; 15:211–214.
4• Spivacow FR, Negri AL, del Valle EE, et al. Metabolic risk factors in children with kidney stone disease. Pediatr Nephrol 2008; 23:1129–1133. The authors describe different clinical presentations and risk factors associated with nephrolithiasis in children.
5 Curhan GC, Willett WC, Rimm EB, Stampfer MJ. Family history and risk of kidney stones. J Am Soc Nephrol 1997; 8:1568–1573.
6 Loredo-Osti JC, Roslin NM, Tessier J, et al. Segregation of urine calcium excretion in families ascertained for nephrolithiasis: evidence for a major gene. Kidney Int 2005; 68:966–971.
7•• Vezzoli G, Soldati L, Gambaro G. Update on primary hypercalciuria from a genetic perspective. J Urol 2008; 179:1676–1682. The article provides an excellent review of the current status of genetic studies in idiopathic hypercalciuria.
8 Reed BY, Heller HJ, Gitomer WL, Pak CY. Mapping a gene defect in absorptive hypercalciuria to chromosome 1q233-q24. J Clin Endocrinol Metab 1999; 84:3907–3913.
9 Reed BY, Gitomer WL, Heller HJ, et al. Identification and characterization of a gene with base substitutions associated with the absorptive hypercalciuria phenotype and low spinal bone density. J Clin Endocrinol Metab 2002; 87:1476–1485.
10 Vezzoli G, Tanini A, Ferrucci L, et al. Influence of calcium-sensing receptor gene on urinary calcium excretion in stone-forming patients. J Am Soc Nephrol 2002; 13:2517–2523.
11 Imamura K, Tonoki H, Wakui K, et al. 4q33-qter deletion and absorptive hypercalciuria: report of two unrelated girls. Am J Med Genet 1998; 78:52–54.
12 Giuffre M, La Placa S, Carta M, et al. Hypercalciuria and kidney calcifications in terminal 4q deletion syndrome: further evidence for a putative gene on 4q. Am J Med Genet A 2004; 126:186–190.
13 Moe OW, Bonny O. Genetic hypercalciuria. J Am Soc Nephrol 2005; 16:729–745.
14 Resnick M, Pridgen DB, Goodman HO. Genetic predisposition to formation of calcium oxalate renal calculi. N Engl J Med 1968; 278:1313–1318.
15 Trinchieri A. Epidemiology of urolithiasis. Arch Ital Urol Androl 1996; 68:203–249.
16 Pak CY, Kaplan R, Bone H. A simple test for the diagnosis of absorptive, resorptive and renal hypercalciuria. N Engl J Med 1975; 292:497–500.
17 Bataille P, Fardellone P, Ghazali A, et al. Pathophysiology and treatment of idiopathic hypercalciuria. Curr Opin Rheumatol 1998; 10:373–388.
18 Bataille P, Achard JM, Fournier A, et al. Diet, vitamin D and vertebral mineral density in hypercalciuric calcium stone formers. Kidney Int 1991; 39:1193–1205.
19 Coe FL, Canterbury JM, Firpo JJ, Reiss E. Evidence for secondary hyperparathyroidism in idiopathic hypercalciuria. J Clin Invest 1973; 52:134–142.
20 Frick KK, Bushinsky DA. Molecular mechanisms of primary hypercalciuria. J Am Soc Nephrol 2003; 14:1082–1095.
21 Stapleton FB, Jones DP, Miller LA. Evaluation of bone metabolism in children with hypercalciuria. Semin Nephrol 1989; 9:75–78.
22 Aladjem M, Barr J, Lahat E, Bistritzer T. Renal and absorptive hypercalciuria: a metabolic disturbance with varying and interchanging modes of expression. Pediatrics 1996; 97:216–219.
23• Fernández P, Santos F, Sotorrío P, et al. Strontium oral load test in children with idiopathic hypercalciuria. Pediatr Nephrol 2007; 22:1303–1307. The authors found no major alterations in intestinal calcium absorption in children with idiopathic hypercalciuria.
24 Coe FL, Favus MJ, Crockett T. Effects of low-calcium diet on urine calcium excretion, parathyroid function and serum 1,25 (OH)2D3 levels in patients with idiopathic hypercalciuria and in normal subjects. Am J Med 1982; 72:25–32.
25 Stapleton FB, Langman CB, Bittle J, Miller LA. Increased serum concentrations of 1,25(OH)2 vitamin D in children with fasting hypercalciuria. J Pediatr 1987; 110:234–237.
26 Parekh DJ, Pope JI, Adams MC, Brock JW 3rd. The role of hypercalciuria in a subgroup of dysfunctional voiding syndromes of childhood. J Urol 2000; 164:1008–1010.
27 Stapleton FB, Roy SJ 3rd, Noe HN, Jerkins G. Hypercalciuria in children with hematuria. N Engl J Med 1984; 310:1345–1348.
28 Stapleton FB. Idiopathic hypercalciuria: association with isolated hematuria and risk for urolithiasis in children. The Southwest Pediatric Nephrology Study Group. Kidney Int 1990; 37:807–811.
29 Parekh DJ, Pope JC 4th, Adams MC, Brock JW 3rd. The association of an increased urinary calcium-to-creatinine ratio, and asymptomatic gross and microscopic hematuria in children. J Urol 2002; 167:272–274.
30 Penido MG, Diniz JS, Moreira ML, Tupinamba AL. Idiopathic hypercalciuria: presentation of 471 cases. J Pediatr (Rio J) 2001; 77:101–104.
31 Patel HP, Bissler JJ. Hematuria in children. Pediatr Clin North Am 2001; 48:1519–1537.
32 Vachvanichsanong P, Malagon M, Moore ES. Recurrent abdominal and flank pain in children with idiopathic hypercalciuria. Acta Paediatr 2001; 90:643–648.
33 Lande MB, Varade W, Erkan E, et al. Role of urinary supersaturation in the evaluation of children with urolithiasis. Pediatr Nephrol 2005; 20:491–494.
34 Alon US, Zimmerman H, Alon M. Evaluation and treatment of pediatric idiopathic urolithiasis-revisited. Pediatr Nephrol 2004; 19:516–520.
35 Alon US, Berenbom A. Idiopathic hypercalciuria of childhood: 4- to 11-year outcome. Pediatr Nephrol 2000; 14:1011–1015.
36 Garcia CD, Miller LA, Stapleton FB. Natural history of hematuria associated with hypercalciuria in children. Am J Dis Child 1991; 145:1204–1207.
37 Lerolle N, Lantz B, Paillard F, et al. Risk factors for nephrolithiasis in patients with familial idiopathic hypercalciuria. Am J Med 2002; 113:99–103.
38•• Stojanović VD, Milosevic BO, Djapic MB, Bubalo JD. Idiopathic hypercalciuria associated with urinary tract infection in children. Pediatr Nephrol 2007; 22:1291–1295. The article found hypercalciuria to be a significant risk factor for recurrent urinary tract infections in children.
39 Biyikli NK, Alpay H, Guran T. Hypercalciuria and recurrent urinary tract infections: incidence and symptoms in children over 5 years of age. Pediatr Nephrol 2005; 20:1435–1438.
40 Vachvanichsanong P, Malagon M, Moore ES. Urinary tract infection in children associated with idiopathic hypercalciuria. Scand J Urol Nephrol 2001; 35:112–116.
41 Lopez MM, Castillo LA, Chavez JB, Ramones C. Hypercalciuria and recurrent urinary tract infection in Venezuelan children. Pediatr Nephrol 1999; 13:433–437.
42 Penido MG, Lima EM, Marino VS, et al. Bone alterations in children with idiopathic hypercalciuria at the time of diagnosis. Pediatr Nephrol 2003; 18:133–139.
43 Penido MG, Lima EM, Souto MF, et al. Hypocitraturia: a risk factor for reduced bone mineral density in idiopathic hypercalciuria? Pediatr Nephrol 2006; 21:74–78.
44•• Schwaderer AL, Cronin R, Mahan JD, Bates CM. Low bone density in children with hypercalciuria and/or nephrolithiasis. Pediatr Nephrol 2008; 23:2209–2214. The authors found a decrease in bone mineral content in a large series of children with hypercalciuria with and without stones. One must consider DXA bone scan as part of comprehensive evaluation of a child with hypercalciuria with or without stones.
45• Gomes SA, dos Reis LM, Noronha IL, et al. RANKL is a mediator of bone resorption in idiopathic hypercalciuria. Clin J Am Soc Nephrol 2008; 3:1446–1452. The article reports an elevated expression of RANKL in transiliac bone biopsies from patients with idiopathic hypercalciuria suggesting a role for increased bone resorption in hypercalciuria.
46 Garcia-Nieto V, Ferrandez C, Monge M. Bone mineral density in pediatric patients with idiopathic hypercalciuria. Pediatr Nephrol 1997; 11:578–583.
47 Freundlich M, Alonzo E, Bellorin-Font E, Weisinger JR. Reduced bone mass in children with idiopathic hypercalciuria and in their asymptomatic mothers. Nephrol Dial Transplant 2002; 17:1396–1401.
48 Butani L, Kalia A. Idiopathic hypercalciuria in children – how valid are the existing diagnostic criteria? Pediatr Nephrol 2004; 19:577–582.
49• Koyun M, Güven AG, Filiz S, et al. Screening for hypercalciuria in schoolchildren: what should be the criteria for diagnosis? Pediatr Nephrol 2007; 22:1297–1301. The authors show the potential problem of using random urine calcium/creatinine ratio over a 24-h urine sample in children.
50•• Srivastava T, Alon US. Pathophysiology of hypercalciuria in children. Pediatr Nephrol 2007; 22:1659–1673. The article provides an excellent review of pathophysiology of hypercalciuria in the context of calcium handling by different segments of the renal tubule.
51 Sakhaee K, Harvey JA, Padalino PK, et al. The potential role of salt abuse on the risk for kidney stone formation. J Urol 1993; 150:310–312.
52 Nordin BE, Need AG, Morris HA, Horowitz M. The nature and significance of the relationship between urinary sodium and urinary calcium in women. J Nutr 1993; 123:1615–1622.
53 Breslau N, McGuire J, Zerwekh J, Pak C. The role of dietary sodium on renal excretion and intestinal absorption of calcium and on vitamin D metabolism. J Clin Endocrinol Metab 1982; 55:369–373.
54 Osorio AV, Alon US. The relationship between urinary calcium, sodium, and potassium excretion and the role of potassium in treating idiopathic hypercalciuria. Pedatrics 1997; 100:675–681.
55 Lemann J Jr. Relationship between urinary calcium and net acid excretion as determined by dietary protein and potassium: a review. Nephron 1999; 81:18–25.
56 Allen L, Oddoye A, Margen S. Protein-induced hypercalciuria: a longer term study. Am J Clin Nutr 1979; 32:741–749.
57 Wasserstein AG, Stolley PD, Soper KA, et al. Case–control study of risk factors for idiopathic calcium nephrolithiasis. Miner Electrolyte Metab 1987; 13:85–95.
58• Polito C, La Manna A, Signoriello G, Lama G. Differing urinary urea excretion among children with idiopathic hypercalciuria and/or hyperuricosuria. J Pediatr Urol 2008; 4:55–59. The authors provide the relevance of dietary protein load in urinary calcium and uric acid excretion in children.
59 Costanzo LS, Windhager EE. Calcium and sodium transport by the distal convoluted tubule of the rat. Am J Physiol 1978; 235:F492–F506.
60•• Jiang Y, Ferguson WB, Peng JB. WNK4 enhances TRPV5-mediated calcium transport: potential role in hypercalciuria of familial hyperkalemic hypertension caused by gene mutation of WNK4. Am J Physiol Renal Physiol 2007; 292:F545–F554. The article provides the role of WNK4 in calcium absorption in the distal renal tubule. They indirectly provide the mechanism underlying the beneficial effect of thiazide in calcium reabsorption in the distal renal tubule.
61 Mayan H, Munter G, Shaharabany M, et al. Hypercalciuria in familial hyperkalemia and hypertension accompanies hyperkalemia and precedes hypertension: description of a large family with the Q565E WNK4 mutation. J Clin Endocrinol Metab 2004; 89:4025–4030.
62 Raja KA, Schurman S, D'mello RG, et al. Responsiveness of hypercalciuria to thiazide in Dent's disease. J Am Soc Nephrol 2002; 13:2938–2944.
63 Zimmermann B, Plank C, Konrad M, et al. Hydrochlorothiazide in CLDN16 mutation. Nephrol Dial Transplant 2006; 21:2127–2132.
64 Bisaz S, Felix R, Hansen NM, Fleisch H. Disaggregation of hydroxyapatite crystals. Biochim Biophys Acta 1976; 451:560–566.
65 Bisaz S, Felix R, Neuman WF, Fleisch H. Quantitative determination of inhibitors of calcium phosphate precipitation in whole urine. Miner Electrolyte Metab 1978; 1:74–83.
66 Barcelo P, Wuhl O, Servitge E. Randomized double-blind study of potassium citrate in idiopathic hypocitraturic calcium nephrolithiasis. J Urol 1993; 150:1761–1764.
67 Ettinger B, Pak CY, Citron JT, et al. Potassium-magnesium citrate is an effective prophylaxis against recurrent calcium oxalate nephrolithiasis. J Urol 1997; 158:2069–2073.
68 Hofbauer J, Höbarth K, Szabo N, Marberger M. Alkali citrate prophylaxis in idiopathic recurrent calcium oxalate urolithiasis – a prospective randomized study. Br J Urol 1994; 73:362–365.
69 Tekin A, Tekgul S, Atsu N, et al. Oral potassium citrate treatment for idiopathic hypocitruria in children with calcium urolithiasis. J Urol 2002; 168:2572–2574.
70 Sarica K, Erturhan S, Yurtseven C, Yagci F. Effect of potassium citrate therapy on stone recurrence and regrowth after extracorporeal shockwave lithotripsy in children. J Endourol 2006; 20:875–879.
71 Auron A, Srivastava T, Blowey DL, et al. Effects of low vs. high dose potassium citrate on urine chemistry and acid-base status. J Am Soc Nephrol 2007; 18:73A.
72 Srivastava T, Winston MJ, Alon US. Urinary citrate in hypercalciuric children with and without urolithiasis. J Am Soc Nephrol 2006; 17:522A.
73 Kremke B, Bergwitz C, Ahrens W, et al. Hypophosphatemic rickets with hypercalciuria due to mutation in SLC34A3/NaPi-IIc can be masked by vitamin D deficiency and can be associated with renal calcifications. Exp Clin Endocrinol Diabetes 2008. [Epub ahead of print]
74 Bushinsky DA, Neumann KJ, Asplin J, Krieger NS. Alendronate decreases urine calcium and supersaturation in genetic hypercalciuric rats. Kidney Int 1999; 55:234–243.
75 Weisinger JR, Alonzo E, Machado C, et al. Role of bones in the physiopathology of idiopathic hypercalciuria: effect of amino-bisphosphonate alendronate. Medicina (B Aires) 1997; 57:45–48.
76 Heilberg IP, Martini LA, Teixeira SH, et al. Effect of etidronate treatment on bone mass of male nephrolithiasis patients with idiopathic hypercalciuria and osteopenia. Nephron 1998; 79:430–437.
77 Ruml LA, Dubois SK, Roberts ML, Pak CY. Prevention of hypercalciuria and stone-forming propensity during prolonged bedrest by alendronate. Miner Res 1995; 10:655–662.
78•• Freundlich M, Alon US. Bisphosphonates in children with hypercalciuria and reduced bone mineral density. Pediatr Nephrol 2008; 23:2215–2220. The authors provide the first report of using bisphosphonates in children with hypercalciuria and osteoporosis.

citrate; hypercalciuria; thiazide; urolithiasis

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