Hypercalciuria Clinical Presentation
- Author: Stephen W Leslie, MD, FACS; Chief Editor: Vecihi Batuman, MD, FACP, FASN more...
Note that hypercalciuria has no significant physical examination findings and is purely a laboratory diagnosis. Important aspects of the patient’s history may include the following:
Skeletal diseases (eg, osteoporosis, Paget disease) may produce hypercalciuria.
Immobilization for various reasons (eg, postoperative, orthopedic injury, burns, intensive care, spinal cord injury, bone marrow transplants) can cause rapid bone remodeling and, hence, elevated calcium excretion; fortunately, this has become less common owing to the use of early mobilization strategies and physical therapy
Nephrolithiasis is commonly associated with hypercalciuria
Malignancy is a common cause of hypercalcemia and hypercalciuria in hospitalized patients; it usually results from bone destruction, bone reabsorption, or humoral factors such as PTH-related protein.
Human immunodeficiency virus (HIV) infection or its treatment may be associated with a higher risk of hypercalciuria in children
Certain medications, such as vitamin-D supplements and furosemide, may contribute to hypercalciuria. All loop diuretics decrease the tubular reabsorption of calcium.
Dietary and fluid intake
Many dietary factors can alter urinary calcium excretion, including the following:
An inverse relationship between phosphate intake and urinary calcium excretion is observed; thus, phosphate-restricted diets result in an increase in urinary calcium excretion. With all of the other dietary items mentioned above, a direct relationship between dietary intake and urinary calcium excretion is observed.
Idiopathic hypercalciuria can run in families, as can diseases that are associated with secondary hypercalciuria. Approximately 50% of persons with kidney stones and hypercalciuria have a first-degree relative who also has hypercalciuria.
Signs and symptoms in children
In children, hypercalciuria is often associated with some degree of hematuria and back or abdominal pain, and is also sometimes associated with voiding symptoms. The standard treatment for pediatric hypercalciuria is limited to dietary or short-term medical therapy, because the patients become asymptomatic when the hypercalciuria is corrected and are often lost to follow-up.
A study involving 124 children with idiopathic hypercalciuria found that 50% of these patients had a family history of kidney stone disease. Fifty-two children developed clinical symptoms of flank or abdominal pain during the study period, but only 6 of these children had actual renal calculi. Twenty-seven children had hematuria, and 10 had incontinence. The children were treated with increased fluid intake and a reduction in dietary oxalate and sodium. Some required treatment with thiazides. All but 5 of the patients responded to therapy. Resolution of the hypercalciuria eliminated the recurrent pain in this patient population.
Another study, looking at the long-term effects of hypercalciuria in children and several possible therapies over a 4- to 11-year period, concluded that, regardless of treatment, most children with hypercalciuria eventually become asymptomatic while remaining hypercalciuric. Because limiting calcium intake in children is unwise, the recommended dietary therapy for hypercalciuria is to use a low-sodium/high-potassium diet, which normalizes the hypercalciuria in most pediatric patients.
In children with hypercalciuria, microcrystallization of calcium with urinary anions has been suggested to lead to injury of the uroepithelium. Consequently, when taking the history of the illness, attempt to identify symptoms relating to the urinary tract. Pay particular attention to the following signs and symptoms:
Change of urinary appearance
Isolated or recurrent urinary tract infections 
Vesicourethral reflux 
Some clinical manifestations are age dependent. For instance, irritability may be the only manifestation in infants, but a teenager may experience renal colic and hematuria.
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|Regular diet (unrestricted)||Women: Urinary excretion >250 mg calcium (6.2 mmol/24 h)
Men: Urinary excretion >275-300 mg calcium (7.5 mmol/24 h)
|Urinary excretion >4 mg calcium (0.1 mmol) per kilogram of body weight per day
Urinary concentration >200 mg calcium per liter
|Restricted diet (400 mg calcium, 100 mEq sodium)||Urinary excretion >200 mg calcium per day|
|Urinary excretion >3 mg calcium per kilogram of body weight per day|
|Hypercalciuria Diagnosis||Urinary Calcium on 400-mg Calcium Diet
(Normal = < 200 mg/24 h)
|Fasting Calcium/Creatinine Ratio
(Normal = < 0.11)
|Post–Calcium Load Calcium/Creatinine Ratio
(Normal = < 0.20)
|Absorptive type I||High||Normal||High|
|Absorptive type II||Normal||Normal||High|
|Absorptive type III (renal phosphate leak)||High||High||High|
|Criteria||Absorptive Type I
Vitamin D–Dependent (Classic Form)
|Absorptive Type I
Vitamin D–Dependent (Variant Form)
|Absorptive Type II
Dietary Calcium Responsive
|Absorptive Type III
(Renal Phosphate Leak)
|Renal Calcium Leak||Resorptive|
|Urinary calcium on regular diet*||High||High||High||High||High||High|
|Urinary calcium on low-calcium diet†||High||High||NL||High||High||High|
|Urinary calcium fasting‡||NL||High||NL||High||High||High|
|Urinary calcium after 1-g calcium load§||High||High||NL||High||High||High|
|Serum PO4 (fasting)||NL||NL||NL||Low||NL or high||Low|
|Serum calcium (fasting)||NL||NL or high||NL||NL or high||NL or low||High|
|Serum PTH||NL or low||NL or low||NL||Low||High||High|
|Serum PTH after 1-g calcium load||NL or low||NL or low||NL||Low||High||High|
|Serum vitamin D-3 (calcitriol)||NL||High||NL||High||High||High|
|Fasting normocalciuria while on ketoconazole||No||Yes||No||Yes||No||No|
|Bone calcium density||NL||NL or low||NL||NL or low||Low||Low|
|NL = normal; PO4 = phosphate; PTH = parathyroid hormone.
* Regular diet is unrestricted calcium and sodium intake. Normal upper limit calciuria is < 4 mg/kg body weight per day.
† Low-calcium diet is 400 mg calcium and 100 mEq of sodium per day. Normal upper limit calciuria is < 200 mg/day.
‡ Fasting is a 12-hour fast. Normal upper limit is < 0.11 mg calcium/mg creatinine.
§ After 1-g calcium load, normal upper limit is < 0.20 mg calcium/mg creatinine.