Nephrocalcinosis Treatment & Management

  • Author: Tibor Fulop, MD; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Jan 12, 2012
 

Medical Care

  • Treatment of hypercalcemia and hypercalcemic nephropathy
    • Adequate hydration by isotonic sodium chloride solution is the single most effective measure to reverse hypercalcemia and protect the kidneys. This may be combined with furosemide to enhance calcium excretion only after clinical euvolemia or mild hypervolemia has been achieved.
    • Other treatments include parathyroidectomy or calcium-sensing receptor stimulant cinacalcet (Sensipar), for correction of hyperparathyroidism; chemotherapy, for osteolytic malignancies; steroids, to decrease intestinal calcium absorption and vitamin-D activity; hydroxychloroquine (Plaquenil), for sarcoid granulomas[35] ; and calcitonin or bisphosphonates, to inhibit bone resorption.
    • Calcium-channel blockers have no role in management.
  • Treatment of macroscopic nephrocalcinosis
    • Thiazide diuretics and dietary salt restriction will reduce renal calcium excretion in medullary nephrocalcinosis. Potassium and magnesium supplementation will increase the solubility of urinary calcium.
    • Citrate supplementation (preferably as potassium citrate) can be used in idiopathic hypercalciuria and in distal RTA, because it increases urinary citrate and decreases urinary calcium excretion.[36]
    • In type 1 hyperoxaluria, treatment with large doses of pyridoxine can lower oxalate production.
    • Magnesium supplementation in magnesium-losing nephropathy may be helpful.
    • Lessening of nephrocalcinosis may occur over time, especially in idiopathic absorptive hypercalciuria and enteric hyperoxaluria after gastrointestinal bypass surgery. In most other cases, however, such as when it results from primary hyperoxaluria, distal RTA, papillary necrosis, or magnesium-losing nephropathy, nephrocalcinosis is largely irreversible. Therefore, early detection and treatment are important.
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Surgical Care

  • With copious fluid intake by the patient and the use of pain control, stones passing the midureter and measuring less then 5-7 mm usually pass on their own. Anecdotally, peripheral vasodilators (alpha blockers and calcium-channel blocker antihypertensive agents) are helpful in assisting stone passage.[37] Surgery may be required for urinary stones causing obstruction; options include percutaneous nephrolithotomy, laser and shock wave lithotripsy, stent placement, and (rarely) open surgery.
  • Parathyroidectomy to remove enlarged adenomas is very helpful in primary hyperparathyroidism and results in a low recurrence rate.
  • Attempting to remove calcium nodules from within the renal parenchyma itself has no obvious benefit and causes harm.
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Consultations

  • Nephrology consultation - Reduced renal function and associated metabolic abnormalities; electrolyte disorders, including metabolic acidosis, hypercalcemia and hypercalciuria; and recurrent nephrolithiasis
  • Endocrinology consultation: - hypercalcemia, vitamin-D and phosphate disorders, and sarcoid in association with hypercalcemia.
  • Rheumatology consultation - distal RTA associated with rheumatology diseases, such us Sj ö gren's syndrome or system lupus erythematosus.
  • Ear-nose-throat or endocrine surgery consultation - For surgical parathyroidectomy (the personal skill and experience of the operating surgeon are important)
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Diet

Dietary interventions can be formulated, as part of consultation with an appropriate specialist, only after the underlying metabolic abnormality has been identified.

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Contributor Information and Disclosures
Author

Tibor Fulop, MD  Associate Professor of Medicine, Medical Director, Outpatient Dialysis Services, Department of Medicine, Division of Nephrology, University of Mississippi Medical Center

Tibor Fulop, MD is a member of the following medical societies: American College of Physicians and American Society of Diagnostic and Interventional Nephrology

Disclosure: Nothing to disclose.

Coauthor(s)

Mahendra Agraharkar, MD, MBBS, FACP, FASN  Clinical Associate Professor of Medicine, Baylor College of Medicine; President and CEO, Space City Associates of Nephrology

Mahendra Agraharkar, MD, MBBS, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology, and National Kidney Foundation

Disclosure: South Shore DaVita Dialysis Center Ownership interest Other

Rupert Patel, MD  Physician, Division of Nephrology, Houston, Texas

Disclosure: Nothing to disclose.

Rajiv Gupta, MD  Assistant Professor, Department of Medicine, Texas A&M Health Science Center College of Medicine; Consulting Staff, Veterans Affairs Medical Center

Rajiv Gupta, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Specialty Editor Board

James W Lohr, MD  Professor, Department of Internal Medicine, Division of Nephrology, Fellowship Program Director, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

James W Lohr, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society of Nephrology, and Central Society for Clinical Research

Disclosure: Alexion Salary Employment

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eleanor Lederer, MD  Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Dept of Veterans Affairs Grant/research funds Research

Rebecca J Schmidt, DO, FACP, FASN  Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine

Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association

Disclosure: Renal Ventures Ownership interest Other

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

Additional Contributors

The primary author would like to thank Dr. Gurvinder Suri, Renal Fellow at the University of Mississippi Medical Center - Nephrology Division, for his valuable peer review.

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Diagram of a nephron.
Nephrocalcinosis.
Nephrocalcinosis.
Nephrocalcinosis.
Nonenhanced coronal computed tomography scans through the kidneys. These images show cortical and medullary nephrocalcinosis (left kidney). Both kidneys appear scarred. Note the thinning of the renal cortex at the upper pole of the left kidney. This patient gave a long history of chronic pyelonephritis, which is an unusual cause of nephrocalcinosis.
Axial computed tomography scans obtained from a patient with a long history of renal tubular acidosis. These images show bilateral medullary nephrocalcinosis (early arterial phase).
Ultrasonogram of the right kidney in a woman with nephrocalcinosis. This image shows hyperechoic foci in the pyramids.
Excretory urogram obtained at 15 minutes in a man with renal papillary necrosis, most likely a patient with diabetes mellitus and repeated urinary tract infections. This image shows bilateral hydronephrosis and a hydroureter due to obstruction by sloughed papillae at the lower end of the ureter.
Plain kidney, ureters, and bladder (KUB) radiograph in a man with renal papillary necrosis, most likely a patient with diabetes mellitus and repeated urinary tract infections. This image shows bilateral renal calcification. A large, sloughed, and calcified renal papilla is present in the region of left vesicoureteric junction. Note the 2 pelvic phleboliths opposite the ischial spine on the right.
 
 
 
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