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Hyperoxaluria: Differential Diagnoses & Workup

Author: Bijan Shekarriz, MD, Director, Laparoscopy and Minimally Invasive Surgery, Associate Professor of Urology, Department of Urology, State University of New York Upstate Medical University
Coauthor(s): Marshall L Stoller, MD, Medical Director of Urinary Stone Center, Professor, Department of Urology, University of California at San Francisco
Contributor Information and Disclosures

Updated: Nov 16, 2009

Workup

Laboratory Studies

  • Obtain a 24-hour urine collection and include analysis for total creatinine (ie, to determine adequacy of the collection) and other urinary chemistry components that can lead to stone formation, such as oxalate, calcium, uric acid, sodium, phosphate, and total urinary volume.  
    • Include an analysis for inhibitors of stone formation, such as potassium, citrate, and magnesium.
    • Assess total urine volume and pH to determine the contribution of dehydration or pH to the tendency toward crystallization.
  • Obtain serum creatinine levels to evaluate renal function.
  • Serum calcium levels may be useful in differentiating hypercalcuria from hyperparathyroidism. Tests to measure plasma oxalate levels are not currently commercially available.
  • All major urinary risk factors (eg, calcium, oxalate, citrate, uric acid, total volume, sodium, phosphate, magnesium) should be periodically reassessed with 24-hour urine collection to monitor treatment efficacy, to identify new kidney stone metabolic risk factors, and to monitor patient compliance. Most experts repeat testing every 2-3 months while various treatment plans are used until acceptable urinary chemistry levels are reached or maximum therapy has been instituted. Thereafter, retesting every 1-2 years depending on the clinical situation is usually sufficient. The overall success of any stone preventive therapy program depends on the individual patient's compliance with long-term preventive therapy and the continuous maintenance of an adequate urinary volume.

Imaging Studies

No specific imaging studies help to identify hyperoxaluria, but calcium oxalate nephrolithiasis can be easily diagnosed. For more information on imaging studies in the evaluation of urolithiasis, please see Nephrolithiasis: Acute Renal Colic.

  • Computed tomography (CT) scanning, specifically spiral CT scanning without intravenous contrast, is rapidly replacing intravenous pyelography (IVP) as the preferred method for evaluating patients with acute flank pain who may have a urinary stone.  
    • CT scanning is faster, requires less effort, does not require any potentially hazardous intravenous contrast, and provides useful information on alternatives in the differential diagnosis. Uric acid stones show up clearly on CT scans, but stones made of protease inhibitor medications do not. Intravenous contrast can be used selectively, if needed, to clarify the diagnosis.
    • Limitations of CT scanning include higher cost, an inability to assess renal function, and an inability to differentiate radiopaque from radiolucent stones. In addition, the precise shape and surgical orientation of a stone can be difficult to determine based on CT scan findings alone. This can be corrected by adding kidney, ureter, and bladder (KUB) radiography, which help not only to determine the size, shape, and location of the stone but also to determine its calcium content based on the degree of radiopacity.
    • CT scanning cannot be used in pregnant women because it is associated with more significant x-ray exposure. In addition, a small distal ureteral stone in a patient with multiple pelvic calcifications and minimal hydronephrosis may be almost impossible to identify with CT scans alone.
  • IVP can easily reveal the precise location of stones in the urinary tract.  
    • IVP images offer the best road map of the upper urinary tract and ureteral anatomy. They also provide valuable information about relative kidney function that CT scanning and ultrasonography cannot offer. Any anatomical anomalies involving urinary flow can more readily be revealed with IVP, and it often costs less than CT scanning.
    • Disadvantages of IVP include possible nephrotoxicity and allergy to the injected contrast agent. In general, IVP cannot be safely performed in patients whose serum creatinine level is higher than 2 mg/dL, and more time is required to perform IVP than CT scanning. The IVP provides only very limited information concerning other potential diagnoses that might mimic acute renal colic, such as abdominal aortic aneurysm, which is visualized much more easily on the CT scan.
  • When used in combination, renal ultrasonography and KUB radiography can be useful initial screening tools for hydronephrosis and urolithiasis. Ultrasonography is the primary diagnostic tool in pregnant patients with a suggestive renal or ureteral calculus.  
    • CT scanning should not be performed during pregnancy because of the high radiation exposure. KUB radiography and limited IVP studies can be performed but should be minimized as much as possible.
    • For more information on the management of kidney stones during pregnancy, see Pregnancy and Urolithiasis.

Other Tests

  • Dietary questionnaire  
    • Dietary excess of oxalate-containing foods (eg, spinach, nuts, rhubarb, cranberry products), can cause hyperoxaluria.
    • Dietary excess of vitamin C can also increase oxalate absorption and excretion, although the degree and importance of vitamin C in the development of calcium oxalate stone disease is somewhat controversial.
    • Evaluate oral fluid intake to exclude dehydration as a component of hyperoxaluria. Fluid intake should be sufficient to generate 2000 mL or more of urine per day.
    • High-protein (meat) intake is known to be a significant risk factor for calcium stone disease because of its effect on urinary calcium and uric acid. A 2001 European study by Nguyen et al evaluated the effect of a diet high in meat protein on urinary oxalate in healthy subjects versus patients with idiopathic calcium stones and those with mildly hyperoxaluric calcium stones.13 The investigators found that approximately one third of those with idiopathic calcium stones responded to the high meat-protein intake with a significant increase in urinary oxalate excretion, while no effect was noted in healthy subjects. This suggests that, in addition to its effects on urinary calcium and uric acid levels, excessive meat-protein intake may increase urinary oxalate excretion.

More on Hyperoxaluria

Overview: Hyperoxaluria
Differential Diagnoses & Workup: Hyperoxaluria
Treatment & Medication: Hyperoxaluria
Follow-up: Hyperoxaluria
Multimedia: Hyperoxaluria
References
Further Reading
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Further Reading

For additional information, see Medscape’s Stone Disease Resource Center.

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Keywords

hyperoxaluria, enteric hyperoxaluria, high urinary oxalate, excessive urinary oxalate, kidney stones, renal stones, nephrolithiasis, oxalosis, oxaluria, primary hyperoxaluria, urinary calculi, oxalic acid, calcium oxalate, nephrocalcinosis, extrarenal oxalosis, progressive renal failure, uremia, alanine-glyoxylate aminotransferase, AGT, AGXT gene, end-stage renal failure, hypocalciuria, hypocitraturia, primary hyperoxaluria, Oxalobacter, Oxalobacter formigenes, O formigenes, cholestyramine, kidney stone formation, dietary hyperoxaluria, idiopathic hyperoxaluria, mild hyperoxaluria, type I hyperoxaluria, type II hyperoxaluria

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Contributor Information and Disclosures

Author

Bijan Shekarriz, MD, Director, Laparoscopy and Minimally Invasive Surgery, Associate Professor of Urology, Department of Urology, State University of New York Upstate Medical University
Bijan Shekarriz, MD is a member of the following medical societies: American Urological Association and Endourological Society
Disclosure: Nothing to disclose.

Coauthor(s)

Marshall L Stoller, MD, Medical Director of Urinary Stone Center, Professor, Department of Urology, University of California at San Francisco
Marshall L Stoller, MD is a member of the following medical societies: American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Martha K Terris, MD, FACS, Professor, Department of Surgery, Medical College of Georgia
Martha K Terris, MD, FACS is a member of the following medical societies: American Cancer Society, American College of Surgeons, American Institute of Ultrasound in Medicine, American Urological Association, New York Academy of Sciences, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Bradley Fields Schwartz, DO, FACS, Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine
Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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