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• W2034206298 abstract "We present here the anatomy and histopathology of kidneys from 11 patients with renal stones following small bowel resection, including 10 with Crohn's disease and 1 resection in infancy for unknown cause. They presented predominantly with calcium oxalate stones. Risks of formation included hyperoxaluria (urine oxalate excretion greater than 45 mg per day) in half of the cases, and acidic urine of reduced volume. As was found with ileostomy and obesity bypass, inner medullary collecting ducts (IMCDs) contained crystal deposits associated with cell injury, interstitial inflammation, and papillary deformity. Cortical changes included modest glomerular sclerosis, tubular atrophy, and interstitial fibrosis. Randall's plaque (interstitial papillary apatite) was abundant, with calcium oxalate stone overgrowth similar to that seen in ileostomy, idiopathic calcium oxalate stone formers, and primary hyperparathyroidism. Abundant plaque was compatible with the low urine volume and pH. The IMCD deposits all contained apatite, with calcium oxalate present in three cases, similar to findings in patients with obesity bypass but not an ileostomy. The mechanisms for calcium oxalate stone formation in IMCDs include elevated urine and presumably tubule fluid calcium oxalate supersaturation, but a low calcium to oxalate ratio. However, the mechanisms for the presence of IMCD apatite remain unknown. We present here the anatomy and histopathology of kidneys from 11 patients with renal stones following small bowel resection, including 10 with Crohn's disease and 1 resection in infancy for unknown cause. They presented predominantly with calcium oxalate stones. Risks of formation included hyperoxaluria (urine oxalate excretion greater than 45 mg per day) in half of the cases, and acidic urine of reduced volume. As was found with ileostomy and obesity bypass, inner medullary collecting ducts (IMCDs) contained crystal deposits associated with cell injury, interstitial inflammation, and papillary deformity. Cortical changes included modest glomerular sclerosis, tubular atrophy, and interstitial fibrosis. Randall's plaque (interstitial papillary apatite) was abundant, with calcium oxalate stone overgrowth similar to that seen in ileostomy, idiopathic calcium oxalate stone formers, and primary hyperparathyroidism. Abundant plaque was compatible with the low urine volume and pH. The IMCD deposits all contained apatite, with calcium oxalate present in three cases, similar to findings in patients with obesity bypass but not an ileostomy. The mechanisms for calcium oxalate stone formation in IMCDs include elevated urine and presumably tubule fluid calcium oxalate supersaturation, but a low calcium to oxalate ratio. However, the mechanisms for the presence of IMCD apatite remain unknown. We have shown elsewhere1.Evan A.P. Lingeman J.E. Coe F.L. et al.Randall's plaque of patients with nephrolithiasis begins in basement membranes of thin loops of Henle.J Clin Invest. 2003; 111: 607-616Crossref PubMed Scopus (468) Google Scholar, 2.Evan A.P. Coe F.L. Gillen D. et al.Renal intratubular crystals and hyaluronan staining occur in stone formers with bypass surgery but not with idiopathic calcium oxalate stones.Anat Rec. 2008; 291: 325-334Crossref Scopus (41) Google Scholar that bowel disease can produce a wide range of renal histopathology and entrain multiple mechanisms for renal stone production and formation of intrarenal crystal deposits. In patients with obesity bypass procedures, calcium oxalate (CaOx) stones are found free in the urinary collecting system. Within the kidney, the only deposits are occasional apatite plugs within inner medullary collecting ducts (IMCDs), rare microscopic linear deposits of CaOx over apical surfaces of otherwise normal-appearing IMCD cells, and a single small IMCD CaOx plug in each of two of the five cases that we have studied.1.Evan A.P. Lingeman J.E. Coe F.L. et al.Randall's plaque of patients with nephrolithiasis begins in basement membranes of thin loops of Henle.J Clin Invest. 2003; 111: 607-616Crossref PubMed Scopus (468) Google Scholar, 2.Evan A.P. Coe F.L. Gillen D. et al.Renal intratubular crystals and hyaluronan staining occur in stone formers with bypass surgery but not with idiopathic calcium oxalate stones.Anat Rec. 2008; 291: 325-334Crossref Scopus (41) Google Scholar Patients with ileostomy produce stones containing both uric acid and CaOx.3.Evan A.P. Lingeman J.E. Coe F.L. et al.Intra-tubular deposits, urine and stone composition are divergent in patients with ileostomy.Kidney Int. 2009; 76: 1081-1088Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar In their kidneys, we have found interstitial apatite (Randall's) plaque, and IMCD plugs composed of apatite and the sodium and ammonium acid salts of uric acid.3.Evan A.P. Lingeman J.E. Coe F.L. et al.Intra-tubular deposits, urine and stone composition are divergent in patients with ileostomy.Kidney Int. 2009; 76: 1081-1088Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Some CaOx stones were found growing over regions of plaque, as is seen in idiopathic CaOx stone formers (ICSFs) and stone formers (SFs) with primary hyperparathyroidism.4.Miller N.L. Gillen D.L. Williams Jr, J.C. et al.A formal test of the hypothesis that idiopathic calcium oxalate stones grow on Randall's plaque.BJU Int. 2009; 103: 966-971Crossref PubMed Scopus (64) Google Scholar, 5.Evan A.E. Lingeman J.E. Coe F.L. et al.Histopathology and surgical anatomy of patients with primary hyperparathyroidism and calcium phosphate stones.Kidney Int. 2008; 74: 223-229Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 6.Evan A.P. Coe F.L. Lingeman J.E. et al.Mechanism of formation of human calcium oxalate renal stones on Randall's plaque.Anat Rec. 2007; 290: 1315-1323Crossref Scopus (148) Google Scholar Other stones were found free in the collecting system. We have little difficulty in explaining the plaque, stones, and urate IMCD deposits that we have thus far encountered in bowel patients. Bypass patients produce no excess of plaque above control subjects and their stones never grow attached to renal papillae. The lack of plaque is consistent with our earlier findings that plaque is promoted by scanty acidic urine and hypercalciuria; bypass patients have high urine volumes and are not hypercalciuric.1.Evan A.P. Lingeman J.E. Coe F.L. et al.Randall's plaque of patients with nephrolithiasis begins in basement membranes of thin loops of Henle.J Clin Invest. 2003; 111: 607-616Crossref PubMed Scopus (468) Google Scholar, 7.Kuo R.L. Lingeman J.E. Evan A.P. et al.Urine calcium and volume predict coverage of renal papilla by Randall's plaque.Kidney Int. 2003; 64: 2150-2154Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar Their urine oxalate excretion is high, and we can presume with reasonable certainty that hyperoxaluria (urine oxalate excretion >45 mg per day) increased urine supersaturation (SS) with respect to CaOx and led to crystal formation, perhaps in free solution. By contrast, ileostomy patients produce scanty and acidic urine, form abundant plaque, and produce attached CaOx stones over areas of papillary plaque. Their urine has a high uric acid SS that accounts for their uric acid stones. Urine sodium and ammonium urate SS was present in three of the five ileostomy patients with these salts in their IMCDs, indicating that, for urate species, IMCDs and urine were not discordant. Altogether, the types of stones formed by bypass and ileostomy patients that we have presented to date, as well as urate IMCD deposits, can be reasonably explained by their urine SS, and plaque abundance has seemed to follow urine volume, calcium, and pH as in ICSFs and normal subjects. What we cannot easily explain is the discordance between apatite IMCD deposits and both urine SS and compositions of stones formed. Though CaOx makes up the bulk of stones in bypass patients, and they are hyperoxaluric, apatite is the predominant IMCD crystal,2.Evan A.P. Coe F.L. Gillen D. et al.Renal intratubular crystals and hyaluronan staining occur in stone formers with bypass surgery but not with idiopathic calcium oxalate stones.Anat Rec. 2008; 291: 325-334Crossref Scopus (41) Google Scholar even though their average urine pH was below 5.5, and, correspondingly, their SS with respect to calcium phosphate (CaP) was below 1. Discordance is even greater with ileostomy. Although stones were composed of uric acid and CaOx, urine pH was low, and CaP SS was well below 1, apatite was the predominant IMCD crystal. In other words, in both diseases, the IMCD environment seems to produce and support apatite that would not be stable or predicted in their urine. Stones reflect the urine conditions, whereas IMCD deposits do not. Discordance is by no means the rule. ICSFs have very modest CaP SS in urine and never produce any IMCD crystal deposits.2.Evan A.P. Coe F.L. Gillen D. et al.Renal intratubular crystals and hyaluronan staining occur in stone formers with bypass surgery but not with idiopathic calcium oxalate stones.Anat Rec. 2008; 291: 325-334Crossref Scopus (41) Google Scholar Brushite SFs have higher urine CaP SS and produce IMCD apatite deposits;8.Evan A.P. Lingeman J.E. Coe F.L. et al.Crystal-associated nephropathy in patients with brushite nephrolithiasis.Kidney Int. 2005; 67: 576-591Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar the same is true for SFs with primary hyperparathyroidism5.Evan A.E. Lingeman J.E. Coe F.L. et al.Histopathology and surgical anatomy of patients with primary hyperparathyroidism and calcium phosphate stones.Kidney Int. 2008; 74: 223-229Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar, 9.Parks J.H. Coe F.L. Evan A.P. et al.Clinical and laboratory characteristics of calcium stone-formers with and without primary hyperparathyroidism.BJU Int. 2009; 103: 670-678Crossref PubMed Scopus (50) Google Scholar or distal renal tubular acidosis.10.Evan A.P. Lingeman J. Coe F. et al.Renal histopathology of stone-forming patients with distal renal tubular acidosis.Kidney Int. 2007; 71: 795-801Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar Hence, apatite deposits can occur, or not, in accord with urine SS; it is in our two bowel diseases that we have encountered a unique disconnect between urine and IMCD, the tubule fluid of which must closely approximate the final urine under normal circumstances. One way to advance the problem is to study additional groups of patients with bowel disease, in the hope that within the groups, we will eventually be able to discern mechanisms for the dissociation of IMCD apatite from final urine conditions and from stones. In this study, we present our work on 11 patients who form CaOx stones and have small bowel resection due to mainly Crohn's disease. For the first time, we can, in some patients, identify sizable IMCD CaOx deposits that are consistent with both urine SS and the stones being formed. However, in these deposits, we also always find apatite, as unexpected as in ileostomy and bypass patients. The details of these patients, taken along with those from bypass and ileostomy patients, lead to an initial hypothesis that might be of value for future research into the mechanisms for IMCD deposit formation, and complete present knowledge of crystal formation in tissues of SFs with bowel disease. In addition, these patients form interstitial plaque, and their urine findings support our past work indicating that scanty and acidic urine can promote plaque in the absence of overt hypercalciuria. In total, 11 patients were studied (Table 1); most patients were men and all but one (case 3) had Crohn's disease. Bowel surgeries numbered from one to seven procedures; the amount of bowel resected is not known to us. None had ileostomy or colostomy. Stone formation began before or after the surgery with a wide variation in timing (Table 1). Numbers of stones and procedures were often quite high. Serum creatinine values were not elevated; metabolic acidosis and hypokalemia were not observed. Stones were overwhelmingly CaOx monohydrate.Table 1Clinical characteristics and serum chemistriesPatientSexAge at first SB surgery (years)Age at first stone (years)Earlier stones (no.)Age at biopsy (years)ESWLPNLTotal proceduresSerum creatinine (mg/dl)Serum CO2 (mmol/l)Serum K (mmol/l) 1M23474481131.3324.1 2F3140>12522140.9273.6 3M112>30383150.8284.1 4M2220>25432251.0253.6 5M3426>10491580.9324.0 6M22283342130.9274.5 7M39393482151.0264.3 8M2424>50601271.1334.7 9F2634>125456120.8284.510M<40<40>10750551.0274.311M40471523260.8284.7Abbreviations: ESWL, extracorporeal shock wave lithotripsy; K, potassium; PNL, percutaneous nephrolithotomy; SB, small bowel.Total procedures include cystoscopy, open surgery, ureteroscopy, as well as ESWL and PNL. Open table in a new tab Abbreviations: ESWL, extracorporeal shock wave lithotripsy; K, potassium; PNL, percutaneous nephrolithotomy; SB, small bowel. Total procedures include cystoscopy, open surgery, ureteroscopy, as well as ESWL and PNL. A majority of papillae contained large deposits of white, interstitial apatite, plaque (Figure 1a–d, 2a and b). Abundance of white plaque ranged from 1.2 to 14.9% of surface area coverage, with a mean of 5±1 (Table 2). Some stones were found attached to papillae in all but one case (patient 11) (Figure 1, Figure 2, Table 2); when detached, they were found to grow over white plaque, as is found in ICSFs, primary hyperparathyroidism, and ileostomy patients.3.Evan A.P. Lingeman J.E. Coe F.L. et al.Intra-tubular deposits, urine and stone composition are divergent in patients with ileostomy.Kidney Int. 2009; 76: 1081-1088Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 4.Miller N.L. Gillen D.L. Williams Jr, J.C. et al.A formal test of the hypothesis that idiopathic calcium oxalate stones grow on Randall's plaque.BJU Int. 2009; 103: 966-971Crossref PubMed Scopus (64) Google Scholar, 5.Evan A.E. Lingeman J.E. Coe F.L. et al.Histopathology and surgical anatomy of patients with primary hyperparathyroidism and calcium phosphate stones.Kidney Int. 2008; 74: 223-229Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar All attached stones were composed of CaOx, with typical apatite deposits adherent at sites at which stones were attached to papillae (Figure 2c–e). In some regions, the density of attached stones over plaque was remarkable and similar to that found in ICSFs (Figure 2b).Figure 2Details of attached stones. (a) An attached stone (double arrow) is seen resting on a region of white plaque (single arrows) and intermixed with small areas of white (single arrow) and yellow plaques (arrowheads). (b) Patient 8 had numerous attached stones (double arrow) atop an extensive area of white plaque (single arrows) similar to that found in some idiopathic calcium oxalate stone formers (ICSFs). Analysis of attached stones by microcomputed tomography (μ-CT) revealed these to be composed of primarily calcium oxalate (CaOx), with small sites of apatite corresponding to a site of attachment to white (Randall's) plaque. (c, d) Light microscopic image of an attached stone revealing the smooth urinary (c) and papillary (d) surface morphology. The papillary surface (d) shows a concave region with crystalline material (single arrow) consistent with an attachment site. The urinary surface (c) shows a damaged region (double arrow) generated during stone removal. (e) Reconstruction of μ-CT images shows regions of CaOx in yellow and areas of apatite in white. The white regions appear to present at the attachment site.View Large Image Figure ViewerDownload (PPT)Table 2Surgical and pathological findings and stone typePatientPapillary deformity (%)Plaque papillary surface area (%)Stones attached to plaqueDilated BDIMCD BD depositsNature of IMCD crystalsGlomTub AtIFStone type 11004.80Yes+++6±2HA———COM (2) 2333.60Yes++2±1HA, CaOx19/1/2/411COM (1) 3103.03Yes+1±1HA33/1/0/222COM (1) 4106.38Yes+2±1HA, CaOx———COM (2) 5752.62Yes++2±1HA12/0/1/1122CaOx 91%, HA 9% (5) 61014.90Yes+1±1HA10/2/1/011COM (1) 7202.17Yes+1±1HA27/2/3/011COM (3) 8506.99Yes++4±1HA8/1/1/222COM (2) 9751.23Yes+++4±2HA17/1/2/322CaOx 95% (4)aSmall amount hydroxyapatite and acid ammonium urate in 1 stone each.10707.68Yes++1±1HA, CaOx13/1/1/1022COM (12)11101.76No+1±1HA5/1/0/211COM 98%, HA 2% (4)Abbreviations: % Papillary deformity, the fraction of papillae visualized at the time of surgery with deformity; % Plaque papillary surface area, mean percent of papillary surface covered by white plaque; CaOx, calcium oxalate; COM, calcium oxalate monohydrate; Dilated BD, degree of dilatation of Bellini ducts; Glom, number of glomeruli/mild/moderate/global sclerosis; HA, hydroxyapatite; IF, cortical interstitial fibrosis graded 1–3; IMCD/BD, inner medullary collecting duct+Bellini duct, mean number of deposits per mm2 of tissue on μ-CT; Stones attached to plaque, stones found attached to papilla on plaque at surgery; Tub At, cortical tubular atrophy, graded 1–3.a Small amount hydroxyapatite and acid ammonium urate in 1 stone each. Open table in a new tab Abbreviations: % Papillary deformity, the fraction of papillae visualized at the time of surgery with deformity; % Plaque papillary surface area, mean percent of papillary surface covered by white plaque; CaOx, calcium oxalate; COM, calcium oxalate monohydrate; Dilated BD, degree of dilatation of Bellini ducts; Glom, number of glomeruli/mild/moderate/global sclerosis; HA, hydroxyapatite; IF, cortical interstitial fibrosis graded 1–3; IMCD/BD, inner medullary collecting duct+Bellini duct, mean number of deposits per mm2 of tissue on μ-CT; Stones attached to plaque, stones found attached to papilla on plaque at surgery; Tub At, cortical tubular atrophy, graded 1–3. Intermixed with white plaque, we observed ample yellow plaque (Figure 1b and c), which is the gross reflection of IMCD crystal plugs (Figure 1b–d). Crystal plugs protrude (Figure 1b–d) from mouths of dilated Bellini ducts (BDs). Dilated BDs were most abundant in flattened and deformed papillae (Table 2). The amount of deformity was less than that found in brushite SFs,8.Evan A.P. Lingeman J.E. Coe F.L. et al.Crystal-associated nephropathy in patients with brushite nephrolithiasis.Kidney Int. 2005; 67: 576-591Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar but greater than that found in ileostomy patients. Intraoperative papillary microbiopsies revealed very large amounts of interstitial plaque (Figure 3a–c). As predicted from the operative appearance, multiple IMCDs were plugged with crystal deposits (Figure 3c, d and 4a–f; Table 2). Patterns of deposit vary from patient to patient. Three patients (Table 2, cases 1, 8 and 9) have a higher number of deposits than other patients. Two patients who do not have a large number of deposits (Table 2 cases 4 and 10), nevertheless, formed deposits of unusually large size (Figure 4a, b, e and f); because the deposits are large, their plugged ducts occupy most of whole regions of papillary tissue in the biopsy sample, to an extent only thus far encountered in renal tubular acidosis and brushite nephropathy.8.Evan A.P. Lingeman J.E. Coe F.L. et al.Crystal-associated nephropathy in patients with brushite nephrolithiasis.Kidney Int. 2005; 67: 576-591Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar, 10.Evan A.P. Lingeman J. Coe F. et al.Renal histopathology of stone-forming patients with distal renal tubular acidosis.Kidney Int. 2007; 71: 795-801Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar Even so, the overall density of plugging, estimated from microcomputed tomography (μ-CT) images (Table 2), is less than that which we have found in ileostomy patients. As usual, we found no inflammation around even extensive interstitial deposits; however, around plugged IMCDs, we found marked interstitial inflammation and fibrosis (Figures 3d and 4a–f).Figure 4Inner medullary collecting duct (IMCD) deposits mixture of apatite and calcium oxalate (CaOx). (a–d) Two different large IMCD plugs from separate patients are seen under nonpolarizing (a, c) versus polarizing (b, d) optics. These deposits show birefringent (arrowheads) and nonbirefringent (single arrows) crystals forming the same deposit, yet not admixed. The nonbirefringent crystals are probably apatite and the birefringent crystals CaOx. (e, f) An occasional small IMCD plug also possessed both birefringent (see arrowheads in panels e, f) and nonbirefringent (see single arrows in panels e, f) crystals. Original magnification × 25 (a–d); × 100 (e, f).View Large Image Figure ViewerDownload (PPT) Cortical changes (Table 2) included moderate glomerular sclerosis in all but two cases of patients (patients 5 and 10) who had global sclerosis of a majority of glomeruli. Tubular atrophy and interstitial fibrosis ranged from mild to moderate and did not track closely with glomerular sclerosis (Table 2). Serum creatinine (Table 1) did not reflect cortical changes. No cortical deposits were detected. All patients had some IMCDs with nonbirefringent crystal deposits, as would be found with apatite (Table 2). Although crystals in most IMCDs were exclusively nonbirefringent, in three patients (cases 2, 4, and 10; Table 2), we found some IMCDs containing both birefringent and nonbirefringent crystals. In fact, the IMCD plugs with both crystals contained mixtures of CaOx and apatite. Using micro-FTIR (fourier-transformed infrared spectroscopy), birefringent deposits were always found to be composed of CaOx (Figure 5 illustrates case 4). Nonbirefringent deposits were always composed of apatite (Figure 5 illustrates case 3). Because we have made these positive determinations by FTIR, we have labeled deposits in Table 2 by their crystal structure and not by their optical appearance. Although present in the same plugs, CaOx and apatite were never admixed together, but occupied separate regions (Figure 4a–f). Urine CaOx SS was quite high in most of the patients (Table 3), the exceptions being cases 4, 8, and 9. Uric acid SS was substantial in cases 6, 7, and 10; no stones contained uric acid. One patient (Table 3, case 9) had some ammonium acid urate in one stone. At the time of our study, the high urine volume and unexceptional urine ammonia level did not create a high SS with respect to that of salt (not shown). Overall, the SS values are reasonably consistent with the predominance of CaOx in stones. As urine pH is generally below 6 and SS with respect to CaP as brushite is below 1 in almost all patient samples, the presence of abundant apatite in IMCD deposits is unexplained.Table 3Urine results (24 h)PatientVolpHCITCaOxNAUANH4SULSS UASS CaOxSS CaPWt (kg) 11.705.413241175713743042231.319.700.1875 20.666.0580158438637664281.1026.903.1057 32.385.532482435727250669371.008.810.3659 41.685.6150693518246052211.074.030.0957 50.755.67898821632583171.4210.21.1050 61.135.272607514223945363272.3717.030.18100 71.135.281281174417450739332.6210.590.2191 82.475.703543710422251236240.703.250.0786 92.365.934342084417834939230.366.360.8461100.855.1456336212128042412.3411.770.0558111.965.614014810625062753331.2814.50.3977Abbreviations: Ca, calcium (mg per day); CaOx, calcium oxalate; CaP, calcium phosphate; CIT, citrate (mg per day); Na, sodium (mEq per day); NH4, ammonium (mEq per day); Ox, oxalate (mg per day); SS, supersaturation; SUL, sulfate (mEq per day); UA, uric acid (mg per day); Vol, volume (l per day).Results are the mean of two collections for each patient. Open table in a new tab Abbreviations: Ca, calcium (mg per day); CaOx, calcium oxalate; CaP, calcium phosphate; CIT, citrate (mg per day); Na, sodium (mEq per day); NH4, ammonium (mEq per day); Ox, oxalate (mg per day); SS, supersaturation; SUL, sulfate (mEq per day); UA, uric acid (mg per day); Vol, volume (l per day). Results are the mean of two collections for each patient. Perhaps the most informative way to discuss these cases is in relation to our earlier findings in patients with ileostomy and bypass for obesity.1.Evan A.P. Lingeman J.E. Coe F.L. et al.Randall's plaque of patients with nephrolithiasis begins in basement membranes of thin loops of Henle.J Clin Invest. 2003; 111: 607-616Crossref PubMed Scopus (468) Google Scholar, 3.Evan A.P. Lingeman J.E. Coe F.L. et al.Intra-tubular deposits, urine and stone composition are divergent in patients with ileostomy.Kidney Int. 2009; 76: 1081-1088Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar As a group, the small bowel, ileostomy, and bypass cases all formed similar numbers of stones per patient year, that is, ~1.1, 1.1, and 0.8, respectively. Surgical procedure rates for stones of all bypasses and for the present series were about 0.6 per patient year; for ileostomy it was 1.5 per patient year. In bypass cases and in the present series, stones were essentially composed of only CaOx; ileostomy patients formed stones composed of uric acid and CaOx. At surgery, bypass patients displayed minimal papillary abnormality, which consisted only of an occasional plugged BD. Ileostomy patients displayed less papillary deformity than the patients of this study, and about the same extent of BD plugging; both markedly exceeded the minimal findings in bypass patients. Histopathologically, IMCD and BD deposits were far more marked in ileostomy patients than in the present group (12 versus 2.2 deposits per mm2, 95% confidence interval of difference 2–17.6, P=0.02); among bypass patients, we found the least of all, only a rare plugged duct. Altogether, the three groups form a gradient of pathology, bypass being the least involved, ileostomy the most, and the cases presented here falling somewhere in between. Only ileostomy patients formed uric acid stones. Plaque, in our present series, was abundant; this is not surprising as urine pH was low and urine volume was often low. Moreover, as noted, urine volume would most likely have been much lower at intervals of worsened diarrhea. Compared with bypass, ileostomy, and routine CaOx SFs, as well as normal people, the patients in this study fall between ileostomy patients and normal subjects in pH and have the lowest volume of ileostomy cases (Figure 6). Plaque abundance is reasonable for their position on the three axes of this plot. Bypass SFs have urine pH similar to that of patients in this study, but of much higher volume and much less plaque. The stones are also not problematic. CaOx SS is high, and we found CaOx stones growing over regions of apatite plaque. Hence, unlike the complex problems raised by deposits, the plaque and stones found here are in accord with, and help to confirm, the model that we have presented elsewhere of plaque formation with a scanty acidic urine3.Evan A.P. Lingeman J.E. Coe F.L. et al.Intra-tubular deposits, urine and stone composition are divergent in patients with ileostomy.Kidney Int. 2009; 76: 1081-1088Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 7.Kuo R.L. Lingeman J.E. Evan A.P. et al.Urine calcium and volume predict coverage of renal papilla by Randall's plaque.Kidney Int. 2003; 64: 2150-2154Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar and subsequent CaOx stone overgrowth driven by urine CaOx SS. The problem here, as in the other bowel diseases, is in explaining apatite IMCD deposits when urine SS would lead one to expect CaOx or uric acid deposits. In bypass cases, we found that IMCD and BD plugs were almost invariably apatite. CaOx was found only as a microscopic linear deposit over the apical surfaces of a few IMCD cells in three of the five patients, and in a small IMCD plug in two of these three patients. Deposits in ileostomy patients were composed of apatite and never of CaOx; we also found ammonium and sodium salts of uric acid that could be explained by urine SS. Here again, we find apatite in IMCDs of all patients; one IMCD in each of the three cases had a plug containing CaOx as well as apatite. Two of these plugs were very large, among the largest IMCD plugs we found, and were vastly larger than the CaOx plugs in our bypass patients. Given that stones were composed of CaOx in all three groups, and sometimes of uric acid in ileostomy cases, IMCD and BD apatite deposits have always diverged from stones and urine SS. How can we account for the divergence and differences between these three groups? One approach is to consider relevant urine chemistry values in relation to the kind of IMCD deposits encountered. For this purpose, we compared measurements in our 5 published cases of bypass surgery1.Evan A.P. Lingeman J.E. Coe F.L. et al.Randall's plaque of patients with nephrolithiasis begins in basement membranes of thin loops of Henle.J Clin Invest. 2003; 111: 607-616Crossref PubMed Scopus (468) Google Scholar, 2.Evan A.P. Coe F.L. Gillen D. et al.Renal intratubular crystals and hyaluronan staining occur in stone formers with bypass surgery but not with idiopathic calcium oxalate stones.Anat Rec. 2008; 291: 325-334Crossref Scopus (41) Google Scholar with measurements of 7 patients with ileostomy,3.Evan A.P. Lingeman J.E. Coe F.L. et al.Intra-tubular deposits, urine and stone composition are divergent in patients with ileostomy.Kidney Int. 2009; 76: 1081-1088Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar as well as with those of the 11 patients of this study, and, for reference, with measurements obtained from 15 ICSFs2.Evan A.P. Coe F.L. Gillen D. et al." @default.
• W2034206298 created "2016-06-24" @default.
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• W2034206298 title "Renal histopathology and crystal deposits in patients with small bowel resection and calcium oxalate stone disease" @default.
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