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Case report
peer-reviewed

Chronic Nephropathy from Dietary Hyperoxaluria: Sustained Improvement of Renal Function after Dietary Intervention



Abstract

A 56-year-old man with stable chronic kidney disease (CKD) for two years following a single episode of calcium oxalate urolithiasis developed progressive elevation of his serum creatinine concentration. Urinalysis revealed pyuria and white cell casts, a few red blood cells, minimal proteinuria, and no crystals. Urine culture was sterile. Gallium scintigraphy was consistent with interstitial nephritis. Proton pump inhibitor intake was discontinued, and a short course of oral corticosteroids was initiated. Percutaneous kidney biopsy, performed because of the continued deterioration of renal function to a minimum estimated glomerular filtration rate (eGFR) value of 15 mL/min per 1.73 m2 and persistent pyuria, revealed deposition of oxalate crystals in the tubules and interstitium, pronounced tubular changes, and interstitial nephritis and fibrosis. Urinary oxalate excretion was very high, in the range usually associated with primary hyperoxaluria. However, investigations for primary or enteric hyperoxaluria were negative. He reported a diet based on various nuts high in oxalate content. Estimated oxalate content in the diet was, for years, approximately four times higher than that in the average American diet. The institution of a diet low in oxalates resulted in the rapid normalization of urinary oxalate excretion and urinary sediment and in the slow, continuous improvement of renal function to near normal levels (eGFR 59 mL/min/1.73 m2) before his death from a brain malignancy 3.5 years later. The manifestations of nephropathy secondary to dietary hyperoxaluria, including the urine findings, can be indistinguishable from other types of interstitial nephritis. The diagnosis of dietary hyperoxaluria requires careful dietary history and a kidney biopsy. Identifying dietary hyperoxaluria as the cause of CKD is important because the decrease in dietary oxalate intake without any other measures can lead to sustained improvement in renal function.



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Case report
peer-reviewed

Chronic Nephropathy from Dietary Hyperoxaluria: Sustained Improvement of Renal Function after Dietary Intervention


Author Information

Yijuan Sun

Epidemiology, Raymond G Murphy VA Medical Center

Bruce L. Horowitz

Medicine, University of Utah School of Medicine, University of Utah

Karen S. Servilla

Nephrology, Raymond G Murphy VA Medical Center

Joanna R. Fair

Radiology, University of New Mexico School of Medicine

Darlene Vigil

Nephrology, Raymond G Murphy VA Medical Center

Kavitha Ganta

Medicine Service, Raymond G Murphy VA Medical Center

Larry Massie

Pathology Service, Raymond G Murphy VA Medical Center

Antonios H. Tzamaloukas Corresponding Author

University of New Mexico School of Medicine


Ethics Statement and Conflict of Interest Disclosures

Human subjects: Consent was obtained by all participants in this study. Human Research Commitee (HRC), Raymond G. Murphy VA Medical Center issued approval Oral approval for case reports is provided by the HRC. Approval obtained for case presentation.
Informed consent was waived. Conflicts of interest: The authors have declared that no conflicts of interest exist.


Case report
peer-reviewed

Chronic Nephropathy from Dietary Hyperoxaluria: Sustained Improvement of Renal Function after Dietary Intervention


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Case report
peer-reviewed

Chronic Nephropathy from Dietary Hyperoxaluria: Sustained Improvement of Renal Function after Dietary Intervention

  • Author Information
    Yijuan Sun

    Epidemiology, Raymond G Murphy VA Medical Center

    Bruce L. Horowitz

    Medicine, University of Utah School of Medicine, University of Utah

    Karen S. Servilla

    Nephrology, Raymond G Murphy VA Medical Center

    Joanna R. Fair

    Radiology, University of New Mexico School of Medicine

    Darlene Vigil

    Nephrology, Raymond G Murphy VA Medical Center

    Kavitha Ganta

    Medicine Service, Raymond G Murphy VA Medical Center

    Larry Massie

    Pathology Service, Raymond G Murphy VA Medical Center

    Antonios H. Tzamaloukas Corresponding Author

    University of New Mexico School of Medicine


    Ethics Statement and Conflict of Interest Disclosures

    Human subjects: Consent was obtained by all participants in this study. Human Research Commitee (HRC), Raymond G. Murphy VA Medical Center issued approval Oral approval for case reports is provided by the HRC. Approval obtained for case presentation.
    Informed consent was waived. Conflicts of interest: The authors have declared that no conflicts of interest exist.

    Acknowledgements


    Article Information

    Published: March 20, 2017

    DOI

    10.7759/cureus.1105

    Cite this article as:

    Sun Y, Horowitz B L, Servilla K S, et al. (March 20, 2017) Chronic Nephropathy from Dietary Hyperoxaluria: Sustained Improvement of Renal Function after Dietary Intervention. Cureus 9(3): e1105. doi:10.7759/cureus.1105

    Publication history

    Received by Cureus: November 22, 2016
    Peer review began: December 02, 2016
    Peer review concluded: March 10, 2017
    Published: March 20, 2017

    Copyright

    © Copyright 2017
    Sun et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 3.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    License

    This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract

A 56-year-old man with stable chronic kidney disease (CKD) for two years following a single episode of calcium oxalate urolithiasis developed progressive elevation of his serum creatinine concentration. Urinalysis revealed pyuria and white cell casts, a few red blood cells, minimal proteinuria, and no crystals. Urine culture was sterile. Gallium scintigraphy was consistent with interstitial nephritis. Proton pump inhibitor intake was discontinued, and a short course of oral corticosteroids was initiated. Percutaneous kidney biopsy, performed because of the continued deterioration of renal function to a minimum estimated glomerular filtration rate (eGFR) value of 15 mL/min per 1.73 m2 and persistent pyuria, revealed deposition of oxalate crystals in the tubules and interstitium, pronounced tubular changes, and interstitial nephritis and fibrosis. Urinary oxalate excretion was very high, in the range usually associated with primary hyperoxaluria. However, investigations for primary or enteric hyperoxaluria were negative. He reported a diet based on various nuts high in oxalate content. Estimated oxalate content in the diet was, for years, approximately four times higher than that in the average American diet. The institution of a diet low in oxalates resulted in the rapid normalization of urinary oxalate excretion and urinary sediment and in the slow, continuous improvement of renal function to near normal levels (eGFR 59 mL/min/1.73 m2) before his death from a brain malignancy 3.5 years later. The manifestations of nephropathy secondary to dietary hyperoxaluria, including the urine findings, can be indistinguishable from other types of interstitial nephritis. The diagnosis of dietary hyperoxaluria requires careful dietary history and a kidney biopsy. Identifying dietary hyperoxaluria as the cause of CKD is important because the decrease in dietary oxalate intake without any other measures can lead to sustained improvement in renal function.



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Create a free account to continue reading this article.

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Yijuan Sun

Epidemiology, Raymond G Murphy VA Medical Center

Bruce L. Horowitz

Medicine, University of Utah School of Medicine, University of Utah

Karen S. Servilla

Nephrology, Raymond G Murphy VA Medical Center

Joanna R. Fair

Radiology, University of New Mexico School of Medicine

Darlene Vigil

Nephrology, Raymond G Murphy VA Medical Center

Kavitha Ganta

Medicine Service, Raymond G Murphy VA Medical Center

Larry Massie

Pathology Service, Raymond G Murphy VA Medical Center

Antonios H. Tzamaloukas, M.D.

University of New Mexico School of Medicine

For correspondence:
antonios.tzamaloukas@va.gov

Yijuan Sun

Epidemiology, Raymond G Murphy VA Medical Center

Bruce L. Horowitz

Medicine, University of Utah School of Medicine, University of Utah

Karen S. Servilla

Nephrology, Raymond G Murphy VA Medical Center

Joanna R. Fair

Radiology, University of New Mexico School of Medicine

Darlene Vigil

Nephrology, Raymond G Murphy VA Medical Center

Kavitha Ganta

Medicine Service, Raymond G Murphy VA Medical Center

Larry Massie

Pathology Service, Raymond G Murphy VA Medical Center

Antonios H. Tzamaloukas, M.D.

University of New Mexico School of Medicine

For correspondence:
antonios.tzamaloukas@va.gov