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ACUTE RENAL FAILURE ASSOCIATED WITH SULFUR CALCULI
0022-5347/01/1656-1985/0 THE JOURNAL OF UROLOGY® Copyright © 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.®
Vol. 165, 1985–1986, June 2001 Printed in U.S.A.
ACUTE RENAL FAILURE ASSOCIATED WITH SULFUR CALCULI MOTOAKI SAITO, CHIHIRO TAKAHASHI, GORO ISHIDA, HIROYUKI KADOWAKI, SHINJI HIRAKAWA AND IKUO MIYAGAWA From the Departments of Urology, Yonago National Hospital and Tottori University Faculty of Medicine, Yonago, Japan KEY WORDS: kidney failure, acute; urinary calculi; sulfasalazine; colitis, ulcerative; kidney
Drug induced urolithiasis originating from sulfasalazine is extremely rare and only a limited number of cases has been reported in the international literature. 1, 2 We report on a patient with acute renal failure caused by sulfur calculi, who had a history of ulcerative colitis and had been treated with sulfasalazine for 14 years. CASE REPORT
An 85-year-old Japanese man presented with abdominal discomfort and general fatigue. History included (stage A1) prostate cancer, G1T1a transitional cell carcinoma of the bladder for 4 years and ulcerative colitis, which had been treated with 4.5 gm. sulfasalazine daily for 14 years. Laboratory examination showed renal failure (serum blood urea nitrogen was 26 mg./dl. and creatinine was 1.71 mg./dl.). Ultrasonography, computerized tomography and x-ray revealed bilateral hydronephrosis, right multiple renal stones, a ureteropelvic junction stone and a left ureterovesical junction stone (see figure). The left ureteral stone was spontaneously discharged 5 days after the initial consult. The patient underwent 4 sessions of shock wave lithotripsy and percutaneous nephrolithotomy to remove stones in the right renal pelvis and ureteropelvic junction, after ureteral stenting. After stenting, renal function returned to normal (blood urea nitrogen 10 mg./dl. and serum creatinine 0.89 mg./dl.). Stone analysis revealed acetylsulfapyridine, which is a metabolite of sulfasalazine. After the final diagnosis, sulfasalazine was replaced with mesalamine (5-aminosalicylic acid) to treat the ulcerative colitis, and at 6-month followup no recurrence of stone disease was observed. DISCUSSION
Is is well known that drugs, for example silicate and acetazolamide, induce calculi, and sulfonamide preparations produce crystalluria and urolithiasis.1, 2 However, urolithiasis induced by sulfasalazine is extremely rare and only a few cases have been reported.1, 2 Although acute renal failure caused by sulfadiazine stones in a patient with AIDS as a complication of toxoplasmosis treatment has been reported,3 to our knowledge we report the first case of acute renal failure caused by sulfasalazine induced calculi. Sulfasalazine is metabolized by intestinal flora into sulfapyridine and 5-aminosalicylic acid. These are acetylated into acetylsulfapyridine and 5-acetylaminosalicylic acid in the liver.1, 2 Most of sulfapyridine and acetylsulphapyridine is excreted in urine. As in cases of aciduria, sulfapyridine and acetylsulfapyridine are hardly resolved, and urine in patients treated with sulfasalazine should be alkalized to prevent crystal formation.1–3 With these particular patients, withdrawal of sulfasalazine or replacement of the drug with mesalamine (5-aminosalicylic acid) and rehydration can prevent the production of sulfasalazine induced calculi. Careful observation of elderly patients treated with sulfasalazine is required to avoid dehydration and aciduria, and the subsequent formation of stones.
Computerized tomography. A, multiple stones in right renal pelvis. B, 2.0 ⫻ 1.5 cm. stone in right ureteropelvic junction. C, small stone in left ureterovesical junction.
Accepted for publication January 19, 2001. 1985
1986
ACUTE RENAL FAILURE ASSOCIATED WITH SULFUR CALCULI
Dr. T. Ikeda assisted with this manuscript. REFERENCES
1. Sillar, D. B. and Kleinig, D.: Sulphur calculi from ingestion of sulphasalazine. Br J Urol, 71: 750, 1993 2. Yanagisawa, R., Kamijo, T. and Nagase, Y.: A case of drug
induced urolithiasis composed of acetyl sulphapyridine associated with ulcerative colitis. Nippon Hinyokika Gakkai Zasshi, 90: 462, 1999 3. Kronawitter, U., Jakob, K., Zoller, W. G. et al: Acute renal failure caused by sulphadiazine stones: a complication of the therapy of toxoplasmosis in AIDS. Dtsch Med Wochenschr, 118: 1683, 1993
Vol. 165, 1985–1986, June 2001 Printed in U.S.A.
ACUTE RENAL FAILURE ASSOCIATED WITH SULFUR CALCULI MOTOAKI SAITO, CHIHIRO TAKAHASHI, GORO ISHIDA, HIROYUKI KADOWAKI, SHINJI HIRAKAWA AND IKUO MIYAGAWA From the Departments of Urology, Yonago National Hospital and Tottori University Faculty of Medicine, Yonago, Japan KEY WORDS: kidney failure, acute; urinary calculi; sulfasalazine; colitis, ulcerative; kidney
Drug induced urolithiasis originating from sulfasalazine is extremely rare and only a limited number of cases has been reported in the international literature. 1, 2 We report on a patient with acute renal failure caused by sulfur calculi, who had a history of ulcerative colitis and had been treated with sulfasalazine for 14 years. CASE REPORT
An 85-year-old Japanese man presented with abdominal discomfort and general fatigue. History included (stage A1) prostate cancer, G1T1a transitional cell carcinoma of the bladder for 4 years and ulcerative colitis, which had been treated with 4.5 gm. sulfasalazine daily for 14 years. Laboratory examination showed renal failure (serum blood urea nitrogen was 26 mg./dl. and creatinine was 1.71 mg./dl.). Ultrasonography, computerized tomography and x-ray revealed bilateral hydronephrosis, right multiple renal stones, a ureteropelvic junction stone and a left ureterovesical junction stone (see figure). The left ureteral stone was spontaneously discharged 5 days after the initial consult. The patient underwent 4 sessions of shock wave lithotripsy and percutaneous nephrolithotomy to remove stones in the right renal pelvis and ureteropelvic junction, after ureteral stenting. After stenting, renal function returned to normal (blood urea nitrogen 10 mg./dl. and serum creatinine 0.89 mg./dl.). Stone analysis revealed acetylsulfapyridine, which is a metabolite of sulfasalazine. After the final diagnosis, sulfasalazine was replaced with mesalamine (5-aminosalicylic acid) to treat the ulcerative colitis, and at 6-month followup no recurrence of stone disease was observed. DISCUSSION
Is is well known that drugs, for example silicate and acetazolamide, induce calculi, and sulfonamide preparations produce crystalluria and urolithiasis.1, 2 However, urolithiasis induced by sulfasalazine is extremely rare and only a few cases have been reported.1, 2 Although acute renal failure caused by sulfadiazine stones in a patient with AIDS as a complication of toxoplasmosis treatment has been reported,3 to our knowledge we report the first case of acute renal failure caused by sulfasalazine induced calculi. Sulfasalazine is metabolized by intestinal flora into sulfapyridine and 5-aminosalicylic acid. These are acetylated into acetylsulfapyridine and 5-acetylaminosalicylic acid in the liver.1, 2 Most of sulfapyridine and acetylsulphapyridine is excreted in urine. As in cases of aciduria, sulfapyridine and acetylsulfapyridine are hardly resolved, and urine in patients treated with sulfasalazine should be alkalized to prevent crystal formation.1–3 With these particular patients, withdrawal of sulfasalazine or replacement of the drug with mesalamine (5-aminosalicylic acid) and rehydration can prevent the production of sulfasalazine induced calculi. Careful observation of elderly patients treated with sulfasalazine is required to avoid dehydration and aciduria, and the subsequent formation of stones.
Computerized tomography. A, multiple stones in right renal pelvis. B, 2.0 ⫻ 1.5 cm. stone in right ureteropelvic junction. C, small stone in left ureterovesical junction.
Accepted for publication January 19, 2001. 1985
1986
ACUTE RENAL FAILURE ASSOCIATED WITH SULFUR CALCULI
Dr. T. Ikeda assisted with this manuscript. REFERENCES
1. Sillar, D. B. and Kleinig, D.: Sulphur calculi from ingestion of sulphasalazine. Br J Urol, 71: 750, 1993 2. Yanagisawa, R., Kamijo, T. and Nagase, Y.: A case of drug
induced urolithiasis composed of acetyl sulphapyridine associated with ulcerative colitis. Nippon Hinyokika Gakkai Zasshi, 90: 462, 1999 3. Kronawitter, U., Jakob, K., Zoller, W. G. et al: Acute renal failure caused by sulphadiazine stones: a complication of the therapy of toxoplasmosis in AIDS. Dtsch Med Wochenschr, 118: 1683, 1993