Pediatr Nephrol (2012) 27:9599

DOI 10.1007/s00467-011-1936-4

ORIGINAL ARTICLE

Urinary calcium and uric acid excretion in children

with vesicoureteral reflux
Abbas Madani & Nooshin Kermani &
Neamatollah Ataei & Seyed Taher Esfahani &
Niloufar Hajizadeh & Zahra Khazaeipour & Sima Rafiei

Received: 7 October 2010 / Revised: 22 May 2011 / Accepted: 24 May 2011 / Published online: 4 August 2011
# IPNA 2011

Abstract Urolithiasis is relatively common in children, and

identifiable predisposing factors for stone formation, including metabolic and structural derangements, can be
established in most cases. Vesicoureteral reflux (VUR) is a
common cause of kidney stone formation. The pathophysiological mechanism of urolithiasis in reflux is related to
urinary tract infection and urinary stasis, both of which
promote urinary crystal formation, but metabolic causes,
such as crystallurias (mostly hypercalciuria), may also be
involved in this process. However, few studies on urinary
calcium and uric acid excretion in children with VUR have
been conducted. We have studied the frequency of hypercalciuria and hyperuricosuria in children with VUR and
compared the results with those from a control group. The
VUR group comprised 108 children with VUR (19 boys,
A. Madani : N. Kermani (*) : N. Ataei : S. T. Esfahani :
N. Hajizadeh
Department of Pediatric Nephrology,
Childrens Hospital Medical Center, School of Medicine,
Tehran University of Medical Sciences,
Tehran, Iran
e-mail: nkermani@irimc.org
Z. Khazaeipour
Brain and Spinal Injury Repair Research Center of Imam
Khomeini Hospital Complex,
Tehran University of Medical Sciences,
Tehran, Iran
S. Rafiei
Department of Management and Health Economics,
Health faculty, Tehran University of Medical Sciences,
Tehran, Iran
S. Rafiei
Students Scientific Research Center (SSRC),
Tehran University of Medical Sciences,
Tehran, Iran

89 girls; age range 3 months to 12 years), and the control

group comprised 110 healthy children without any history
of reflux or urinary tract infection (30 boys, 80 girls; age
range 2 months to 12 years). Fasting urine was analyzed for the
calcium/creatinine (Ca/Cr) and uric acid/creatinine (UA/Cr)
ratios. Hypercalciuria was more frequently diagnosed in the
VUR patients than in the control group (21.3 vs. 3.6%; P=
0.0001). Significant differences between the two groups were
also found for the mean Ca/Cr and UA/Cr ratios (P=0.0001
and P=0.0001, respectively). No differences were found in the
urinary Ca/Cr or UA/Cr ratios related to VUR grading or
unilateral/bilateral VUR in the patient group, with the exception
of those for hypercalciuria and mild VUR (P=0.03). The
association of urinary stones and microlithiasis in the VUR
group was 29.6%. Our results demonstrate that the frequency
of hypercalciuria and hyperuricosuria was higher in pediatric
patients with VUR than in healthy children. Knowing this
relationship, preventive and therapeutic interventions for stone
formation in VUR could be greatly expanded.
Keywords Vesicoureteral reflux . Hypercalciuria .
Hyperuricosuria children

Introduction
Urinary calculi in children is a relatively common entity for
which an annual incidence of about 1% have been observed
in some countries [1]. The many factors contributing to
stone formation fall into two broad categories, namely,
anatomical abnormalities and metabolic disorders [25].
Anatomical abnormalities, such as ureteropelvic junction
obstruction (UPJO) or vesicoureteral reflux (VUR) are
associated with infection and urinary stasis, both of which
enhance stone formation [3, 6]. The traditional view of

96

urolithiasis is that a number of different factors, such as

urinary stasis and infection, are involved in stone formation. However, the current belief is that metabolic abnormalities, including hypercalciuria and hyperuricosuria, also
play an important role as risk factors [1, 3]. Crystallurias,
mostly due to hypercalciuria, can predispose children to
hematuria, dysuria, frequency, and urgency, but although
there is evidence of an association between hypercalciuria
and urinary tract infections (UTI), there is no definitive
evidence showing that hypercalciuria leads to UTI [716].
In actual fact, urinary calcium excretion increases in a
patient with a UTI [2, 10, 13, 14].
VUR is an important cause of kidney damage in children
and is commonly identified in children with urolithiasis.
The prevalence of VUR in patients with renal stones has
been estimated to be between 8 and 18% [1721]. It has
been reported that some patients who were treated for VUR
in childhood presented in later life with renal stones [22]. A
number of authors have proposed an association between
hypercalciuria and VUR to explain this phenomenon [5,
2224], but others claim that this association is purely by
chance [23]. A link between hypercalciuria and UPJO,
however, has been explained [6, 25].
Few studies have focused on the association of hypercalciuria and hyperuricosuria with VUR. Hence, the aim of
our study was to determine the frequency of hypercalciuria
and hyperuricosuria in Iranian pediatric patients with VUR
and compare this frequency with that in a healthy pediatric
control group.

Patients and methods

This was a cross-sectional study conducted in the clinics of
Children's Medical Center Hospital, which is affiliated to
Tehran University of Medical Sciences, from November
2001 to May 2009. The study cohort comprised 108
pediatric patients (19 boys, 89 girls) with known VUR [in
whom VUR was diagnosed after urinary tract infection
(UTI) episodes] aged 3 months to 12 years (VUR group)
and 110 healthy children (30 boys, 80 girls ) aged 2 months
to 12 years (control group). The patient and control groups
were obtained according to prevalence of hypercalciuria in
the normal pediatric population and in children with VUR
[23, 26]. The children were studied for microscopic hematuria, pyuria, dysuria and voiding disorders, such as enuresis and
incontinence, and for calcium/creatinine (Ca/Cr) and uric acid/
creatinine (UA/Cr) ratios. All children were checked for
microscopic hematuria (5 erythrocyte/hpf on a centrifuged
urine specimen) and pyuria (10 white blood cells/hpf)
according to reference values [27, 28]. Two fasting urine
samples were obtained from each subject in the morning,
about 2 weeks apart. All samples were examined for urine

Pediatr Nephrol (2012) 27:9599

analysis, culture, Ca/Cr (mg/mg) and UA/Cr ratios (mg/mg).

We included subjects with negative urine cultures and
without conditions that adversely affect laboratory results.
The children were on regular diets. According to VUR
grading based on two different methods of cystography
(nuclear or conventional), we considered the VUR to be mild
(grade I), moderate (grade IIIII), or severe (grade IVV)
[29]. All tests were performed using standard laboratory
techniques. Urine calcium and uric acid were measured
using a photometric and enzymatic colorimetric method,
respectively; both tests were performed on a Hitachi
model 911 chemistry autoanalyzer (Roche Diagnostics,
Mannheim Germany). Urine creatinine was measured on
a Cobas Mira chemistry autoanalyzer (Roche Diagnostics) using a colorimetric assay based on the Jaffe
reaction. According to reference values, a Ca/Cr ratio
(mg/mg) of >0.8 in infants aged 06 months, >0.6 in
infants aged 612 months, and >0.21 in children >2 years
and a UA/Cr ratio (mg/mg) of >1 can be considered as
abnormal and significant [9, 26, 3037].
The collected data were analyzed by SPSS ver. 16
software (SPSS, Chicago, IL) using Students t test, the
MannWhitney U test, chi-square test, and logistic regression analysis, with P values of <0.05 considered to be
significant. As the age range of the subjects in the two
study groups was different, we used the logistic regression
model and analysis of covariance test (ANCOVA) for
adjusting age. Quantitative variables are shown as the
mean standard deviation (SD) and qualitative variables
are given as percentages.
Prior to starting the investigation, we explained the
nature, aims, and benefits of the study to the parents or
guardians and written informed consent. The study was
approved by the ethics committee of Tehran University of
Medical Sciences.

Results
The VUR group consisted of 108 children with VUR (19
boys, 89 girls) and the control group comprised 110 healthy
children (30 boys, 80 girls). The mean age of patients in the
VUR group was 29.6929.27 months and that of the children
in the control group was 59.3635.71 months. Demographic
data for both groups are presented in Table 1. There were 23
children (21.3%) in the VUR group and four children (3.6%)
in the control group with hypercalciuria, [odds ratio (OR)
7.17, 95% confidence interval (CI) 2.3821.53, P=0.0001).
We also identified 20 children (18.5%) in the VUR group and
two children (1.8%) in the control group with hyperuricosuria (OR12.27, 95% CI 2.7953.94, P=0.0001) (Table 1).
The mean Ca/Cr and mean UA/Cr ratios differed
significantly between the two study groups (case vs.

Pediatr Nephrol (2012) 27:9599

97

Table 1 Demographic data on the two study groups in relation to hypercalciuria and hyperuricosuria
Demographic data

Case

Control

Pa

Number of patients
Age, years (meanSD)
Sex (male:female)
Hypercalciuria
Hyperuricosuria

108
29.6929.27
19 (17.6%):89 (82.4 %)
23 (21.3%)
20 (18.5%)

110
59.3635.71
30 (27.3%):80 (72.7%)
4 (3.6 %)
2 (1.8 %)

<0.001b
0.08
<0.0001
<0.0001

SD, Standard deviation

Data are presented as the number (n) of subjects in each group, with the percentage in parenthesis, unless indicated otherwise
a

Pearson chi-square test

t test

control: 0.310.22 vs. 0.180.09, P =0.0001; 0.510.46

vs. 0.350.14, P =0.0001, respectively). In the ANCOVA
test, the mean Ca/Cr and UA/Cr ratios in the VUR group
were significantly higher than those of the control group,
adjusting for age (P=0.004 and P=0.003, respectively). In
the logistic regression analysis, an increase of 1 unit of Ca/Cr
increased the odds of VUR (OR24.5, 95.0% CI 2.1281.2,
P=0.01) adjusted for age.
The urinary excretion of calcium was not normally
distributed, as shown in Table 2 (the data were analyzed
using the one-sample KolmogorovSmirnov test).
Voiding disorders, such as incontinence or enuresis, were
found in two VUR patients (1.9%) free of crystallurias.
We found no significant differences in urinary Ca/Cr and
UA/Cr ratios related to VUR grading or unilateral/ bilateral
reflux in the VUR group, with the exception of hypercalciuria
and mild reflux (P=0.03) (Table 3). The statistical analysis
did indicate that hypercalciuria was significantly associated
with VUR grading, but we noted that, on the whole, the
possibility of hypercalciuria was low in mild VUR (OR0.36,
95% CI 0.140.95). Also, although the possibility of
developing hypercalciuria increased with increasing VUR
grading, the correlation was not statistically significant.
The frequency of urinary stones and microlithiasis in
children with VUR was 29.6%, and the association of
hypercalciuria and urinary stones was 62.5% in hypercalciuric children (OR7.5, 95% CI 2.720.5, P=0.001).
The association of hyperuricosuria and urinary stones
was 50% in hyperuricosuric children (OR3, 95% CI 1.1
8.1). Thirty-two patients (29.6%) in the VUR group had
urinary stones, of whom 15 had hypercalciuria (46.9%) and
Table 2 Ca/Cr and UA/Cr ratios in the two study groups

Ca/Cr, Calcium/creatinine ratio;

UA/Cr, uric acid/creatinine ratio
a

t test

ten had hyperuricosuria (31.2%). We did not find any child

in the control group with urinary stones. Eleven children
with urinary stones (34.4%) in the VUR group were free of
these crystallurias.
Among the children in the VUR group, microscopic
hematuria was observed in 11 children with hypercalciuria
(40.7%; P=0.001, OR4.17) and in eight children with
hyperuricosuria (36.4%; P=0.01, OR 3.16) . None of our
patients had macroscopic hematuria. Four children had
pyuria (20%; P=0.004, OR21.7), and four children had
dysuria with hyperuricosuria (20%; P=0.03, OR=5.2).
Among the hypercalciuric patients there were three cases of
dysuria (13%; P=0.2), but none of these patients had pyuria.
There were seven children (6.5 %) with both hypercalciuria
and hyperuricosuria in the VUR group (P=0.007), but we did
not find anyone with these crystallurias in the control group.
Logistic regression analysis was performed with the aim of
evaluating the effect of hyperuricosuria and hypercalciuria on
VUR, Adjusting for age and sex, the results showed that
hypercalciuria (OR4.5, 95% CI 1.414.5, P=0.01) and hyperuricosuria (OR 6.8, 95% CI 1.432, P=0.01) are significant
predictors of VUR. In a second logistic regression analysis
adjusting for independent variables, sex, age, and hyperuricosuria, the odds of having hypercalciuria was significantly
higher in VUR patients (OR4.4, 95% CI 1.314.6, P=0.015).

Discussion
Our results demonstrate that among the children participating in this study, the frequency of hypercalciuria was

Ca/Cr and UA/Cr ratios

Group

Mean

SD

Median

Range

Pa

Ca/Cr (mg/mg)

Control
Case
Control
Case

110
108
110
108

0.1808
0.3102
0.3500
0.5167

0.09689
0.22155
0.14822
0.46991

0.15
0.18
0.33
0.30

0.110.60
0.111.08
0.121.30
0.191.96

<0.0001

UA/Cr (mg/mg)

<0.0001

98
Table 3 Association of hypercalciuria, hyperuricosuria and
Ca/Cr with VUR grading

VUR, Vesicoureteral reflux

Data are presented as the
number (n) of patients with
the 95% confidence interval
given in parenthesis
a

Chi-square test

MannWhitney U test

Pediatr Nephrol (2012) 27:9599

Risk factors

VUR

Positive

Negative

Pa

Hypercalciuria

Mild
Moderate
Severe
Mild
Moderate
Severe
Mild
Moderate
Severe

9 (14.3%)
9 (22.5%)
7 (24.1%)
10 (15.9%)
8 (20.0%)
7 (24.1%)
0.18 (0.110.96)
0.27 (0.120.90)
0.15 (0.110.90)

54 (85.7%)
31( 77.5%)
22 (75.9%)
53 (84.1%)
32 (80.0%)
22 (75.9%)
0.30 (0.121.08 )
0.18 (0.111.08)
0.19 (0.111.08)

0.03
0.8
0.6
0.4
0.7
0.3
0.1b
0.3b
0.3b

Hyperuricosuria

Ca/Cr

significantly higher in children with VUR than in healthy

children (21.3 vs. 3.6%). The prevalence of hypercalciuria
in normal children has been reported to range from 2.9 to
3.8% [26, 30], while in healthy Iranian children, the
prevalence of hypercalciuria has been reported to be
approximately 35.4% [36, 38]. The frequency of hyperuricosuria in our cases (VUR group) was also much higher
than that in the control group (18.5 vs. 1.8%). We also
observed that the mean Ca/Cr and UA/Cr ratios were much
higher in the VUR group. Although hypercalciuria can
transiently be observed during a UTI, during this study
none of our patients presented with a UTI based on the
results of laboratory investigations.
The frequency of combined crystallurias (calcium and uric
acid) in the VUR group was 6.5%, but we did not find such
cases in the control group. Garcia-Nieto et al. found the
prevalence of hypercalciuria in patients with VUR to be 58.6%,
whereas this figure dropped dramatically to 3.8 % in the
healthy control group [22]. Ristoska-Bojkovska et al. reported
the concurrence of hypercalciuria and reflux in 18.7% of their
patients with VUR, although 4.4% of the healthy children
also had elevated urinary calcium excretion [23].
In our study, the frequency of microscopic hematuria in
children with hypercalciuria (40.7%) or hyperuricosuria
(36.4%) was higher in the VUR group than in the control group.
There was no significant correlation between hypercalciuria and hyperuricosuria with VUR grading or VUR condition
(unilateral/bilateral), except for hypercalciuria and mild VUR
(P=0.03). In contrast, Garcia-Nieto et al. did not observe any
relationship between hypercalciuria and VUR grading or
unilateral/bilateral reflux [22]. The frequency of urinary
stones in our patients was 29.6%; in comparison, the
frequency of urinary stones in a pediatric population in Iran
has been reported to be one case in 300 pediatric hospitalizations [39]. Garcia-Nieto et al. reported urinary stones in
19.6% of their patients [22], while we found the family
history of urolithiasis in the VUR group to be 15.6%.
In conclusion our data suggest that urolithiasis in
children with VUR has an additional predisposing factor
(metabolic factor). Although other factors, such as infection

or urinary stasis, have been known to be involved in stone

formation, the metabolic cause is crystalluria (mostly
hypercalciuria), which is an inheritable condition. There
is no evidence in the literature on the genetic background
of the association between hypercalciuria and VUR, which
link two disorders together by a common gene, but as
both conditions are inheritable, we assume there is some
linkage between these conditions. There does seems to be
some correlation among these inherited disorders (hypercalciuria, VUR, and urolithiasis). In addition, children
with VUR are at a higher risk for hypercalciuria and
urinary stones. Hence, patients with VUR, whether
resolved spontaneously or surgically, should be closely
followed for future renal stones.

References
1. Kroovand RL (1997) Pediatric urolithiasis. Urol Clin North Am
24:173184
2. Mathew R, Matto TK (2008) Vesicoureteral Reflux. In: Geary DF,
Schaefer F (eds) Comprehensive pediatric nephrology, 1st edn.
Mosby Elsevier, Philadelphia, pp 499525
3. Naseri M, Varasteh AR, Alamdaran SA (2010) Metabolic factors
associated with urinary calculi in children. Iran J Kidney Dis
4:3238
4. Kheradpir MH, Bodaghi E (1990) Childhood urolithiasis in Iran
with special reference to staghorn calculi. Urol Int 45:99103
5. Fallahzadeh MK, Fallahzadeh MH, Mowla A, Derakhshan A
(2010) Hypercalciuria in children with urinary tract symptoms.
Saudi J Kidney Dis Transpl 21:673677
6. Garcia-Nieto V, Navarro JF, Luis-Yanes MI, Lopez-Mendes M,
Garcia-rodriguez V (2007) Hypercalciuria in pediatric patients
with ureteropelvic junction obstruction is of genetic origin. Scand
J Urol Nephrol 41:144148
7. Rodriguez A, Calahora FJ, Castro M, Andres A, Montoyo C,
Praga M (1990) Hypercalciuria and hyperuricosuria causing
hematuria in the absence of nephrolithiasis. Actas Urol Esp
14:188191
8. Levy FL, Kemp RD, Breyer JA (1994) Macroscopic hematuria
secondary to hypercalciuria and hyperuricosuria. Am J Kidney
Dis 24:515518
9. Penido MG, Diniz JS, Guimeraes MM, Cardoso RB, Souto MF,
Penido MG (2002) Urinary excretion of calcium, uric acid, and citrate
in healthy children and adolescents. J Pediatr (Rio J) 78:153160

Pediatr Nephrol (2012) 27:9599

10. Sadeghi-Bojd S, Hashemi M (2008) Hypercalciuria and recurrent
urinary tract infection among children in zahedan, Iran. J Pak Med
Assoc 58:624626
11. Zwolinska D, Medynska A, Killis PK (2000) Hyperuricosuria in
children. Pol Merkur Lekarski 8:179180
12. La Manna A, Polito C, Marto A, Lovene A, Dietro R (2001)
Hyperuricosuria in children: clinical presentation and natural
history. Pediatrics 107:8690
13. Lopez MM, Castillo LA, Chavez JB, Ramones C (1999) Hypercalciuria and recurrent UTI in Venezuelan children. J Pediatr
Nephrol 13:433437
14. Biyikli NK, Alpay H, Guran T (2005) Hypercalciuria and
recurrent UTI: Incidence and symptoms in children over 5 years
of age. J Pediatr Nephrol 20:14351438
15. Stojanovic VD, Milosevic BO, Djapic MB, Bubalo JD (2007)
Idiopathic hypercalciuria associated with urinary tract infection in
children. Pediatr Nephrol 22:12911295
16. Vachvanichsanong P, Malagon M, Moore ES (2001) Urinary tract
infection in children associated with idiopathic hypercalciuria.
Pediatrics 35:112116
17. Noe HN, Stapleton FB, Jerkins GR, Roy S (1983) The third clinical
experience with pediatric urolithiasis. J Urol 129:11661168
18. Ghazali S, Barratt TM, Williams DI (1973) Childhood urolithiasis
in Britain. Arch Dis Child 48(4):291295
19. Roberts JP, Atwell JD (1989) Vesicoureteral reflux and urinary
calculi in children. Br J Urol 64:1012
20. Schwartz BF, Stoller ML (2000) The vesical calculus. Urol Clin
North Am 27:333346
21. Rizvi SA, Naqvi SA, Hussain Z, Hashmi A, Hussain M, Zafar
MN, Sultan S, Mehdi H (2002) Pediatric urolithiasis, developing
nation prospective. J Urol 168:15221525
22. Garcia-Nieto V, Siverio B, Monge M, Toledo C, Molini N (2003)
Urinary calcium excretion in children with vesicoureteral reflux.
Nephrol Dial Transplant 18:507511
23. Ristoska-Bojkovska N, Nikolov V, Tasic V (2004) Vesicoureteral
reflux and idiopathic hypercalciuria: an association by chance?
Nephrol Dial Transplant 19:16591660
24. Mahmoodzadeh H, Nikibakhsh A, Karamyyar M, Gheibi Sh,
Gholizadeh Sh, Hooshmand HR (2010) Idiopathic hypercalciuria
in children with vesicoureteral reflux and recurrent urinary tract
infection. Urol J 7:9598
25. Tekin A, Tekgul S, Atsu N, Ergen A, Kendi S (2001) Ureteropelvic junction obstruction and coexisting renal calculi in
children: role of metabolic abnormalities. J Urol 57:542546

99
26. Milliner DS (2004) Urolithiasis. In: Avner ED, Harmon WE,
Niaudet P (eds) Pediatric nephrology. Lippincott, Williams and
Wilkins, New York, pp 10911111
27. Moxey-Mims M (2007) Hematuria and proteinuria. In: Kher K,
Schnaper HW, Makker SP (eds) Clinical pediatric nephrology, 2nd
edn. Informa UK, London, pp 129141
28. Jantausch B, Kher K (2007) Urinary tract infection. In: Kher K,
Schnaper HW, Makker SP (eds) Clinical pediatric nephrology, 2nd
edn. Informa UK, London, pp 553573
29. Khoury A, B gli DJ (2007) "Reflux and megaureter" In: Wein AJ,
Kavoussi LR, Novick AC, Partin AW, Peters CA (eds) CampbellWalsh urology, 9th edn. Saunders Elsevier, Philadelphia, pp 34233481
30. Kruse K, Kracht U, Kruse U (1984) Reference values for urinary
calcium excretion and screening for hypercalciuria in children and
adolescents. Eur J Pediatr 143:2531
31. Domino FJ (2010) Nephropathy urate. In: Domino FJ (ed) The 5minute clinical consult 2011, 19th edn. Lippincott, Williams and
Wilkins, Philadelphia, pp 884-886.
32. Poyrazoglu HM, Dusunsel R, Yazici C, Durmaz H, Dursun I, Sahin
H, Gunduz Z, Gurgoze MK (2009) Urinary uric acid/creatinine
ratios in healthy Turkish children. Pediatr Int 51:526529
33. Alon US, Srivastava T (2007) Urolithiasis. In: Kher K, Schnaper
HW, Makker SP (eds) Clinical pediatric nephrology, 2nd edn.
Informa UK, London, pp 539551
34. Hoppe B, Leumann E, Milliner DS (2008) Urolithiasis and
nephrocalcinosis in childhood. In: Geary DF, Schaefer F (eds)
Comprehensive pediatric nephrology, 1st edn. Mosby Elsevier,
Philadelphia, pp 499525
35. Giugliani R, Dutra-Filho CS, Pereira ML, Enk V (1985) Use of
the Urine uric acid to creatinine ratio for the detection of disorders
of purine metabolism: normal values among 0 to 12 years old
children. Braz J Genet 3:421425
36. Ahmadzadeh A, Hakimzadeh M, Safa-Abadi A (2008) Idiopathic
hypercalciuria in Iranian children. Iran J Pediatr 18:163166
37. Matos V, Van Melle G, Werner D, Bardy D, Guignard JP (1999)
Urinary oxalate and urate to creatinine ratios in a healthy pediatric
population. Am J Kidney Dis 34:E6
38. Esfahani ST, Madani A, Siadati AA, Nabavi M (2007) Prevalence
and symptoms of idiopathic hypercalciuria in primary school
children of Tehran. Iran J Pediatr 17:353358
39. Kheradpir MH, Armbruster T (1985) Childhood urolithiasis in
Iran: a comprative study on the calculi composition of 121 cases.
Z Kinderchir 40:163169