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MNH 290206

REVIEW

CURRENT
OPINION Nephrolithiasis in women: how different from men?
Lada Beara-Lasic and David S. Goldfarb

Purpose of review
Men have more kidney stones compared with women; however, the difference is progressively decreasing.
The reasons for higher prevalence of stones in men, as well as increasing prevalence in women, is a
subject of ongoing speculation. In this review, we summarize the evidence of differences between men and
women and expand on the speculative causes.
Recent findings
Stone incidence is rising in women and adolescent girls. Stone disease is more heritable among men than
women, and women demonstrate greater influence of the unique environment. Women under the age of
50 years who have been pregnant, have more than double the odds of kidney stones compared with those
who have never been pregnant. Women are more burdened with obesity, bariatric surgery and dieting, all
associated with increased stones. Women have higher urinary pH because of greater absorption of dietary
organic anions leading to increased urinary citrate, compared with men, and they differ in tubular calcium
handling.
Summary
It is obvious that the cause of stones in men and women is complex and requires further study. Potential
clues offered are in the change of the female environment, influencing increasing incidence in stones,
particularly of younger women and female adolescents.
Keywords
calcium, calculi, men/boys, nephrolithiasis, renal, urolithiasis, women/girls

INTRODUCTION women in all age groups, but the difference between

Kidney stones affect a significant number of patients
(approximately 1/11 in the United States) with
increasing incidence in the United States and the
rest of the world [1,2]. Men are still more commonly
affected, with a ratio currently less than 2 : 1 and
progressively decreasing. Recent local population-
based data indicate stone incidence is rising in the
previously lower risk groups of women and adoles-
cent girls [3–5]. In the Olmstead County adult pop-
ulation data from 1984 to 2012, it was observed that
women ages 18 to 39 years had the highest absolute
men and women was lowest in the ages 10–29 years
and more than 90 years [7]. Additionally, the analy-
sis of the population data from the National Health
and Nutrition Examination Survey data (NHANES)
between 1976 and 1994 demonstrated that 20–29-
year-old women had an approximately 50% higher
prevalence of stones than men of the same age [8].
More recently NHANES data from the 2007–2012
for adults younger than 50 years, showed no differ-
ence in stone prevalence between men and women,
and this finding continued to be present in the
&&

increase in the incidence of confirmed symptomatic subpopulations of age by decade [9 ]. Unfortu-

kidney stones [4].
Interestingly, the analysis of the 43 545 individ-
uals’ first stones submitted to the Mayo Clinic Metal
Laboratory during year 2010, the number of stones
submitted was even greater among adolescent girls
(10–19 years old) and young adult women (20–29
years old), when compared with men of the same
age. It was almost the same for men and women
greater than 90 years. In the ages between 10 and
29 years, women submitted about 60% of all stones
[6]. Similarly, in a French study based on analysis of
27 980 calculi, men submitted more stones than
nately, cross-sectional survey data of NHANES do
Nephrology Division, NYU Langone Health, NYU School of Medicine,
and New York Harbor VA Healthcare System, New York, New York, USA
Correspondence to Lada Beara-Lasic, MD, MS, Nephrology Section,
New York Harbor VA Healthcare System, Clinical Assistant Professor of
Medicine, New York University School of Medicine, New York Harbor
VAMC, 423 E. 23 Street, New York, NY 10010, USA.
Tel: +1 212 686 7500 3880; fax: +1 212 951 6842;
e-mail: lada.bearalasic@nyulangone.org
Curr Opin Nephrol Hypertens 2019, 28:000–000
DOI:10.1097/MNH.0000000000000577

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CE: Tripti; MNH/290206; Total nos of Pages: 6;
MNH 290206
Clinical nephrology
KEY POINTS
 Men have more kidney stones than women; ratio is less
than 2 : 1 and progressively decreasing and women
ages 18–39 years have the highest absolute increase
in the incidence of confirmed symptomatic
kidney stones.
 Women have higher urinary pH because of greater
absorption of food organic anions leading to increased
urinary citrate, compared with men.
 Women have more calcium phosphate and
struvite stones.
 Stone disease is more heritable among men than
among women, and women demonstrate greater
influence of the unique environment.
 Women under the age of 50 years who have been
pregnant, have more than double the odds of kidney
stones compared with those who have never been
pregnant and the prevalence and odds of stones
increase with increasing number of pregnancies.
not capture types of stones; therefore, they do not
provide insight on the cause of recent increasing
incidence of stones in women.
The most common types of stones are calcium
oxalate (CaOx), and about 80% of all stones are
CaOx and/or calcium phosphate (CaP). Most CaP
stones are composed of hydroxyapatite. The data on
stone distribution by type submitted from multiple
referral laboratories are similar. From the Mayo
Clinic 2010 first stone analysis, 67% of stones were
CaOx, followed by hydroxyapatite (16%), uric acid
(8%), struvite (3%), brushite (0.9%), and cystine
(0.35%) [6]. The proportion of hydroxyapatite and
struvite stones is higher in women compared with
men; in fact, women submitted the majority of
hydroxyapatite stones (65%) and struvite stones
(65%). Women made the highest percentage of
hydroxyapatite between ages 20 and 39 years and
struvite stones after age 70 years. The uric acid stone
proportion increased significantly after the age of
50 years for both sexes. In another study of 1201
stone formers, men and women, followed over three
decades, the percentage of CaP in both sexes
increased about three-fold and the stones from
women had higher percentage CaP composition.
This study also confirmed younger onset of stone
disease in CaP stone patients for both sexes [10].
DIFFERENCE OF URINE PH BETWEEN MEN
AND WOMEN
Urinary pH is normally maintained close to 6, which
avoids precipitation of uric acid at lower, and CaP at
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the higher urinary pH. (Higher urine pH titrates a
proton off monobasic H2PO4 and converts it into
the divalent dibasic HPO4¼, which readily precip-
itates with calcium, a divalent cation.) Large epide-
miologic studies have shown that the pH of 24-h
urines in women on a free-choice diet, are higher
than in men [11–13]. This finding of higher urinary
pH in women largely explains higher prevalence of
CaP stones in women compared with men, although
calcium oxalate stones (CaOx) are still the most
prevalent stones in both sexes [10]. The sex pH
difference has been attributed to differences in diet;
however, the recently published work by Worcester
et al. who studied seven normal men and seven
women on a standardized diet, demonstrated that
women have higher urinary pH only in fed and not
in fasting state, as a result of greater absorption of
food anions. Urine citrate was higher in women
than men in the fed state, and fractional excretion
&&
of citrate was higher in women than men [14 ]. The
basis for these findings is currently not clear.
According to the recent analysis of the first stones
submitted by patients to the Mayo Clinic Metal Lab-
oratory during year 2010, hydroxyapatite stones
(associated with higher urinary pH) were indeed
more common among young women, the demo-
graphic group who had the highest increase in the
incidence rate of kidney stones [6]. In fact, in women
between the ages of 20 and 29 years, the percentage of
hydroxyapatite stones was even greater than the
percentage of CaOx stones (the only period where
CaOx was not the most common stone type). The
question remains, what is the reason for this increase?
If the rise in pH in women is noticed only in fed states,
can we speculate that a change in diet in women is
driving this change? What else has changed in the
environment of adolescent and young women to lead
them to form more CaP stones?
DIFFERENCE OF KIDNEY CALCIUM
HANDLING BETWEEN MEN AND WOMEN
WITH HIGHER URINARY CALCIURIA
The cause of higher urinary calcium excretion
among calcium stone formers with higher urine
calcium excretion is reduced renal tubular calcium
reabsorption, detected using the endogenous lith-
ium clearance measurements, in the fasting state but
most pronounced after eating [15]. Using the same
model, the primary mechanism detected in women
with higher urinary calciuria was decreased distal
nephron calcium reabsorption compared with nor-
mal women, whereas in men, it was decreased prox-
imal tubular calcium reabsorption, with a more
modest reduction in distal calcium reabsorption
when compared with normal men [16].
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IMPACT OF PREGNANCY AND
LACTATION ON KIDNEY STONES
During pregnancy, women’s calcium and phospho-
rus metabolism changes to adapt to the skeletal
needs of the fetus. Increased intakes are not required
in women who consume adequate calcium and
there are not thought to be long-term consequences
for the maternal skeleton, except for women with
low mineral intake or preexisting disorders, because
of the doubling of the efficiency of intestinal cal-
cium absorption during pregnancy. This effect is
mediated by the increase in the parathyroid hor-
mone-related protein (PTHrP) and also estradiol,
prolactin, and placental lactogen causing the stimu-
lation of CYP27b1 to produce increased levels of 1,25-
dihydroxy vitamin D (1,25-D) and suppression of
parathyroid hormone (PTH). Levels of 25-hydroxy
vitamin D do not appear to have a significant role in
pregnancy, as supplementation with as much as 5000
units daily did not alter maternal serum Ca, P, PTH or
blunt the rise in 1,25 D. The hormonal changes result
in the increase of 24 h urinary calcium, likely a con-
sequence of increased intestinal absorption and the
increased filtered load of calcium with the increased
glomerular filtration rate of pregnancy [17]. In addi-
tion to higher calciuria, urines of pregnant women
have greater uricosuria, oxaluria and elevated urine
pH, which increases calcium phosphate urinary
supersaturation [18].
During lactation, intestinal calcium and phos-
phorus absorption falls to nonpregnant values, coin-
ciding with the fall of 1,25-D, despite persistently
high PTHrP. The calcium needed for breast milk is
now released from the bone. At the same time, the
tubular maximum for calcium increases and the
fractional excretion of calcium decreases, likely
mediated by PTHrP. Any additional calcium taken
from supplements or from food will increase urinary
calcium without affecting milk calcium or amount
of bone resorbed. This information is important for
our hypercalciuric women during lactation. A mod-
est increase in intestinal calcium absorption might
occur during postweaning recovery; female bone is
thought to completely recover its mineral content
3–6 months after ending lactation [17].
The data have not consistently shown increase of
kidney stone incidence during pregnancy; however,
the potentially lithogenic state of pregnancy may
carry a risk of future stone development. NHANES
data analysis from 2007 to 2012 demonstrated that
the odds of nephrolithiasis are more than two-fold in
women who have been pregnant compared with
those who have never been pregnant [19]. The prev-
alence and odds of nephrolithiasis increased with the
increasing number of pregnancies.
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Nephrolithiasis in women Beara-Lasic and Goldfarb
WOMEN AND HORMONAL THERAPY
Oral contraception has been used as a significant
mode of contraception: the nationally representa-
tive survey conducted in 2004 showed 38% of all
women using oral contraceptive methods [20]. Ado-
lescence is a critical period for bone development as
the peak bone mass occurs by the end of the second,
or early in the third decade of life [21]. Oral contra-
ceptives taken in adolescence decrease the peak
bone mass and are associated with the decreased
bone turnover markers, increasing the risk of osteo-
&
porosis [22 ,23]. Could we speculate that the
increasing use of oral contraceptives may have influ-
enced rising incidence of stones in the adolescent
girls? This area requires further study.
BONE DISEASE AND KIDNEY STONES IN
MEN AND WOMEN
Low bone mineral density (BMD) has been associ-
ated with kidney stones in smaller studies as well as
population-based studies [24–26]. However, these
studies did not differentiate between men and
women or analyzed men only. In the cross-sectional
analysis of NHANES III data, a history of any kidney
stones (not limited to calcium stones) was signifi-
cantly associated with lower BMD in men but not in
women [27]. An earlier population-based study
demonstrated the risk of vertebral fracture to be
greatly increased among men who formed kidney
stones, and only to be mildly elevated among
women [28]. Looking at the female data only, the
prospective analysis of 96 092 women in the Nurses’
Health Study II, showed increased adjusted relative
risk for an incident kidney stone for participants
with history of low bone density compared with
participants without [29]. In a study of postmeno-
pausal women with osteoporosis, higher urinary
calcium excretion was present in 19% and was
found to be the most important predictor of low
bone mass [30]. This implicates more complex
mechanisms, such as potential use of hormones in
female bone loss and points to the differences
between men and women.
OBESITY/WEIGHT REDUCTION
SURGERIES/EATING DISORDERS AND
KIDNEY STONES IN MEN AND WOMEN
Women have been highly affected in the obesity
epidemic. According to the 2013–2014 NHANES
data, the age-adjusted prevalence of obesity was
35% for men and 40.4% for women [31]. Obesity
is associated with lower urinary pH increasing prob-
ability of uric acid crystallization as well as increased
intake of salt that increases urinary calcium
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Clinical nephrology
excretion. Insulin resistance, associated with the
obesity epidemic, may also possibly increase intes-
tinal absorption and urinary excretion of calcium
[32]. From the 11 099 stones submitted to a Labora-
tory for Stone Research in Massachusetts in the
period from 1990 to 2010, there was a significant
increase in the proportion of uric acid stones only in
women; it was not seen in men [33]. However, men
were still more likely to submit uric acid stones (10.3
versus 5.5%), compared with women and there was a
significant increase of uric acid stones in both sexes
after approximately age 50 years, uric acid constitut-
ing more than 20% of stones in those greater than
90 years old. In general, the sex differences in stone
composition were much less prominent over age
70 years and most marked under age 30 years, con-
sistent with the previously discussed data. Stone
analysis from a Korean study has also shown obesity
associated with higher likelihood of uric acid and
CaOx stones compared with the occurrence of mixed
CaOx/CaP stones, and CaP stones [34].
The number of bariatric surgeries is increasing
worldwide and 70–80% of patients undergoing sur-
gery are women [35,36]. Patients with weight reduc-
tion surgery, specifically intestinal bypass (Roux-en-
Y), will have increased CaOx stone formation. In
these patients, fat malabsorption causes increased
calcium binding in the intestinal lumen, and con-
sequently increased free oxalate absorption, leading
to the increase of urinary oxalate excretion. Bile salts
also increase colonic permeability and facilitate oxa-
late absorption. Gastric banding, which does not
lead to steatorrhea, does not increase urinary oxalate
excretion [37–39].
On the other side of the spectrum, dieting has
been associated with lower bone mineral accrual
and more severe eating disorders with kidney
stones. Girls are more affected. According to the
recent nationally representative data from US high
school students surveyed from 2010 to 2011, 61% of
girls and 32% of boys reported trying to lose weight;
17% of girls and 7% of boys reported fasting for more
than 24 h and 6% of girls and 2.5% of boys reported
vomiting or laxative use within 30 days of survey
[40]. Girls who first reported dieting to lose weight
by age 11 years showed a significantly lower bone
mineral accrual compared with girls who first
reported dieting after 11 years or not at all [41 ].
&
Dietary restraint has been associated with lower
levels of bone formation markers in young adult
women [42]. Is the dietary restriction and related
behaviors influencing stone formation in the cohort
of young adolescent girls with increasing incidence
of stones? This area has not been investigated.
Kidney stones are noted to be associated with
eating disorders, such as anorexia nervosa, bulimia,
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and laxative abuse; however, there is a paucity of
cases reported. Possible links with kidney stones are
extracellular fluid volume depletion and electrolyte
and acid–base disturbances, including hypokalemia
leading to hypocitraturia, both favoring the forma-
tion of kidney stones. In addition, ammonium acid
urate stones, more commonly seen in underdevel-
oped countries, were reported in women with laxa-
tive abuse and bulimia [43]. It is of interest to note
that women with anorexia and bulimia have associ-
ated loss of bone mineral density, which is even
noted in women with normal weight bulimia, indi-
cating causes other than weight loss affecting bone
mineral metabolism.
INFECTIONS/ANTIBIOTICS AND STONES
IN MEN AND WOMEN
Female children and adult women have higher prev-
alence of urinary tract infections, and as expected,
data indicate that women with calcium kidney
stones have more urinary infections [44]. Women
also have more struvite stones, occurring because of
recurrent urinary tract infections with urease-pro-
ducing organisms, such as Proteus spp. [6].
Use of antibiotics has also been associated with
kidney stones, supporting the hypothesis that
changes in the intestinal microbiome induced by
antibiotics modulates the intestinal handling of
calcium and oxalate to favor stone formation. In a
large case–control study from United Kingdom, the
exposure to five different antibiotic classes given for
varying indications was associated with increased
odds of nephrolithiasis, particularly in younger
ages. Both cohorts included 35% women; however,
men and women were not compared [45]. In the
more recent analysis of The Nurses’ Health Study
(NHS) I and II cohort, the use of antibiotics for a total
of 2 months or more during early-to-middle adult-
hood was independently associated with higher
subsequent risk for developing kidney stones in later
life [46]. Kidney stone formers are indeed found to
have different intestinal microbiome composition
[47,48]. However, no comparison between men and
women is available.
CONCLUSION
The reasons for overall increased prevalence of
stones in men compared with women remains a
topic of ongoing speculation. One of the factors
commonly hypothesized is the difference in diet
influencing solute excretion and urine volume.
The NHANES 2007–2012 for adults younger than
50 study has analyzed the three most common
dietary factors associated with stone formation
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MNH 290206
and has found that men, as previously hypothe-
sized, showed higher salt and protein intake. Men,
surprisingly, had a slightly higher water intake than
&&
women (less than 100 ml) [9 ]. Men are more likely
to be employed as drivers, or having prostate
enlargement limiting intake of fluid; however, we
can also speculate that women in their child-rearing
ages tend to significantly reduce fluid intake and
both sexes tend to drink less fluid in older ages. It is,
therefore, not surprising that in the NHANES study,
urine volume was not found to be significantly
different. Perhaps the most striking difference
between women and men, in part accounting for
differences in stone prevalence, is that men have
higher urinary oxalate excretion.
It is evident, however, that the cause of stones is
far more complex. Further subdivisions by the age of
patients, might give us clues for better understand-
ing. Differences in genetics of men and women
influencing final urine composition, as well as diet-
ing and life events, such as pregnancy and lactation,
might play a role more significant than previously
suspected. According to our recent study of the 7053
same-sex pairs with kidney stone data from the
Washington State Twin Registry, stone disease was
more heritable among men than among women (57
vs. 46%, P < 0.05) and women demonstrated greater
&
influence of the unique environment [49 ]. The
intriguing question is what is the recent change of
the female environment that is influencing increas-
ing incidence in stones, particularly of younger
women and female adolescents? If we look at our
own individual stone clinic practices, we can cer-
tainly recognize the multitudes of factors influenc-
ing stone formation, and it would be worthwhile
investigating closer and further to improve both
prevention and treatment.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
L.B.-L.: none; D.S.G.: consultant: Allena, AstraZeneca,
Retrophin; Equity holder: Dr Arnies.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Scales CD, Smith AC, Hanley JM, Saigal CS; Urologic Diseases in America
Project. Prevalence of kidney stones in the United States. Eur Urol 2012;
62:160–165.
1062-4821 Copyright ß 2019 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Nephrolithiasis in women Beara-Lasic and Goldfarb
2. Sorokin I, Mamoulakis C, Miyazawa K, et al. Epidemiology of stone disease
across the world. World J Urol 2017; 35:1301–1320.
3. Tasian GE, Ross ME, Song L, et al. Annual incidence of nephrolithiasis among
children and adults in South Carolina from 1997 to 2012. Clin J Am Soc
Nephrol 2016; 11:488–496.
4. Kittanamongkolchai W, Vaughan LE, Enders FT, et al. The changing incidence
and presentation of urinary stones over 3 decades. Mayo Clin Proc 2018;
93:291–299.
5. Dwyer ME, Krambeck AE, Bergstralh EJ, et al. Temporal trends in incidence of
kidney stones among children: a 25-year population based study. J Urol 2012;
188:247–252.
6. Lieske JC, Rule AD, Krambeck AE, et al. Stone composition as a function of
age and sex. Clin J Am Soc Nephrol 2014; 9:2141–2146.
7. Daudon M, Doré JC, Jungers P, Lacour B. Changes in stone composition
according to age and gender of patients: a multivariate epidemiological
approach. Urol Res 2004; 32:241–247.
8. Stamatelou KK, Francis ME, Jones CA, et al. Time trends in reported pre-
valence of kidney stones in the United States: 1976-1994. Kidney Int 2003;
63:1817–1823.
9. Tundo G, Khaleel S, Pais VM. Gender equivalence in the prevalence of
&& nephrolithiasis among adults younger than 50 years in the United States. J
Urol 2018; 200:1273–1277.
Study of NHANES data from the 2007–2012 for adults younger than 50 years,
showed no difference in stone prevalence between men and women, present also
in the subpopulations of age by decade.
10. Parks JH, Worcester EM, Coe FL, et al. Clinical implications of abundant
calcium phosphate in routinely analyzed kidney stones. Kidney Int 2004;
66:777–785.
11. Curhan GC, Taylor EN. 24-h uric acid excretion and the risk of kidney stones.
Kidney Int 2008; 73:489–496.
12. Lieske JC, Turner ST, Edeh SN, et al. Heritability of dietary traits that
contribute to nephrolithiasis in a cohort of adult sibships. J Nephrol 2016;
29:45–51.
13. Taylor EN, Stampfer MJ, Mount DB, Curhan GC. DASH-style diet and 24-h
urine composition. Clin J Am Soc Nephrol 2010; 5:2315–2322.
14. Worcester EM, Bergsland KJ, Gillen DL, Coe FL. Mechanism for higher urine
pH in normal women compared with men. Am J Physiol Renal Physiol 2018;
&&
314:F623–F629.
Study comparing seven normal men and seven women on a standardized diet
found that women have higher urinary pH only in fed and not in fasting state, as a
result of greater absorption of food anions.
15. Worcester EM, Coe FL, Evan AP, et al. Evidence for increased postprandial
distal nephron calcium delivery in hypercalciuric stone-forming patients. Am J
Physiol Renal Physiol 2008; 295:F1286–F1294.
16. Ko B, Bergsland K, Gillen DL, et al. Sex differences in proximal and distal
nephron function contribute to the mechanism of idiopathic hypercalcuria in
calcium stone formers. Am J Physiol Regul Integr Comp Physiol 2015;
309:R85–R92.
17. Kovacs CS. Maternal mineral and bone metabolism during pregnancy, lacta-
tion, and post-weaning recovery. Physiol Rev 2016; 96:449–547.
18. Smith CL, Kristensen C, Davis M, Abraham PA. An evaluation of the physi-
cochemical risk for renal stone disease during pregnancy. Clin Nephrol 2001;
55:205–211.
19. Reinstatler L, Khaleel S, Pais VM. Association of pregnancy with stone
formation among women in the United States: a NHANES analysis 2007
to 2012. J Urol 2017; 198:389–393.
20. Frost JJ, Darroch JE. Factors associated with contraceptive choice and
inconsistent method use, United States, 2004. Perspect Sex Reprod Health
2008; 40:94–104.
21. Baxter-Jones AD, Faulkner RA, Forwood MR, et al. Bone mineral accrual from
8 to 30 years of age: an estimation of peak bone mass. J Bone Miner Res
2011; 26:1729–1739.
22. Rizzo ADCB, Goldberg TBL, Biason TP, et al. One-year adolescent bone
& mineral density and bone formation marker changes through the use or lack of
use of combined hormonal contraceptives. J Pediatr (Rio J) 2018;
95:567–574.
Oral contraceptives taken in adolescence decrease the peak bone mass.
23. Callegari ET, Gorelik A, Garland SM, et al. Bone turnover marker reference
intervals in young females. Ann Clin Biochem 2017; 54:438–447.
24. Keller JJ, Lin CC, Kang JH, Lin HC. Association between osteoporosis and
urinary calculus: evidence from a population-based study. Osteoporos Int
2013; 24:651–657.
25. Jaeger P, Lippuner K, Casez JP, et al. Low bone mass in idiopathic renal stone
formers: magnitude and significance. J Bone Miner Res 1994; 9:1525–1532.
26. Pietschmann F, Breslau NA, Pak CY. Reduced vertebral bone density in
hypercalciuric nephrolithiasis. J Bone Miner Res 1992; 7:1383–1388.
27. Lauderdale DS, Thisted RA, Wen M, Favus MJ. Bone mineral density and
fracture among prevalent kidney stone cases in the Third National Health and
Nutrition Examination Survey. J Bone MinerRes 2001; 16:1893–1898.
28. Melton LJ, Crowson CS, Khosla S, et al. Fracture risk among patients with
urolithiasis: a population-based cohort study. Kidney Int 1998; 53:459–464.
29. Prochaska M, Taylor E, Vaidya A, Curhan G. Low bone density and bispho-
sphonate use and the risk of kidney stones. Clin J Am Soc Nephrol 2017;
12:1284–1290.
www.co-nephrolhypertens.com 5
CE: Tripti; MNH/290206; Total nos of Pages: 6;
MNH 290206
Clinical nephrology
30. Giannini S, Nobile M, Dalle Carbonare L, et al. Hypercalciuria is a common
and important finding in postmenopausal women with osteoporosis. Eur J
Endocrinol 2003; 149:209–213.
31. Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity among
adults in the United States, 2005 to 2014. JAMA 2016; 315:2284–2291.
32. R€umenapf G, Schmidtler J, Schwille PO. Intestinal calcium absorption during
hyperinsulinemic euglycemic glucose clamp in healthy humans. Calcif Tissue
Int 1990; 46:73–79.
33. Moses R, Pais VM, Ursiny M, et al. Changes in stone composition over two
decades: evaluation of over 10,000 stone analyses. Urolithiasis 2015;
43:135–139.
34. Jeong JY, Doo SW, Yang WJ, et al. Differences in urinary stone composition
according to body habitus. Korean J Urol 2011; 52:622–625.
35. Gagnon C, Schafer AL. Bone health after bariatric surgery. JBMR Plus 2018;
2:121–133.
36. Angrisani L, Santonicola A, Iovino P, et al. Bariatric surgery and endoluminal
procedures: IFSO Worldwide Survey 2014. Obes Surg 2017; 27:2279–2289.
37. Asplin JR, Coe FL. Hyperoxaluria in kidney stone formers treated with modern
bariatric surgery. J Urol 2007; 177:565–569.
38. Lieske JC, Mehta RA, Milliner DS, et al. Kidney stones are common after
bariatric surgery. Kidney Int 2015; 87:839–845.
39. Liu M, Nazzal L. Enteric hyperoxaluria: role of microbiota and antibiotics. Curr
Opin Nephrol Hypertens 2019; 28:352–359.
40. Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance - United
States, 2011. MMWR Surveill Summ 2012; 61:1–162.
41. Hohman EE, Balantekin KN, Birch LL, Savage JS. Dieting is associated with
& reduced bone mineral accrual in a longitudinal cohort of girls. BMC Public
Health 2018; 18:1285.
6 www.co-nephrolhypertens.com
Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Girls who first reported dieting to lose weight by age 11 years showed a
significantly lower bone mineral accrual compared with girls who first reported
dieting after 11 years or not at all.
42. Cano Sokoloff N, Eguiguren ML, Wargo K, et al. Bone parameters in relation
to attitudes and feelings associated with disordered eating in oligo-amenor-
rheic athletes, eumenorrheic athletes, and nonathletes. Int J Eat Disord 2015;
48:522–526.
43. Leaf DE, Bukberg PR, Goldfarb DS. Laxative abuse, eating disorders, and
kidney stones: a case report and review of the literature. Am J Kidney Dis
2012; 60:295–298.
44. Parks JH, Coe FL, Strauss AL. Calcium nephrolithiasis and medullary sponge
kidney in women. N Engl J Med 1982; 306:1088–1091.
45. Tasian GE, Jemielita T, Goldfarb DS, et al. Oral antibiotic exposure and kidney
stone disease. J Am Soc Nephrol 2018; 29:1731–1740.
46. Ferraro PM, Curhan GC, Gambaro G, Taylor EN. Antibiotic use and risk of
incident kidney stones in female nurses. Am J Kidney Dis 2019. [Epub ahead
of print]
47. Ticinesi A, Milani C, Guerra A, et al. Understanding the gut-kidney axis in
nephrolithiasis: an analysis of the gut microbiota composition and functionality
of stone formers. Gut 2018; 67:2097–2106.
48. Tang R, Jiang Y, Tan A, et al. 16S rRNA gene sequencing reveals altered
composition of gut microbiota in individuals with kidney stones. Urolithiasis
2018; 46:503–514.
49. Goldfarb DS, Avery AR, Beara-Lasic L, et al. A twin study of genetic influences
& on nephrolithiasis in women and men. Kidney Int Rep 2019; 4:535–540.
Study of the same-sex pairs with kidney stone data from the Washington State
Twin Registry showed stone disease was more heritable among men than women
and women show greater influence of the unique environment.
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