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High Urinary Calcium Excretion and Genetic Susceptibility to Hypertension and Kidney Stone Disease

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High Urinary Calcium Excretion and Genetic Susceptibility to Hypertension and Kidney Stone Disease High Urinary Calcium Excretion and Genetic Susceptibility to Hypertension and Kidney Stone Disease Andrew Mente,* R. John D’A. Honey,† John M. McLaughlin,* Shelley B. Bull,* and Alexander G. Logan* *Prosserman Centre for Health Research, Samuel Lunenfeld Research Institute, Mount Sinai Hospital, and Department of Public Health Sciences, and †St. Michael’s Hospital, Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada Increased urinary calcium excretion commonly is found in patients with hypertension and kidney stone disease (KSD). This study investigated the aggregation of hypertension and KSD in families of patients with KSD and hypercalciuria and explored whether obesity, excessive weight gain, and diabetes, commonly related conditions, also aggregate in these families. Consec- utive patients with KSD, aged 18 to 50 yr, were recruited from a population-based Kidney Stone Center, and a 24-h urine and their spouse were interviewed by telephone (333 ؍ sample was collected. The first-degree relatives of eligible patients (n to collect demographic and health information. Familial aggregation was assessed using generalized estimating equations. Multivariate-adjusted odds ratios (OR) revealed significant associations between hypercalciuria in patients and hypertension (OR 2.9; 95% confidence interval 1.4 to 6.2) and KSD (OR 1.9; 95% confidence interval 1.03 to 3.5) in first-degree relatives, specifically in siblings. No significant associations were found in parents or spouses or in patients with hyperuricosuria. Similarly, no aggregation with other conditions was observed. In an independent study of siblings of hypercalciuric patients with KSD, the adjusted mean fasting urinary calcium/creatinine ratio was significantly higher in the hypertensive siblings compared with normotensive siblings (0.60 ؎ 0.32 versus 0.46 ؎ 0.28 mmol/mmol; P < 0.05), and both sibling groups had significantly higher values than the unselected study participants (P < 0.001). Urinary sodium/creatinine and uric acid/ creatinine ratios were not different among the groups. Although an environmental effect cannot be excluded fully, our findings suggest that the disturbance in calcium metabolism in hypertension and KSD has a genetic basis. J Am Soc Nephrol 17: 2567–2575, 2006. doi: 10.1681/ASN.2005121309 ϩ isturbances in calcium (Ca2 ) metabolism have been weight gain, and type 2 diabetes, commonly associated with ϩ reported in hypertension (1,2), obesity (1,3), and kid- hypertension and KSD, aggregate in families with Ca2 abnor- D ney stone disease (KSD) (4,5), and there are strong malities. We hypothesized that hypercalciuria would be asso- associations among these conditions (6–8). Normotensive off- ciated with familial aggregation of hypertension, KSD, obesity, ϩ spring of hypertensive patients also have disturbed Ca2 me- weight gain, and diabetes in patients with KSD. We further ϩ tabolism, suggesting a possible genetic basis for these abnor- tested our hypothesis by comparing urinary Ca2 excretion in malities (9,10). We previously reported familial aggregation of patients with KSD and an independent sample of siblings of hypertension in patients with KSD and hypercalciuria and patients with KSD and hypercalciuria. Last, the study explored hyperuricosuria but not with either urinary abnormality alone whether the associations for disease aggregation in families (11,12). Hypertension in first-degree relatives, however, was vary by patients’ body mass index (BMI), age, and gender and ascertained from reports by patients, an insensitive method of relatives’ age of disease onset. identifying disease status in family members. Moreover, spou- sal information, which may help to control for environmental effects, was not collected (11,12). Materials and Methods This study investigated the aggregation of hypercalciuria Selection of Participants and Assessment with hypertension and separately with KSD in families of pa- Consecutive patients who were aged 18 to 50 yr and attended the St. tients with KSD, taking into account the shortcomings of earlier Michael’s Hospital’s Kidney Stone Center between February 2002 and March 2004 were eligible for recruitment. The center, which contains studies (11,12). It also explored whether obesity, excessive one of only three shockwave lithotriptors in Ontario, serves the health needs of approximately six million people, including the Greater To- ronto Area community, and may be considered a population-based Received December 22, 2005. Accepted June 8, 2006. treatment facility. The hospital’s Research Ethics Board approved the Published online ahead of print. Publication date available at www.jasn.org. study. Age-eligible patients were contacted by telephone before their sched- Address correspondence to: Dr. Alexander G. Logan, Department of Medicine, uled lithotripsy appointment to describe the nature of the study and to Division of Nephrology, Mount Sinai Hospital, Room 435, 600 University Ave- nue, Toronto, Ont M5G1X5, Canada. Phone: 416-586-5187; Fax: 416-586-8434; determine their willingness to participate and allow the study staff to E-mail: [email protected] contact family members. Reasons for nonparticipation were docu- Copyright © 2006 by the American Society of Nephrology ISSN: 1046-6673/1709-2567 2568 Journal of the American Society of Nephrology J Am Soc Nephrol 17: 2567–2575, 2006 mented. Potential participants were asked to collect a single 24-h urine individual family member. The covariates were patient age, gender, specimen, starting the morning before their lithotripsy treatment, and BMI, personal history of disease, use of antihypertensive agents, and were not provided with any specific dietary instruction. At the center, relative age (11). Other potential confounders included patient ethnic- patients, after giving informed consent, were interviewed to collect ity, marital status, education, area of residence (inside/outside city), personal and family information about sociodemographic characteris- country of birth (inside/outside Canada), smoking status, and use of ϩ tics and family composition; personal and family history of hyperten- Ca2 /vitamin D products. These factors were included in analytic sion, diabetes, and KSD; and weight and height estimates in first- models when singly they changed the point estimate by 10% (24). degree relatives (excluding offspring) and spouses. Weight (measured Regression parameter estimates were computed for first-degree rela- in a light hospital gown) and height (without shoes) were measured to tives, individual relative categories, and spouses. Brothers, sisters, calculate BMI. Sitting BP (average of two readings using a mercury mothers, and fathers were analyzed separately and as siblings and sphygmomanometer) was assessed in a standard manner (13). Routine parents. Stratified analyses were undertaken to assess for effect modi- peripheral venous blood samples also were drawn. fication using strata defined by the median values for age, BMI, or time With their consent, relatives and spouses were interviewed by tele- of disease onset to avoid sparse data within urinary categories. Likeli- phone to collect information about the presence of hypertension, dia- hood ratio tests were conducted to test for homogeneity. PROC betes, and KSD; their current height and weight; and their weight 5 yr GENMOD with a REPEATED statement in SAS software version 8.1 (SAS ago. Weight change was calculated by subtracting their current weight Institute Inc., Cary, NC) was used for the GEE regression analyses (25). from their weight of 5 yr earlier. Both the interviewer and the family member were “blind” as to the results of the patient’s metabolic anal- Independent Study of Siblings ysis at the time of the interview. We further tested our hypothesis of a genetically determined abnor- ϩ ϩ mality in Ca2 metabolism by assessing urinary Ca2 excretion in study Classification of Urinary Variables and Disease Status participants and an independent sample of siblings of patients with Standard definitions of hypercalciuria (14,15) and hyperuricosuria hypercalciuria. The latter sample came from a previous study that (16) were used. To increase specificity, as recommended for aggrega- recruited 75 patients with KSD and hypercalciuria, aged 18 to 50 yr, tion studies (17), restrictive definitions for outcome variables were using the same protocol as used in this study (26). The urinary results used. Accordingly, hypertension was defined as being treated with have never been reported. With their consent, siblings were inter- antihypertensive medications to lower BP (18), and type 2 diabetes was viewed by telephone to collect information on demographic character- defined as being treated with oral hypoglycemic agents at any age or istics, the presence of hypertension and KSD, the names of all pre- with insulin after the age of 40 yr (19). Individuals with a BMI of 30 scribed medications and supplementary health products, and their ϩ kg/m2 or higher were classified as obese (20). Weight gain was arbi- current weight and height. Individuals who were taking Ca2 supple- trarily considered excessive when the change exceeded the 75th per- ments or multivitamins were excluded. A urine bottle and instructions centile of the gender-specific 5-yr weight change distribution, because to collect a fasting urine sample were mailed to the eligible patients. A there is no standard definition (21). This was Ͼ5.1 kg for men and Ͼ6.8 total of 114 siblings (63 brothers and 51 sisters)
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