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Background: Crystallization is believed to be the initiation step of urolithiasis, even though it is unknown where inside the nephron the first crystal nucleation occurs., Methods: Direct nucleation of calcium oxalate and subsequent events including crystal retention, cellular damage, endocytosis, and hyaluronan (HA) expression, were tested in a two-compartment culture system with intact human proximal tubular HK-2 cell monolayer., Results: Calcium oxalate dihydrate (COD) was nucleated and bound onto the apical surface of the HK-2 cells under hypercalciuric and hyperoxaluric conditions. These cells displayed mild cellular damage and internalized some of the adhered crystals within 18h post-COD-exposure, as revealed by electron microscopy. Prolonged incubation in complete medium caused significant damage to disrupt the monolayer integrity. Furthermore, hyaluronan disaccharides were detected in the harvested media, and were associated with HAS-3 mRNA expression., Conclusion: Human proximal cells were able to internalize COD crystals which nucleated directly onto the apical surface, subsequently triggering cellular damage and HAS-3 specific hyaluronan synthesis as an inflammatory response. The proximal tubule cells here demonstrate that it plays an important role in facilitating urolithiasis via endocytosis and creating an inflammatory environment whereby free hyaluronan in tubular fluid can act as crystal-binding molecule at the later segments of distal and collecting tubules., (Copyright 2010 Elsevier B.V. All rights reserved.)

Urinary polyanions recovered from the urine samples of kidney stone-formers and normal controls were subjected to preparative agarose gel electrophoresis, which yielded fractions 1-5 in a decreasing order of mobility. In both groups, chondroitin sulfates were identified in the fast-moving fractions and heparan sulfates in the slow-moving fractions. Furthermore, two types of heparan sulfates were identified based on their electrophoretic mobility: slow-moving and fast-moving. The fractionated urinary polyanions were then tested in an in vitro calcium oxalate crystallization assay and compared at the same uronic acid concentration, whereby, the chondroitin sulfates of stone-formers and heparan sulfates of normals enhanced crystal nucleation. Fraction 5 of the normals, containing glycoproteins (14-97 kDa) and associated glycosaminoglycans, were found to effectively inhibit crystallization. Papainization of this fraction in stone-formers revealed crystal-suppressive effects of glycoproteins, which was not seen in similar fractions of normals. It was concluded that glycoproteins could modulate the crystal-enhancing glycosaminoglycans such as chondroitin sulfates of stone-formers but not in normals. The differing crystallization activities of electrophoretic fraction 1 of normals and stone-formers revealed the presence of another class of glycosaminoglycan-hyaluronan. Hence, in the natural milieu, different macromolecules combine to have an overall outcome in the crystallization of calcium oxalate.

To study the influence of renal polyanions on crystallization of urinary calcium oxalate, we recovered polyanionic macromolecules from media conditioned by primary cultures of renal proximal tubular epithelial cells of rats in serum-free, hormonally defined medium. Cells cultured on microporous supports showed a higher degree of morphological and functional proximal differentiation into a polarized monolayer than those on plastic impervious substrata. Papainization of the polyanions yielded the glycosaminoglycans chondroitin/dermatan sulphate and heparan sulphate. These accounted respectively for 60% and 80% of the crystal nucleation-promoting activities of polyanions recovered from the apical and basal media conditioned by polarized cultures on microporous supports. Similar relative activities were observed among the urinary glycosaminoglycans and polyanions similarly tested. Primary cultures of polarized proximal tubular epithelial cells are useful then as an in vitro model to study the crystallizing activities of polyanionic macromolecules produced by renal cells.

The potential of whole urine of stone-formers and normal controls to precipitate crystals of calcium oxalate dihydrate from ions endogenous in urine was investigated by the method of rapid evaporation to 1250 mOsm/kg and subsequent freezing. Over 90% incidence in crystallization was achieved in the two groups. When the population density and size of these crystals were compared, it was found that 50% of urine samples from stone formers (30-50 years of age) were rich in crystal-nucleating and growth-inhibiting factors and the other 50% were not different from normal controls. These effects were observed when polyanionic macromolecules recovered from pooled urine samples of stone-formers or normal controls were dissolved in urine ultrafiltrate and similarly tested. That the urinary polyanions were the active modifiers in the test system was further corroborated by the reversal of crystallization activity of urine samples and the urinary polyanions after they had been through an acidification-reneutralization procedure. The urinary polyanionic macromolecules were found, after enzymatic and/or chemical treatment, to contain chondroitin sulphates, dermatan sulphates, heparan sulphates and glycoproteins.

1. Urinary glycosaminoglycans were recovered from the papain digest of polyanions precipitated sequentially by cetylpyridinium chloride and sodium acetate-saturated ethanol. Those from the early morning urine of 48 stone formers and 43 normal control subjects measured 11 and 16 micrograms of uronic acid/ml of urine, respectively. 2. Preparative agarose gel electrophoresis of the recovered glycosaminoglycans in barium acetate buffer (pH 5.8) yielded fractions containing purely chondroitin sulphate, co-polymeric chondroitin/dermatan sulphates and heparan sulphate. Identification was based on the susceptibility of the fractions to chondroitinase or nitrous acid treatment. Similar compositions of glycosaminoglycan classes were observed in samples from stone formers and normal control subjects. 3. The fractionated glycosaminoglycans were dissolved in urine ultrafiltrate to assay for nucleation-promoting and growth-inhibiting activities towards crystallization of urinary calcium oxalate. When compared at the same uronic acid concentration, both the urinary chondroitin sulphate isomers and heparan sulphates of stone formers demonstrated the capacity to enhance crystal nucleation from calcium oxalate endogenous in urine ultrafiltrates, whereas only urinary heparan sulphates of normal control subjects demonstrated this capacity. 4. Tissue-derived reference chondroitin sulphate, dermatan sulphate and heparin, when similarly tested, showed negligible crystal nucleation-promoting activity. The tissue-derived heparan sulphate was similar to the urinary heparan sulphates in showing marked crystal nucleation-promoting activity. 5. Crystal-growth inhibitory activity was evident in all urinary glycosaminoglycan fractions studied. In particular, urinary heparan sulphate of normal control subjects showed higher activity than that of stone formers or the chondroitin sulphate isomers of both stone formers and normal control subjects (P < 0.005).

The nucleation-promoting and growth-inhibiting activities of urinary macromolecules on the crystallization of calcium oxalate endogenous in urine of stoneformers and normal controls were studied by freezing the ultrafiltrate and retenate fractions of concentrated whole urine (pH 5.3, 1,250 mosmol/kg). Among the normal controls, macromolecules nominally of 10-20 kDa showed nucleation-promoting and growth-inhibiting activities; the 5-10 kDa population was incapable of such effects but did cooperate with molecules greater than 10 kDa in enhancing the effect. In the case of stone-formers, molecules in the nominal ranges of 5-10 kDa and 10-20 kDa when considered separately were not active in the aspects studied but collectively could cooperate to produce pronounced effects. Application of the test to urine ultrafiltrate reconstituted with polyanionic macromolecules recovered from urine indicated that molecules from stoneformers were more powerful than those from normal controls in bringing about promotion of nucleation and inhibition of growth of crystals from urinary calcium oxalate.

The inhibitory activity of urine on calcium oxalate crystallization was measured as an inhibitory index using a gel model modified from Schneider et al. [8]. Urine samples from 36 recurrent stone formers and 21 controls in 3 separate periods (morning, afternoon and evening) were tested. Mean inhibitory indices of greater than 0 were observed among normal controls in the 3 sampled periods and among stone formers in the morning and afternoon samples. A significantly lower (negative) value was observed in the evening samples of stone formers, indicating a higher tendency towards crystallization than normal. The gel method may be applied to identify individuals at risk of stone formation if sufficient numbers of period-defined urine samples from the individual are tested for a statistically significant mean inhibitory index but whether this is practical in a clinical laboratory will need further evaluations.