Proposing a clinical algorithm for better diagnosis of hypophosphatasia in resource-limiting situations.

Early diagnosis of hypophosphatasia (HPP) is challenging. Here, we propose to broaden the diagnostic criteria of HPP by reviewing published data on BMD and fractures in HPP patients. Non-osteoporotic fractures and higher than normal lumbar BMD were recurrent in HPP patients and could be included as diagnostic criteria. HPP is a genetic disorder caused by autosomal recessive or dominant loss-of-function mutations in the ALPL gene that encodes for tissue-nonspecific alkaline phosphatase (TNSALP). Expressive genetic heterogeneity and varying severity of TNSALP deficiency lead to a wide-ranging presentation of skeletal diseases at different ages that coupled with HPP's rarity and limitation of biochemical and mutational studies present serious hurdles to early diagnosis and management of HPP. To widen the scope of HPP diagnosis, we assessed the possibility of areal bone mineral density (BMD) as an additional clinical feature of this disease. PubMed, Web of Science, and ScienceDirect were searched with the following keywords: ("Hypophosphatasia OR HPP") AND ("Bone Mineral Density OR BMD") AND "Human". Studies and case reports of subjects with age ≥ 18 years and having BMD data were included. We pooled data from 25 publications comprising 356 subjects (90 males, 266 females). Only four studies had a control group. Biochemical hallmarks, pyridoxal 5'-phosphate (PLP) and phosphoethanolamine (PEA), were reported in fifteen and six studies, respectively. Twenty studies reported genetic data, nineteen studies reported non-vertebral fractures, all studies reported lumbar spine (LS) BMD, and nineteen reported non-vertebral BMD. Higher than normal and normal BMD at LS were reported in three and two studies, respectively. There was marked heterogeneity in BMD at the non-vertebral sites. Higher than normal or normal LS BMD in an adult with minimal or insufficient fractures, pseudofractures, non-healing fractures, fragility fractures, and stress fractures may be included in the diagnostic protocol of HPP. However, genetic testing is recommended for a definitive diagnosis.

Acromegaly: Cardiovascular risk factors, cardiovascular manifestations and early vascular alterations in relation to disease activity.

Acromegaly is associated with increased cardiovascular morbidity and mortality. 49 acromegaly patients were evaluated for presence of cardiovascular risk factors and manifestations using 2D-Echocardiography, strain, strain-rate, carotid intima media thickness (CIMT) and flow mediated dilatation (FMD) and correlated with disease activity. 32 patients with growth hormone (GH) level >1 ng/ml were considered active. Patients with active disease have more LV dysfunction as assessed by strain(p-0.031) and strain rate(p-0.001); trend towards lower ejection fraction(p-0.11) with significant correlation to GH(cc -0.252,p-0.05). Patient with active disease have reduced FMD(p- 0.042); with no difference in prevalence of cardiovascular risk factors and CIMT inrelation to disease activity.

Genetic Diversity of Clinical Bordetella Pertussis ST2 Strains in comparison with Vaccine Reference Strains of India.

Objectives: Pertussis is a highly contagious disease of the respiratory tract caused by Bordetella pertussis, a bacterium that lives in the mouth, nose, and throat. Current study reports the highly accurate complete genomes of two clinical B. pertussis strains from India for the first time. Methods: Complete genome sequencing was performed for two B. pertussis strains using Ion Torrent PGM and Oxford nanopore sequencing method. Data was assembled de novo and the sequence annotation was performed through PATRIC and NCBI server. Downstream analyses of the isolates were performed using CGE server databases for antimicrobial resistance genes, plasmids, and sequence types. The phylogenetic analysis was performed using Roary. Results: The analysis revealed insertional elements flanked by IS481, which has been previously regarded as the important component for bacterial evolution. The two B. pertussis clinical strains exhibited diversity through genome degradation when compared to whole-cell vaccine reference strains of India. These isolates harboured multiple genetic virulence traits and toxin subunits, which belonged to sequence type ST2. Conclusion: The genome information of Indian clinical B. pertussis strains will serve as a baseline data to decipher more information on the genome evolution, virulence factors and their role in pathogenesis for effective vaccine strategies.

Moderate/subclinical calcium deficiency attenuates trabecular mass, microarchitecture and bone growth in growing rats.

Adequate dietary calcium (Ca) intake is essential for bone accretion, peak bone mass (PBM) attainment, bone quality and strength during the mammalian growth period. Severe Ca deficiency during growing age results in secondary hyperparathyroidism (SHPT) and poor bone quality and strength. However, the impact of moderate Ca deficiency during rats early growth period on bone health and the reversibility with supplementing calcium later in adult life remains unclear. Female Sprague-Dawley (SD) rats (postnatal 28th day, P28) were initiated either with a moderate calcium-deficient diet (MCD, 0.25% w/w Ca) or a control diet (0.8% w/w Ca, control group) till P70. Thereafter, MCD rats were continued either with MCD diet or supplemented with calcium diet (0.8% w/w Ca, calcium supplemented group, CaS) till P150. Another group (control rats) were fed 0.8% w/w Ca containing diet from P28 till P150. MCD group, as compared to the control group, had significantly reduced serum ionized Ca and procollagen type 1 N-terminal propeptide (P1NP) at P70 while no significant change was observed in serum corrected Ca, inorganic phosphate (P), alkaline phosphatase (ALP), 25-hydroxy vitamin D [25(OH)D], intact parathyroid hormone (iPTH), and urinary C-terminal telopeptide of collagen 1 (CTX-1), Ca, and P. Femoral and tibial metaphysis in MCD rats had significantly reduced linear growth, cortical and trabecular volumetric BMD (vBMD), trabecular microarchitecture (BV/TV%, trabecular thickness, separation and number, structural model index and connectivity density), cortical thickness, and bone stiffness despite the absence of secondary hyperparathyroidism (SHPT). Continued MCD at P70-P150 results in persistence of compromised bone strength while calcium supplementation (CaS group) improved all the parameters related to bone strength and microarchitecture. Our results indicate that uncorrected moderate/subclinical calcium deficiency in growing rats can result in poor bone quality and strength despite the absence of SHPT. This finding could have relevance in children with poor calcium intake in childhood and adolescence.

Calcium repletion to rats with calcipenic rickets fails to recover bone quality: A calcipenic "memory".

Calcipenic rickets is prevalent in underprivileged children in developing countries. Calcipenic rickets resulting from dietary calcium (Ca) deficiency decreases bone mass and deteriorates bone microstructure in humans. The effect of dietary Ca replenishment (CaR) on rachitic bones in animal models depends on the amount, critical period and duration of replenishment, however, the extent of recovery in various bone parameters including bone quality remains unclear. We investigated the effect of CaR in rat skeleton after inducing calcipenic rickets. Female SD rats (postnatal 28 days/P28) were rendered calcipenic by feeding calcium deficient (CaD) diet (0.1% Ca) till P70 while control SD rats were fed Ca sufficient diet (0.8% Ca). At P70, calcipenic rats were switched to 0.8% Ca diet till P150 for one group and P210 for another group (endpoint). The CaD groups received 0.1% Ca diet throughout the study (P210). In the CaD groups, serum Ca and phosphate, and bone mineral density (BMD) were significantly decreased whereas serum alkaline phosphatase (ALP), iPTH and CTX-1 were increased compared to age-matched controls. Moreover, at the endpoint, the CaD group had reduced bone mass, surface referent bone formation parameters, tissue mineralization and strength accompanied by the increased osteoid thickness and microarchitectural decay (measured by trabecular geometric parameters) with poor crystal packing. The CaR group showed complete recovery in serum Ca, iPTH, ALP and CTX-1, and BMD, however, the bone quality parameters including bone strength, microarchitectural decay, tissue mineralization, and crystallinity were incompletely restored. Decreased surface referent bone formation and increased unmineralized bones (osteoid) indicative of osteomalacia were also observed in the CaR group at P210 compared with control despite prolonged replenishment. We conclude that a prolonged Ca repletion following the induction of calcipenic rickets in rats although shows the recovery of biochemical measures of bone metabolism and bone mass, however, the bone quality remains compromised. This suggests that a "memory" of calcipenia occurring at the early growth stage persists in the skeleton of adult rats despite a prolonged Ca replenishment.

PHPT Masquerading as Rickets in Children and Presenting with Rare Skeletal Manifestations: Report of Three Cases and Review of Literature.

Primary hyperparathyroidism (PHPT) is an uncommon condition in children and adolescents. However, rapid growth spurt during puberty may result in unmasking and development of certain skeletal manifestations of PHPT. We present three cases of PHPT associated with rare skeletal manifestations of rickets. All three patients had radiological evidence of rickets with primary hyperparathyroidism. All the three patients had single gland adenoma. Literature is sparse regarding reversal of features of rickets following parathyroidectomy. In all three patients of our series, there was a complete resolution of bone/joint pain. However, in two children only the genu valgum persisted but their growth was normal and they had no proximal muscle weakness. In another child multiple corrective surgeries were done to correct the deformities.

Mutational Profile of Papillary Thyroid Carcinoma in an Endemic Goiter Region of North India.

INTRODUCTION: Mitogen activated protein kinase (MAPK) pathway is regularly altered in papillary thyroid carcinomas (PTCs). Serine/threonine-protein kinase B-Raf (BRAF) V600E mutations were observed very frequently in PTC along with less frequent rat sarcoma (RAS) and rearranged during transfection (RET) gene, also known as RET/PTC translocation. The present study aimed to analyze the mutational profile of PTCs from an endemic Goiter area of North India. METHODOLOGY: Tissues from 109 PTC patients were used to isolate DNA and RNA. BRAF V600E was detected by restriction fragment length polymorphism-polymerase chain reaction (PCR). RAS mutations were screened by using Sanger's sequencing method. RET/PTC rearrangements were analyzed by real-time PCR. RESULTS: BRAF V600E mutation was detected in 51.38% (56/109) of PTCs, whereas RAS mutations were less frequent. No RET/PTC rearrangements were observed. BRAF V600E was found to be associated with the aggressive clinicopathological features such as lymph node metastasis, distant metastasis, higher tumor-node-metastasis stages, and high-risk groups. CONCLUSION: The prevalence of BRAF V600E is high in patients from Indian Subcontinent and found to be associated with aggressive features of PTC. Concomitant mutations of BRAF V600E and RAS mutations impart more aggressiveness to PTCs.

Molecular Profiling of Follicular Variant of Papillary Thyroid Cancer Reveals Low-Risk Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features: A Paradigm Shift to Reduce Aggressive Treatment of Indolent Tumors.

INTRODUCTION: Encapsulated follicular variant of papillary thyroid carcinoma (EFVPTC) has been reclassified into noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) and invasive EFVPTC. NIFTP is considered a low-risk neoplasm. Therefore, follicular variant of papillary thyroid cancer (FVPTC) presently has two distinct histopathological subtypes - invasive EFVPTC and infiltrative/diffuse FVPTC. Molecular characteristics of these groups remain unclear. METHODOLOGY: Thirty FVPTCs (10 NIFTPs, 12 invasive EFVPTCs, and 8 infiltrative/diffuse variants) were reviewed and screened for BRAF and RAS mutations by restriction fragment length morphism-polymerase chain reaction (PCR) and Sanger sequencing. The mRNA expression levels of iodine-metabolizing genes were analyzed using real-time PCR. The mutations status and mRNA expression levels were correlated with clinicopathological features. RESULTS: All 10 NIFTPs had predominant follicular pattern. One case showed NRAS mutation, whereas none showed BRAF mutation. All invasive EFVPTC had capsular and/or lymphovascular invasion and 4/12 showed lymph node metastasis. BRAF and NRAS were seen in three cases each of invasive FVPTC. All eight infiltrating/diffuse FVPTCs showed infiltration into adjacent thyroid parenchyma and lymph node metastasis. CONCLUSION: BRAF mutation was observed in 62.5% of cases; however, no NRAS mutation was found. Sodium iodide symporter (NIS) expressions in NIFTP were similar to that of normal thyroid tissue, whereas it was downregulated in invasive and infiltrative/diffuse FVPTC. Our study supports the argument that NIFTP can be considered as low-risk follicular thyroid neoplasm. Those tumors that harbor BRAF mutations may be offered a complete thyroidectomy because they show decreased expression of NIS gene which confers a tendency to lose radioactive iodine avidity and further recurrence of the tumor.

Optimal Levothyroxine Replacement Adequately Improves Symptoms of Hypothyroidism; Residual Symptoms Need Further Evaluation for Other than Hypothyroidism Causation.

OBJECTIVES: Many patients with hypothyroidism complain of persistent residual symptoms, despite optimal treatment, although the similar prevalence is seen in patients with documented absence of thyroid disorder in primary health-care setup. We aimed to investigate symptomatic relief in new cases of primary hypothyroidism and compare with controls with other chronic conditions. METHODS: This prospective case-control follow-up study enrolled patients from July 2014 to May 2015 in an endocrine outpatient clinic of a tertiary hospital. Controls were age- and gender-matched ambulatory individuals with well-controlled other chronic diseases and no major comorbidity. Thyroid symptom questionnaire (TSQ) was administered at pretreatment to all the cases and then they were started on levothyroxine (LT). At euthyroidism, TSQ was readministered. For controls, TSQ was administered only once. TSQ was measured on Likert scale 1-4 for lack of energy, dry skin, constipation, aches and pains, cold intolerance, poor memory, depression, weight gain, tiredness after walking, and difficulty in getting up (DGU). P < 0.05 was considered statistically significant. RESULTS: A total of 194 cases (147 females and 47 males) and 259 controls (187 females and 72 males) were analyzed. A significant difference in the symptoms prevalence was seen between controls and pretreatment cases, except for DGU, and between subclinical and overt hypothyroidism. Pretreatment serum thyroid-stimulating hormone in cases correlated significantly with all their pretreatment symptoms score. All symptoms prevalence decreased significantly posttreatment. At euthyroidism, the mean symptoms score in posttreatment cases was similar or lower than the controls. CONCLUSION: LT effectively improves the symptoms of hypothyroidism in newly diagnosed cases of primary hypothyroidism. The residual symptoms need an alternation explanation other than hypothyroidism.

Interleukin 27 (IL-27) Alleviates Bone Loss in Estrogen-deficient Conditions by Induction of Early Growth Response-2 Gene.

A growing understanding of the bone remodeling process suggests that inflammation significantly contributes to the pathogenesis of osteoporosis. T cells and various cytokines contribute majorly to the estrogen deficiency-induced bone loss. Recent studies have identified the IL-12 cytokine family as consisting of pro-inflammatory IL-12 and IL-23 and the anti-inflammatory IL-27 and IL-35 cytokines. IL-27 exerts protective effects in autoimmune diseases like experimental autoimmune encephalomyelitis; however, its role in the pathogenesis of osteoporosis remains to be determined. In this report, we study the effect of IL-27 supplementation on ovariectomized estrogen-deficient mice on various immune and skeletal parameters. IL-27 treatment in ovariectomized mice suppressed Th17 cell differentiation by inhibiting transcription factor RORγt. Supplementation of IL-27 activates Egr-2 to induce IL-10 producing Tr1 cells. IL-27 treatment prevented the loss of trabecular micro-architecture and preserved cortical bone parameters. IL-27 also inhibited osteoblast apoptosis through increased Egr-2 expression, which induces anti-apoptotic factors like MCL-1. IL-27 suppressed osteoclastogenesis in an Egr-2-dependent manner that up-regulates Id2, the repressor of the receptor activator of nuclear factor-κB ligand-mediated osteoclastogenesis. Additionally, these results were corroborated in female osteoporotic subjects where we found decreased serum IL-27 levels along with reduced Egr-2 expression. Our study forms a strong basis for using humanized IL-27 toward the treatment of post-menopausal osteoporosis.

Prevalence of colonic polyp and its predictors in patients with acromegaly.

BACKGROUND: There are conflicting data regarding the prevalence of colorectal polyp in patients with acromegaly. SUBJECTS AND METHODS: Consecutive forty-seven acromegalic patients (21 men, 26 women), with a mean age of (40 ± 12 years) attending endocrinology outpatient department underwent full colonoscopy. All the patients underwent clinical and biochemical evaluation (glucose suppressed growth hormone (GH), Insulin-like growth factor-1 [IGF-1], fasting insulin, and glucose). The control group (n = 120) for colonoscopy was adult subjects undergoing evaluation for symptoms of irritable bowel syndrome. Clinical and biochemical parameters in acromegalic patients with colonic polyp were compared to those without a polyp. RESULTS: Patients with acromegaly had significantly higher prevalence of colonic polyp as compared to control subjects (10.6% vs. 0.8%). None of the patients with polyp had skin tags. There was no significant difference between subjects with and without colonic polyp in duration of illness, basal, and glucose-suppressed GH and most recent IGF-1. Fasting blood sugar was significantly higher (P < 0.05) in adenoma group after adjusting for age, body mass index (BMI), and insulin levels. Patients in adenoma group showed a trend toward male gender and younger age as compared to those without adenoma. CONCLUSIONS: Subjects with acromegaly as compared to control have a higher prevalence of colonic polyps. There was no association of polyps seen with age, BMI, skin tags, homeostasis model assessment of insulin resistance index, duration of disease, and basal and glucose-suppressed GH and IGF-1 levels. There were no specific predictive factors detected. Screening full colonoscopy is recommended in all cases with acromegaly.

Molecular Characteristics of Large Parathyroid Adenomas.

INTRODUCTION: The clinical entity of large parathyroid adenomas (LPTAs) has not been well defined. It is speculated that LPTAs would have biochemical, histological, and molecular characteristics different from small adenomas. Our study aimed to find out occurrence of atypia and carcinomas in large parathyroid lesions and the presence of distinct molecular abnormalities in LPTAs. MATERIALS AND METHODS: We divided the parathyroid lesions into large (>7 g, i.e., LPTAs) and small (<7 g) adenomas. We performed parafibromin, APC (adenomatous polyposis coli), galectin 3, and PGP9.5 (protein gene product 9.5) analysis by immunohistochemistry in adenomas without atypia, atypical adenomas, and carcinomas. RESULTS: Mean serum calcium, alkaline phosphatase, and intact PTH were significantly higher in large parathyroid tumor group. The presence of both atypical adenoma and carcinoma was higher in large parathyroid tumor group. There was higher percentage of atypia in patients with LPTAs >10 g (33%), and 68% of tumors showed at least one marker suggestive of malignancy in this group. Detailed analysis of immunohistochemical features of LPTA >10 g revealed that six patients showed complete loss of parafibromin immunoreactivity (out of these four showed atypia), while seven showed partial loss. In histopathologically proven malignancy (n = 9), six patients showed complete loss of parafibromin staining, 5 (55%) APC negativity, and 45% showed both galectin 3 and PGP9.5 positivity. Three out of these showed all IHC markers s/o malignancy, and all of them had evidence of metastases or recurrence. 32% of atypical adenoma and 13% of atypical adenoma showed complete loss of parafibromin staining, however none developed metastases or recurrence in follow-up (median follow-up 40 months). Loss of parafibromin staining (complete or partial) was higher in LPTA group (56%) than that in small adenoma (39%); however, it was not statistically significant. APC, galectin 3, and PGP9.5 markers suggestive were higher in LPTA group but were not significant. CONCLUSION: LPTAs may show some morphological and immunohistochemical features suggestive of malignancy and can be considered a separate entity. However, the immunohistochemical markers are unable to clearly segregate those LPTAs that may show premalignant potential. Further, we would like to recommend that LPTAs showing complete parafibromin loss together with atypia should be kept under close follow-up.

Efficacy of a Novel Fenugreek Seed Extract (Trigonella foenum-graecum, Furocyst) in Polycystic Ovary Syndrome (PCOS).

Polycystic ovary syndrome (PCOS) is one of the most prevalent hormonal disorders among women of reproductive age causing irregular menstrual cycles, excessive body or facial hair, miscarriage and infertility. The latter being a most common PCOS symptoms. Because the symptoms are seemingly unrelated to one another, PCOS is often overlooked and undiagnosed. The present study is an open label, one-arm, non-randomized, post-marketing surveillance study in 50 premenopausal women (18-45 years, BMI<42) diagnosed with PCOS using a novel Trigonella foenum-graecum seed extract (fenugreek seed extract, Furocyst, 2 capsules of 500 mg each/day) extract, enriched in approximately 40% furostanolic saponins, over a period of 90 consecutive days. The study was conducted to determine its efficacy on the reduction of ovarian volume and the number of ovarian cysts. Ethical committee approval was obtained for this study. Furocyst treatment caused significant reduction in ovary volume. Approximately 46% of study population showed reduction in cyst size, while 36% of subjects showed complete dissolution of cyst. It is important to mention that 71% of subjects reported the return of regular menstrual cycle on completion of the treatment and 12% of subjects subsequently became pregnant. Overall, 94% of patients benefitted from the regimen. Significant increases in luteinizing hormone (LH) and follicular stimulating hormone (FSH) levels were observed compared to the baseline values. Extensive blood chemistry, hematological and biochemical assays demonstrated the broad-spectrum safety. Furocyst caused significant decrease in both ovarian volume and the number of ovarian cysts. Serum ALT, BUN and CK were assessed to demonstrate the broad-spectrum safety of Furocyst. No significant adverse effects were observed. In summary, Furocyst was efficacious in ameliorating the symptoms of PCOS.

Primary hyperparathyroidism presenting as hypercalcemic crisis: Twenty-year experience.

CONTEXT: To study hyperparathyroid-induced hypercalcemic crisis (HIHC). AIMS: We see very advanced cases of primary hyperparathyroidism (PHPT) and therefore, we sought to determine the incidence of HIHC in our surgically-treated PHPT patients, clinical presentation, and short- and long-term results with the use of bisphosphonate therapy and expeditious parathyroidectomy over a 20-year period at a single institution. SETTINGS AND DESIGN: Retrospective review of PHPT patients at Department of Endocrine Surgery, a tertiary care referral center. MATERIALS AND METHODS: Retrospective review of 177 patients of advanced PHPT who underwent parathyroidectomy at a single institution from 1989 to 2010. All patients with serum calcium ≥14 mg/dl (≥3.5 mmol/l) were included in HIHC group. STATISTICAL ANALYSIS: Analysis of variance (ANOVA) was used to determine differences between groups. Data is expressed as mean ± standard error of the mean (SEM); P values less than 0.05 were considered significant. RESULTS: We observed a higher incidence of HIHC (n = 37, 21%) with higher incidence of pancreatitis (n = 5, 13.5%). Crisis patients had heavier (6,717 mg) glands. Use of bisphosphonate therapy in seven crisis patients resulted in quicker lowering of serum calcium (mean: 4.5 vs 14.6 days in other crisis patients, P = 0.027) permitting early surgery. The incidence of postoperative hypocalcemia was not higher in these patients. Although the parathyroid adenoma was common pathology in both the groups, the incidence of parathyroid carcinoma was higher in crisis group (10.8%). Outcome with regards to postoperative eucalcemia was similar in both groups. CONCLUSIONS: Crisis patients are at risk of developing pancreatitis. Bisphosphonate therapy has the potential to quickly lower the serum calcium permitting early surgery without added risk of postoperative hypocalcemia. Successful and sustained eucalcemia with excellent long-term survival is possible with use of bisphosphonates and semi-emergent, focused parathyroidectmy.

Ethno-botanical study of medicinal plants of Paddar Valley of Jammu and Kashmir, India.

The Paddar Valley, historically known as Sapphire Valley situated in Kishtwar district, is a prime landmark in the Jammu region of J&K state and is known for its rich cultural and plant diversity because of diverse habitats such as rivers, streams, meadows and steep mountain slopes. The area is located in the dry temperate region comprising typical vegetation which disappears completely on the eastern slopes, dominated by a variety of economical species which play an important role in the rural life. The inhabitants are dependent on plant resources for food, fuel, timber, shelter, fodder/forage, household articles and traditional medicines in treating diseases like malaria, cancer, gastro-intestinal ailments, etc. This paper deals with the observations on traditional therapeutic application by the inhabitants of Paddar Valley. The ethno-botanical information on medicinal plants would not only be useful in conservation of traditional cultures and biodiversity but also community health care and drug development. Exploration survey in Paddar Valley has revealed that people collect and sell these medicinal species through local intermediaries / contractors to earn their livelihood. But the scientific cultivation and appropriate post-harvest management would improve employment opportunity and income of local farmers in the region.

Metabolic evaluation in first-time renal stone formers in North India: a single center study.

The risk of stone recurrence in first-time stone formers (FTSF) varies from 26% to 53%. There is no consensus regarding metabolic evaluation in these individuals. We evaluated the metabolic abnormalities in first-time renal stone forming patients in North India. Thirty-nine patients, (29 males and 10 females with mean age 39.3 ± 12.9 years) who presented with nephrolithiasis for the first time were evaluated. We evaluated the calcium homeostasis [serum corrected total calcium, phosphorous, creatinine, alkaline phosphatase, albumin, parathormone (iPTH), 25-hydroxy cholecalciferol (25(OH)D 3 ), 1-25 di-hydroxy cholecalciferol (1,25(OH) 2 D 3 )] and performed the calcium load test also. Two 24-h urine collections were taken for citrate, oxalate, calcium and uric acid. Ammonium chloride loading test for diagnosis of distal renal tubular acidosis was performed in all patients. For each of the diagnostic categories, descriptive statistics were computed for all biochemical variables. A two-tailed P-value <0.05 was regarded as significant. Metabolic abnormalities were detected in 92.3% of the patients (n = 39) studied. Of them, almost 60% had two or more metabolic abnormalities. The most common metabolic abnormality was hypo-citraturia (82%), followed by hyper-oxaluria (56%) and hyper-calciuria (41%). Five percent of the patients had incomplete renal tubular acidosis, signifying the importance of the ammonium chloride loading test in patients with renal stones. None of the study patients were detected to have primary hyperparathyroidism. In three patients, the etiology could not be detected. Our findings suggest that an underlying disorder is present in majority of first-time renal stone formers. Intervention with appropriate treatment can prevent recurrences. Hence, comprehensive metabolic evaluation is recommended in all FTSF.