Absence of Oxalobacter formigenes in cystic fibrosis patients: a risk factor for hyperoxaluria

Background Patients with cystic fibrosis have an increased risk of hyperoxaluria, and of subsequent nephrocalcinosis and calcium-oxalate urolithiasis. Oxalate homoeostasis is controlled, in part, by the intestinal bacterium, Oxalobacter formigenes. The loss of this bacterium from the gut flora is associated with an increased risk of hyperoxaluria and calcium-oxalate urolithiasis. We investigated whether the absence of O formigenes and the presence of hyperoxaluria are correlated in cystic fibrosis (CF) patients. Methods Stool specimens from 43 patients with CF aged 3–9 years and from 21 similarly aged healthy volunteers were examined for O formigenes by culture and DNA analysis. At the same time, 24 h urine samples were collected and analysed for oxalate and other factors that promote or inhibit stone formation. Findings 15 (71%) of 21 healthy volunteers but only seven (16%) of 43 CF patients were colonised with O formigenes. Detection of O formigenes in six of these seven patients required DNA-based identification, suggesting low numbers of colony-forming units, and the CF patient with normal numbers of O formigenes was the only one of the 43 patients who had not been treated with antibiotics. All seven CF patients colonised with O formigenes had normal urinary oxalate levels, but 19 (53%) of 36 patients not colonised with O formigenes were hyperoxaluric, with the most severe hyperoxaluria occurring in young patients. Interpretation Absence of O formigenes from the intestinal tract of CF patients appears to lead to increased absorption of oxalate, thereby increasing the risk of hyperoxaluria and its complications (eg, nephrocalcinosis, urolithiasis). Prolonged widespread use of antibiotics, and alterations of the gastrointestinal tract that occur in CF, may induce a permanent decolonisation in CF patients.