Reversible hypocalciuria with marginal hypercalcaemia in renal magnesium wasting

Low urinary calcium levels and hypomagnesaemia were observed in three subjects with renal tubular abnormalities. The first, with severe hypomagnesaemia due to congenital renal magnesium wasting, had mildly raised serum ionized calcium levels (1.34-1.36 mmol/l). The other two, a brother and sister, had features of Bartter's syndrome with hypokalaemia, mild hypomagnesaemia and hyperreninaemia with normal serum ionized calcium levels. Hypocalciuria was seen in 24-h urine collections and in 2-hourly timed urine collections. Magnesium loading with intramuscular MgSO4 was used to raise serum Mg to within the normal range. Tubular reabsorption of Mg (TMg) rose while TCa fell, with a rise in fractional excretion of ionized Ca and a small drop in serum ionized Ca. Serum parathyroid hormone levels rose or remained constant. This pattern is consistent with a shared Ca/Mg reabsorptive pathway with a rise in TCa when TMg is low, returning to normal when TMg is raised by Mg loading. In one subject, this imbalance was associated with marginal hypercalcaemia. The site for this pathway is likely to be the thick ascending limb of the loop of Henle.