What is your approach to managing patients with recurrent nephrolithiasis and hypercalciuria who develop sun photosensitivity following thiazide diuretic initiation?

I am afraid my answer is too prebian. If I cannot use a thiazide and I need to lower urine calcium and protein in order to prevent stones, I resort to reducing dietary calcium to about 60 mEq/day. People who do not respond to a lower diet in sodium and protein with a fall in urine calcium often have some alternative causes beyond idiopathic hypercalciuria, in particular. I have noted it in a few cases of NaPi-2c defects (not published).

Sun avoidance and/or protection are my first thoughts. Failing that, I would recommend more intense dietary modification and look for other metabolic abnormalities amenable to pharmaceutical treatment. Treatment follow-up is critically important, preferably with CT scanning, looking to see if there is a worsening in stone volume or the number of stones.