Bouquet of flower calcification in renal tubular acidosis.

Nephrocalcinosis, marked by calcium phosphate deposition in the kidneys, is often linked to distal renal tubular acidosis (dRTA). While typically driven by hypercalciuria, hyperphosphaturia can also promote crystal formation in alkaline urine. A 24-year-old female with recurrent fractures and hip pain presented with hypokalemia, metabolic acidosis, and hyperphosphaturia but without hypercalciuria. Imaging revealed medullary nephrocalcinosis and osteomalacia, secondary to dRTA. Potassium citrate improved her condition. This case emphasizes early recognition of dRTA to prevent renal and skeletal complications.