Diet management in stone Disease
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Transcript of Diet management in stone Disease
Diet management in Diet management in stone Diseasestone Disease
Dr. Anmar Nassir, FRCS(C)
Canadian board in General Urology
Fellowship in Andrology (U of Ottawa)
Fellowship in EndoUrology and Laparoscopy (McMaster Univ)
Assisstent Prof Umm Al-Qura
Consultant Urology King Faisal Specialist Hospital
Introduction
• Nephrolithiasis is influenced by – Genetic factors– Environmental factors
• Diet is a major environmental component
Risk factors
• Intrinsic factors– Heredity– Age and Sex
• Extrinsic factors – Geography
– Climate and season
– Water intake
– Diet – Occupation
So why it’s So why it’s ignored ?ignored ?
Stone Management
• Treatment of the stone(s)
• F/u of the stone formers– Who?– When?
Evaluation of First Stone Former
All patients get at least simple workup• History
– Diet– Stone-provoking meds– Fluid loss– UTI
• Investigations– Stone analysis– CBC, lytes, Cr, Ca, phosphate, uric acid– KUB – UA C&S,
Campbell’sCampbell’s
Evalution of recurrent Stone Former
• What to do?• Clinical practice
– 24 h urine via automated process (pH, Ca, oxalate, uric acid, citrate, Na, sulfate, phosphorus, Mg) once,
– then depending on the above :• repeated with blood work and PTH after dietary
modification
– Bone density study if marked hypercalciuria or hypercalcemia
Campbell’sCampbell’s
Evalution of recurrent Stone Former
• Research protocol:– Two, separate 24h urine collection for Ca, oxalate,
Mg, phosphorus, uric acid, creatinine, citrate, pH, sodium, sulfate on random diet one week apart
– Third visit :• Restricted diet• 24h urine collections for Ca, Na, oxalate• PTH• Fast and calcium load test• Bone density if available
Campbell’sCampbell’s
Who needs more evaluation?
– Recurrent episodes– High risk– Abnormality of simple workup – Multiple stones– Nephrocalcinosis– FHx of stones– Bone or GI disease– Gout– Chronic UTI
Campbell’sCampbell’s
How far should patients with single renal stone be evaluated? • Pak CY 1982AH 55.9 %
renal hypercalciuria 11.8 %
primary hyperparathyroidism 2.9 %
hyperuricosuric calcium oxalate 8.8 %
no metabolic abnormality 20.6 %
• The same physiological and environmental disturbances as in recurrent stone former
Pak CY 1982Pak CY 1982
• In men, – # number of metabolic abnormalities with recurrent
stones (2.20+/-0.86) vs. first-time stones (1.46+/-1.27).
• In women– only be demonstrated for women if low urine volume
was excluded
– a statistically significant difference was only noted in the frequency of hypocitraturia (11.1% versus 37.8%, P < 0.05).
• There were no significant differences in the calcium oxalate supersaturation in all groups
37 vs 136 Yagisawa 1998Yagisawa 1998
Comprehensive vs. Limited Metabolic Evaluations
• specific metabolic diagnosis was made in: – 90% by the comprehensive metabolic evaluation – 68% by 1 24-hour urine collections – 75% by 2 24-hour urine collections.
• Hypercalciuria, hyperoxaluria, and hypocitruria were diagnosed significantly more often
• Type II AH was the most common (1/3) • Dietary calcium-sensitive oxaluria was present in
22% of patients.
Yagisawa T, et al J Urol 1999
• Aplication of that remains controversial for several reasons:– First, if you diagnose hypercalciuria,
hyperoxaluria, or hypocitruria, does specific medical therapy really alter the course of recurrent stone disease?
– Second, several recent studies have shown that nonselective medical therapy may provide control of recurrent calcium urolithiasis.
Comments
What do we do in our hospital?
• 24 hr X 2 urine collection
• Diet Hx
• Which days of the week?
Norman et al, 1996
–Average 24 h urine volume was higher on weekdays than at weekends. –Calcium, oxalate, and uric acid excretion did not differ
When to evaluate?• At least 3/12 • The in-hospital 24-hour urine volumes were
high • decreased gradually to approach the
relatively constant volume of the control group by 3 months.
• The opposite trend occurred with respect to the 24-hour urinary excretion of calcium
• no significant changes in pH,Ox,U.a.
Norman et al, 1984
What is the type of stone?
• Stone analysis
• Expert radiologist
• Past record by pt or relatives
Dretler identfied 4 pattern of stones w varying COM & COD on KUB
Jurol 1996
Type of stoneType of stone %%
Calcium Calcium Oxalate mono & dihydrate
Phosphate
Ox & Phos
~ 80
35-50
10-20
10-35
StruviteStruvite 10-20
Uric a.Uric a. 6-16
CystineCystine 0.5-3
OtherOtherTriamterene
Xanthine
Matrix (noncryst.)
~ 1
What are the diet Factors?
• Fluids• Protien• Na +
• K +
• Ca ++
• Fiber• Vit D
• Ascorbic Acid• Vit B 6• CHO• Fat• Mg• Phosphorus
FLUIDS
• Increased fluid consumption– Recommended since the era of Hippocrates– May decrease supersaturation – Benefits all stone formers
FLUIDS
• Adult male and female first-time stone for-mers had significantly lower urinary volumes compared with age-matched controls: – Mean 24-hour vol = 1057 mL and 990 mL– Vs control groups = 1401 mL and 1239 mL
Borghi et al 1996Borghi et al 1996
Others didn’t Show thatOthers didn’t Show that
FLUIDS
• Prospective study of a cohort of 45,619 male• RR decreased with increased fluid consumption:
< 1275 ml, 1.0
1275-1669 ml, 1.05
1670-2049 ml, 0.82
2050-2537 ml, 0.72
> 2537 ml, 0.52
• The risk varies with the type of beverage
Curhan et al 1993Curhan et al 1993
FLUIDS
• The risk for kidney-stone development decreased by:– coffee, 10% – tea, 14% – beer, 21% – wine, 39%
But may promote Ca++ excretion
(Hasling et al 1992)Has high oxalate contentSo don’t recommend it to
your pt(Assimos et al 2000)Alcohaol can induce
hyperuicosuria(Zechnar 1985)
Curhan et al 1993Curhan et al 1993
FLUIDS
• The risk increased with – Apple juice, 35%– grapefruit juice, 37%
Curhan et al 1993Curhan et al 1993
High Ca++High Na+High CHO
FLUIDS
• Other beverages - did not significantly influence stone, including – water, skim or low fat milk, orange juice,
tomato juice, lemonade, all types of cola, non cola soda, and hard liquor
Curhan et al 1993Curhan et al 1993
May be useful in Hypocitraturic pt
(Wabner et al, 1993)
FLUIDS
? Increasing fluid intake ? Increasing fluid intake might have a deleterious might have a deleterious
effecteffectThis could lower the This could lower the
conc. of urinary conc. of urinary inhibitors. inhibitors.
Just a hypothesisJust a hypothesis
FLUIDS
• Although it is possible
• But this should not promote crystallization.
• Increasing fluid intake actually has been demonstrated to have a positive effect on:– Citrate – Tamm-Horsfall protein.
Jeager et al 1995Jeager et al 1995
Increase it’s inhibitory activity
Inhibit it’s reabsorption
FLUIDS (water Hardness)
• It reflects the amount of dissolved calcium and magnesium.
• Its effect on stones has been debated for yrs
Stones less prevalence at
higher hardness Juuti, 1980
Correlates in some areas onlyRose 1975
No CorrelationChyrchill, 1980
Negative CorrelationBetween stones & degree of
Hardness Sierakawski, 1979
No correlation Kohri 1989
FLUIDS• Patients w stones vs. inguinal hernia repair • There was no significant difference in these two
patient groups with respect to (Ca++ and Mg++) in the respective tap water consumed in – North and South Carolina (soft water) – the Rocky Mountain area (hard water).
• Conclusion:– that water hardness did not influence stone forma-lion.
• However, well water relative to city water significantly increased the risk for stone events in both areas.
Shuster et al 1982Shuster et al 1982
FLUIDS
• Tap water vs. mineral water– X 2 Ca ++ / Mg in the water – Both produce favorable changes in risk
parameters – More in profound in mineral
Rodgers et al 1997Rodgers et al 1997
FLUIDS
• The effect of different calcium content in mineral water
• 15.3: 123.9: 380 mg/L
• 380 mg/L– Significant dec in Ox & Ox : Ca
Caudarella et al 1998Caudarella et al 1998
FLUIDS
• Random prospective study on Ca Ox stone formers
• gr 1 (99 pt ) instructed to have > 2 L/d
• gr 2 (100 pt) told:
You have isolated stone No change in fluid intake were
needed !!!!
Borghi et al 1996Borghi et al 1996
FLUIDSAfter 5 yrsAfter 5 yrs Borghi et al 1996Borghi et al 1996
gr 1 gr 1 gr 2gr 2
Base line volBase line vol
(ml)(ml)
10681068 10081008
F/u volF/u vol
(ml)(ml)
2127 – 26542127 – 2654 1005 – 12581005 – 1258
Stone Stone recurrentrecurrent
12%12% 27%27%
Mean interval Mean interval to stone form.to stone form.
38.7 mo38.7 mo 25.1 mo25.1 mo
ProteinAnderson et al 1973Anderson et al 1973100 % greater
X 4
Protein
• Curhan et al reported – animal protein was directly associated with a
risk for stone
Robertson et al 1979Robertson et al 1979
•Recurrent stone formers consumed more total and animal protein than controls
Protein
• In our population – Males:
• no difference except in youngest age gr
– Females • had significantly higher than controls
Al Zahrani Norman et al, 2000
Protein
• Metabolic changes:– Inc Ca++ u.a. Exc– Dec citrate– 75g pr Ca++ 100mg/d– Ox contraversal
• Animal pr significantly higher– More sulfur in a.a.
Many studies
Protein• Randomized controlled • 50 first-time calcium oxalates stone formers
– increase fluid intake and consume a high-fiber, law- animal proteins diet,
• 49 control– toId just to drink more fluid.
• 4.5-year, – the control gr had significantly less stone events. – 2 vs 12
Hiatt et al 1996Hiatt et al 1996
This supports the finding of the statistical findings of the protective effect in AL Zahrani et al
Al Zahrani Norman et al, 2000
Protein
• These unexpected results could be due to– effect of fiber, – Non-control of calcium intake, – a higher fluid intake for the controls– or patient compliance.
• A better designed randomized study is needed
Assimos et al 2000Assimos et al 2000
CommentComment
Sodium
• metabolic changes– inc in urinary
• pH, calcium, and cystine
– dec in • citrate excretion
– Inc PTH & vit D
Na restriction should be
recommended in pt w Cystinuria
Sodium
• Urinary exc reported to be higher in hypercalciuria than normo-
• Intake not frequently seen to be higher in stone formers
• Curhan: not as a risk
Iguchi et al 1990Iguchi et al 1990
Trinchieri et al 1998Trinchieri et al 1998
Potassium
• Potassium has been demonstrated to decrease calcium excretion.
• Stone formers have an inc urinary Na/K
• Curhan et al RR= 0.49 in > 4041 mg.d compare to < 2896 mg/d K
• Others didn’t show thisMartini et al 1998Martini et al 1998
Calcium
• 50 – 40 yrs: calcium-restricted diet was a mainstay in the treatment of stones
• S/E :– Inc U Ox exc– bone health is another potential problem
Calcium
• RR of stone formation dec w increased Ca++ intake
Calcium
Ca ++ intakeCa ++ intake RRRR
< 605 mg< 605 mg 1.01.0
605 - 722 mg605 - 722 mg 0.710.71
723 - 840 mg723 - 840 mg 0.640.64
849 - 1049 mg849 - 1049 mg 0.610.61
> 1000 mg> 1000 mg 0.560.56
Curhan et al 1997Curhan et al 1997
In males
Calcium
Ca ++ intakeCa ++ intake RRRR
< 408 mg< 408 mg 1.01.0
400 - 642 mg400 - 642 mg 0.780.78
643-801 mg643-801 mg 0.660.66
802-1098 mg802-1098 mg 0.70.7
> 1098 mg> 1098 mg 0.490.49
In females
Curhan et al 1997Curhan et al 1997
Calcium
• In our pts– AL Zahrani et al study supports the protective
role of dietary Ca++ in men but not in women
Al Zahrani Norman et al, 2000
Calcium.
• Supplemental Ca++ inc rather than dec the risk
• Statistically significant only in women
Curhan et al 1997Curhan et al 1997
Calcium
• The bulk of individuals didn’t take it with meals,• To be protective it should be taken with meals to
bind dietary oxalate • It is now believed that levels at calcium intake
above the 800 mg recommended may be beneficial,
• But the optimum value to decrease stone risk has not been identified
• 3858 mg Ca++/d // 2220 mg Ox /d
Assimos et al 2000Assimos et al 2000
CommentComment
Hess et al 1998Hess et al 1998
Oxalate
• absorbed all along the alimentary tract
• > ½ in SI
• Diet can provide 80 % of urinary Ox
Oxalate
• increasing dietary oxalate significantly increases urinary oxalate
• the relationship is nonlinear,
• the response is variable / generic influence
• the amount of Ca++ in the diet has a large impact on the absorption of Ox
Assimos et al 2000Assimos et al 2000
Oxalate
• definitive studies showing that the amount of Ox ingested is a risk factor for the disease are lacking
• Based or the available evidence, restriction of dietary Ox intake is reasonable advice
Assimos et al 2000Assimos et al 2000
Fiber
• 4 –5 X inc in Fiber produce a 20 % reduction in intestinal time
& • Dec Ox absorption / less time• Dec Ox excretion
Bind to Ca++ / phytic a.
+ve correlation w urinary citrate excretion
Hess et al 1994Hess et al 1994
Fiber
In our pts
Higher intake only among young & females
Al Zahrani Norman et al, 2000
Carbohydrates
• Curhan reported that sucrose was not risk factor in male but it is in female
• Not detected in other studies
• CHO inc Ca++ absorption & excretion
• Endogenous Ox synthesis may inc– (gluconeogenesis & ureagenesis)
Assimos et al 2000Assimos et al 2000
Carbohydrates
In our pts
Higher intake than control
Correlated positively w stone
Al Zahrani Norman et al, 2000
Fat
• Animal & vegetable fat was mentioned as risk factor for stones in previous studies
• Not identified by Curhan et al
Fat
• In Halifax QEII– Higher consumption in both male & female
than control– Even higher in younger – As a risk
• in step- wise but not in logistic test
500 pt
Al Zahrani Norman et al, 2000
Fat
• More extensive work studying the effect on urinary risk factors showed:– No relation to PH, Mg, Cit, Ox, Ca, U.a, in men– Weak association between fat intake & U.a in
female
Bailly, Norman 2000Bailly, Norman 2000476 pt
Vitamin B 6
• No association in males
• Limits the risk in female
Carhan et al 1996Carhan et al 1996
Carhan et al 2000
(not published yet)
Carhan et al 2000
(not published yet)
M/A
Dec Ox exc
Mitwalli et al 1988Mitwalli et al 1988
Vitamin C
• Controversial
• Curhan et al 1996:– No association
• Higher intake among males & females was documented in our pts
Al Zahrani Norman et al, 2000
? Inc urinary Ox? decomposition
Vitamin D
• Pursued mainly to expalain the seasonal nature
• Curhan et al recently:– No association
Carhan et al 2000
(not published yet)
Carhan et al 2000
(not published yet)
Magnesium
• Influence not well defined
• Curhan et al – No association
M/A in normal & stone former
Urinary Ca++ & Cit inc
Ox dec
Lindberg et al 1990Lindberg et al 1990
Phosphorus
• Dec Urinary Ca++– Due to dec vit D activity– Its more of the preparation than of the diet
• Should be avoided in struvite & Brushite
• Curhan et al – No association