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Coconut Water: An Unexpected Source of Urinary Citrate

Authors:

Abstract

Purpose: Coconut water has long been touted for its medicinal qualities including natural hydration. We sought to determine whether its consumption would induce changes to urinary lithogenic factors beyond changes in urine volume. Materials and methods: After Institutional Review Board approval, volunteers with no prior history of nephrolithiasis were recruited. Each participant was randomized initially to either the coconut water or the water phase of the study. Participants kept meticulous food and fluid intake logs during the first phase of the study and were asked to replicate that diet for the second phase. For each phase the participant consumed 2L of either Taste of Nirvana® pure coconut water or tap water daily for four days. Participants were not restricted to consume additional fluid of their choice during their assigned study phase. During days 3 and 4 of each phase the participant collected a 24-hour urine specimen. Coconut water citrate and malate content were measured and were used along with the beverage pH to calculate the total alkali content of the coconut water. Supersaturation levels were calculated using Equil2. Nonparametric paired analysis using the Wilcoxon test was performed for statistical analysis. Results: There were 4 adult male and 4 adult female participants. Each individual's 24-hour urine collection had a creatinine excretion within 20% of the mean for each subject's four samples corroborating that all samples were collected properly. The two samples from each phase for each individual were averaged. The coconut water itself was also analyzed and it was calculated to have a total alkali content of 13.8 mEq/L. Consumption of coconut water significantly increased urinary citrate (29%, p=0.02), urinary potassium (130%, p=0.01), and urinary chloride (37%, p=0.03), without affecting urine pH (p=0.16) or volume beyond that of tap water (p=1.00). Conclusions: Coconut water consumption increases urinary potassium, chloride, and citrate in nonstone forming individuals.
Research Article
Coconut Water: An Unexpected Source of Urinary Citrate
Roshan M. Patel ,1Pengbo Jiang,1John Asplin,2Ignacio Granja,2Taylor Capretz,1
Kathryn Osann,3Zhamshid Okhunov,1Jaime Landman,1and Ralph V. Clayman1
1Department of Urology, University of California, Irvine, USA
2Litholink Corporation, Laboratory Corporation of AmericaHoldings, USA
3Department of Medicine University of California, Irvine, USA
Correspondence should be addressed to Roshan M. Patel; roshanmp@uci.edu
Received 3 May 2018; Revised 18 September 2018; Accepted 26 September 2018; Published 1 November 2018
Guest Editor: Ephrem Olweny
Copyright ©  Roshan M. Patel et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Purpose. Coconut water has long been touted for its medicinal qualities including natural hydration. We sought to determine
whether its consumption would induce changes to urinary lithogenic factors beyond changes in urine volume. Materials and
Methods. Aer Institutional Review Board approval, volunteers with no prior history of nephrolithiasis were recruited. Each
participant was randomized initially to either the coconut water or the water phase of the study. Participants kept meticulous
food and uid intake logs during the rst phase of the study and were asked to replicate that diet for the second phase. For each
phase the participant consumed L of either Taste of Nirvanapure coconut water or tap water daily for four days. Participants
were not restricted to consume additional uid of their choice during their assigned study phase. During days  and  of each
phase the participant collected a -hour urine specimen. Coconut water citrate and malate content were measured and were used
along with the beverage pH to calculate the total alkali content of the coconut water. Supersaturation levels were calculated using
Equil. Nonparametric paired analysis using the Wilcoxon test was performed for statistical analysis. Results. ere were  adult
male and  adult female participants. Each individual’s -hour urine collection had a creatinine excretion within % of the mean
for each subject’s four samples corroborating that all samples were collected properly. e two samples from each phase for each
individual were averaged. e coconut water itself was also analyzed and it was calculated to have a total alkali content of .
mEq/L. Consumption of coconut water signicantly increased urinary citrate (%, p=.), urinary potassium (%, p=.),
and urinary chloride (%, p=.), without aecting urine pH (p=.) or volume beyond that of tap water (p=.). Conclusions.
Coconut water consumption increases urinary potassium, chloride, and citrate in nonstone forming individuals.
1. Introduction
e worldwide prevalence of kidney stones has increased
dramatically over the past few decades with calcium oxalate
nephrolithiasis continuing to be the most common type of
urolith in the United States of America. [, ] In patients with
calcium oxalate nephrolithiasis, hypocitraturia is found in up
to % of samples on quantitative -hour urine chemistry.
[] e mainstay medical treatment in these patients is
potassium citrate; however, adherence to this supplement is
notoriously poor given the frequency to take the medications
(usually three times a day), the number of tablets needed,
cost, and side eects. [] Alternatively, patients are also
counseled on dietary modications and they are encouraged
to increase their consumption of uids high in citrate content
(e.g., lemonade, crystal light).
Coconutwateristheliquidendospermofgreencoconuts
(Cocos nucifera L.), which is the most naturally widespread
fruit plant on Earth. [] Known to Hawaiian’s as Noelani,
meaning “dew from the heavens,” it is rich in electrolytes,
vitamins, minerals, cytokines, and proteins and has long been
touted for its medicinal qualities, including natural hydration,
high ber content, laxative and diuretic eect, antiaging
impact, antimicrobial properties, and energy enhancement.
[]Saatetal.comparedrehydrationaerexercisewith
coconut water, carbohydrate-electrolyte beverage and water.
[] ey found that coconut water was well tolerated and
subjects reported having greater ease in consuming a large
Hindawi
BioMed Research International
Volume 2018, Article ID 3061742, 5 pages
https://doi.org/10.1155/2018/3061742
BioMed Research International
T : Taste of Nirvana coconut water nutritional facts adjusted
to L serving size and % daily value adjusted according to  FDA
guidelines.
Nutritional Facts % Daily Value
Serving size (L) . —
Calories  —
Total Fat (g) 
Cholesterol (g) 
Sodium (mg)  
Potassium (mg)  
Total Carb o hydr ate (g)  
Sugar (mg)  —
Protein (mg) —
Chloride —
Calcium —
Vitamin C —
Magnesium —
amount of coconut water as opposed to an energy drink or
water.
Gandhi et al. studied the eect of coconut water con-
sumption on ethylene glycol induced nephrocalcinosis in
male Wistar rats. [] e study demonstrated that coconut
water consumption inhibited crystal deposition in renal
tissue and decreased the number of crystals in the urine.
However, the possible antilithogenic eects of coconut water
have never been studied in humans. An anecdotal patient
encounter piqued our interest in the potential of coconut
water as an antilithogenic natural substance. In the resulting
study, our primary goal was to determine the impact of
drinking coconut water on known urinary lithogenic factors.
2. Materials and Methods
Aer Institutional Review Board approval, adult volunteers
with no prior history of nephrolithiasis were recruited. Each
participant was randomized initially to either a coconut water
or a water phase. Participants kept meticulous food and
uid intake logs during the rst phase of the study and
were asked to replicate that diet for the second phase. For
each phase, the participant consumed .L of either Taste
of Nirvanapure coconut water or tap water daily for four
days.enutritionalfactsprovidedbythemanufacturerand
percent daily value are shown in Table . Participants were
not restricted with regard to the consumption of additional
uid of their choice during the study. On days  and  of each
phase the participant collected a -hour urine specimen. A
washout phase of a minimum of  weeks and a maximum of
 weeks between phases was implemented in this study.
Citrate and malate concentrations of the coconut water
were measured using ion chromatography (Dionex, Sun-
nyvale CA). Electrolytes were measured with ion specic
electrodes and pH was measured using a pH electrode. Total
alkali of the coconut water was calculated from the citrate and
malate concentrations, the beverage pH and the pKs of the
anions. e pK of tricarboxylic acid citrate used to calculate
T : Coconut water analysi s. Each can contains .L of c oconut
water.
Taste of NirvanaPure Coconut Water
pH .
Citrate mM/L .
Malate mM/L .
To ta l A l k a l i m E q/ L .
Na mM/L .
KmM/L .
Cl mM/L .
anion content was ., ., and . and for dicarboxylic malate
pK was . and ., respectively. e total alkali is expressed
in milliequivalents per liter (mEq/L). Supersaturation levels
were calculated using Equil.
Nonparametric paired analysis using the Wilcoxon test
was performed for statistical analysis. Analysis was con-
ductedusingSYSTATv(SystatSoware,Inc.,ChicagoIL).
3. Results
A total of  subjects were recruited into this study:  adult
males and  adult females. e average age of the male
participants was . years (- years) and for female
participants  years (-). Each individual’s -hour urine
collection had a creatinine excretion within % of the
mean for each subject’s four samples corroborating that all
samples were collected properly. e two samples from each
phase for each individual were averaged. e coconut water
itselfwasalsoanalyzed(Table).isshowedthatthetotal
alkali content was .mEq/L. Each can of Taste of Nirvana
contained .L of coconut water.
e average total urine volume for the participants was
.L during both the coconut water and water phase of
the studies. Consumption of coconut water signicantly
increased urinary citrate as compared to tap water by %
(p=.). In addition, consumption of coconut water as
compared to tap water increased urinary potassium by
%(p=.) and urinary chloride by % (p=.) (Table ).
Increases in urinary citrate, potassium, and chloride with
consumption of coconut water were similar for males and
females and for younger (<=) and older subjects (>).
Numbers in these subgroups were too small to obtain statis-
tical signicance in stratied analyses.
ere was no signicant alteration in urine volume,
urine pH, supersaturation of calcium oxalate and calcium
phosphate, urine calcium, and urine sodium.
4. Discussion
Hypocitraturia, dened as urinary citrate excretion less than
mg per day for adults, is an important metabolic abnor-
mality in stone formers with an incidence as high as %
[, ]. Citrate is a well-known inhibitor of calcium stone for-
mation through multiple mechanisms, including complexing
with calcium, preventing nucleation of both calcium oxalate
and calcium phosphate, and blocking crystal agglomeration
BioMed Research International
T : Mean values from -hour urine.
Wat e r S D Coconut Water SDp-value
Volume (L/d) . . . . .
SSCaOx . . . . .
Ca (mEq/d)     .
Oxalate (mEq/d) .  . . .
Citrate (mEq/d)     .
SSCaP . . . . .
pH . . . . .
SSUA . . . . .
Uric Acid (g/d) . . . . .
Na (mEq/d)  .  . .
K (mEq/d)  .  . .
Mg (mEq/d)  .   .
P(g/d) . . . . .
NH4 (mEq/d) . . . . .
Cl (mEq/d)  .  . .
Sulfate (mEq/d) . . . . .
Urea N (g/d) . . . . .
Creatinine (mEq/d)     .
SD: standard deviation.
BioMed Research International
and growth []. Oral potassium citrate, available in various
forms, increases urinary citrate levels and urinary pH; it is the
main treatment for hypocitraturia associated nephrolithiasis
[, ].
Despite its proven ecacy, compliance with potassium
citratetherapyispoor.Inonestudythatlookedatlong-
term follow-up of stone formers who were treated with
potassium citrate, only % consistently took the medication
[]. In addition, given that potassium citrate therapy is costly,
upward o  USD/month for three times daily dosing of
 meq, alternative dietary therapies have been evaluated [].
Lemonjuicetherapyintheformoflemonadewasinitially
reported to signicantly increase urinary citrate levels [].
Subsequentstudieshaveshownmixedresultsandhavecast
some doubt on the eectiveness of lemonade therapy. Ko et
al. performed a crossover design trial comparing potassium
citratetherapyandlemonadetherapy[].eyfoundno
dierence in urinary citrate or urine pH in the lemonade
group, while the potassium citrate group demonstrated sig-
nicantincreaseinbothurinarycitrate(%)andurine
pH (%). Using controlled metabolic conditions, Odvina
and colleagues measured urinary stone risk factors and
demonstrated that orange juice had a greater alkalinizing and
citraturiceectthanlemonade[];themeanincreasein
urinary citrate per ml of orange juice was mg compared
to only mg during lemonade consumption. Similarly, uri-
nary pH was higher by . units in the orange juice group
compared with lemonade and control phases of the study.
Halebian et al. performed quantitative analysis of citrate
content amongst commercially available beverages. Grape-
fruitjuicewasfoundtohavethehighestcitratecon-
tent (.mmol/L), followed by lemon juice (.mmol/L),
orange juice (.mmol/L), pineapple juice (.mmol/L),
and home-made lemonade (.mmol/L). Crystal Light had
the highest concentration of citrate (.mmol/L) among
non-juice beverages []. However, because of how the body
absorbs and metabolizes citrate, only a small amount of
dietary citrate reaches the urine. Instead, urinary citrate
excretion depends closely on acid-base physiologic states. In
a state of acid loading, the proximal tubule reabsorbs citrate.
On the contrary, during alkali loading, there is decreased
renal tubule reabsorption of citrate, which thereby increases
urinary citrate excretion [].
Given the importance of systemic alkalinization and its
eect on renal citrate handling, Eisner et al. analyzed lemon-
ade and  diet sodas to determine citrate and malate as alkali
andthetotalalkaliload.Lemonadehad.mEq/Lcitrate
as alkali, far lower than several other beverages such as Diet-
Up (. mEq/L), Diet Sunkist Orange (. mEq/L), and
Sierra Mist Free (. mEq/L). e pH of lemonade is usually
less than , so most citrate in lemonade is present as citric
acid, limiting the amount of alkali delivered. e majority of
beverages tested did not have signicant measurable malate
as alkali, except for Diet Sunkist Orange, Diet Canada Dry
Ginger Ale, and Diet Orange Crush. e total alkali content
was highest in Diet Sunkist Orange (. mEq/L), Diet-Up
(. mEq/L), and Diet Canada Dry Ginger Ale (. mEq/L)
[]. Of note, coconut water, at . mEq/L, has far greater
alkalicontentthananyoftheprioruids.
In our study, despite relatively low citrate content (.
mmol/L), coconut water therapy revealed a signicant
increase in urinary citrate excretion from baseline (mean
increase of mg/d). is citraturic eect is likely due to the
very high total alkali load (. mEq/L), which is higher than
inanyoftheotherjuicesornonjuiceuidsdiscussed[].
e high total alkali load is mainly a function of the high pH
of coconut water and the malate content. Of note is that this
increase in citrate occurred in nonstone forming individuals
with a normal citrate at baseline; whether there would be a
similarorgreaterimpactoncitratelevelsinhypocitraturic
stone-formers has yet to be tested. Interestingly, we did not
record a signicant change in urinary pH. Our ndings
also revealed signicant increase in urinary potassium and
chloride, which may be explained by the high potassium
and chloride content of coconut water. e coconut water
studied contains approximately  mg/L (. mEq) of
potassium, which is % of the Food and Drug administration
daily recommended value for adults []. Of note, potassium
depletionhasbeenassociatedwithhypocitraturia[].
Of interest, coconut water contains a signicant amount
of chloride, which is unusual for a fruit beverage. Potassium
content of a beverage is oen used as a gauge of alkali content
on the assumption that most potassium is accompanied by
organic anions. In coconut water, this assumption is not
correctasmostpotassiumisactuallypotassiumchloride.is
point highlights the need for direct measurement of organic
anions and pH to assess the alkali content of a beverage.
e ideal dietary therapy for decreasing urinary stone risk
factors should be low in calories, animal protein, sodium, and
oxalate and high in citrate and total alkali load. Compared to
commercially available grapefruit and orange juice, coconut
water has approximately % less calories and % less
sugar content.While there is less overall citrate content
compared to other citrus beverages, the very high alkali
load is associated with a signicant and substantial citraturic
eect. Indeed, coconut water may represent a more ideal
beverage for increasing urinary citrate compared to lemon
juice, lemonade, and other beverages.
To our knowledge, this is the rst analysis of coconut
water for its antilithogenic properties in humans and the
results are promising. Additionally, dierences in pH and
supersaturation of calcium oxalate between the two groups
may have reached signicance if suciently powered. We
chose initially to include only individuals with no prior
history of nephrolithiasis to determine if coconut water
consumption would change urinary stone risk factors. Future
studies with larger sample sizes are needed to evaluate if the
citraturic eect of coconut water is operational in calcium
stone forming patients with hypocitraturia.
5. Conclusions
Coconut water consumption increases urinary potassium,
chloride, and citrate in nonstone forming individuals without
altering the urine pH.
Abbreviations
mEq: Milliequivalents.
BioMed Research International
Data Availability
e datasets generated during and/or analyzed during the
current study are available from the corresponding author on
reasonable request.
Conflicts of Interest
e authors declare that there are no conicts of interest
regarding the publication of this article.
Acknowledgments
is study was funded by the UC Irvine Department of
Urolog y.
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... 10,17 Hypocitraturia is one of the most common urinary metabolic disorders among patients with renal lithiasis and the use of citrus fruits shows the bene t of increasing citraturia. 34 About 50% of participants, surprisingly with no signi cant differences between groups, reported having heard of citrate. The frequency of identi cation of food sources such as oranges and lemons was low, close to 35%. ...
... However, melon, a non-citrus fruit with a high citrate content, was cited by only 3.5%. 34 Although it may mean a low level of knowledge about citrate sources, this result is justi ed by the di culty, in clinical practice, in identifying citrate sources, since this data is not available in food composition tables. Other non-citrus fruits like coconut water, were also evaluated to reverse hypocitraturia.36 ...
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Kidney stones is a very prevalent disease, whose morbidity is associated with the recurrence of stone formation. Food plays an important role in the prevention and treatment of the disease, but this impact is still not widespread. Objective: The present study aims to evaluate the knowledge of the general population and of individuals with nephrolithiasis regarding the formation of kidney stones and the dietary measures recommended for their prevention. Methods: This is a descriptive, cross-sectional study, with a convenient sample. Data were collected using an online questionnaire containing 39 questions [sociodemographic data (8), health data (14), and dietary treatment knowledge (17)], shared on social media. Results: The questionnaire was answered by 283 participants [76.1% women; median age 34.5 (28-75.41) years], 61. 5% reporting being lithiasic. The lythiasic group had more comorbidities than the non-lythiasic one. Most of the participants (85.9%) believed that diet could prevent the formation of kidney stones, with higher frequency in the non-lythiasic group (93.6% vs lythiasics81%, p=0.003).Lithiasics in comparison with non-lythiasics presented lower frequency of correct answers for the items "increased fluid intake" (87.9% vs 95.4%, p=0.034) and "regular consumption of fruits, vegetables and vegetables" (47.7% vs 60.6%, p=0.035), the factors that decrease stone formation; and "milk chocolate being the most indicated for individuals with oxalate-based stones" (5.7% vs 13.8%, p=0.021). However, lithiasics had a higher frequency of correct answers about "low calcium intake increases stone formation" (29.9% vs non-lithiasics: 24.8%, p=0.018). Conclusion: the present study shows that there are gaps in knowledge about dietary advice in patients with renal lithiasis, which is even more worrying about the few differences when compared to non-lithiasic individuals.
... Fresh tomato juice was shown to be a good source of citrate (82.4 mmol/L) but was not associated with a reduction in stone risk in large observational cohort studies [40,48]. Finally, coconut juice, which provides 13.8 mEq/L of alkali, comparable to that of Crystal Lite ® , yielded increases in urinary citrate, potassium, and chloride compared to tap water when consumed at 2 L daily [37,49]. However, no studies evaluating the clinical impact of these changes have been reported. ...
Article
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Diet plays a central role in the development and prevention of nephrolithiasis. Although pharmacologic treatment may be required for some patients who are resistant to dietary measures alone, dietary modification may be sufficient to modulate stone risk for many patients. While there is no single specialized diet for stone prevention, several dietary principles and recommendations for stone prevention are supported by practice guidelines, including adequate fluid intake, modest calcium intake, low dietary sodium, and limited animal protein. In this review, we summarized the evidence supporting these dietary recommendations and reviewed the current literature regarding specific dietary components and comprehensive diets for stone prevention.
... The extended range of concentrations of different observations can be assumed due to soil quality, genetic variation or maturation of the fruit (Jackson, et al., 2004;Uphade, et al., 2008). Coconut water is a good source of citrate and malate ions (Patel et al., 2018) and the anions of the salt form may shift towards those ions rather than chloride ion with increasing age. ...
Article
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Coconut water, extracted from the fruit of Cocos nucifera L., is a popular drinks throughout the tropics. The variable nature of the composition of the drinks had been established multiple times before, with regards to age, location and genetic variation. However, in Bangladesh, such studies were not carried out before. Thus, this study aims to compare electrolytes, amino acids and carbohydrates concentration in coconut water of different age collected from an inland region of the country. To determine electrolyte concentration atomic absorption spectrophotometry and Mohr titrimetric method were applied. Determination of carbohydrate and amino acid concentration required two separate high performance liquid chromatography (HPLC) methods. Regarding electrolytes concentration, rise of potassium, calcium and chloride ion concentration and fall of sodium and magnesium ion concentration were apparent. Potassium ion was the most abundant cation (50.88-67.56 mEq/L) while steep rise of magnesium ion concentration from 4 month to 6 months (4.14±0.17 to 12.72±2.52 mEq/L) was observed. Fructose and dextrose concentrations also escalated with coconut age. Amino acid concentrations varied as well. Histidine (0.43 g/100ml), arginine (0.053 g/100ml) and arginine (0.142 g/100ml) were the most abundant amino acids found in water 4, 6 and 8 months old coconuts. Overall, the trends of variation of components show intake of coconut water can bring different physical outcomes to different consumers and therefore, must be chosen carefully for patients with electrolytic imbalance and other medical complications.
... Coconut water has preventive effects on the kidney and treats urethral stones [19] . Studies have shown the beneficial effect of coconut water on degenerated kidneys in alloxan-induced diabetes in Wistar rats. ...
Article
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Cocos nucifera (L.), (C. nucifera) Arecaceae, also called the coconut tree, is probably the widely most extensively dispersed fruit plant and supplies all the necessities of life. It is an important economic plant that feeds a million people. All the parts of coconut plant are extensively used for religious practices, culinary purposes, for making household equipment’s and is also used as traditional medicine. The goal of the review is to provide an insight into its phytochemical profile and its therapeutic potential in metabolic diseases. The plant as a whole possess plethora of uses such as, neuroprotective activity, antidiabetic activity, anticancer activity, antihypertensive and lipid lowering activity. Various study reports its safety in preclinical and clinical setup.
... Overall, the relative risk of calcium oxalate stone formation was unaffected [70,72] or reduced [71] in healthy volunteers but increased in stone patients after the intake of cranberry juice [72]. Finally, a study of healthy subjects showed that the consumption of 1.9 L/day of coconut water compared to tap water significantly raised urinary citrate, potassium, and chloride excretion, without affecting urine pH [73]. Although fruit and vegetable juices could be useful in the dietary therapy of kidney stone disease, the oxalate concentration has to be taken into account. ...
Article
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The prevalence of kidney stone disease is increasing worldwide. The recurrence rate of urinary stones is estimated to be up to 50%. Nephrolithiasis is associated with increased risk of chronic and end stage kidney disease. Diet composition is considered to play a crucial role in urinary stone formation. There is strong evidence that an inadequate fluid intake is the major dietary risk factor for urolithiasis. While the benefit of high fluid intake has been confirmed, the effect of different beverages, such as tap water, mineral water, fruit juices, soft drinks, tea and coffee, are debated. Other nutritional factors, including dietary protein, carbohydrates, oxalate, calcium and sodium chloride can also modulate the urinary risk profile and contribute to the risk of kidney stone formation. The assessment of nutritional risk factors is an essential component in the specific dietary therapy of kidney stone patients. An appropriate dietary intervention can contribute to the effective prevention of recurrent stones and reduce the burden of invasive surgical procedures for the treatment of urinary stone disease. This narrative review has intended to provide a comprehensive and updated overview on the role of nutrition and diet in kidney stone disease.
... Dietary factors affect urinary components and pH, leading to the formation and growth of urinary stones (Pak 1998;Parivar et al. 1996;Taylor and Curhan 2006;Baatiah et al. 2020). In general, the diet plays an important role in the formation of kidney stones, as increasing the intake of vegetables and fruits and reducing dairy, fatty substances, and red meat reduce the incidence of stones (Taylor and Curhan 2006;De La Guéronnière et al. 2011;Robertson 2016;Ferraro et al. 2017;Geraghty et al. 2017b;Khambati et al. 2017;Patel et al. 2018). Many studies are linking high kidney stones to the type of diet (Ishii et al. 2016;Geraghty et al. 2017a;Rob et al. 2017). ...
Article
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The purpose of this study is to determine the factors responsible for the prevalence of urinary stones disease among the inhabitants of selected regions in northern Jordan and to trace the extent of their link with the hydrogeochemical properties of groundwater in the area in addition to geoenvironmental factors and some certain dietary habits. By comparing the disease spread in the studied areas, results showed that the elevated areas (Irbid and Amman) are the most affected regions with the disease. One hundred and thirty water samples collected from 15 wells were distributed across the three studied regions to identify urinary stone patients among individuals. All samples were analyzed for percentages of cations and anions to assess water quality. Anions are distributed in the following order: HCO3− >Cl− >SO42− >NO3− >F− >PO43−, while the cations are distributed as follows: Ca2+ >Mg2+ >Na+ >K+ >Fe2+. The hydrogeochemical analysis results for the three regions compared using the Wilcoxon rank-sum test. The significant difference in the values of TDS, TH, Cl−, NO3−, Ca2+, and Mg2+ is p < 0.05 compared with water quality in the regions of Amman–Mafraq and Irbid–Mafraq. Depending on Gibbs’ diagram and the factor analysis, elements ratio plots strongly suggest that the source of chemical ions in the groundwater is the interaction of water with carbonate rocks. Therefore, this study confirms the strong relationship between urinary stones formation and the geochemistry of drinking water during the high calcium content and increase of the water hardness used by the residents of the study areas. The effect of temperature on the formation of urinary stones was observed through the direct correlation with the amount of water consumed by individuals. In winter, the daily water intake decreases, which leads to an increase in the concentration of Ca, Na, and P ions in the bladder. The high temperature in the summer increases the dehydration process in the body, which increases the concentration of calcium and other ions to create an opportunity for urine stones to form.
... Some studies involved participants keeping a food diary for the duration of the intervention, made of self-selected diet, which was then replicated in each arm of the intervention. [31,32] Although this provides some consistency in terms of diet during the studies, it does not eliminate the massive variation in diet between participants, as each individual will have their own dietary preferences when given the choice of choosing their own food to consume. This highlights the necessity of standardizing diet when conducting future studies on fluid intake. ...
Article
Objective: The incidence of kidney stone disease (KSD) is rising worldwide; hence, more focus must be directed toward its etiology and risk factors. Increasing fluid intake is recommended as the most ideal prevention; yet, there is inconsistent evidence surrounding optimum volumes and types of fluid that affect stone formation. This review aimed to analyze the published literature on fluid intake and types of fluid consumed and their impact on KSD prevention. Material and methods: Papers were acquired from databases: MEDLINE, EMBASE, PubMed, CINAHL, and Cochrane Library. Included English language studies that involved adults consuming beverages along with a standardized diet in relation to KSD. Those failing to control dietary factors were excluded. Results: After an initial search of 1099 papers, 9 (541 participants) were included in the final review. Six varieties of water and ten different types of juices were investigated. Higher fluid intake was associated with increased urine output and reduced stone formation. Water with high calcium content seemingly increased the rate of calcium oxalate (CaOx) stone formation. The relative supersaturation of CaOx in urine was decreased with grapefruit, apple, orange juices, and sodas, whereas cranberry juice increased it. Plum juice and the energy drink Gatorade had no effect on stone formation. Conclusion: Fluids low in calcium seem to reduce the risk of KSD. Certain varieties of fluid, such as grapefruit, apple, and orange juices reduce urine CaOx saturation, with a subsequent reduction in stone formation. Findings from this review could contribute to primary prevention for those at risk of KSD.
Chapter
Kidney stones are becoming more common and are associated with significant morbidity. In the current day, it is well understood that nutritional factors play a role in the development of kidney stones. Putative dietary promoters of calcium-containing stones include high sodium, high protein, and high sucrose intake. Putative dietary inhibitors of calcium-containing stones include higher potassium, high magnesium, high fiber, and high vitamin B6 intake. The American Urologic Association, the European Association of Urology, and other organizations have recently published dietary guidelines (generally expert opinion) for the management of kidney stones. We will review the data for optimal fluid, calcium, protein, sodium, citrate, vitamin C, vitamin D, sugar, potassium, and phytate intake. New insights into the physiology of stone formation may illuminate the similarity of disease progression to vascular calcification and inflammation, which gives rise to coronary artery disease (CAD). The implications may be that a diet intended to prevent kidney stones may mitigate diabetes, metabolic syndrome, and high blood pressure while addressing the risk for CAD and low bone mineral density. For that reason, we also promote the US Dietary Guidelines for Americans 2015–20, which promote health in general. Although those guidelines do not specifically address kidney stones and have not been tested for that purpose, we believe that adherence to those guidelines would likely reduce stones, promote bone health, and reduce metabolic syndrome and its accompanying comorbidities (https://health.gov/dietaryguidelines/2015/guidelines/).
Article
Purpose: The pursuit of a dietary source to increase urine pH and citrate in stone formers has been ongoing for more than 30 years. Early evidence showed that orange juice (OJ) contains alkali and citrate but high sugar and ascorbic acid content limited the use of OJ as a viable daily source of alkali. Recently, novel low calorie OJs have emerged and could potentially be a better option. Methods: Beverages with high concentrations of alkali citrate and malate were identified using ion chromatography. Two low calorie OJ beverages, in addition to Crystal Light Lemonade (CLLB) were chosen. Healthy volunteers (5 men, 5 women) drank 1L of OJ or CLLB with 1L water daily for 7 days and then completed a 24-hour urinalysis. A washout week was instituted between trial weeks. The study design is a prospective randomized cross over control trial. A paired analysis using comparison of means was used to evaluate low calorie OJ and CLLB. Volunteers had no prior history of kidney stones and maintained a journal with beverage compliance, side effect, and dietary consumption data. Results: Tropicana 50 (TRP50), Kroger low calorie OJ (KLCO) and CLLB were found to have a total alkali content of 56.60, 47.9, and 17.3 mEq/L, respectively, based on ion chromatography. Consumption of all three beverages raised urinary citrate (116.6 [-118 to 373, 177.9 [-3 to 359], 155.6 [-4 to 237] mg/d 95% CI) and urinary pH (0.25 [0.08-0.53], 0.74 [0.41-1.07 p<0.05], 0.25 [0.25-0.64]) respectively, compared to water phase. Based on volunteer journal entries , TRP50 had the most side effects (90% participants) felt to be a result of the artificial sweetener (Stevia ®). Conclusion: Low-calorie orange juice, and to a lesser extent CLLB, have alkali and citrate based on ion chromatography. Daily consumption, by healthy volunteers of KLCO can raise urinary pH.
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Cocos nucifera (L.) (Arecaceae) is commonly called the "coconut tree" and is the most naturally widespread fruit plant on Earth. Throughout history, humans have used medicinal plants therapeutically, and minerals, plants, and animals have traditionally been the main sources of drugs. The constituents of C. nucifera have some biological effects, such as antihelminthic, anti-inflammatory, antinociceptive, antioxidant, antifungal, antimicrobial, and antitumor activities. Our objective in the present study was to review the phytochemical profile, pharmacological activities, and toxicology of C. nucifera to guide future preclinical and clinical studies using this plant. This systematic review consisted of searches performed using scientific databases such as Scopus, Science Direct, PubMed, SciVerse, and Scientific Electronic Library Online. Some uses of the plant were partially confirmed by previous studies demonstrating analgesic, antiarthritic, antibacterial, antipyretic, antihelminthic, antidiarrheal, and hypoglycemic activities. In addition, other properties such as antihypertensive, anti-inflammatory, antimicrobial, antioxidant, cardioprotective, antiseizure, cytotoxicity, hepatoprotective, vasodilation, nephroprotective, and anti-osteoporosis effects were also reported. Because each part of C. nucifera has different constituents, the pharmacological effects of the plant vary according to the part of the plant evaluated.
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Purpose: Many medicinal plants have been employed during ages to treat urinary stones though the rationale behind their use is not well established. Thus, the present study was proposed to evaluate the effect of coconut water as a prophylactic agent in experimentally induced nephrolithiasis in a rat model. Materials and methods: The male Wistar rats were divided randomly into three groups. Animals of group I (control) were fed standard rat diet. In group II, the animals were administrated 0.75% ethylene glycol in drinking water for the induction of nephrolithiasis. Group III animals were administrated coconut water in addition to ethylene glycol. All the treatments were continued for a total duration of seven weeks. Results and conclusion: Treatment with coconut water inhibited crystal deposition in renal tissue as well as reduced the number of crystals in urine. Furthermore, coconut water also protected against impaired renal function and development of oxidative stress in the kidneys. The results indicate that coconut water could be a potential candidate for phytotherapy against urolithiasis.
Article
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Coconut water (coconut liquid endosperm), with its many applications, is one of the world's most versatile natural product. This refreshing beverage is consumed worldwide as it is nutritious and beneficial for health. There is increasing scientific evidence that supports the role of coconut water in health and medicinal applications. Coconut water is traditionally used as a growth supplement in plant tissue culture/micropropagation. The wide applications of coconut water can be justified by its unique chemical composition of sugars, vitamins, minerals, amino acids and phytohormones. This review attempts to summarise and evaluate the chemical composition and biological properties of coconut water.
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The most common presentation of nephrolithiasis is idiopathic calcium stones in patients without systemic disease. Most stones are primarily composed of calcium oxalate and form on a base of interstitial apatite deposits, known as Randall's plaque. By contrast some stones are composed largely of calcium phosphate, as either hydroxyapatite or brushite (calcium monohydrogen phosphate), and are usually accompanied by deposits of calcium phosphate in the Bellini ducts. These deposits result in local tissue damage and might serve as a site of mineral overgrowth. Stone formation is driven by supersaturation of urine with calcium oxalate and brushite. The level of supersaturation is related to fluid intake as well as to the levels of urinary citrate and calcium. Risk of stone formation is increased when urine citrate excretion is <400 mg per day, and treatment with potassium citrate has been used to prevent stones. Urine calcium levels >200 mg per day also increase stone risk and often result in negative calcium balance. Reduced renal calcium reabsorption has a role in idiopathic hypercalciuria. Low sodium diets and thiazide-type diuretics lower urine calcium levels and potentially reduce the risk of stone recurrence and bone disease.
Article
Purpose: We determine patient adherence to and quality of outcome of medical kidney stone treatment during a 30-year duration at a single university based referral clinic. We also analyze time trends in adherence and timing of followup measurements, and supersaturation reduction during treatment. Materials and Methods: Data on all patients who entered the University of Chicago Kidney Stone Prevention Program from 1970 to 2000 were analyzed. Fractions of new patients who had any followup and those remaining in followup at increasing intervals were analyzed. Timing of followup was measured. Changes in adherence during the 3 decades were also analyzed, as was reduction in supersaturation in regard to calcium oxalate, calcium phosphate and uric acid. Results: A total of 70% to 80% of patients were retained at each successive followup cycle with 2 physicians, and a clinical protocol that always required 6-week followup with 24-hour urine collection and a yearly one thereafter for stone risk factors. Retention decreased during the last 5 years of the 1990s. Supersaturation reduction was present by the first followup and remained constant or improved with time. Timing of followup measurements was in accord with our protocol. Conclusions: At best, one can retain only 70% to 80% of patients in a followup program at each interval, and achieve supersaturation reductions that are constant and significant during the long term. Timing of followup measurements can be close to that of the protocol in use.
Article
The last nationally representative assessment of kidney stone prevalence in the United States occurred in 1994. After a 13-yr hiatus, the National Health and Nutrition Examination Survey (NHANES) reinitiated data collection regarding kidney stone history. Describe the current prevalence of stone disease in the United States, and identify factors associated with a history of kidney stones. A cross-sectional analysis of responses to the 2007-2010 NHANES (n=12 110). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Self-reported history of kidney stones. Percent prevalence was calculated and multivariable models were used to identify factors associated with a history of kidney stones. The prevalence of kidney stones was 8.8% (95% confidence interval [CI], 8.1-9.5). Among men, the prevalence of stones was 10.6% (95% CI, 9.4-11.9), compared with 7.1% (95% CI, 6.4-7.8) among women. Kidney stones were more common among obese than normal-weight individuals (11.2% [95% CI, 10.0-12.3] compared with 6.1% [95% CI, 4.8-7.4], respectively; p<0.001). Black, non-Hispanic and Hispanic individuals were less likely to report a history of stone disease than were white, non-Hispanic individuals (black, non-Hispanic: odds ratio [OR]: 0.37 [95% CI, 0.28-0.49], p<0.001; Hispanic: OR: 0.60 [95% CI, 0.49-0.73], p<0.001). Obesity and diabetes were strongly associated with a history of kidney stones in multivariable models. The cross-sectional survey design limits causal inference regarding potential risk factors for kidney stones. Kidney stones affect approximately 1 in 11 people in the United States. These data represent a marked increase in stone disease compared with the NHANES III cohort, particularly in black, non-Hispanic and Hispanic individuals. Diet and lifestyle factors likely play an important role in the changing epidemiology of kidney stones.
Article
Citrate is a known inhibitor of calcium stone formation. Dietary citrate and alkali intake may have an effect on citraturia. Increasing alkali intake also increases urine pH, which can help prevent uric acid stones. We determined citrate, malate and total alkali concentrations in commonly consumed diet sodas to help direct dietary recommendations in patients with hypocitraturic calcium or uric acid nephrolithiasis. Citrate and malate were measured in a lemonade beverage commonly used to treat hypocitraturic calcium nephrolithiasis and in 15 diet sodas. Anions were measured by ion chromatography. The pH of each beverage was measured to allow calculation of the unprotonated anion concentration using the known pK of citric and malic acid. Total alkali equivalents were calculated for each beverage. Statistical analysis was done using Pearson's correlation coefficient. Several sodas contained an amount of citrate equal to or greater than that of alkali and total alkali as a lemonade beverage commonly used to treat hypocitraturic calcium nephrolithiasis (6.30 mEq/l citrate as alkali and 6.30 as total alkali). These sodas were Diet Sunkist Orange, Diet 7Up, Sprite Zero, Diet Canada Dry Ginger Ale, Sierra Mist Free, Diet Orange Crush, Fresca and Diet Mountain Dew. Colas, including Caffeine Free Diet Coke, Coke Zero, Caffeine Free Diet Pepsi and Diet Coke with Lime, had the lowest total alkali (less than 1.0 mEq/l). There was no significant correlation between beverage pH and total alkali content. Several commonly consumed diet sodas contain moderate amounts of citrate as alkali and total alkali. This information is helpful for dietary recommendations in patients with calcium nephrolithiasis, specifically those with hypocitraturia. It may also be useful in patients with low urine pH and uric acid stones. Beverage malate content is also important since malate ingestion increases the total alkali delivered, which in turn augments citraturia and increases urine pH.
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Chronic monomyelocytic leukemia (CMML) is a relatively rare clonal hematologic disorder with features of myelodysplastic syndrome and myeloproliferative disease. Renal impairment from CMML is infrequent and can result from both direct (ie, infiltrative) and indirect (eg, vasculitis, infarction) mechanisms. This case report describes a patient with refractory gross hematuria requiring nephroureterectomy with diffuse involvement of the upper tract by CMML and accompanying extramedullary hematopoiesis. Underscored are the need to maintain a broad differential diagnosis for upper tract lesions in the setting of gross hematuria, and the potential need for drastic measures to control upper tract bleeding if conservative measures fail.
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Recurrent nephrolithiasis is a burden to the individual patient as well as the healthcare system. A lack of new medications for treatment of stone disease and continued poor compliance with drug therapy has led to a growing interest in dietary manipulation and novel therapies aimed at preventing recurrent stone formation. Despite initial enthusiasm for lemonade therapy, recent metabolic studies suggest that beverages with a high potassium citrate content, rather than citric acid, may be more effective in reducing stone risk because of the alkali load and citraturic response. In addition, there is increasing epidemiologic and metabolic evidence that obesity and dietary excess, including fructose-rich and purine-rich foods, are associated with increased stone risk. Finally, alternative measures for reducing urinary risk factors, such as probiotics, show promise in reducing urinary oxalate and may be effective in the treatment of primary and enteric hyperoxaluria or even idiopathic calcium oxalate nephrolithiasis. Although changes in urinary stone risk factors may reduce the need for surgical treatment of stone disease, the best management for recurrent nephrolithiasis is likely a combination of surgical and medical therapy. Dietary measures and novel probiotic therapy are promising adjuncts for preventing recurrent nephrolithiasis.
Article
The long-term effects of potassium citrate therapy (usually 20 mEq. 3 times daily during 1 to 4.33 years) were examined in 89 patients with hypocitraturic calcium nephrolithiasis or uric acid lithiasis, with or without calcium nephrolithiasis. Hypocitraturia caused by renal tubular acidosis or chronic diarrheal syndrome was associated with other metabolic abnormalities, such as hypercalciuria or hyperuricosuria, or occurred alone. Potassium citrate therapy caused a sustained increase in urinary pH and potassium, and restored urinary citrate to normal levels. No substantial or significant changes occurred in urinary uric acid, oxalate, sodium or phosphorus levels, or total volume. Owing to these physiological changes, uric acid solubility increased, urinary saturation of calcium oxalate decreased and the propensity for spontaneous nucleation of calcium oxalate was reduced to normal. Therefore, the physicochemical environment of urine following treatment became less conducive to the crystallization of calcium oxalate or uric acid, since it stimulated that of normal subjects without stones. Commensurate with the aforementioned physiological and physicochemical changes the treatment produced clinical improvement, since individual stone formation decreased in 97.8 per cent of the patients, remission was obtained in 79.8 per cent and the need for surgical treatment of newly formed stones was eliminated. In patients with relapse after other treatment, such as thiazide, the addition of potassium citrate induced clinical improvement. Thus, our study provides physiological, physicochemical and clinical validation for the use of potassium citrate in the treatment of hypocitraturic calcium nephrolithiasis and uric acid lithiasis with or without calcium nephrolithiasis.