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Dietary Restriction: A Major Factor in Prophylaxis against Calcium Oxalate Urolithiasis

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Abstract

Urolithiasis (Ur) Is A Worldwide Problem That Affects All Groups Of Ages. Nearly 80% Of Renal Stones Are Calcium Oxalate (Cao) And 50% Of The Affected Patients Have Recurrent Disease Within 10 Years. Our Prospective Study Was Conducted Over 4 And ½ Years And Evaluated The Role Of Dietary Manipulation In Prophylaxis Against Cao Ur. A Total Of 212 Patients With Recurrent Cao Ur, Who Lacked Anatomical Or Metabolic Derangement, Were Subjected To A Practical And Specific Diet. The Latter Had: (A) Low Salt, Red-Meat And Green Leafy Vegetable, (B) Moderate Amounts Of Milk, Dairy Products, Poultry And Certain Fish-Items, And (C) High Water Intake (2 Liters/Day). A Total Of 66/70 (96%), 87/108(88%) And 146/167(87.4%) Patients Were Stone-Free By The End Of 1, 2 And 3 Years Of Follow Up. The Median Time For Stone-Free Duration Was 33 (28.7-37.3) Months. Adding A Thiazide And Allopurinol To The 19 Patients Who Had Failed Dietary Prophylaxis Prevented Stone Formation In 16 More Patients Leaving Only 3 True Failures. Four Patients Could Not Tolerate The Latter 2 Drugs For Allergy. In Conclusion; Our Practical Dietary Modification Can Aid In Prophylaxis Against Cao Ur. Keywords: Diet, Calcium Oxalate, Urolithiasis, Urinary Tract Stones, Prophylaxis
Kamel El-Reshaid et al Journal of Drug Delivery & Therapeutics. 2019; 9(6):126-129
ISSN: 2250-1177 [126] CODEN (USA): JDDTAO
Available online on 15.11.2019 at http://jddtonline.info
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Open Access Research Article
Dietary Restriction: A Major Factor in Prophylaxis against Calcium Oxalate
Urolithiasis
Kamel El-Reshaid *, Shaikha Al-Bader **
*Department of Medicine, Faculty of Medicine, Kuwait University, P O Box 24923, 13110 Safat, Kuwait
** Department of Medicine, Nephrology Unit, Amiri Hospital, Ministry of Health, Kuwait
ABSTRACT
Urolithiasis (Ur) Is A Worldwide Problem That Affects All Groups Of Ages. Nearly 80% Of Renal Stones Are Calcium Oxalate (Cao) And 50% Of
The Affected Patients Have Recurrent Disease Within 10 Years. Our Prospective Study Was Conducted Over 4 And ½ Years And Eva luated The
Role Of Dietary Manipulation In Prophylaxis Against Cao Ur. A Total Of 212 Patients With Recurrent Cao Ur, Who Lacked Anatomical Or
Metabolic Derangement, Were Subjected To A Practical And Specific Diet. The Latter Had: (A) Low Salt, Red-Meat And Green Leafy Vegetable,
(B) Moderate Amounts Of Milk, Dairy Products, Poultry And Certain Fish-Items, And (C) High Water Intake (2 Liters/Day). A Total Of 66/70
(96%), 87/108(88%) And 146/167(87.4%) Patients Were Stone-Free By The End Of 1, 2 And 3 Years Of Follow Up. The Median Time For
Stone-Free Duration Was 33 (28.7-37.3) Months. Adding A Thiazide And Allopurinol To The 19 Patients Who Had Failed Dietary Prophylaxis
Prevented Stone Formation In 16 More Patients Leaving Only 3 True Failures. Four Patients Could Not Tolerate The Latter 2 Drugs For Allergy.
In Conclusion; Our Practical Dietary Modification Can Aid In Prophylaxis Against Cao Ur.
Keywords: Diet, Calcium Oxalate, Urolithiasis, Urinary Tract Stones, Prophylaxis
Article Info: Received 10 Sep 2019; Review Completed 23 Oct 2019; Accepted 28 Oct 2019; Available online 15 Nov 2019
Cite this article as:
El-Reshaid K, Al-Bader S, Dietary Restriction: A Major Factor in Prophylaxis against Calcium Oxalate Urolithiasis , Journal
of Drug Delivery and Therapeutics. 2019; 9(6):126-129 http://dx.doi.org/10.22270/jddt.v9i6.3716
*Address for Correspondence:
Dr. Kamel El-Reshaid, Professor, Dept. Of Medicine, Faculty of Medicine, Kuwait University, P O Box 24923, 13110 Safat,
Kuwait
INTRODUCTION
Urolithiasis (Ur) Is A Worldwide Problem Which Can Affect
All Groups Of Ages And Is A Major Source Of Morbidity
Around The World. The Incidence Of Ur Is About 0.5% Per
Year In North America And Europe [1]. Between 1-15% Of
People Globally Are Affected By Kidney Stones At Some Point
In Their Lives. In 2015, 22.1 Million Cases Occurred And Had
Resulted In 16,000 Deaths Despite All The New Innovations
In Its Urological Interventions [2, 3]. The Etiology Of Ur
Includes; Genetic/Familial Predisposition, Metabolic
Disorders And Anomalies In The Urinary Tract [4]. Nearly
80% Of Renal Stones Are Calcium Oxalate (Cao) And 50% Of
Patients Have Recurrent Disease Within 10 Years Despite
Lack Of Metabolic And Anatomical Diseases [5]. The Latter
Phenomenon Manifests As An Effect Of The Socioeconomic
Status And Geographic Residency (Stone Belts) [4].
Fortunately, A Wide-Range Of Surgical Options Are Currently
Available For Treatment Of Cao Ur Yet The Role Of Its
Prophylaxis Is Under-Estimated And Especially The Dietary
One [6]. In The Present Study We Evaluated The Role Of
Dietary Manipulation In Prevention Of New Stone-Formation
In Patients With Recurrent Cao Ur.
PATIENTS AND METHODS:
Study Design:
Patients With Uncomplicated Yet Recurrent Cao Ur Who
Attended Dr. El-Reshaid Kidney Clinic From 1st January 2014
To 31st June 2019 Were Analyzed Prospectively For Stone
Prophylaxis. The Clinic Was Established In 1997 In The
Center Of Kuwait City. It Is A Referral Center And With
Adequate Diagnostic As Well As Therapeutic Facilities To
Care For Both In- And Out-Patients With All Medical And
Renal Diseases.
Inclusion Criteria:
Patients Were Included, In The Study, If They Have Recurrent
Cao Stones. The Latter Was Defined As (A) Having > Than 2
Radio-Opaque Renal Stones < 6 Mm, (B) Has 1 Stone < 6 Mm
And Had Passed > 1 Before, And (C) Had Passed > 2 Stones
Before.
Exclusion Criteria:
1- Patients Older Than 60 Years At Start Of Symptoms Or
Less Than 14 Years.
Kamel El-Reshaid et al Journal of Drug Delivery & Therapeutics. 2019; 9(6):126-129
ISSN: 2250-1177 [127] CODEN (USA): JDDTAO
2- Those With Morbid Obesity, Hyperparathyroidism,
Nephrocalcinosis, Gastrointestinal Disorders (Short
Bowels, Inflammatory Bowel Disease And
Malabsorption), Chronic Inflammatory Conditions
Associated With Hypercalcemia Viz. Sarcoidosis Or
Malignancy, Cystinuria, Primary Hyperoxaluria, Distal
Renal Tubular Acidosis. Moreover, Patients With
Medullary Sponge Kidneys, Adult Polycystic Kidney
Disease, Urinary Tract Obstruction Or Anomalies Were
Also Excluded. The Exclusion Was Done With
Laboratory And Radiological Testing (Vida Infra).
3- Patients with Hypercalcemia (Corrected Serum Calcium
> 2.3 Mmol/L), Hyperuricemia (Serum Uric Acid > 450
Umol/L), Hypercalcuria (Urinary Calcium Excretion >
200 Mg/Day), Hyperuricosuria (Urinary Uric Acid >
800 Mg/Day), Hyperoxaluria (Urinary Oxalate > 50
Mg/Day), Hypocitraturia (Urinary Citrate < 320
Mg/Day) And Cystinuria (Urinary Cysteine > 350
Mg/Day) Or Positive Nitroprusside Cyanide Test.
4- Patients with Creatinine Clearance < 60 Ml/Minute.
5- Patients with Osteoporosis Requiring Maintenance
Calcium + Vitamin D Supplementation.
Initial Assessment:
Included; Laboratory And Radiological Testing. The
Laboratory Ones Were: (A) Serum Electrolytes Viz. Corrected
Calcium, Magnesium And Bicarbonate Content, Uric Acid (B)
Urine Routine And Microscopy (C) Urine Ph, Sodium,
Calcium, Uric Acid, Oxalate, Citrate And Nitroprusside
Cyanide Test. Radiological Tests Included; Ultrasound As
Well As CT Of The Abdomen And Pelvis When Indicated
Initially Or On Follow Up.
Follow Up Testing:
Included; Routine Clinical, Laboratory And Ultrasound
Assessment Every 2 Months. Twenty Four Hour Urine
Collections Were Done Every 6 Months To Ensure
Compliance. Adherence To Low-Salt Diet Was Confirmed By
Having Urinary Sodium < 225 Mmol/Day.
Stone Prophylaxis:
All Patients Had Instructions Regarding Dietary Measures
That Included Increasing Water Intake To 2 Liters/Day Via 5
Bottles-Regimens. A 250 Ml Of Water Upon Waking Up And
1 Hour Before Night Sleep As Well As 500 Ml ½ Hour Before
Respective Meals. In Addition; (A) Avoidance Of Calcium And
Vitamin D Supplementation Yet Permission Of Moderate
Low-Fat Milk And Dairy Products, (B) Avoidance Of Red Meat
And Their Internal Organs Yet Permission Of < 30 G Of Lean
Poultry Products As Well As Fish In Moderation Except For
Sardines, Tuna And Shrimps, (C) Dark-Green Leafy
Vegetables And (D) Stored Or Frozen Food-Products. The
Latter Was Intended To Limit Salt Intake Which Was
Complemented With Normal Intake Of Home Food Except
For Extra Salt Addition After Cooking And Salty Appetizers
Such As Pickles, Mustard, Salad Dressings, Yogurt And
Frozen Foods. Patients Who Did Not Improve (Recurrent
Renal Colics Or Had Increase Stone Load) Were Further
Retested After Addition Of A Combination Of Thiazide (250
Mg Daily And Allopurinol 100 Mg Daily).
Statistical Analysis:
Since The Age, Duration Of Stone Formation Prior To
Treatment And Duration Of Follow Up Were Not Normally
Distributed; The Median And (Interquartile Range) Were
Used To Express The Groups. Moreover, For Estimation Of
Efficacy Of Prophylaxis/Treatment Years; The Kaplan-Meier
Method Was Used To Calculate The Median Survival Time
And Its 95% Confidence Interval.
RESULTS
Over The Past 4 And 1/2 Years, A Total Of 258 Patients With
Ur Were Screened. Sixteen Patients Were Excluded For The
Following Reasons; (A) 5 With Isolated Hyperuricosuria (B)
2 With Isolated Hypercalcemia (C) 2 Patients With
Hyperuricemia (D) 2 Patients With Cysteine Stones (E) 2
With Distal Renal Tubular Acidosis (F) 2 With Primary
Hyperoxaluria (G) 1 With Hyperparathyroidism. Moreover,
14 Had Congenital Or Acquired Urinary Tract Disease, 11
Had Creatinine Clearance < 60 Ml/Minute And 5 Patients
Lost To Follow Up. Demographical Data And Results Of Their
Treatment Is Summarized In Table 1.
Table 1. The Demographical Data on 212 Patients with Recurrent Idiopathic Cao Urolithiasis and Results of Their
Treatment
Kamel El-Reshaid et al Journal of Drug Delivery & Therapeutics. 2019; 9(6):126-129
ISSN: 2250-1177 [128] CODEN (USA): JDDTAO
Demographical Data:
A Total Of 212 Patients Were Included In The Study. All
Patients Were Adults With A Median Age Of 32(11) And
Youngest Was 21 And Eldest Was 56 Years. The Median Of
Duration Of Follow Up Was 30(21) Months And Shortest Was
3 And Longest Was 54 Months.
Efficacy of Prophylaxis:
During The Study, Only 23 (11%) Patients Had Failed Dietary
Prophylaxis And Formed New Stones. Using Survival Time
Analysis; A Total of 66/70 (96%), 87/108(88%) And
146/167(87.4%) Patients Were Stone-Free By The End Of 1,
2 And 3 Years Of Follow Up. The Median Time for Stone-Free
Duration Was 33 (28.7-37.3) Months.
Management of the Initial Non-Responders:
Adding A Thiazide And Allopurinol To Those Who Failed
Dietary Prophylaxis Prevented New Stone Formation In 13
Of 19 Patients Who Could Tolerate The Drugs.
Tolerance to Prophylaxis:
In General There Was No Major Complaint With Our Dietary
Management. However, 2 Patients Could Not Tolerate
Thiazide For Pruritus. Two Patients Had Mild Hypokalemia
That Was Corrected By Increase In Intake Of Lemon Juice.
Two More Patients Could Not Tolerate Allopurinol For
Urticaria Which Persisted Despite Shifting To Febuxostat.
DISCUSSION
Treatment of Patients with Recurrent Ur Is Cost Effective
Even It Involves Drug Prophylaxis [7]. In The Latter Study,
The Savings Achieved By Reducing Hospitalization And
Urological Procedures In 1,092 Patients With Ur Prophylaxis
By Using Diagnostic Testing, Metabolic Evaluation And Use
Of Inexpensive Drugs Viz. Thiazides, Potassium Citrate And
Allopurinol Was $2,158 Per Patient Per Year. Given The
Proven Benefit Of Prophylaxis, Medicare And Most Managed-
Care Organizations Typically Cover The Costs Of Diagnosis
And These Particular Medical Treatments. In Our
Prospective Study; Few Patients with Recurrent Cao Ur Had
Metabolic Disorders (Hypocitremia, Hyperoxaluria and
Hyperuricemia) And Secondary (Anatomical, Infection And
Metabolic) Causes. The Latter Indicates That The Most Cao
Renal Stones Are Of Benign Nature And Amenable To Dietary
Manipulations Aimed At Calcium And Urate Absorptive
Mechanisms [8, 9]. Moreover, The Success Of Our Additional
Drug-Therapy In Those Who Failed The Dietary
Manipulation Confirms Our Findings. Thiazides Decrease
Urinary Calcium Excretion and Zyloric Decrease Synthesis of
Uric Acid and Hence It’s Excretion Leading To Further
Prevention Of Paroxysms Of Hypercalcuria And
Hyperuricosuria In Partially Compliant Patients [10, 11].
Our Study Further Emphasizes The Role Of Metabolic
Screening In Patients With Cao Ur To Decrease The Cost Of
Their Management. Patients With Recurrent Stone-
Formation And Normal Metabolic Screen; Can Benefit From
Our Practical Dietary Manipulations And The Use Of
Inexpensive Drugs Viz. Thiazides And Allopurinol If
Compliance Is An Issue. In Our Study; And To Improve Our
Patient’s-Compliance, We Limited The Water Intake To 2
Liters Divided At Regular Intervals. The Timing Is Essential
To Improve Patient’s Compliance And The Night Dose Was 1
Hour Before Sleep With Instruction To Have A Minimum Of 2
Urinary Voids Prior To Sleep To Avoid Nocturia That May
Decrease Compliance With The Last Dose. The Restriction
Of Dietary Calcium, Sodium, Animal Proteins, And Leafy
Vegetables Was Calculated To Improve Patient’s-Compliance
[12]. Dietary Calcium Was Moderate To Assist In Providing
Adequate Supply To The Growing Teeth And Bones As Well
As To Bind With Meal-Oxalate And Prevent Their Absorption
[13]. High Salt Intake Leads To Hypercalcuria Due To
Inhibition Of Re-Absorbency Of Calcium In The Proximal
Tubule [14]. Our Limitation Of Sodium-Intake Was Practical
And Acceptable By Our Patients. It Kept The Members Of
The Family Together By Just Limiting External Food Intake
And In-House High Salt-Content Items. The Restrictions Of
Animal Proteins Were Limited To Red Meat And Internal
Organs Which Are Purine-Rich Items And Result In High Uric
Acid Levels. Moderate Poultry Products and Most Fish-Items
Were Acceptable Alternatives And Did Not Significantly
Increase Uric Acid Excretion Or Result In Hyperuricosuria.
The Latter May Have Been Due To Their Higher Content Of
Guanine And Xanthine Compared To Adenine And Xanthine
In Meat As Well As Their Alkalization Effect (Similar To The
Milk And Dairy Products) Which Facilitates Uric Acid
Elimination In Urine [15]. Lastly, Leafy Vegetables Are A
Major Source Of Oxalates. The Latter Is A Major Risk Factor
For Cao Ur [16]. They Were Neglected By Most Of Our
Patients And Even Large-Percentage Of Our Population Still
Believes That The Drinks Containing Bagdonis Aids In
Stone Expulsion. This Believe Stemmed From Misconception
Of Higher Frequency Of Stone Passage Masquerading A
Rather More New Ur. In Conclusion; Our Dietary
Manipulations Offers Patients With Recurrent Idiopathic Cao
Ur A Simple And Palatable Diet With Adequate Essential
Elements To Improve Their Compliance And Prevent Disease
Progression.
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... Exceptions entail patients with dehydration, non-oliguric acute tubular necrosis (ATN), recovering polyuric phase of ATN, and chronic reflux nephropathy. Moreover, certain kidney diseases such as calcium oxalate urolithiasis, cystinuria, autosomal dominant polycystic kidneys, and recurrent urinary tract infections indicate high fluid intake with 2 liters/day to cleanse their urinary tract from stones and bacteria [3] [4]. Finally, the myth of "kidney protection with excessive water intake" should be discouraged since (a) intact thirst center dictates water urges after sensing increased serum osmolality, and (b) extravagant polydipsia leads to undue day/night polyuria and may generate disease-phobia. ...
... In CRD-patients with uncontrolled hyperP, hypoCa and low 1,25 vit D, progressive hyperplasia of the parathyroid glands culminates into adenomatous changes with severe hyperCa (tertiary hyperparathyroidism) that indicates excision of the adenomatous gland[35]. In patients with urolithiasis; Ca and different forms of vitamin D should be restricted to avoid further stone formation[3]. ...
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Background This study aimed to evaluate the risk factors associated with the development of urolithiasis in a population in Southern China. Material/Methods A questionnaire-based study was conducted between March 2017 to April 2018 that included 1,519 patients in Southern China and included questions on patient demographics, diet, and lifestyle. Patients were divided into the urolithiasis group who had urinary calculi and the control group. Results There were 829 patients (54.6%) in the urolithiasis group and 690 patients (45.4%) in the control group. Using a chi-squared (χ²) test, 13 variables were found to be significantly associated with urolithiasis, including age, physical activity, and dietary factors that included high sodium, protein, fat, lean meat, vegetables, pickled food, fluid intake, drinking habits and tea consumption, and frequency and duration of physical exercise. Multivariate logistic regression analysis showed that dietary factors, including vegetables (OR, 0.856; 95% CI, 0.769–0.948), pickled foods (OR, 1.271; 95% CI, 1.030–1.357), and animal protein intake (OR, 1.138; 95% CI, 1.031–1.258), drinking strong tea (OR, 0.793; 95% CI, 0.702–0.897), fluid intake (OR, 0.758; 95% CI, 0.644–0.816), and duration of physical exercise (OR, 0.840; 95% CI, 0.808–0.973) were significantly associated with the occurrence of urolithiasis and were independent risk factors. Conclusions High consumptions of pickled foods and animal protein were the main risk factors for the development of urolithiasis in a population of southern China, but high fluid intake with a preference for strong tea, a diet of vegetables, and physical exercise were protective factors.
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By contrast, both total deaths and age-standardised death rates due to communicable, maternal, neonatal, and nutritional conditions significantly declined from 2005 to 2015, gains largely attributable to decreases in mortality rates due to HIV/AIDS (42·1%, 39·1-44·6), malaria (43·1%, 34·7-51·8), neonatal preterm birth complications (29·8%, 24·8-34·9), and maternal disorders (29·1%, 19·3-37·1). Progress was slower for several causes, such as lower respiratory infections and nutritional deficiencies, whereas deaths increased for others, including dengue and drug use disorders. Age-standardised death rates due to injuries significantly declined from 2005 to 2015, yet interpersonal violence and war claimed increasingly more lives in some regions, particularly in the Middle East. In 2015, rotaviral enteritis (rotavirus) was the leading cause of under-5 deaths due to diarrhoea (146 000 deaths, 118 000-183 000) and pneumococcal pneumonia was the leading cause of under-5 deaths due to lower respiratory infections (393 000 deaths, 228 000-532 000), although pathogen-specific mortality varied by region. Globally, the effects of population growth, ageing, and changes in age-standardised death rates substantially differed by cause. Our analyses on the expected associations between cause-specific mortality and SDI show the regular shifts in cause of death composition and population age structure with rising SDI. Country patterns of premature mortality (measured as years of life lost [YLLs]) and how they differ from the level expected on the basis of SDI alone revealed distinct but highly heterogeneous patterns by region and country or territory. Ischaemic heart disease, stroke, and diabetes were among the leading causes of YLLs in most regions, but in many cases, intraregional results sharply diverged for ratios of observed and expected YLLs based on SDI. Communicable, maternal, neonatal, and nutritional diseases caused the most YLLs throughout sub-Saharan Africa, with observed YLLs far exceeding expected YLLs for countries in which malaria or HIV/AIDS remained the leading causes of early death. Interpretation: At the global scale, age-specific mortality has steadily improved over the past 35 years; this pattern of general progress continued in the past decade. Progress has been faster in most countries than expected on the basis of development measured by the SDI. Against this background of progress, some countries have seen falls in life expectancy, and age-standardised death rates for some causes are increasing. 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