Diet management in stone Disease

1. 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 Diet management in stone Disease

2. Introduction • Nephrolithiasis is influenced by • Genetic factors • Environmental factors • Diet is a major environmental component

3. Risk factors • Intrinsic factors • Heredity • Age and Sex • Extrinsic factors • Geography • Climate and season • Water intake • Diet • Occupation So why it’s ignored ?

4. Stone Management • Treatment of the stone(s) • F/u of the stone formers • Who? • When?

5. Campbell’s 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,

6. Campbell’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

7. Campbell’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

8. Who needs more evaluation? Campbell’s • Recurrent episodes • High risk • Abnormality of simple workup • Multiple stones • Nephrocalcinosis • FHx of stones • Bone or GI disease • Gout • Chronic UTI

9. How far should patients with single renal stone be evaluated? • Pak CY 1982

10. Pak CY 1982 • The same physiological and environmental disturbances as in recurrent stone former

11. Yagisawa 1998 37 vs 136 • 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

12. Yagisawa T, et al J Urol 1999 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.

13. Comments • 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.

14. 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

15. Norman et al, 1984 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.

16. 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

18. Fluids Protien Na + K + Ca ++ Fiber Vit D Ascorbic Acid Vit B 6 CHO Fat Mg Phosphorus What are the diet Factors?

20. FLUIDS • Increased fluid consumption • Recommended since the era of Hippocrates • May decrease supersaturation • Benefits all stone formers

21. Borghi et al 1996 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 Others didn’t Show that

22. Curhan et al 1993 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

23. Curhan et al 1993 FLUIDS But may promote Ca++ excretion (Hasling et al 1992) • The risk for kidney-stone development decreased by: • coffee, 10% • tea, 14% • beer, 21% • wine, 39% Has high oxalate content So don’t recommend it to your pt (Assimos et al 2000) Alcohaol can induce hyperuicosuria (Zechnar 1985)

24. Curhan et al 1993 FLUIDS • The risk increased with • Apple juice, 35% • grapefruit juice, 37% High Ca++ High Na+ High CHO

25. May be useful in Hypocitraturic pt (Wabner et al, 1993) Curhan et al 1993 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

26. Just a hypothesis FLUIDS ? Increasing fluid intake might have a deleterious effect This could lower the conc. of urinary inhibitors.

27. Jeager et al 1995 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. Inhibit it’s reabsorption Increase it’s inhibitory activity

28. FLUIDS (water Hardness) • It reflects the amount of dissolved calcium and magnesium. • Its effect on stones has been debated for yrs

29. No Correlation Chyrchill, 1980 Negative Correlation Between stones & degree of Hardness Sierakawski, 1979 Stones less prevalence at higher hardness Juuti, 1980 Correlates in some areas only Rose 1975 No correlation Kohri 1989

30. Shuster et al 1982 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.

31. FLUIDS Rodgers et al 1997 • Tap water vs. mineral water • X 2 Ca ++ / Mg in the water • Both produce favorable changes in risk parameters • More in profound in mineral

32. Caudarella et al 1998 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

33. Borghi et al 1996 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 !!!!

34. Borghi et al 1996 FLUIDS After 5 yrs

36. 100 % greater X 4 Anderson et al 1973 Protein

37. Protein • Curhan et al reported • animal protein was directly associated with a risk for stone Robertson et al 1979 • Recurrent stone formers consumed more total and animal protein than controls

38. Al Zahrani Norman et al, 2000 Protein • In our population • Males: • no difference except in youngest age gr • Females • had significantly higher than controls

39. 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

40. Protein Hiatt et al 1996 • 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 Al Zahrani Norman et al, 2000 This supports the finding of the statistical findings of the protective effect in AL Zahrani et al

41. Comment Protein Assimos et al 2000 • 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

43. Sodium Na restriction should be recommended in pt w Cystinuria • metabolic changes • inc in urinary • pH, calcium, and cystine • dec in • citrate excretion • Inc PTH & vit D

44. Sodium Iguchi et al 1990 • 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 Trinchieri et al 1998

45. 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 this Martini et al 1998

47. 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

48. Calcium • RR of stone formation dec w increased Ca++ intake

49. Curhan et al 1997 Calcium In males

50. Curhan et al 1997 Calcium In females