Dietary Restriction in Nephrolithiasis

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Dietary Restriction in Nephrolithiasis

  1. 1. Dietary Restriction for Recurrent Nephrolithiasis Iris Thiele Isip Tan MD, FPCP, FPSEM Clinical Associate Professor, UP College of Medicine Section of Endocrinology, Diabetes & Metabolism Department of Medicine, Philippine General Hospital
  2. 2. Increase fluid intake to ensure a urine volume of at least 2 liters/day
  3. 3. Urinary Lithogen Factors Calcium >170 mg/L Oxalate pH < 5.5 pH > 6.0 >250 mg/24h >40 mg/24 h >300 mg/24h Urate Citrate Phytate >650 mg/L <350 mg/24 h <1 mg/24h >600 mg/24h >800 mg/24h Grases et al, Nutrition Journal 2006;5:23
  4. 4. pH < 5.5 Calcium Citrus juices oxalate Softdrinks Uric acid Citric acid rich beverages Cystine Calcium oxalate/ Animal uric acid mixed protein Grases et al, Nutrition Journal 2006;5:23
  5. 5. pH > 6 Calcium oxalate Hydroxyapatite Brushite Vegetarian diet Citrus juices Calcium oxalate/ Softdrinks Hydroxyapatite Citric acid rich beverages mixed Grases et al, Nutrition Journal 2006;5:23
  6. 6. Oxalate >40 mg/24h Chives Beet leaves Calcium Spinach Amaranth oxalate Rhubarb Okra Purslane Green tea Parsley Chocolate Sweet potatoes Lambsquarters Oxalate rich foods Ascorbic acid rich foods (vit C intake >2 g/day) Grases et al, Nutrition Journal 2006;5:23
  7. 7. Calcium >170 mg/L Control vit D >250 mg/24h consumption >300 mg/24h & calcium supplements Water Hydroxyapatite intake >2 li/day Calcium oxalate Sodium Calcium oxalate/ Animal Hydroxyapatite protein mixed Grases et al, Nutrition Journal 2006;5:23
  8. 8. Avoid Ca restriction in hypercalciuric patients ❖ No clear distinction between absorptive and renal hypercalciuria ❖ No prospective studies to support belief that calcium restriction leads to reduction in stone recurrence ❖ Calcium restriction induces secondary hyperoxaluria Heilberg I. Nephrol Dial Transplant 2000;15:117-123
  9. 9. Avoid Ca restriction in hypercalciuric patients ❖ Predisposes to bone loss (negative calcium balance) ❖ Chronic Ca restriction might upregulate vitamin D receptors (stimulate intestinal Ca absorption and bone resorption) ❖ Other nutrients (protein, Na, oxalate and K) affect calcium excretion Heilberg I. Nephrol Dial Transplant 2000;15:117-123
  10. 10. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria Recurrent calcium oxalate stones with idiopathic hypercalciuria (Italy) normal Ca, low animal low Ca diet 5-year protein, low salt diet follow-up n = 60 n = 60 Avoid milk, yoghurt & TCR: 2540 kcal cheese to reduce Ca intake Total protein: 15% 10 mmol/day Lipids: 33% Avoid oxalate-rich foods CHO: 52% (walnuts, spinach, rhubarb, Ca: 30 mmol/day parsley, chocolate) NaCl: 50 mmol/day Avoid oxalate-rich foods Both diets allowed 2-3 liters of water/day Borghi et al, NEJM 2002:346:77-84
  11. 11. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria Primary outcome measure: Time to first recurrence of symptomatic renal stone* or presence of radiographically identified stone** normal Ca, low animal low Ca diet protein, low salt diet n = 60 n = 60 23/60 had relapses 12/60 had relapses Urinary Ca Urinary Ca Urinary oxalate Urinary oxalate (5.4 mg/d or 60 umol/d) (7.2 mg/d or 80 umol/d) * Typical renal colic, episode of hematuria, expulsion or removal of previously undiscovered stone ** Renal UTZ/abdominal flat plate yearly Borghi et al, NEJM 2002:346:77-84
  12. 12. Comparison of two diets: cumulative incidence of recurrence (%) 50 40 Cumulative Incidence of Recurrence (%) 30 Low calcium Low calcium 20 Normal calcium, low protein, Normal calcium, low salt 10 low protein, low salt RR = 0.49 (95%CI 0.24-0.98), p=0.04 0 0 6 12 18 24 30 36 42 48 54 60 Month NO. AT RISK Low calcium 60 59 51 49 46 44 42 39 33 31 28 Normal calcium, 60 57 53 47 46 45 44 43 41 40 40 low protein, low salt Borghi et al, NEJM 2002:346:77-84
  13. 13. Delayed effect of intervention due to early recurrences in the highest-risk patients 80 Low-calcium diet — men at highest risk (n=9) Cumulative Incidence of Recurrence (%) Normal-calcium, low-protein, low-salt diet — men at highest risk (n=14) 70 Low-calcium diet — other men (n=51) Normal-calcium, low-protein, low-salt diet — 60 other men (n=46) 50 40 30 20 10 0 0 6 12 18 24 30 36 42 48 54 60 Month High-risk: >5 colic episodes in the year before randomization, >10 stones before randomization or both Borghi et al, NEJM 2002:346:77-84
  14. 14. Citrate < 350 mg/24 h Hydroxyapatite Calcium oxalate Calcium oxalate/ Citrate-rich foods Hydroxyapatite Citric acid rich mixed beverages Grases et al, Nutrition Journal 2006;5:23
  15. 15. Phytate < 1 mg/24 h Calcium oxalate Phytate rich foods Brushite Cereal germ i.e. corn germ Cereal bran i.e. wheat cereal (100% bran) Whole cereals i.e. wild rice Beans i.e. whole bean, bean flour, tofu Nuts i.e. brazil nuts Grases et al, Nutrition Journal 2006;5:23
  16. 16. Urate >650 mg/L >600 mg/24h >800 mg/24h Seafood Canned seafood (anchovies, sardines in oil, herrings) Fish roe Meat Organ meat (liver, kidney, sweetbreads) Uric acid Meat extracts, consomme, gravies Calcium oxalate/ Purine rich foods uric acid mixed Alcoholic drinks Grases et al, Nutrition Journal 2006;5:23
  17. 17. General Dietary Recommendations ❖ Daily intake of a suitable liquid volume (minimum 2 L water/day) ❖ Avoid strictly vegetarian diets ❖ Avoid excessive animal protein diets Grases et al, Nutrition Journal 2006;5:23
  18. 18. High Protein Intake Hyperuricosuria Hypercalciuria (purine overload) ↑ bone resorption Hyperoxaluria (↑ oxalate synthesis) ↓ tubular Ca reabsorption Hypocitraturia (↑ tubular citrate ↑ Ca filtered load reabsorption) Heilberg I, Arq Bras Endocrinol Metab 2006;50:823-31
  19. 19. General Dietary Recommendations ❖ Avoid excessive salt (NaCl) consumption ❖ Avoid excessive vitamin C and/or vitamin D consumption ❖ Consume phytate-rich products (natural dietary bran, legumes and beans, whole cereals) Grases et al, Nutrition Journal 2006;5:23
  20. 20. Thank You http://www.endocrine-witch.info

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