|Year : 2006 | Volume
| Issue : 4 | Page : 387-388
Diabetes mellitus: A long term sequelae of shock wave lithotripsy?
Samiran Adkikary, Nitin S Kekre
Department of Urology, CMC, Vellore, India
Department of Urology, CMC, Vellore
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Adkikary S, Kekre NS. Diabetes mellitus: A long term sequelae of shock wave lithotripsy?. Indian J Urol 2006;22:387-8
Krambeck AE, Gettman MT, Rohlinger AL, Lohse CM, Patterson DE, Segura JW. Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of follow-up. J Urol 2006;175:1742-7.
| Summary|| |
Segura et al had recently reported their data of 19 years follow-up of 630 patients, who underwent SWL using HM-3 lithotriptor. A structured questionnaire focusing on possible adverse medical effects related to SWL was sent to 578 patients listed as being alive in the records in 2004. Patients of urolithiasis, who were managed conservatively served as controls (matched by age and sex). Of the 578 patients to 89 were deceased and only 288 responded (58.9%). Of the 288 responders, 234 (81.4%) did not return for subsequent follow-up post SWL. Preexisting hypertension was noted in 9.7%, preexisting renal insufficiency was noted in 5.6%. New onset hypertension was noted in 36.4%. Renal insufficiency since the date of SWL was noted in 5.2%. New onset DM was noted in 48 patients (16.8%), of whom 12.5% were insulin-dependent. Of the 288 controls preexisting hypertension was noted in 16.7%, preexisting renal insufficiency was noted in 1.7% and preexisting DM was noted in 3.1% at stone diagnosis in 1985. New onset hypertension and renal insufficiency were identified in 27.4 and 8.0% respectively, while newly diagnosed DM was noted in 6.6%.
The development of DM was significantly different between SWL-treated patients and controls. Patients treated with SWL had more new onset DM at 19 years of follow-up (OR 3.23, 95% CI 1.73 to 6.02, P <0.001). Though there was a higher number of obese patients in the SWL than controls, a multivariate analysis controlling for obesity in 2004 revealed a persistent significant risk of DM after SWL compared to that in controls (OR 3.28, 95% CI 1.49 to 7.24, P = 0.003). Controlling for the change in BMI again showed a persistent risk of DM in the SWL group (OR 3.75, 95% CI 1.56 to 9.02, P <0.003). New onset DM was related to the total number of shocks (median 1300 shocks@20kv) delivered and average intensity (median 26,200) ( P = 0.005 and 0.028, respectively). Stone location and side of treatment did not have any bearing on the incidence of DM. There was no statistically significant difference in the development of renal insufficiency between cases and controls. Case-control comparison demonstrated a significant difference in the development of hypertension between the SWL and control groups with the SWL group more likely to have hypertension (OR 1.47, 95% CI 1.03 to 2.10, P = 0.034). New onset hypertension was not related to the total number of shocks or average intensity. However, bilateral SWL was associated with hypertension ( P = 0.033).
| Comments|| |
This is a retrospective follow-up of patients in Mayo Clinic, who underwent SWL in 1985. It's a well reported study with important clinical observations. The main observation relates to the development of new onset DM, which was significantly higher than the control. This was independent of BMI, obesity, stone side and location. New onset hypertension was observed but was significant only in cases that had bilateral SWL. The hypothesis presented by authors suggests that this is mainly as a result of damage to pancreatic islet cells, as they come in the blast path of the HM-3 regardless of the side of treatment. It is known that SWL for renal calculi affects pancreatic tissue without overt pancreatitis since increases in serum and urinary amylase and serum lipase have been noted., There are a few drawbacks of this study. Only 18.6% of the patients were followed post SWL in the clinic. The long-term outcome data on patients with SWL were obtained largely by a questionnaire. Patients who died before 2004 were not studied and, therefore, adverse long-term outcomes in these patients are not available. Secondly, this study was based on the HM-3 lithotriptor. Though it is the gold standard for SWL when stone-free rates (success of SWL) are considered, it is also unique due to its large focal zone, with very high energy levels, which may contribute to the deleterious effects associated with SWL. But the significance of this paper is about the possible long-term complication following SWL, which would have a profound effect on young patients undergoing SWL. Though the cause and effect relation is not proven, this clinical observation should stimulate further prospective studies to document the long-term adverse effects of SWL with newer generation of lithotriptors, which are having smaller focal zones with lower energy levels. Caution needs to be exercised while interpreting this clinical observation for counseling patients for SWL and at the same time there is a possibility that this article may get attention in the lay press causing an unnecessary scare for SWL.
| References|| |
|1.||Krambeck AE, Gettman MT, Rohlinger AL, Lohse CM, Patterson DE, Segura JW. Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of follow-up. J Urol 2006;175:1742-7. [PUBMED] [FULLTEXT]|
|2.||Conlin M. Complications of extracorporeal shock wave lithotripsy. In : Tanefa SS, Smith RB, Ehrlich RM, editors, Complications of Urologic Surgery. WB Saunders Co: Philadelphia; 155-64. |
|3.||Hassan I, Zietlow SP. Acute pancreatitis after extracorporeal shock wave lithotripsy for a renal calculus. Urology 2002;60:1111. [PUBMED] [FULLTEXT]|