Year : 2011 | Volume
: 27 | Issue : 4 | Page : 563--564
Dietary counseling: An ignored aspect of urinary stone management
Neeraj Kumar Goyal
Neeraj Kumar Goyal
|How to cite this article:|
Goyal NK. Dietary counseling: An ignored aspect of urinary stone management.Indian J Urol 2011;27:563-564
|How to cite this URL:|
Goyal NK. Dietary counseling: An ignored aspect of urinary stone management. Indian J Urol [serial online] 2011 [cited 2020 Nov 30 ];27:563-564
Available from: https://www.indianjurol.com/text.asp?2011/27/4/563/91459
A retrospective cohort study was done with the aim of investigating the current impact of dietary counseling on the risk for urolithiasis.  One hundred thirty-seven patients who were managed with dietary intervention alone at multidisciplinary stone clinic from July 2007 to Feb 2009 were included in this study. Inclusion criteria were age >18 years, at least two 24-h urine collections and recurrent stone formation. Two sequential 24-h urine collections were done at baseline (Litholink Laboratory Reporting System) for high urine sodium (>150 mmol/ day), hyperuricosuria (men >800 mg/day; women >750 mg/ day), hypercalciuria (urinary calcium: male >250 mg/ day; female >200 mg/ day), hyperoxaluria (urinary oxalate excretion >40 mg/day), low urine volume (<2.0 l/ day), and hypocitraturia (men <450 mg/day; women <550 mg/day). The initial urine sample was taken prior to any intervention and the later was taken after the dietary counseling by a registered dietician based on the 24-h urine results. Counseling included hydration to keep urine volume above 2 l/day, sodium restriction to <2400 mg/day, protein moderation 3-4 oz per day, adequate calcium intake (1000- 1200 mg/ day) with an emphasis on timing with meals and inclusion of lemon juice in diet. Follow up of every patient was done by a clinic based urologist and Litholink 24-h urine collections were performed at three-monthly intervals until urinary parameters came within the normal range. Pharmacological intervention was supplemented in patients who failed dietary counseling. The primary endpoint of the study was to analyze the impact of dietary intervention on levels of urinary metabolites and electrolytes that are known risk factors for stone disease. Secondary endpoint of the study was to see for the proportion of patients converting from abnormal to normal urinary parameters after dietary manipulation including the change in relative urinary super-saturation for calcium oxalate.
The study showed that after dietary counseling alone, 58.1% of subjects showed significant changes in urine sodium (229.68 ± 72.51 to 144.65 ± 52.70 mmol/day, P<0.0001), 43.8% in urine calcium (314.33 ± 95.75 to 216.81 ± 80.90 mg/ day, P<0.0001), 50% in urinary uric acid (0.821 ± 0.210 to 0.622 ± 0.128 g/day, P<0.0001), 52.1% in urinary citrate (583.19 ± 330.86 to 797.36 ± 412.31 mg/day, P<0.0001), 55.6% in urine oxalate (46.28 ± 10.31 to 32.56 ± 9.02 mg/ day, P<0.0001) and 71.1% in urine volume (1.68 ± 0.68 to 2.59 ± 0.80 l/day, P<0.0001). Also the super-saturation for calcium oxalate changed significantly from the baseline (9.34 to 5.03, P<0.0001). However, in large number of patients, total normalization of the urinary parameters could not be achieved with dietary manipulation alone. Pharmacological therapy with pyridoxine, indapamide, allopurinol, or potassium citrate, was advised in patients with persistent hyperoxaluria (44.4%), hypercalciuria (56.2%), hyperuricosuria (50%), and hypocitraturia (49.2%), respectively.
Urinary stone disease is multifactorial in etiology, characterized by multiple recurrences; various modifiable, nonmodifiable and genetic factors contributing to its complex pathophysiology.  As estimated in the year 2000, the annual economic cost posed by treatment of urinary stone disease in United States alone was as high as $ 2.1 billion indicating the importance and cost-effectiveness of preventive care in stone formers.  These figures further highlight the critical role of preventive measures in stone disease especially in developing nations such as India, where cost of management is a significant financial constrain on the entire health system. Studies have provided enough evidence of the importance of diet as one of the major modifiable factor in urolithiasis; dietary manipulations playing a central role in both prevention and long-term management of stone disease.  Despite this well-established role of dietary intervention, the implementation and reinforcement of dietary counseling is often ignored. The lack of registered dieticians and noncompliance of the patients usually results in failure of conservative management. The evaluation with a licensed dietitian is critical to identify risk factors according to sex and age and to tailor the follow-up protocols. It highlights the importance of dietary manipulations as a significant component of multidisciplinary approach in the management of kidney stones. A registered dietician should be an integral part of every stone clinic, and there should be a strict dietary protocol tailor made for every individual patient. Regular follow-ups and reinforcement of the dietary protocol should be done at every visit. Thus these simple measures if implemented and followed would be of great help to reduce urinary stone recurrences.
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