Dietary Management of Nephrolithiasis. Sarah Yttri, NP Duke University Duke Comprehensive Kidney Stone Center

Transcription

1 Dietary Management of Nephrolithiasis Sarah Yttri, NP Duke University Duke Comprehensive Kidney Stone Center

2 None Disclosures

3 Prevalence 1 in 11 individuals in the US 10.6% of men, 7.1% of women 70% increase Increasingly linked to diabetes, obesity, HTN Recurrence: 50% in 5 years, 80% in 10 years (2) 1

4 Risk Factors Prior stone event(s) Family history Malabsorptive conditions Short or altered bowel Inflammatory bowel disorders, chronic diarrhea Medications Carbonic anhydrase inhibitors, triamterene, chemoinduced tumor lysis syndrome, protease inhibitors Genetic disorders RTA, primary hyperoxaluria, cystinuria Food intolerances, restrictions, eating disorders

5 Effect Of Diet Evidence is mixed Strong: role of fluids

6 Why Care? 87% Overall interest in nutrition for KS 88% Provider 47% Non-provider 23% RD 14% Nephrologist 9% Nurses Wertheim M, Nakada SY, Penniston KL,

7 Wertheim M, Nakada SY, Penniston KL, 2014

8 Assessment Medical history Surgical history Stone analysis 24 hour urine studies Biochemical studies Food/nutrition history

9 Food/Nutrition Assessment Open ended questions Avoid leading questions Avoid asking just about meals Ascertain portion sizes Food frequency questionnaire Referral to registered dietician

10 If NO dietary cause there will be NO dietary solution

11 Diet recommendations followed without cause No effect on stone recurrence Frustration & distrust

12 Empiric vs tailored SD NSD 5 0 Rec Stone Rec & Grow

13 AUA Guidelines High risk or interested first-time stone formers and recurrent stone formers One or two 24-hour urine collections Dietary modifications recommended based on diagnosis of abnormality AUA Guidelines, 2014

14 What Does High Risk Mean? Prior stone event(s) Family history Malabsorptive conditions Short or altered bowel Inflammatory bowel disorders, chronic diarrhea Medications Carbonic anhydrase inhibitors, triamterene, chemoinduced tumor lysis syndrome, protease inhibitors Genetic disorders RTA, primary hyperoxaluria, cystinuria

15 Metabolic Abnormality Low Urine Volume Hypercalciuria Hyperoxaluria Hypocitraturia Low Urine ph Hyperuricosuria Dietary Strategies Fluid intake Fluid Loss Excessive sodium intake Excessive calcium/vit d intake? Low fiber High PRAL, caffeine, ETOH, refined carbs Low calcium intake Excessive oxalate intake (supplements) Malabsorption Low fiber, fruits/vegetables High PRAL Low citrate intake Low fruit/vegetable intake Magnesium intake High PRAL Minimize bicarbonate loss Decrease flesh foods (high purine) High ETOH

16 Low Urine Volume Goal 2.5 liters/day for all stone formers 4,8 Fluid intake of about 3 liters/day or more Compensate for dermal, GI loss as needed Total volume most important

17 Metabolic Abnormality Low Urine Volume Hypercalciuria Hyperoxaluria Hypocitraturia Low Urine ph Hyperuricosuria Dietary Strategies Fluid intake Fluid Loss Excessive sodium intake Excessive calcium/vit d intake? Low fiber High PRAL, caffeine, ETOH, refined carbs Low calcium intake Excessive oxalate intake (supplements) Malabsorption Low fiber, fruits/vegetables High PRAL Low citrate intake Low fruit/vegetable intake Magnesium intake High PRAL Minimize bicarbonate loss Decrease flesh foods (high purine) High ETOH

18 Hypercalciuria Dietary Causes Excessive dietary calcium Excessive dietary sodium Vitamin D supplementation??

19 Hypercalciuria I was told not to eat calcium

20 Hypercalciuria Excessive Calcium Intake Total daily calcium at RDA ( mg/day) May use supplemental calcium if inadequate dietary intake (Calcium Citrate) In absence of malabsorption, no need to consume excess to RDA TIMED WITH MEALS

21 Is All Calcium Created Equal? NHS 1 20 High intake of dietary calcium associated with decreased risk of symptomatic stones Those on supplemental calcium 65% did not take with a meal, or with low oxalate meal

22 Calcium vs. Sodium Borghi, et al, 2002

23 Calcium vs. Sodium Borghi, et al, 2002

24 Hypercalciuria Excessive sodium intake Sodium results in expansion of extracellular volume and decreased calcium reabsorption mg as upper limit norm = 3000 mg dietary salt intake Recommended sodium 1500 mg/day

25 I don t use salt

26 Penniston, AUA abstract 2014

27 Hypercalciuria Vitamin D Increases hypercalcemia, hypercalciuria 7 No apparent increase in stone formation 7

28 Hypercalciuria Excessive caffeine or alcohol intake bone reasorbtion High refined carb intake increased GI absorption High PRAL intake increased bone reabsorption

29 Metabolic Abnormality Low Urine Volume Hypercalciuria Hyperoxaluria Hypocitraturia Low Urine ph Hyperuricosuria Dietary Strategies Fluid intake Fluid Loss Excessive sodium intake Excessive calcium/vit d intake? Low fiber High PRAL, caffeine, ETOH, refined carbs Low calcium intake Excessive oxalate intake (supplements) Malabsorption Low fiber, fruits/vegetables High PRAL Low citrate intake Low fruit/vegetable intake Magnesium intake High PRAL Minimize bicarbonate loss Decrease flesh foods (high purine) High ETOH

30 I stopped drinking tea

31 Hyperoxaluria Decrease Oxalate Intake RF for only 20% of calcium oxalate stone formers Studies mixed Foods encouraged to eat for other conditions and in just about everything Lists vary dramatically 6 Most high in fiber, magnesium, phytate, antioxidants Bioavailability

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33 Hyperoxaluria Normalize Calcium Intake RDA recommended values mg/day WITH meals Either dietary calcium or supplemental calcium 11

34 Hyperoxaluria Malabsorption Gastric bypass, bowel resection, short bowel syndromes Fatty acids complex with calcium, magnesium Increased oxalate availability Likely need higher calcium intake Treat cause of malabsorption

35 Hyperoxaluria Supplements Vit C not food high in Vit C Cranberry Plant based supplements (photos of different supplements) Supplementation with magnesium 9,10 Vitamin B mg daily PH1

36 Hyperoxaluria Dysbiosis Frequent antibiotics, inflammatory bowel disease Decreased oxalate degradation Probiotics Oxalobacter formigenes Lactobacillus, bifidobacterium, enterococcus

37 Metabolic Abnormality Low Urine Volume Hypercalciuria Hyperoxaluria Hypocitraturia Low Urine ph Hyperuricosuria Dietary Strategies Fluid intake Fluid Loss Excessive sodium intake Excessive calcium/vit d intake? Low fiber High PRAL, caffeine, ETOH, refined carbs Low calcium intake Excessive oxalate intake (supplements) Malabsorption Low fiber, fruits/vegetables High PRAL Low citrate intake Low fruit/vegetable intake Magnesium intake High PRAL Minimize bicarbonate loss Decrease flesh foods (high purine) High ETOH

38 Hypocitraturia Increase dietary citrate intake Citrus fruits/juices

39 Pretherpy Post therapy Change LT PC+LT

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41 Penniston et al, 2009

42 Hypocitraturia Increase intake of fruits/vegetables Confer net alkali load Provide K+, bicarbonate precursors to regulate acid-base balance Renal citrate reabsorption is reduced

43 3 2.5 Citrate mmol/day SF NSF F/V No F/V Meschi, et al, 2004

44 Hypocitraturia Decrease intake of PRAL Reduce need for citrate as buffer High PRAL Intake Flesh Foods Cheese Grains Milk, yogurt, fats (neutral) Fruits/Vegetables (negative) Remer & Manz, 1995

45 Metabolic Abnormality Low Urine Volume Hypercalciuria Hyperoxaluria Hypocitraturia Low Urine ph Hyperuricosuria Dietary Strategies Fluid intake Fluid Loss Excessive sodium intake Excessive calcium/vit d intake? Low fiber High PRAL, caffeine, ETOH, refined carbs Low calcium intake Excessive oxalate intake (supplements) Malabsorption Low fiber, fruits/vegetables High PRAL Low citrate intake Low fruit/vegetable intake Magnesium intake High PRAL Minimize bicarbonate loss Decrease flesh foods (high purine) High ETOH

46 High PRAL Intake Flesh Foods Cheese Grains Milk, yogurt, fats (neutral) Fruits/Vegetables (negative) Low Urine ph Remer & Manz, 1995

47 Metabolic Abnormality Low Urine Volume Hypercalciuria Hyperoxaluria Hypocitraturia Low Urine ph Hyperuricosuria Dietary Strategies Fluid intake Fluid Loss Excessive sodium intake Excessive calcium/vit d intake? Low fiber High PRAL, caffeine, ETOH, refined carbs Low calcium intake Excessive oxalate intake (supplements) Malabsorption Low fiber, fruits/vegetables High PRAL Low citrate intake Low fruit/vegetable intake Magnesium intake High PRAL Minimize bicarbonate loss Decrease flesh foods (high purine) High ETOH

48 Hyperuricosuria Endogenous sources Catabolism of AA De novo purine synthesis Medical conditions Myeloproliferative disorders, metabolic disorders (Lesch-Nyhan syndrome, sickle cell), gout, DM Exogenous Purines Alcohol Fructose

49 Hyperuricosuria Purines More than just red meat 16 Plan purines does not cause hyperuricosuria 17 Beef Chicken Fish Serum Uric Acid (mg/dl) Urinary Uric Acid (mg/dl)

50 Other Stones Cystine High fluid intake for >3 L/day output 4 Low sodium 4 Reduce animal protein intake 4 Struvite High fluid intake Metabolic risk factors if present