Medical Nutrition

Therapy
for Nephrolithiasis

Meghan M. Smart
Concordia College
Moorhead, MN
Fall 2004

Objectives
Describe the condition of

nephrolithiasis
Recognize contributing factors in
the development of kidney stones
Identify renal stones according to
their composition
Identify recommended treatment
for nephrolithiasis

What is
Nephrolithiasis?
Condition marked by the

presence of renal calculi

Calculi: abnormal concretion
in the body, usually formed of
mineral salts.
Solid accumulation of material
that forms in the tubal system
of the kidney

Pathophysiology
Complex process of stone

formation includes:
Saturation
Supersaturation
Nucleation
Crystal growth/aggregation
Crystal retention
Stone formation in presence
of promoters, inhibitors,
complexors in the urine

Pathophysiology
in other words
Kidney stones form when

dissolved substances in the

urine become crystalline
and cling together to
create a larger solid mass.

Clinical Features of
Renal Stones
Urinary Tract Symptoms
Colicky

pain in kidney or groin

regions
Hematuria- occuring in 90% of
cases
May be microscopic or gross
Dysuria and strangury

Clinical Features of
Renal Stones
Systemic Symptoms
Restlessness- pain and distress
Nausea, vomiting
Fever and chills
Asymptomatic
Incidental
90%

stones

are smaller than 5 mm

Take 1-3 weeks to pass
1/3 may become symptomatic

Types of Renal Calculi

Calcium Stones
Calcium

Oxalate (60%)
Calcium Phosphate (10%)
Calcium Oxalate and Calcium
Phosphate (10%)
Struvite Stones (10-15%)
Uric Acid Stones (5-10%)
Cystine Stones (1-2%)

Principal Components
of the Urinary System
Kidneys
Cortex
Medulla
Renal

Pelvis
(hilum)

Ureters
Urinary

Bladder
Urethra

Physiology and
Function of the
Kidneys
Large compound
tubular glands bilaterally

attached to posterior wall

Act in elimination of toxic nitrogenous
end products of protein catabolism
Functional unit: Nephron
Responsible for filtration, excretion,
resorption
Regulate ion balance and water amounts
Stabilize blood pressure
Maintain adequate oxygen-carrying
capacity of the blood by secreting
erythropoietin

Function of the
Kidneys:
Maintain the
unique internal
environment of
the body and
minimize
unbalancing
effects of
processes that
are inclined to
alter the bodys
composition

Significance of
Nephrolithiasis
10% of all people will have a kidney

stone in their lifetime

1 in 1,000 adults are hospitalized
annually in the United States for
renal calculi
50% of those who develop a renal
stone will have a recurrence within
the next 5-7 years
Urinary calculi found in 1% of all
autopsies

Renal Stones
Characterized by:

Repeated presence of calculi

between ages 30 and 50

Predominance in males (3x risk)
High proportion of occurrences
for caucasians
History of gout
Previous experience with kidney
stones
Primary hyperparathyroidism
Family history of renal calculi

Impact of Family
History

Still researching:
Genetic

Factors
Environmental exposures

Health Professionals

Follow-Up Study
8-year follow-up

study
37, 999 male participants
Mailed questionnaires
Curhan GC, Willett WC, Rimm EB, Stamfer MJ. Family
history and risk of kidney stones. J Am Soc Neohrol 1997;
8:1568-73.

Family History Study

Results
Findings:
795

stone cases documented over 8 yrs

After adjusting for risk factors, the relative risk of
incident calculi formation in males with a family
history, compared to those without, was 2.57.

Curhan GC, Willett WC, Rimm EB, Stamfer MJ. Family history and risk of kidney stones. J Am Soc Neohrol 1997; 8:1568-73.

Keep In Mind
Although a person

may have several

risk factors for the
development of
nephrolithiasis,
prevention and
management
through Medical
Nutrition Therapy
can deter renal
calculi formations.

Calcium Stones
Hereditary Hypercalciuria condition
Main risk factor for calcium stone

development in the United States

Mean value of calcium in urine in
excess of:
300

mg/day (7.5 mmol/day) for males

250 mg/day (6.25 mmol/day) for females
4 mg/day (0.1 mmol/kg/day) for either in
random urine collections
30-40% patients with calcium stones

have hypercalciuria

Calcium Oxalate Calculi

Multiple calcium

oxalate stones (0.5 x

0.5 cm) in the
collecting system of a
kidney

(reproduced courtesy of C F Verkoelen,

Josephine Nefkens Institute, Netherlands)

Causes of Ideopathic
Hypercalciuria
:

Increased dietary calcium intake

Exaggerated intestinal absorption
of calcium
Decreased renal tubular
reabsorption of calcium
Prolonged bed rest
Low serum phosphorus levels
Diseases:
Primary hyperparathyroidism,
sarcoidosis, hyperthyroidism,
renal tubular acidosis, multiple
myeloma, hyperoxaluria

Medical Nutrition
Therapy
Calcium DRI for healthy

bones and less risk of

stones

1000 mg/day for men and

women aged 50 yrs and
younger
1200 mg/day for those older
than 50 years

Increase fluid intake > 2

L/day
May need to supplement
potassium

Dietary Calcium and

Calculi Study
Longitudinal 5 year study
120 male participants with recurring calculi
60 men followed low calcium diet (400

mg/day)
60 men followed normal calcium
requirement of 1200 mg/day, reduced
sodium chloride (50 mmol/day) and
decreased animal protein (52g/day)

Borghi L, et al. Comparison of two diets for the prevention of recurrent stones in idiopathic
hypercalciuria. N Engl J Med. 2002; 346:77

Calcium Study Findings

Low calcium diet
23 of the 60 men had stone recurrences
Oxalate excretion was increased
Normal calcium, decreased sodium

and reduced animal protein diet

12

of the 60 men had stone recurrences

Oxalate excretion was decreased
Contrary to previous therapy, calcium
restriction does not prevent prevent stone
formation, but may do the opposite.

Calcium Stones and

Oxalate

Hyperoxaluria

Urinary excretion of oxalate in excess of 45

mg/day
Results from endogenous synthesis and from
absorption of dietary oxalate
Observed in 20% of recurrent calculi formers
Normal diet contains oxalate range of 80-100
mg/day (absorption does not exceed 10-20%
amount in food consumed)
Oxalate cannot be metabolized in body
renal route is the only excretion method
Normal healthy adult excretion is 15-40
mg/day

Calcium Stones and

Oxalate

Oxalate to calcium ratio 1:5

Low calcium diets increase passive absorption

of free oxalate and enhance urinary oxalate
excretion, promoting the risk of calcium oxalate
stones

Disease states resulting in

hyperoxaluria

Inflammatory bowel disease, ileal disease, short

bowel syndrome, gastrointestinal
decolonization of Oxalobacter formigens

Hyperoxaluria also due to:

Autosomal recessive genetic defect of a hepatic

enzyme, resulting in 3 to 8 times normal level

Medical Nutrition
Therapy
Be aware of foods responsible for

increased urinary oxalate

excretion:
Tea
Spinach
Nuts
Rhubarb
Wheat bran
Beets
Chocolate
Strawberries
Patients may benefit from pyridoxine (B 6), which

increases transaminase activity responsible for the

conversion of glyoxylate, the immediate oxalate
precursor to glycine (The Merck Manual 2004).

Calcium Stones and Animal

Protein

Increased protein intake facilitates

nephrolithiasis risk by contributing to:

Hypercalciuria
Hyperuricosuria (urinary uric acid > 750

mg/day for women or > 800 mg/day for men)

Hyperoxaluria
Low

urine pH
Hypocitraturia (urinary citrate < 350 mg/day)
1/3 of calcium calculi formers are sensitive
to meat protein and so excrete oxalate

Calcium Stones and Animal

Protein
Male Health Professions

Observational Study
found:
33% increased risk of
renal nephrolithiasis
with a 77 g/day versus
a 50 g/day animal
protein diet
Medical Nutrition
Therapy: 0.8 g/kg body
weight (kg=2.2 lbs)
Martini LA, Wood RJ. Should dietary calcium and protein be restricted in patients with
nephrolithiasis? Nutr Rev 2002; 58: 111.

Calcium Stones and

Citrate

Citrate: Acts as a urinary stone

inhibitor

Prevents formation of calcium oxalate or

calcium phosphate stones
Disease states that decrease citrate levels
in body: distal renal tubular acidosis,
acidosis along with hypokalemia, enteric
hyperoxaluria and malabsorption syndrome,
as well as excessive meat intake.
Normal urinary citrate level > 640 mg/day
Medical Nutrition Therapy: 4 oz. lemon juice
diluted with 2 L water
Standard Medical Practice: oral alkali (K
citrate)

Calcium Stones and

Sodium

Dietary and urinary sodium is directly linked

with excretion of calcium in the urine, so a

reduction in sodium excretion will produce a
reduction in calcium excretion, resulting in
reduced risk of developing calculi.
For every 60 mmol (1380mg) increase in urine
sodium, the risk of hypercalciuria rises 1.63
times.
Medical Nutrition Therapy: to prevent, keep
sodium amounts to < 100 mmol/day or 2300 mg
With recurring calculi condition, restrict sodium
intake
< 50 mmol/day
Parmar MS. Kidney Stones, Clinical Review. BMJ 2004; 328:1420-4.

Calcium Stones and

Potassium

Potassium intake is inversely

proportional to nephrolithiasis
risk.
For every 104 mmol/day (4042
mg/day) vs. 74 mmol/day
(2895 mg/day), there was a
50% decrease in renal stone
manifestation.
Medical Nutrition Therapy:
Advise patients to eat variety
of low oxalate fruits and
Curhan, et al. Family history and risk of kidney stones. J Am Soc Neohrol 1997; 8:1568-73.
vegetables

To Sum It All Up:

Dietary Influence for Calcium

Stone Formation Risk
Increased

Risk

Decreased

Risk

Oxalate

Calcium

Animal

Magnesium

Protein
Sodium

Potassium
Fluid

Intake

Fiber
Pyridoxine
Mahan LK, Escott-Stump S. Krauses Food, Nutrition, and Diet Therapy 2004; 989.

Evidence-Based
Medicine
Become familiar with
products that may be
popular, but are not
necessarily scientifically
proven for the treatment
of kidney stones:

Cranberry concentrate pills

Wild yam
Flaxseed
Zinc
Copper
Vitamin A
Evening primrose oil
Goldenrod

Struvite Stones
Triple phosphate or infection stones
Occur twice as often in women than in

men
Form only with presence of bacteria
that have urea-splitting enzyme urease

Proteus mirablis, Kelbsiella, Serratia,

Mycoplasma, Psuedomonas, Urealyticum

Alkaline urine promotes struvite calculi

formation

Urea-splitting organisms break down urea

Carbon dioxide and ammonia are
produced
Urine pH increases
Carbonate levels rise

Struvite Stones
Under these conditions, struvite stones

grow into large staghorn stones in renal

pelvis
Medical Nutrition Therapy: Advise
balanced meals with variety of fruits and
vegetables to maintain health, help fight
bacteria
Standard Medical Treatment

Surgical removal
Extracorporeal shockwave lithotripsy
Culture-specific antimicrobials with urease
inhibitors
Goal: Prevent and eliminate UTIs through
regular screening and monitoring of urine
cultures

Uric Acid Stones

Uric Acid: end product of purine metabolism
Derived

from exogenous sources

Produced endogenously during cell
turnover
Contributing disease states to uric-acid
stones:
Inflammatory bowel disease,
lymphoproliferative and myeloproliferative
disorders due to increased cellular
breakdown which causes purines to be
released and so increases uric acid load

Uric Acid Stones

Medical Nutrition Therapy: moderately

use foods high in purines such as:

Organ meats
Anchovies, herring
Animal flesh proteins
Fish, poultry

Standard Medical Practice:

Potassium citrate dissolution therapy
Urine alkalinization (pH 6.0-6.5)
Sodium bicarbonate therapy discouraged
Increases monosodium urate along
with calcium

Effect of Urine pH
on Stone Formation
pH

< 5.5
5.5 - 7.5

State of
Urate
Undissociate
d urate
Dissociated
urate

Likely
Stone
Developm
ent
Uric acid
stones
Calcium
oxalate
stones

Dissociated
Calcium
> 7.5
Mahan LK, Escott-Stump S. Krauses Food,
Nutrition, and Diet Therapy
2004; 989.
urate
phosphate

Cystine Stones
Autosomal recessive trait

Inborn dysfunction in transport of

dicarboxylic acids of cystine, ornithine,
lysine, arginine (sometimes seen as
COLA)
1 in 15,000 people in U.S are affected
Normal cystine excretion: < 20 mg/day
> 7.0 urine pH promotes cystine solubility
Medical Nutrition Therapy: increase fluid
intake >4 L/day, decrease sodium, may
restrict protein since methionine is
precoursor to cystine
Standard Medical Practice: with
medications, keep pH alkaline 24 hrs/day

Investigations for
Diagnosis
Urinalysis
urine pH, culture, 24-hr assessment
Serum electrolytes
calcium, phosphate, bicarbonate, uric
acid
Blood urea nitrogen
to determine level of renal function
Serum creatinine
to determine level of renal function
Parathyroid hormone
if elevated serum calcium
Stone analysis
if possible

Parmar MS. Kidney Stones, Clinical Review. BMJ 2004; 328:1420-4.

Investigations for
Diagnosis
Plain Abdominal Film/Kidney-Ureter-Bladder

View
Assessment of radio-opacity of stone
Allows monitoring calculus progression
Guides shockwave lithotripsy
Un-enhanced Helical Computed Tomography
99% accurate
Provides measurement of stone density
Stones with density > 1000 Housnfield
units respond less well to lithotripsy
Parmar MS. Kidney Stones, Clinical Review. BMJ 2004; 328:1420-4.

Standards of Practice
Every patient with a diagnosis of

nephrolithiasis should have a chart note with

assessment of:
Body weight and appropriate body weight
Calcium, protein, sodium recommendations
Fluid recommendation for the individual,
usually
> 2 L /day
Pain is chief complaint
Medications such as morphine, codeine,
short-term prednisone, antibiotics for
infection, and local warming of abdomen
and lower back have been shown to be
effective for nausea and pain of renal colic.

Standards of Practice

Lab values of 24-hour urine assessment

including:
Urine volume (fluid ins and outs, I/O)
Calcium concentrations
Oxalate concentrations
Uric acid concentrations
Citrate concentrations
Urine sodium levels
Creatinine excretion levels
Phosphate concentrations
Bicarbonate levels
Blood urea nitrogen

General MNT for

Nephrolithiasis
Diet Component

Intake
Recommended

24-hour Urine
Check

protein

normal intake,
avoid excess

monitor urinary
urea

calcium

normal intake:
1000 mg/day <
age 50
1200 mg/day >
age 50

urinary calcium <

150 mg/L (<3.75
mmol/L)

oxalate

avoid mod to high

oxalte foods,
resrict if needed

Urinary oxalte <

20 mg/L (<220
umol/L)

fluids

> 2 L, assess fluid

type and provide
guidelines

urine volume > 2

L/day

General MNT for

Diet Component
Intake Recommended
Nephrolithiasis
24-hour
avoid excess
protein intake,
follow 0.8 g/kg
body wt, aviod
high purine foods

Urine
uric
acid < 336
mg/L (< 2 mmol/l)

vitamin C

<2 g/day

monitor urinary
oxalate

vitamin D/cod liver

oil

supplement not
recommended

vitamin B6

40 mg/day
reduces risk
no
recommendation
made

purines
Check

Ethical Issues with

Nephrolithiasis
Normal nutrient intake vs. altered

intake
Calcium
Protein

Pain medications may be habit-

forming
Alternative medicine techniques

Nephrolithiasis
Reference List

American Dietetic Association. (2000). Effect of ascorbate

supplement on urinary oxalte and risk of kidney stones.
Journal of the American Dietetic Association 100: 516.
Borghi, L., Schianchi, T., Meschi, T. (2002). Comparasin of two
diets for the preventin of recurrent stones in ideopathic
hypercalciuria. New England Journal of Medicine 346: 77.
Carson-Dewitt, R.S. (1999). Kidney Stones. Gale Encyclopedia
of Medicine.
Available online:
http://www.findarticles.com/p/articles/mi_g2601/is/ooo7/ai_2601
000792/print
Cormack, D.H. (2001). Essential Histology. Philadelphia,
Pennsylvania: Lippincott Williams and Wilkins.
Curham, G.C., Willett, W.C., Rimm, E.B., Stampfer, M. J. (1993).
A prospective study of dietary calcium and other nutrients
and the risk of symptomatic kidney stones. New England
Journal of Medicine 833: 8.
Curhaam, G.C., Willett, W.C., Rimm, E.B., Stampfer, M.J. (1997).
Family history and risk of kidney stones. Journal of the
American Society of Nephrology 8: 1668-73.

Nephrolithiasis
Reference List

Eroschenko, V.P. (2005). diFiores Atlas of Histology with

Functional Correlations. Baltimore, Maryland: Lippincott
Williams and Wilkins
Mahan, L.K., Escott-Stump, S. (2004). Krauses Food,
Nutritition, and Diet Therapy. Philadelphia, Pennsylvania:
Saunders.
Martini, L.A., Wood, R.J. (2002). Should dietary calcium and
protein be restricted in patients with nephrolothiasis?
Nutrition Review 58: 111.
Merck Manual. (2004). Section 17 Genitourinary Disorders,
Chapter 221 Urinary Calculi: Stones, Nephrolithiasis,
Urolithiasis.
Available online:
http://www.merck.com
National Kidney Foundation. (2004). Diet and kidney
stones.
Available online:
http://www.kidney.org.atoz/atozPrint.cfm?id=41

Thank You!