Received: 29 April 2018 Revised: 1 August 2018 Accepted: 2 August 2018

DOI: 10.1111/ijun.12169

REVIEW PAPER

Dietary and lifestyle recommendations for urolithiasis

prevention: A systematic literature review
Mattia Boarin RN, MSN1 | Giulia Villa RN, MSN, PhD (stud.)1 | Claudia Capuzzi RN2 |
Denmart Remon RN3 | Francesco Abbadessa RN, PGDip4 |
Duilio Fiorenzo Manara RN, MSN5

1
Department of Urology, Ospedale San
Raffaele, Milan, Italy What are the dietary, fluid intake and lifestyle indications for the disease management and
2
Department of Surgery, Ospedale recurrences prevention in patients with urolithiasis? Despite the progress in urolithiasis diagno-
San Raffaele, Milan, Italy sis and treatment, its incidence has increased in the last decades and a high rate of recurrence is
3
Department of Surgery, Istituto Clinico still a real problem. Dietary and lifestyle modifications represent the most effective preventive
Humanitas, Rozzano, Italy
measures. Recommendations and evidence available in literature are not always accurate and
4
Western Sussex Hospital, Chichester, UK
consistent, negatively affecting patients’ education. A systematic review was conducted starting
5
School of Nursing, Università Vita-Salute
from a research in electronic databases; the study selection process was based on PRISMA indi-
San Raffaele, Milan, Italy
cations. Methodological quality and risk of bias were assessed. Data were analysed in three
Correspondence
M Boarin, Ospedale San Raffaele, phases: (1) critical review of articles; (2) data extraction; (3) evidence synthesis. Thirty-six studies
Department of Urology, Via Olgettina, were included: researchers used prevalently non-probabilistic sampling methods and data from
60 - 20132 Milan, Italy. several studies derived from small samples, mainly from Western countries. Despite these limi-
Email: boarin.mattia@hsr.it
tations, the below listed themes for urolithiasis prevention arose: (1) the importance of a preva-
lently vegetarian regime with a reduced intake of meats and fats, decreasing the risk of stones
formation from the accumulation of uric acid; (2) water intake greater than two litres per day is
proven to prevent recurrences and drinking beverages, such as decaffeinated coffee, tea, beer
and wine, also seems to be associated with a decrease in risk; (3) being physically active and
having a healthy lifestyle can help to prevent recurrences. Various dietary and lifestyle modifica-
tions have a potential to prevent urolithiasis and recurrences. Clinicians should advise patients
to reduce animal proteins and fats, increase fruits and vegetables, and increase water intake, as
well as having a healthy lifestyle. Further rigorous methodological studies are needed.

KEYWORDS

calculi, diet, drinking water, fluid intake, life style, primary prevention, renal calculi, secondary
prevention, urolithiasis

1 | I N T RO D UC T I O N In Italy, the National Institute of Statistics database showed a

Urolithiasis is a common condition, with a prevalence of about 10% in
the general population, associated with high morbidity and costs.1 It rep-
resents the third most common urinary disease and evidence shows that
its incidence has increased continually during the past decades.2
Urolithiasis is a multifactorial condition which involves epidemio-
logical, biochemical and genetic factors, with a prevalence that varies
widely and depends greatly on diverse factors such as geographic
area, racial distribution, socio-economic status and dietary habits (high
3,4
protein consumption, hypercaloric and fatty diets).
prevalence of 1.7% and an incidence of 0.17 cases per 1000 patients
in 1994, whilst these figures raised to 4.1% and 2.23 cases per 1000
patients in 2012, respectively.3
Historically, the treatment options for urolithiasis include pharma-
cological therapy, extracorporeal shock wave lithotripsy and surgical
removal of stones.5
Several potentially modifiable dietary and lifestyle risk factors
have been identified, including higher body mass index, lower fluid
intake and certain food and drinks. Moreover, reduced levels of physi-
cal activity are associated with an increase of urolithiasis risk.1,6

Int J Urol Nurs. 2018;12:53–70. wileyonlinelibrary.com/journal/ijun © 2018 BAUN and John Wiley & Sons Ltd. 53
54 BOARIN ET AL.

WHAT IS KNOWN ABOUT THE SUBJECT

• Urolithiasis is a multifactorial condition with a preva-
lence that depends on geographic, socio-economic and
dietary factors. Its incidence has increased persistently,
partly due to improvements in diagnosis but also due to
obesity, dietary and fluid intake changes. A high rate of
recurrence is still a real problem.

WHAT THIS PAPER ADDS

• Dietary and lifestyle modifications represent the most
effective and inexpensive measures for primary and
secondary prevention.
• This review found that increasing fruits and vegetables,
with a reduced intake of meats and animal fats, increas-
ing water intake, regular physical activity rather than
constant, and a healthy lifestyle, can help to prevent the
FIGURE 1 PRISMA diagram of the literature search (modified from calculi formation and recurrences.
Moher et al. 200913)

Patients with co-morbidities, such as diabetes, obesity, hyperten- High intakes of fruit, fibre from wholegrain cereals and magne-
sion, inflammatory bowel disease and metabolic syndrome, also have sium are also associated with a lower risk of stone formation, whereas
additional risk factors.7 a high intake of zinc is associated with a higher risk.8

FIGURE 2 Detailed flow-diagram of the study selection process

TABLE 1 Summary of primary studies included

Author(s) Year Study design Country Tool(s) Sampling method Population/sample Aim(s) Main results
Awasthy and 2013 Analytical India Questionnaire Random sampling. 130 kidney stone To assess the family • Dietary habits and less intake of fluids
BOARIN ET AL.

Malhotra29 cross-sectional. patients. history and mineral are responsible for concentrating and
intake of kidney stone thus decreasing the urine volume which
patients and to study in turn increases the excretion of stone
the relationship forming components.
between gender, age • The higher sodium intake may be a
and income on mineral cause of kidney stones because of
intake. increased urinary calcium excretion.
• Urinary calcium excretion decreases
with increase in potassium intake.
Borghi et al30 1996 RCT Italy Urine samples Convenience sampling. 220 patients with first To define the role of • Water intake may exert a protective
analysis. episode of idiopathic urine volume as a effect against recurrences of stone
calcium nephrolithiasis stone risk factor in formation: in patients with high-water
and absence of idiopathic calcium intake, during follow-up the
retained calculi, arterial stone disease and recurrences risk was noted reduced
hypertension or assess the actual (P = 0.008) and the average interval for
metabolic diseases. preventive recurrences was increased (P = 0.016).
effectiveness of a • A high-water intake results in a strong
high-water intake. lithogenous salts saturation reduction
which if chronically maintained
represents a prevention for
recurrences.
Curhan et al16 1993 Cohort United States Questionnaire Convenience sampling. 45,619 health care men To examine the relation • No data to support that a diet low in
professionals with no between calcium calcium might reduce the risk of kidney
history of kidney intake and the stone.
stones. incidence of kidney
stones.
Curhan et al15 1996 Cohort United States Questionnaire Convenience sampling. 45,289 health care men To evaluate the relation • Great intakes of decaffeinated coffee,
professionals with no between 21 specific tea, beer and wine were associated
history of kidney beverages on the with a decreased risk of stone
stones. urolithiasis risk formation.
reduction. • Increased intakes of apple and
grapefruit juice were related to
increased risk.
Curhan et al9 1998 Cohort United States Questionnaire Not specified (data 81,093 women in the To examine the • An increase in total fluid intake can
from previous study). Nurse’s Health Study association between reduce the risk for kidney stones.
(NIH) who were 40 to the intake of 17 • The choice of beverage differs in its
65 y of age in 1986, beverages and risk for effect on risk, because constituents
with no history of kidney stones in may influence stone formation
kidney stones. women. differently: caffeine increases flow of a
more dilute urine by interfering with
the action of antidiuretic hormone on
the distal nephron, thus decreasing risk
for crystal formation; alcohol also
inhibits secretion of antidiuretic
hormone, leading to increased urine
flow and decreased urinary
concentration.
55
 56

TABLE 1 (Continued)

Author(s) Year Study design Country Tool(s) Sampling method Population/sample Aim(s) Main results
Dai et al31 2013 Case-control China Questionnaire Convenience sampling. CASES: 1019 patients To investigate the dietary • Grains had negative effects on stones
with new diagnosis of risk factors in relation only in women who consumed grains
kidney stones; to risks of kidney one or two times per day.
CONTROLS: 987 healthy stones in a Chinese • Consuming leafy vegetable had also
volunteers. population. negative effects on the high level of
oxalate in local leafy vegetable, mostly
cabbage and spinach.
• Daily vegetable intake was
recommended, but an excessive
consuming of vegetable should be
avoided.
• Increased fluid intake showed a
significant protective effect against
kidney stones in men.
De et al32 2014 Analytical United States Questionnaire Not specified (data Not specified (data from To identify any changing • Consuming cereal products, including
cross-sectional. from previous surveys). previous surveys). trends in lithogenic whole grain wheat, wheat flakes, flour,
and protective couscous, bulgur and pasta were high
components of the in oxalate and avoiding leafy green
American diet in a vegetables (spinach and collard greens)
period of an increased were strictly recommended.
prevalence in stone • A protective element in diet were fruits
disease. containing citric acid.
De La 2011 RCT France Questionnaire Not specified (data from 48 healthy subjects. To evaluate the effects of • Crystalluria was significantly less
Gueronnière previous study). water intake on several frequent in patients who experienced
et al33 urinary risk factors for an increase in water intake.
urolithiasis in healthy
subjects through
measurement of
Tiselius Crystallization
Risk Index.
Ferraro et al5 2015 Cohort United States Questionnaire Not specified (data from HPFS (Health To analyse the • Physical activity and total energy intake
previous study). Professionals independent are not independent risk factors.
follow-up study): associations between
51,529 male health physical activity,
care professionals; energy intake and
NHS I: 121,700 female incident kidney stones.
nurses; NHS II:
116,430 female
nurses.
BOARIN ET AL.
TABLE 1 (Continued)

Author(s) Year Study design Country Tool(s) Sampling method Population/sample Aim(s) Main results
Ferraro et al1 2017 Cohort United States Questionnaire Not specified (data from HPFS: 51,529 male To estimate the • A normal body mass index, eating a diet
BOARIN ET AL.

previous surveys). health care population attributable high in fruits, vegetables and low-fat
professionals; NHS I: fraction and the dairy products with an adequate intake
121,700 female number needed to of calcium were associated with a
nurses; NHS II: prevent for modifiable clinically meaningful lower risk of
116,430 female urolithiasis risk factors. urolithiasis.
nurses. • Drinking an adequate amount of fluid
and avoiding frequent sugar sweetened
beverages decrease the risk of kidney
stones.
• Lifestyle interventions aimed at
modifying risk factors could
substantially prevent a large proportion
of urolithiasis.
Jabbar et al34 2015 Analytical Pakistan Questionnaire; Convenience sampling. 101 kidney stone To determine the urinary • Lack of drinking sufficient amount of
cross-sectional blood samples subjects. risk factors involved in water, increasing weight/obesity and
analysis. kidney stone family history are some major factors
formation; to assess contributing to the increased risk of
prevalence of kidney kidney stone formation.
stone disease in • To prevent stones is very important to
different age groups live a healthy life, drink clean or boiled
and to evaluate the water and control weight.
association of
self-history of kidney
stones with age, sex,
history and
geographical
residence.
Krieger et al10 1996 Case-control United States Standardized Random sampling CASES: 240 men To assess whether • Subjects on a low fat or weight
telephone between 25 and 55 y selected behaviours reduction diet and vegetarians had a
interview. old experiencing their and dietary habits substantially reduced risk of urolithiasis
first episode of were associated with may be at low risk for urinary stones.
urolithiasis; the risk of urinary • Post-secondary school education (OR
CONTROLS: 392 men calculi. 0.42, P < 0.0001) and African-American
between 2 and 55 y ethnicity (OR 0.29, P < 0.03) are
old chosen from a associated with reduced risk for urinary
computerized list of calculi, instead an increased incidence
randomly selected with is associated with economic
no history of development.
urolithiasis.
Liu et al35 2009 Case-control Taiwan Questionnaire; Simple random sampling. CASES: 354 cases with To evaluate the • Quitting cigarette smoking and betel
interviews. calcium urolithiasis; independent and quid chewing can greatly reduce the
CONTROLS: 354 sex & combined effects of risk, because both are independent risk
age matched, with no alcohol drinking, factors for stone formation and the risk
history of urinary cigarette smoking and is increased in people with both habits.
stone disease and no betel quid chewing on
clinical finding of the risk of calcium
stone. urolithiasis.
57
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TABLE 1 (Continued)

Author(s) Year Study design Country Tool(s) Sampling method Population/sample Aim(s) Main results
36
Mandel et al 2013 Analytical United States Questionnaire; Not specified (data from HPFS: 51,529 male To examine the • Dietary animal protein restriction and
cross-sectional. urine samples previous study). health care independent relations increased intake of fruits and
analysis. professionals; between specific vegetables (major sources of dietary
NHS I: 121,700 female dietary and lifestyle potassium) are generally recommended
nurses; NHS II: factors and medical to individuals with nephrolithiasis and
116,430 female conditions and the hypocitraturia.
nurses. 24-h urinary excretion • Smoking cigarettes resulted in being
of citrate. associated with lower urinary citrate
leading to an increase risk in stone
formation.
Massey et al37 2002 Quasi- United States Questionnaire; diet; Convenience sampling Eight healthy adults from To examine oxalate • Soyfood and soybean frequent
experimental. oxalate load test; (self-reported). university faculty, staff absorption by consumption may be a risk factor for
urine samples and students. measuring changes in kidney stone formation in case of prior
analysis. urinary excretion after history of calcium stones, high normal
ingestion of urinary oxalate concentrations or
oxalate-containing intestinal disease.
soybeans and soyfood;
to determine whether
consumption of
soybeans and soyfoods
may be a risk factor for
calcium oxalate kidney
stone formation.
Meschi et al17 2004 Quasi- Italy Diet; urine Convenience sampling. Twelve subjects with no To evaluate the effect of • Withdrawing fruits and vegetables from
experimental. samples analysis. history of stone fruits and vegetables the healthy subjects’ diet caused
disease and free from on urinary stone risk adverse changes in urinary stone risk,
silent stone as per profile in normal instead the addition of these aliments
renal ultrasound; 26 subjects and in calcium to the stone group diet, not only
patients displaying stone formers affected significantly increased citrate excretion
hypocitraturia. by hypocitraturia. without affecting oxalate excretion, but
also decreased calcium oxalate from
10.17 to 4.96 (P < 0.001) and uric acid
relative saturation fell from 2.78 to
1.12 (P = 0.003).
• Withdrawal of fruits and vegetables
may expose even healthy subjects to
the risk of developing renal calcium
stones, whereas supplementing the diet
with these food items might be helpful
as a preventive measure in
hypocitraturic stone formation patients.
BOARIN ET AL.
TABLE 1 (Continued)

Author(s) Year Study design Country Tool(s) Sampling method Population/sample Aim(s) Main results
38
Meschi et al 2012 Case-control Italy Medical records; Convenience sampling + CASES: 143 To determine if the • Dietary habits were different in the
BOARIN ET AL.

dietary diary; snowball sampling. normotensive women dietary habits of adult two groups, consisting in a low fruit
questionnarie. with recurrent female stone formers and vegetable intake and in a high
idiopathic calcium are significantly intake of simple sugars, protein and salt
nephrolithiasis; different from healthy in the first group (high risk), explaining
CONTROLS: 170 healthy women; to determine their higher risk of stone formation and
normotensive female if their diet is related recurrence.
volunteers. to nephrolithiasis • Need of wider awareness campaigns to
clinical course. reduce wrong dietary habits,
considered risk factors for other
metabolic diseases too.
Noori et al26 2014 RCT Iran Diet; urine samples Convenience sampling. 41 participants with a To compare the effects • A DASH-style regimen showed positive
analysis; metabolic history of at least two of a low-oxalate diet effect, attributable in part to the
parameters episodes of calcium with a DASH (Dietary increased urine citrate excretion and in
measurement. oxalate kidney stones approaches to stop part to the ability of ingested calcium
and documented Hypertension) diet in to bind oxalate in the intestinal lumen
hyperoxaluria, reducing calcium and reduce its absorption.
hypocitraturia and/or oxalate • Combining DASH diet with restricted
hyperuricosuria. supersaturation. oxalate intake, could be suggestive to
stimulate its effectiveness for
prevention.
Nouvenne et al39 2010 RCT Italy Diet; urine samples Convenience sampling. 210 patients with a To evaluate the effect of • A low-salt diet may correct idiopathic
analysis. diagnosis of idiopathic a low-salt diet on hypercalciuria and also seemed to have
calcium-oxalate stone urinary calcium a positive effect on other urinary stone
disease, absence of excretion in patients risk factors.
diseases associated affected by idiopathic
with the production of calcium nephrolithiasis.
calcium stones.
Prieto et al40 2010 Analytical Spain Questionnaire; Random sampling 40 subjects follow To relate the • Phytate intake brought health benefits
cross-sectional urine samples (from a previous RCT). Mediterranean diet Mediterranean diet including the prevention for
analysis. with low proportion of intake with low and pathological calcifications such as renal
phytate-rich food; high proportions of calculi.
41 subjects follow phytate-rich foods on
Mediterranean diet phytate excretion in
with high proportion of urine.
phytate-rich food.
Salmeh et al41 2012 Analytical Iran Questionnaire Convenience sampling. 190 patients with kidney To evaluate if health • Increasing of fluid intake can be
cross-sectional. stones. behaviours could effective in preventing recurrences and
prevent the stone the consumption of at least two litres
progression and of water is strongly recommended).
influence the • There was a significant relationship
recurrence of kidney between history of disease in families
stones. with sports and level of daily physical
activity (P < 0.005).
• The correction of unhealthy behaviours
and supervision of health personnel on
a regular basis and continuous exercise
can be effective in prevention and
reducing recurrences.
59
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TABLE 1 (Continued)

Author(s) Year Study design Country Tool(s) Sampling method Population/sample Aim(s) Main results
Shirazi et al2 2014 Case-control. Iran Questionnaire Sequential sampling. CASES: 161 patients with To determine the • Dietary habits, such as the
idiopathic renal stone relationship between consumption of vegetables, fruits, meat
disease; dietary habits, food and sources of calcium, potassium,
CONTROLS: 254 healthy resources intake and vitamins A, C, D, may play a role in
subjects with no the risk factors related urinary stone formation.
history of stone to urinary stone • Through a nutritional education, that
disease. formation. aims to modify the dietary habits of
high risk of stone formation patients
and their families, the disease risk and
related recurrences could be reduced.
Siener and Hesse42 2003 Quasi- Germany Diet; urine samples Convenience sampling. 10 healthy male To investigate the effect • An intake of a balanced vegetarian and
experimental. analysis. volunteers. of an ovo-lacto fruit diet with a moderate animal
vegetarian diet and protein and purine content brings a
different omnivorous lower risk for uric acid crystallization
diets on the risk of uric compared to omnivorous diets.
acid crystallization.
Soucie et al43 1996 Analytical United States Questionnaire Convenience sampling. 501,025 men and To examine relations • The ambient temperature and sunlight
cross-sectional. 665,984 women between stones levels were independently associated
volunteers. prevalence and with the kidney stones prevalence,
environmental representing important risk factors and
exposures. contributing to urolithiasis geographic
variability: the exposure to high
temperatures with an inadequate fluid
intake increases the urine
concentration and acidity.
• Sunlight stimulates an increased skin
production of
25-hydroxycholecalciferol, which, after
conversion to 1.25 dihydroxy-vitamin
D by the kidneys, enhances intestinal
absorption of calcium.
Soueidan et al7 2015 Analytical Canada Questionnaire Convenience sampling. 163 subjects To evaluate relationships • No consistent relationship between
cross-sectional. between leisure time physical activity and urolithiasis,
physical activity and although smoking appeared to be a
other modifiable risk strong predictor of the disease.
factors on urolithiasis. • Smoking cessation programs should be
included in the routine management of
urolithiasis.
Tang et al44 2008 Quasi- United States Diet; urine samples Simple random sampling. Eleven healthy non-stone To assess if supplemental • The percentage of oxalate differed
experimental analysis. formers. doses of cinnamon and markedly between cinnamon (6%) and
turmeric increase the turmeric (91%), which appeared to be
risk of kidney stone the primary cause of the greater urinary
formation. oxalate excretion/oxalate absorption.
• The consumption of supplemental
doses of turmeric could significantly
increase urinary oxalate levels, thereby
increasing risk of stone formation in
susceptible individuals.
BOARIN ET AL.
TABLE 1 (Continued)

Author(s) Year Study design Country Tool(s) Sampling method Population/sample Aim(s) Main results
45
Tarplin et al 2016 Analytical United States Questionnaire Convenience sampling. 302 patients with a To determine how kidney • Awareness of future stone risk,
BOARIN ET AL.

cross-sectional. diagnosis of stone patients’ preference for water, counselling on

urolithiasis. knowledge, behaviours stone prevention by a urologist and
and preferences specific strategies used for increasing
toward fluid intake fluid intake varied between patients
differed from those who were successful or unsuccessful
reporting being with fluid intake.
successful or
unsuccessful at
increasing fluid intake
for prevention.
Taylor et al27 2009 Cohort United States Questionnaire Not specified (data from HPFS: 51,529 male To examine the relation • DASH-style diet is associated with a
previous study). health care between a DASH style marked decrease in the risk of
professionals (45,821 diet and the risk of developing kidney stones: the
men remained); NHS I: incident kidney stone. consumption of fruits and vegetables
121,700 female nurses increases urinary citrate.
(94,108 remained); • A diet with normal to high calcium
NHS II: 116,430 content but low in animal protein and
female nurses sodium decrease the risk of calcium
(101,837 remained). oxalate stone recurrence by 51%.
Turney et al8 2014 Cohort United Kingdom Questionnaire Convenience sampling. 51,336 participants. To investigate the • Increasing meat intake was associated
association between with a higher risk of developing kidney
diet and kidney stone stones: both red meat and poultry were
risk in a population associated with risk: hazard ratio for
with a wide range of the highest vs lowest third of
diets. intake = 1.53, 95%CI 1.04-2.26 for red
meat (P trend = 0.02), and 1.35, 95%CI
0.95-1.93 for poultry (P trend = 0.04).
• Fresh fruit intake was inversely
associated with risk of kidney stones:
hazard ratio for the highest vs lowest
third of intake = 0.70, 95%CI 0.53-0.93
(P trend = 0.03).
Wallace et al46 2011 RCT United States Questionnaire; Random sampling. 36,282 postmenopausal To evaluate if calcium • No significant differences in the
supplements. women aged 50-79 y. plus vitamin D increase calcium plus vitamin D trial participants
the risk of kidney at screening were found between
stone formation. groups.
Yasui et al47 2013 Analytical Japan Questionnaire Cluster sampling 92,797 patients with a To evaluate the • There is an increased risk of calculi
cross-sectional. diagnosis of association between formation in a diet low on fruits and
urolithiasis. regional variations in vegetables.
urolithiasis incidence • The incidence of urolithiasis was higher
and nutrition intake. in geographic areas where populations
had a low fruit and high sugar intake
indeed.
61
62 BOARIN ET AL.

The literature suggests a moderate intake of beer, wine and addition

of thiazide, citrate and allopurinol to reduce the risk of recurrences.9,10
The dietary and lifestyle indications reported in the literature are not
always consistent and this has repercussions on the advice given to patients.
A personalized dietary intervention to prevent urolithiasis recur-
rences should be suggested to all patients and recommendations should
be tailored to the individual patient based on specific urinary profile and
stone type; it is also essential that the patients perform follow-up mea-
surements to evaluate the impact of dietary indications.11

1.1 | Aim
The aim of this systematic review is to identify dietary and lifestyle indi-
cations for the primary and secondary prevention of urolithiasis and sys-
tematically synthetize information retrieved from the literature.

2 | METHODS

2.1 | Design
This systematic review follows the Reviewers’ Manual criteria of
Joanna Briggs Institute,12 and also the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA) indications.13
The review is guided by following research questions:
1. What are the dietary indications for the disease management and
recurrence prevention in patients with urolithiasis?
2. What are the fluid intake indications for disease management and
recurrence prevention in patients with urolithiasis?
3. What are the lifestyle indications for disease management and recur-
rence prevention in patients with urolithiasis?

2.2 | Search methods

The database searching process was conducted in CINAHL, Cochrane
Library, Embase, PubMed and Scopus, starting from December 2016
and constantly updated until January 2018. FIGURE 3 Analytical cross-sectional analysis with corresponding
Both medical subject headings (MeSH) and free-text terms, as check-list items [Colour figure can be viewed at wileyonlinelibrary.com]
well as variations of root words, were searched. The reference search
included the following keywords: diet/food modification, diet habit, research and study design (guidelines, meta-analysis/systematic reviews,

dietary style, drinking, eating, drinking water, food habits, kidney calculi, randomized controlled trials [RCTs], quasi-experimental studies, analyti-

kidney stones, life style, nephrolithiasis, patient education as topic, cal cross-sectional studies, cohort studies, case-control studies). Inclu-

renal calculi, secondary prevention, self-care, ureteral calculi, urinary sion criteria have been identified to limit the risk of bias and ensure the

bladder calculi, urinary calculi, urinary stones, urolithiasis. relevance of selected articles to research questions.

2.3 | Study selection method 2.3.2 | Exclusion criteria

A preliminary selection of studies after database searching process
was performed independently by two researchers, through title and
abstract analysis, in order to verify their adherence to the review’s
topic and research questions.
Duplicate documents have been deleted; the remaining have
been screened and later selected based on the following inclusion and
exclusion criteria.
Articles involving the paediatric population and pharmacological treatments
for urolithiasis; case reports/case series, survey and prevalence study, quali-
tative studies, narrative reviews/expert opinions, in vitro studies.
In order to include additional significant contributions, the refer-
ences of the eligible articles were evaluated by conducting a retro-
spective process to retrieve and analyse these sources.

2.3.1 | Inclusion criteria 2.4 | Critical appraisal process

Population (adult patients with urinary tract stones such as kidneys, ure- The selected studies were subjected to a critical appraisal of methodo-
ters, bladder and urethra), intervention (food, fluids and lifestyle indica- logical quality. The process was independently supervised by two dif-
tions); outcomes (disease management and recurrences prevention); ferent researchers. In relation to the different research designs of
BOARIN ET AL.
FIGURE 4 Case-control analysis with corresponding check-list items [Colour figure can be viewed at wileyonlinelibrary.com]
included studies, specific JBI’s checklists were used to evaluate meth-
odological quality and estimate the risk of bias: data from checklists’
items analysis were processed using the Review Manager® software,
14
version 5.3, by creating graphs of bias risk synthesis, in order to
evaluate the generalizability of study results. None minimal number of
check-lists items was considered sufficient for studies inclusion.
2.5 | Data extraction and analysis
The data were analysed in three phases: (1) critical review of included
articles; (2) data were tabulated through data extraction tables by pub-
lication information (author[s], year and country), methodological
63
aspects (research design, aims, methods, population, sampling, limits),
interventions, data collection, data analysis, results and conclusions/
practice indications; (3) results of the selected studies were synthe-
tized and the literature indications/recommendations were systemati-
cally organized in relation to research questions (evidence synthesis).
3 | RE SU LT S
3.1 | Study selection process
Through the study selection process (Figure 1), we initially identified
716 potentially relevant abstracts and after duplicates removal,
64
FIGURE 5 Cohort studies analysis with corresponding check-list items [Colour figure can be viewed at wileyonlinelibrary.com]
588 records remained. Of these, only 127 articles were considered eli-
gible, depending on title/abstract, and screened. Forty-one studies
potentially met the inclusion criteria and other three studies15–17 were
added after the eligible articles references evaluation. Totally 44 full-
texts were examined for eligibility (Figure 2).
After the full-text analysis, another rather than other three studies18–20
were excluded because the content was not considered pertinent and rel-
evant to the review topic or in relation to exclusion criteria. Five more
studies21–25 were excluded after the JBI’s check-list completion.
At the end of the study selection process, 36 studies were
included and analysed: 10 analytical cross-sectional, 7 cohort, 5 case-
BOARIN ET AL.
control, 5 RCTs, 4 quasi-experimental, 4 systematic reviews and
1 meta-analysis.
3.2 | Critical appraisal of included studies
3.2.1 | Primary studies
The Table 1 summarizes the characteristics of primary studies.
After the articles’ analysis with the corresponding JBI’s check-list,
among the analytical cross-sectional studies, some did not respect
certain items and others resulted unclear: Figure 3 shows the number
of items of specific check-list that each study satisfies.
BOARIN ET AL.
FIGURE 6 Quasi-experimental studies analysis with corresponding
check-list items [Colour figure can be viewed at wileyonlinelibrary.com]
Among the case-control studies, only three satisfied completely
the check-list’s items (Figure 4).
All of the cohort studies seem to be of good quality (Figure 5).
Although none of the quasi-experimental studies satisfied entirely
the check-list’s items, overall, their findings can be considered reliable
because all of the them resulted unsatisfied or unclear in one or two
items only (Figure 6).
None of RCTs fully satisfied the check-list: none researcher used
double or triple blind method (Figure 7).
3.2.2 | Secondary studies
The Table 2 summarizes the characteristics of included secondary
studies.
65
The meta-analysis and systematic reviews included did not
completely satisfy the specific check-list (Figure 8).
3.3 | Evidence synthesis
Tables 1 and 2 summarize the main results from the primary and sec-
ondary studies included, considering dietary, fluid intake and lifestyle
indications.
4 | DI SCU SSION
The study design mainly used by researchers to investigate interven-
tions to prevent urolithiasis is analytical cross-sectional design. Most
researchers used questionnaires and semi-quantitative surveys to col-
lect information about dietary, fluid intake, lifestyle habits and medical
history. Data of RCTs and quasi-experimental studies derived preva-
lently from laboratory results on urine samples. Researchers mostly
used a non-probabilistic sampling method, generally of convenience;
in some studies, the sampling method was not clearly identifiable; only
few studies, prevalently RCTs, applied a probabilistic sampling
method. In several cases, primary studies data derive from little or
very small samples (Table 1). Regarding secondary studies, one sys-
tematic review considered only one RCT; the majority of researchers
did not use a blinding procedure in performing RCTs: this is probably
due to impossibility to blind a specific intervention to modify dietary
or lifestyle habits on a human sample (Table 2). The analysed system-
atic reviews did not clearly explicit the research question/s and the
majority did not assess the publication bias likelihood. The majority of
the included studies are rather recent, with the most recent being
published last year; only five articles are previous to the year 2000,
with the oldest to be dated in 1993.
Furthermore, the majority of analysed studies were conducted in
various contexts, mainly on Caucasian human samples, from industri-
alized and Western countries; only one study was conducted on
African-American ethnicity. Few researches conducted on Asian
populations (from China, Japan, and Taiwan) were found and included;
studies concerning other ethnicities, such as African, were not found
(Table 1).
From the included papers emerged that some dietary habits, such
as the consumption of vegetables, fruits, meat and sources of calcium,
potassium and specific vitamins, may play a role in urinary stone for-
mation. Several studies in fact have investigated correlations between
food consumption and urolithiasis risk and/or its recurrences.
Researchers also suggest that through nutritional education that aims
at modifying the dietary habits of patients and their families, the dis-
ease risk and related recurrences could be reduced. Many researchers
have studied, in particular, the benefits of fruits and vegetables intake
and the risk of high intake of animal proteins: studies show an
increased risk of calculi formation in a diet low on fruits and vegeta-
bles and in an increased meat intake (both red meat and poultry).
Fresh fruit consumption seems to be inversely associated with risk of
kidney stones. These results mean that the intake of a balanced vege-
tarian and fruit diet with a moderate animal protein and purine con-
tent brings a lower risk for uric acid crystallization and the withdrawal
66
FIGURE 7 RCTs analysis with corresponding check-list items [Colour figure can be viewed at wileyonlinelibrary.com]
of fruits and vegetables may expose even healthy subjects to the risk
of developing renal calcium stones, whereas supplementing the diet
with these food products might be helpful as a preventive measure in
hypocitraturic stone patients. In fact, the consumption of fruits and
vegetables seems to increase urinary citrate, an important inhibitor of
calcium stone formation and a diet with normal to high calcium con-
tent but low in animal protein and sodium seems to decrease the risk
of calcium oxalate stone recurrence. Therefore, dietary animal protein
BOARIN ET AL.
restriction and increased intake of fruits and vegetables are generally
recommended to individuals with nephrolithiasis and hypocitraturia,
instead, avoiding of leafy green vegetables (spinach and collard
greens) is strictly recommended. Some studies investigated other spe-
cific aliments, such as soy or turmeric. Frequent consumption of soy-
food and soybean may be a risk factor for kidney stones formation in
case of prior history of calcium stones; a consumption of high doses
of turmeric could significantly increase urinary oxalate levels,
BOARIN ET AL. 67

TABLE 2 Summary of secondary studies included

N. of primary
Author(s) Year Study design Aim(s) studies included Main results
Bao and Wei48 2012 Systematic To assess the effectiveness of One RCT • The increased water intake reduces the
review increased water intake for the risk of urinary stones recurrence and
primary and secondary prevention prolongs the average interval for
of urinary stone in a population recurrences in predisposed patients.
with and without stone disease.
Fink et al49 2009 Systematic To clarify the evidence on the Eight RCTs • A high-water intake lowered long-term
review benefits and the adverse effects risk of recurrence by
of diet, fluids and supplement approximately 60%.
treatments for secondary
prevention of nephrolithiasis.
Fink et al50 2013 Systematic To evaluate the benefits and harms 28 RCTs • Increased fluid intake reduces
review of interventions to prevent recurrence risk.
recurrent kidney stones. • In patients with multiple past calcium
stones, addition of thiazide, citrate or
allopurinol further reduced risk.
Prezioso et al51 2015 Systematic To assess the effects of different 41 studies (RCTs, • Diets with a calcium content ≥1 g/d, a
review dietary interventions for the case-control and moderate dietary salt restriction and a
modification of urinary risk cohort studies). low-normal protein intake, decreases
factors in patients with urinary calciuria, could have a protective effect
stone disease. and be useful for primary and
secondary prevention of
nephrolithiasis.
• A diet low in oxalate and/or a calcium
intake normal to high (800-1200 mg/d),
and a reduction in protein intake may
reduce the oxalate excretion, although
a vegetarian diet may lead to an
increase in urinary oxalate and adding
bran to a diet low in oxalate cancels its
effect of reducing it.
• In patients with renal calcium stones
the decrease of urinary excretion of
uric acid after restriction of dietary
protein and purine is suggested,
although not clearly demonstrated.
• The administration of alkaline-citrates
salts is recommended for treatment of
high risk patients with hypocitraturia,
as increased intake of fruit and
vegetables increases citrate excretion,
with a significant protective effect
Wang et al52 2014 Meta-analysis To estimate the association between Two cohorts studies, • Coffee intake is associated with
coffee consumption and four case-control decreased risk of kidney stone
urolithiasis. studies. formation.

therefore increasing risk of stone formation in susceptible individuals.
Another study found that a low-salt diet may correct idiopathic hyper-
calciuria and also seemed to have a positive effect on other urinary
stone risk factors.
Some researchers have studied the effect of specific types of diet,
like the Dietary Approaches to Stop Hypertension (DASH), an Ameri-
can dietary pattern to prevent and control hypertension: this diet is
rich in fruits, vegetables, whole grains and low-fat dairy foods, includ-
ing meat, fish, poultry, nuts and beans; it is limited in sugar-sweetened
foods and beverages, red meat and added fats.6,26,27
Researchers also investigated correlations between fluid intake
and urolithiasis risk and/or its recurrences. Several studies show that
an increase in total fluid intake, especially water, can reduce the risk
and may bring a protective effect against recurrences. A high-water
intake results, in fact, in a strong reduction of lithogenous salts satura-
tions and less frequent episodes of crystalluria, which, if chronically
maintained, represents prevention for recurrences.
Other studies show that intake of coffee, tea, beer and wine were
also associated with a decreased risk of stone formation; on the con-
trary, increased intakes of apple and grapefruit juice were related to
higher risk.
Lifestyle recommendations were also explored, and some
researchers found that correction of unhealthy behaviours and
encouragement of regular and continuous exercise, can be effective in
prevention and reducing recurrences. Specifically, some researchers
concluded that physical activity and total energy intake are not inde-
pendent risk factors.
Several studies show that smoking cigarettes appeared to be
a strong predictor of urolithiasis and resulted to be associated
with lower urinary citrate, leading to an increase risk in stone for-
mation, thereby smoking cessation programs should be included in
the routine management of urolithiasis. Some research findings
show that quitting cigarette smoking and betel quid chewing can
greatly reduce the risk, because are both independent risk factors
68
FIGURE 8 Meta-analysis/systematic reviews analysis with corresponding check-list items [Colour figure can be viewed at wileyonlinelibrary.com]
for stone formation, specifically in people with the two habits
association.
Some studies have also observed that the advanced school
education and African-American ethnicity are characteristics associ-
ated with reduced risk for urinary calculi, in the contrary an increased
incidence is associated with economic development; also, the ambient
temperature and sunlight exposure resulted important risk factors for
kidney stones.
4.1 | Study limitations
Although this review contributes to synthesize dietary, fluid intake
and lifestyle indications for urolithiasis prevention, there are several
limitations that might limit findings generalizability. First, with regard
to studies selection process, searches were limited to five information
sources (electronic databases), while other comprehensive databases
were not searched. Second, only articles published in English or Italian
were considered for inclusion, while dissertations, conference
abstracts and other-language articles were not covered. Third, it is
necessary to consider the heterogeneity of the included studies;
moreover, diverse methodological weaknesses were identified in most
studies, reducing their rigour and limiting the generalizability of our
BOARIN ET AL.
findings. Fourth, meta-analysis was not possible due to the diversity
of the included studies, as they varied in design, method and outcome
measures.
5 | CONC LU SIONS
Evidence from this systematic review indicate that dietary animal pro-
tein restriction, increased intake of fruits and vegetables and high-
water intake are generally recommended to reduce the risk of urolith-
iasis and recurrences. Limited data suggest that coffee intake and
smoking cessation may provide additional benefits. Data on other
food consumption, specific beverages and lifestyle factors interven-
tions are inconclusive.
6 | RELEVANCE TO CLINICAL PRACTICE
This literature review systematically analysed knowledge and evi-
dence about dietary, fluid intake and lifestyle indications for the
primary and secondary urolithiasis prevention. This review found that
increasing fruits and vegetables, with a reduced intake of meats and
BOARIN ET AL.
animal fats, increasing water intake, regular physical activity rather
than constant, and a healthy lifestyle, can help to prevent the calculi
formation and recurrences.
Despite the methodological quality of the included studies, this
review summarizes potentially useful information to provide to
patients suffering from urolithiasis with the aim of supporting them
with further conduction of high-quality studies. Further homogeneous
studies, in design method and outcomes measurement, and with high
methodological quality, are needed to better clarify whether there is
additional benefit from other specific dietary and lifestyles changes.
Meanwhile, the National Institute for Health and Care Excel-
lence28 is developing guidelines for urolithiasis management, that it
will publish in 2019, providing recommendations and interesting sug-
gestions for future research.
ACKNOWLEDGEMEN TS
The authors declare that they received no funding. This article does
not contain any studies with human participants or animals performed
by any of the authors.
Conflict of interest
The authors declare no conflict of interest.
Author contribution
Study design: MB, GV; data collection and analysis: MB, GV, CC, DR;
manuscript preparation: MB, GV, CC, DR, FA, DFM.
ORCID
Mattia Boarin http://orcid.org/0000-0002-2294-928X
Giulia Villa http://orcid.org/0000-0001-7429-0504
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How to cite this article: Boarin M, Villa G, Capuzzi C,
Remon D, Abbadessa F, Manara DF. Dietary and lifestyle rec-
ommendations for urolithiasis prevention: A systematic litera-
ture review. Int J Urol Nurs. 2018;12:53–70. https://doi.org/
10.1111/ijun.12169