ALIMENTATIA PACIENTULUI

LITIAZIC
controverse
 Introducere

 Urolitiaza este o problema clinica cu un efect economic

important asupra societatii dar si asupra calitatii vietii
pacientilor.
 Afecteaza atat femeile cat si barbatii avand o prevalenta de
13%(F) si 7%(B)¹.
 Importanta managementului litiazai renale sta in recurenta
mare a bolii dupa primul episod.
 Literatura citeaza ca aproximatov 50% din pacienti ce au avut
un episod de litiaza renala, vor mai avea unul in urmatorii 5
ani.²
¹Coe FL, Keck J, Norton ER. The natural history of calcium urolithiasis. J Am Med Assoc. 1977
²Williams RE. Long-term survey of 538 patients with upper urinary tract stone. Br J Urol. 1963
 Daca perioada de urmarire a pacientilor cu primul episod de
litiaza renala este extinsa la 25 de ani, sansa de recurenta
creste la 100%.¹ ²
 Impactul economic si social al bolii este unul major:
Factori de risc
Tipuri de calculi
 Dieta in litiaza renala
introducere

 Modificarile de dieta in litiaza renala sunt cele mai

accesibile unelte, in speranta de a scadea incidenta
formarii calculilor.
 Majoritatea recomandarilor sunt: cresterea
consumului de lichide, scaderea consumului de sodiu
si scaderea aportului de proteine.
Proteinele de origine animala si litiaza
CRESC RISCUL LITIAZEI

 Recomandarile OMS pentru DRI (Dietary Reference

Intake) pentru proteine sunt de 0,8g/kg corp.
 In medie la un barbat sedentar - 56g/zi de proteine
 In medie la o femeie sedentara - 46g/zi de proteine
Animal protein should not be consumed in excess and
limited to 0.8-1.0 g/kg body weight. Excessive
consumption of animal protein has several effects that
favour stone formation, including hypocitraturia, low
urine pH, hyperoxaluria and hyperuricosuria.
 One of the most outstanding names in history of Islamic
science of the Middle Ages is without any doubt that of the
Persian scholar Ibn Sina, Avicenna (980-1037), and his work
Al-Qanun fi-l-tibb (Canon of Medicine) is one of the most
representative writings of the medieval Arabic medicine.
 He has explained pathophysiology of renal stones at first
and then enumerated factors that cause stone formation.
 He believed that nutritional habits are important factor in
this process.
 He restricted some foods such as milk, cheese, some types
of fishes and camel, cow and goat meat for patients with
renal stone
 Eight healthy male volunteers, university students, were studied
after giving informed consent
 They all had normal renal function and none had a history of
urolithiasis or was taking any medications
 1) Basal diet (Basal): 140 mmol sodium and 1 g protein/kg-day
 2) High protein diet (Protein): 140 mmol sodium and 2 g
protein/kgday
 3) High sodium diet (Salt): 310 mmol sodium and 1 g protein/kg•
day
 4) High sodium and high protein diet (Combined): 310 mmol
sodium and 2 g protein/kg • day
 Rezultate:

 In conclusion, dietary excesses in animal protein and/or

sodium induce significant changes in the chemical composition
of urines and reduce their ability to inhibit the agglomeration
of calcium oxalate monohydrate crystals. The latter effect was
further related to the urinary citrate content
 Eighty volunteers were screened for the study.
 Ten healthy subjects (seven women, three men) participated
 All subjects participated in the three stages of the study
 Subjects remained on their usual non–weight-reducing diet for
the first 2 weeks (usual diet).
 Subjects then consumed an Atkins’-type induction diet for 2
weeks (induction diet), followed by an Atkins’-type maintenance
diet for 4 weeks (maintenance diet)
 Atkins diet consists of a normocaloric, very low carbohydrate,
normal/high protein and high fat intake. Some variants of Atkins
diet emphasize the benefits of animal protein, so they may
overlap to high protein diets described above.
Rezultate:
 In conclusion, low-carbohydrate diets are popular and are
consumed by many people in an attempt to reduce their weight.
 Our study shows that such a diet delivers an exaggerated acid
load.
 Clinical implications of this enhanced acid load include an
increase in kidney stone risk, decrease in estimated calcium
balance, and potential increase in risk for bone loss.
 Our study represents a metabolic study of short duration in a
limited number of subjects. However, acid excess will be
sustained as long as carbohydrate restriction and high-protein
intake are maintained. Thus, the increased risk for stone
formation might be expected during the entire duration of such
a diet.
 This study was designed to test the oxaluric response to a meat protein load in
male recurrent idiopathic calcium stone formers (ICSFs) with and without mild
metabolic hyperoxaluria (MMH and non-MMH, respec- tively), as well as in
healthy controls
 Twelve MMH, 8 non-MMH, and 13 healthy males were studied after five days
on a high meat protein diet (HPD; 700 g meat/fish daily) following a run-in
phase of five days on a moderate protein diet (MPD; 160 g meat/fish daily).
 In both diets, oxalate-rich nutrients were avoided, as well as sweeteners and
vitamin C-containing medicines.
 Twenty-four–hour urinary excretion of oxalate was measured on the last day of
each period, along with 4-pyridoxic acid (U4PA) and markers of protein intake,
that is, urea, phosphate, uric acid, and sulfate.
 Rezultate:

 In conclusion, about one third of ICSFs, with or without

MMH, are sensitive to meat protein in terms of oxalate
excretion, and this response to meat protein could be a
more meaningful criterion to define a subgroup of stone
formers than so-called MMH.
 Mechanisms underlying this sensitivity to meat protein
remain to be elucidated and do not seem to involve
vitamin B6 deficiency.
Proteinele de origine animala si litiaza

NU INFLUENTEAZA RISCUL LITIAZEI

 A total of 11 healthy human subjects (6 males and 5 females)
 The subjects denied ever having kidney stones or any condition that may affect
the intestinal or renal transport of ions or the metabolism of nutrients.
 Subjects consumed controlled, eucaloric diets that contained 0.6, 1.2 or 1.8 g of
protein/kg body wt/day. These protein levels are considered to be low, normal and
high, respectively
 While the amounts of vegetable protein were the same for all three phases, animal
protein consumption varied for each sequence.
 Each protein diet was consumed for 6 days in random order and consisted of a 3
day menu cycle. There was a 3–5 days washout period between protein phases.
 The subjects were asked to refrain from vigorous exercise and the use of
supplements including calcium and vitamin C.
Rezultate:
 The analysis of 24 h urine collections confirmed that as protein
intake increased, urinary calcium and glycolate increased and
urinary pH and citrate decreased.
 Total daily urinary oxalate excretion did not change. When
indexed to creatinine there was a small but significant decrease
in oxalate excretion. This is most likely due to hyperfiltration.
 These results indicate that as dietary protein intake increases,
the catabolism of diet-derived amino acids is not associated
with an increased endogenous oxalate synthesis in normal
subjects.
  We prospectively examined, during an 8-year period, the association
between dietary factors and the risk of incident symptomatic kidney stones
among 96 245 female participants in the Nurses' Health Study II
 Aged 27 to 44 years, no history of kidney stones
 Self-administered food frequency questionnaires were used to assess diet in
1991 and 1995.
 The main outcome measure was an incident symptomatic kidney stone.
 We documented 1223 incident symptomatic kidney stones
Rezultate:
 We prospectively examined intakes of protein (dairy, nondairy
animal, and vegetable), potassium, and animal protein-to-
potassium ratio (an estimate of net acid load) and risk of
incident kidney stones in the Health Professionals Follow-Up
Study, the Nurses’ Health Study I, and the Nurses’ Health
Study II. Multivariable models were adjusted for age, body
mass index, diet, and other factors.
 We also analyzed cross-sectional associations with 24-hour
urine
 1978 and 1982
 During the 5 years 31,310 men resident in the 72 areas were discharged
from hospital after emergency admission for renal stones or colic.
 The strongest relation for nutrients found in our survey was the negative
correlation between the incidence of renal stones and the consumption of
fat and protein
 The relation with fat and protein was partly determined by the negative
relation between stone incidence and meat consumption
 Intake of Fiber

 DECREASE the risk of incident kidney stone formation

 Dietary Intake of Fiber, Fruit, and Vegetables Decrease the Risk of
Incident Kidney Stones in Women: A Women's Health Initiative
(WHI) Report
Mathew D. Sorensen, MD, MS, Ryan S. Hsi, MD, Thomas Chi, MD, Nawar Shara, MS, PhD, Jean Wactawski-Wende, PhD, 
Arnold J. Kahn, PhD, Hong Wang, MD, MS, Lifang Hou, MD, PhD, andMarshall L. Stoller, MD

 Women's Health Initiative (WHI) Observational Study

 prospective, multicenter study investigating the health of postmenopausal women
 93,676 women, age 50-79, enrolled from 1993 to 1998 and were followed for a
median of 8 years
 food frequency questionnaire (FFQ) was administered at enrollment
 Women who never answered the incident kidney stone questions, women who did
not complete the FFQ, and those reporting extremes of energy intake (<600 or
>5000 kcalories per day) were excluded from these analyses (7,912 total women)
 leaving a final analytic cohort of 83,922 women
 Included in this cohort were 3,471 women with a history of kidney stones prior to
enrollment. These participants were considered a separate group for all analyses.

J Urol. 2014 December ; 192(6): 1694–1699. doi:10.1016/j.juro.2014.05.086.

 Rezultate:
 After a median follow-up of 8 years, there were 2,937 stone events
reported
 Only 3% of the women with no history of stones developed a stone during
the study, while more than 15% of women with a history of stones
reported an event during the study
 Women with a history of kidney stones had lower mean intake of fiber,
fruit, and vegetables, with the greatest proportion of women in the lowest,
and second lowest quintiles of intake
 In multivariate analyses, women with no history of stones with the highest
dietary fiber intake were 22% less likely to report an incident stone event
during the study compared to women with the lowest fiber intake
 Women with a history of kidney stones prior to study participation did not
demonstrate a significant relationship between fiber, fruit, or vegetable
intake and kidney stone occurrence during the study.
 Higher intake of fruits, vegetables and fiber are
associated with a decreased risk of incident kidney
stone formation in postmenopausal women,
independent of the effect of BMI and other
nephrolithiasis risk factors including dietary intake of
water, sodium, animal protein and calcium. This
protective effect was not seen in women with a
history of stones.
 Kidney International, Vol. 66 (2004), pp. 2402–2410

The effect of fruits and vegetables on urinary stone risk

factors
 TIZIANA MESCHI, UMBERTO MAGGIORE, ENRICO FIACCADORI, TANIA SCHIANCHI

 Twelve normal subjects with no medical history of stone disease and free from silent
stones as per renal ultrasound
 8 males and 4 females
 a fairly large quantity of fruits and vegetables for a two-week period, followed by a
further two weeks on a diet totally devoid of fruits and vegetables.
 Compared with the former period, the fruit-vegetable free diet caused a number of
significant variations in 24-hour excretion of various urinary solutes, consisting of a
decrease of potassium (−62%), magnesium (−26%), citrate (−44%), oxalate (−31%),
and an increase of calcium (+49%) and ammonium (+12%).
 The volume of urine decreased to the limits of statistical significance.
 As a consequence, the relative saturation for calcium oxalate and calcium phosphate
increased, while that of uric acid did not change, owing to pH and uric acid
concentrations remaining relatively stable.
 CONCLUSION

 The total elimination of fruits and vegetables in normal

subjects brings about adverse changes in the urinary
stone risk profile that are only partially counterbalanced
by a reduction in oxalate.
 In contrast, the addition of these foods to the diet of
hypocitraturic stone formers not used to eating them not
only significantly increases citrate excretion without
affecting oxalate excretion, but also decreases calcium
oxalate and uric acid relative saturation.
 Intake of Fiber

 DO NOT DECREASE the risk of incident kidney

stone formation
 Effects of low animal protein or high-fiber diets on urine
composition in calcium nephrolithiasis
 MICHEL ROTILY, FRANC¸ OISE LE´ ONETTI, CECILIA IOVANNA, PATRICE BERTHEZENE, PATRICIA
DUPUY, ALAIN VAZI, and YVON BERLAND

 between January 1996 and January 1998, 96 ICSFs (idiopathic calcium stone formers)

were included regardless of the number of stone episodes.
 All patients were evaluated in our center for clinical investigations to exclude those
with a metabolic or urological cause of stone formation
 were randomly assigned a low animal protein diet (<10% of total energy), a high-fiber
diet (>25 g/day), or a usual diet (control group); all patients were recommended to
increase their fluid intake. 
 Compliance with dietary recommendations was checked by validated 
food frequency questionnaires. 
 The LAPD group was instructed to decrease their intake of animal protein - less than
10% of energy needs and eat refined cereals (that is, pasta and rice).
 The HFD group was instructed to increase their intake of raw and dried fruit, vegetables
, and to substitute their usual cereals with whole grain dietary products in order to limit
the increase in energy. The target was to obtain a daily total fiber intake of more than 25
g.
 Rezultate:

 The main result of our randomized and controlled 

nutritional intervention is that a decrease in animal 
protein intake, with a urine urea output of more than 50
mmol/day, among ICSFs can lead to a decrease in daily
urine calcium output. Our study has also shown that an
increase in dietary fiber intake did not succeed in
modifying the main predictive factors of calcium oxalate 
stone formation, calcium, and oxalate outputs.
 A randomized trial of low-animal-protein or high-fiber diets for
secondary prevention of calcium nephrolithiasis.
 Dussol B1, Iovanna C, Rotily M, Morange S, Leonetti F, Dupuy P, Vazi A, Saveanu A, Loundou A, Berland Y.

 a 4-year randomized trial comparing the effect of 2 diets in

175 idiopathic calcium stone formers. January 1996 and
January 2001.
 55 were assigned to a LAPD ( 13% of total energy derived
from protein)
 60 were assigned to a HFD ( 125 g/day fiber)
 60 were placed on a normal diet (control group).
 Daily urine compositions were analyzed at baseline, at
month 4 (M4), M12, M24, M36 and M48
 Rezultate:

 Seventy-three patients completed the trial

 Recurrence was 48% (11/23) in the LAPD group, 63% (17/27) in
the HFD group and 48% (11/23) in the control group
 During follow-up, urinary calcium levels and other urine
parameters did not change significantly in the 3 groups, except for
a significant decrease in 24-hour urinary sulfate in the LAPD
group.

 In idiopathic calcium stone formers, neither a LAPD nor a

HFD appeared to provide protection against recurrence.
 Randomized controlled trial of a low animal protein, high fiber diet in the
prevention of recurrent calcium oxalate kidney stones.
Hiatt RA1, Ettinger B, Caan B, Quesenberry CP Jr, Duncan D, Citron JT. Abstract
 Am J Epidemiol. 1996 Jul 1;144(1):25-33.

 randomly assigned 99 persons who had calcium oxalate stones for the first time to a
low animal protein, high fiber diet that contained approximately 56-64 g daily of
protein, 75 mg daily of purine (primarily from animal protein and legumes), one-
fourth cup of wheat bran supplement, and fruits and vegetables.
 intervention subjects were also instructed to drink six to eight glasses of liquid daily
and to maintain adequate calcium intake from dairy products or calcium
supplements.
 Control subjects were instructed only on fluid intake and adequate calcium intake.
 Both groups were followed regularly for up to 4.5 years with food frequency
questionnaires, serum and urine chemistry analysis, and abdominal radiography; and
they were urged to comply with dietary instructions.
 In the intervention group of 50 subjects, stones recurred in 12 compared with two in
the control group
 The authors conclude that advice to follow a low animal protein, high fiber, high
fluid diet has no advantage over advice to increase fluid intake alone.
LICHIDELE
An inverse relationship between high fluid intake and
stone formation has been repeatedly demonstrated.
The effect of fruit juices is mainly determined by the
presence of citrate or bicarbonate. If hydrogen ions are
present, the net result is neutralisation. However, if
potassium is present, both pH and citrate are increased.
 UN APORT CRESCUT DE LICHIDE
INFLUENTEAZA INCIDENTA LITIAZEI
 Au fost inclusi 101 subiecti control si 199 pacienti cunoscuti cu un
episod litiazic (compozitia calculului: oxalat de calciu sau mixta cu o
componenta de fosfat de calciu) dupa rezolvarea acestuia
 Au fost exclusi din studiu pacienti cu litiaza restanta, HTA sau
patologie metabolica asociata ce implica restrictii alimentare sau
medicatie
 Dupa 3 luni este prelevata urina pe 24 ore pentru a determina profilul
de baza
 Sunt impartiti randomizat in doua grupuri si supravegheti pe durata a 5
ani
 GRUP 1: aport crescut de lichide fara modificari ale dietei
 GRUP 2: nu primesc nici o indicatie
 REZULTATE:

 In grupul 1 recurenta litiazei a fost de 12.1%, comparativ cu 27%

in grupul 2
 Media perioadei de recurenta s-a plasat la 25 luni
 Cresterea aportului de apa a crescut diureza in cadrul grupului 1 ce
a dus la o scadere a valorilor suprasaturatiei pentru oxalat de calciu
si brushit comparativ cu grupul control
 Volumul diurezei la un pacient cu litiaza calcica este mai scazut
coparativ cu al unui subiect sanatos, iar un consum adecvat de apa,
chiar daca nu este acompaniat de modificari ale dietei poate avea
un efect pozitiv asupra recurentei prin scaderea saturatiei sarurilor
lithogenice
 Daca hipercalciuria este prezenta se impune modificarea dietei sau
implementarea unui regim medicamentuos
 O meta-analiza ce are scopul de a evalua eficienta unui
consum crescut de lichide in prevenirea incidentei si a
recurentei litiazei
 Au fost incluse 9 studii: 2 trialuri randomizate cuun total de
269 pacienti si 7 studii observationale cu un total de 273.685
indivizi
 Doar unul din cele 9 studii a detaliat ca aprot crescut de
lichide inseamna cresterea aportului de apa
 REZULTATE:

 Este o asociere semnificativa intre un aport crescut de

lichide si un risc scazut de incidenta a litiazei
 Acelasi beneficiu a fost observat la femei/barbati
 De asemenea a fost decelata si o scadere a riscului
recurentei litiazei
 Nu se observa diferente intre un aport crescut de apa sau de
lichide in general
 Chiar daca este o legatura intre cresterea aportului de lichide
si incidenta litiazei, nu se poate face o corelatie exacta intre
un anumit volum de lichide si gradul de beneficiu adus
 Aprilie 2013 – aprilie 2017
 Colectate informatii cu privire la regiunea in care locuiesc,
cantitatea de apa consumata si sursa – de la 1.266 pacienti
cunoscuti litiazici
 Au fost exclusi pac. cu afectiuni metabolice, gastro-intestinale,
renale, endocrinologice; eliminare urinara excesiva de calciu,
oxalat, citrat, urati; administrare steroizi sau diuretice
 Apa a fost prelevata in 3 perioade: vara, in timpul musonului si
iarna
 Probele au fost evaluate pentru pH, duritate, salinitate, total solide
dizolvate (TDS) si conductibilitate electrica (ofera date cu privire
la continutul mineral si salinitate)
 REZULTATE:

 61.7% barbati, 38.3% femei

 Tendinta de a forma pietre a fost mai mare in cazul
pacientilor cu un stil de viata sedentar (68.2%)
 46.4% consum > 3L lichide/zi in timp ce 53.6% cunsum
< 3L
 Datele au aratat ca litiaza este mai prevalenta in unele
regiuni dar nu au fost decelate diferente semnificative cu
privirea la calitatea apei consumate
 Nu conteaza calitatea apei ci cantitatea de apa
consumata in cazul recurentei bolii litiazice
 Au fost analizate 2 baze de date: 74 941 femei din
comunitati urbane din China (1996 – 2000) si 61 480
barbati (2002 – 2006) cu o includere de 92.7% pt femei
si 74.1% pt barbati
 Sunt evaluati prin chestionare la 2-4 ani
 Este estimat consumul de ceai si cantitatea de planta
utilizata
 REZULTATE:

 1202 barbati si 1451 femei au raportat incidente litiazice

 Formatorii de calculi fac mai des parte din grupul celor ce nu au o
ocupatie ce implica efort fizic intens si prezinta un IMC mai mare
 In cazul femeilor acestea sunt mai inclinate sa prezinte antecedente de
boala coronariana, AVC sau litiaza biliara
 In cazul barbatilor acestia sunt mai inclinati spre HTA
 Consumul in mod regulat de ceai este asociat cu o scadere cu 13 % a
riscului litiazic la femei si cu 22% la barbati
 Initierea consumului de ceai este asociata cu o scadere cu 30% a riscului
de litiaza in cazul barbatilor dar nu si in cazul femeilor
 Este observata si o legatura intre doza de planta utilizata pe luna,
regularitatea cu care se face consumul si incidenta litiazei
 Studii au aratat ca un consum de apa minerala bogata in
bicarbonat are un efect pozitiv asupra urinei suprasaturata cu
oxalat de calciu
 34 pacienti cu episoade recurente de litiaza cu oxalat de calciu
 Studiu dublu orb in care pacientii primeau 1,5l de apa minerala cu
2.673 mg HCO3/l (apa testata) sau aceeasi cantitate de apa cu un
nivel mineral scazut (98 mg HCO3/l – apa control), zilnic, timp de
3 zile
 Se colecteaza urina pe 24 ore la inceputul perioadei si in ziua a 3-a
 Perioada intre cele 2 testari a fost de minim o saptamana
 REZULTATE:

 Analiza urinei de baza a aratat ca 22 din cei 34 pacienti aveau

hipercalciurie, hiperoxalurie sau chiar ambele
 A crescut valoarea pH-ului in cazul consumului de apa bogata in
bicarbonat, atingand o valoare medie de 6.73
 In timpul perioadei de consum al apei bogate in bicarbonat apare o
crestere semnificativ statistica a inhibitorilor magneziu si citrat, ceea ce
nu s-a intamplat in cazul apei test
 In cazul promotorilor se observa o scadere a concentratiei calciului si
oxalatului, comparativ cu baza si apa control
1. In cazul litiazei dovedite cu oxalat de calciu sau mixte (oxalat/ac uric)
aportul crescut de apa bogata in magneziu si bicarbonat este recomandat
2. In cazul unui diagnostic incert, sau fosfat de calciu se recomanda
metafilaxia cu apa ce are un continut mineral scazut
NU TOATE LICHIDELE SUNT CREATE EGAL
 Principalul scop a fost evaluarea asocierii intre diferitele tipuri de
sucuri carbogazoase (indulcite cu zahar, indulcitori artificiali,
sucuri non-cola) si incidenta litiazei, la indivizii fara antecedente
litiazice.
 A fost evaluata si legatura cu alte tipuri de bauturi.
 Baza de data evaluata: The Health Professionals Follow-Up Study
(51,529 barbati – 1986), The Nurses’ Health Study I (121,700
femei – 1976) si The Nurses’ Health Study II (116,430 femei –
1989)
 Au fost exclusi subiectii cu litiaza sau cancer, sau care au dezvoltat
cancer
 194,095 participanti evaluati pe 8 ani (HPFS si NHS II) si 13 ani
(NHS I).
 REZULTATE:

 Consumul a 1 sau mai multe portii de cola indulcit cu zahar este

asociat cu o crestere cu 23 % a riscului de a dezvolta litiaza
comparativ cu cei ce consuma mai putin de o portie pe saptamana
 Riscul creste cu 33% in cazul celor ce consuma sucuri non-cola
indulcite cu zahar - We used the term noncola for carbonated
beverages without cola (e.g., clear soda).
 O crestere cu 18% a riscului in cazul consumului de fruit punch
 Consumul de cola cu indulcitori artificiali este ascociata cu o scadere
a riscului de litiaza in timp ce bauturile non-cola indulcite artificial
sunt asociate cu un risc marginal mai crescut
 De partea cealalta consumul de cafea scade cu 26% riscul, cafea
decafeinizata – 16%, ceai – 11%, vin rosu – 31%, vin alb – 33%, bere
– 41%, suc portocale – 12%
 OXALATUL
 Oxalatul este o sare organica produsa de plante, in principal de frunze, fructe, nuci
si coaja
 In general plantele ce cresc in zone unde apa freatica contine Ca in exces vor avea
un continut mai crescut de oxalat
 Poate fi produs si de organism in ficat sau convertita Vitamina C cand este
metabolizata.
 Se leaga de minerale in timpul digestiei (oxalat de Ca, Fe) in general in colon si se
elimina prin scaun, prevenind o parte din acestea sa fie absorbite, in special cand
sunt combinate cu fibre.
 Daca nu se poate lega va fi eliminat pe cale renala
 La oameni se pare ca oxalatul nu prezinta un rol, fiind un punct final al
metabolismului, asemenea ac. uric. Daca nu ar fi pentru afinitatea crescuta a
acestuia pentru calciu si solubilitatea scauta, interesul fata de acesta ar fi neglijabil
 Aportul din dieta se situeaza in jur de 80-120 mg/zi dar poate varia intre 44-350
mg in cadrul dietei occidentale
 S-a efectuat o evaluare a obiceiurilor alimentare in
cazul a 186 pacienti formatori de calculi de oxalat de
calciu
 Lot 1- 93 prezentau hiperoxalurie (>= 0.5 mmol/zi)
 Lot 2- 93 cu excretie normala
 Valorile energetice, proteine totale, grasimi si
carbohidrati sunt comparabile in cele 2 loturi
Lot 1 a prezentat o medie a aportului de 130mg/zi
oxalat si 812 mg/zi Ca
Lot 2 101 mg/zi oxalat si 845 mg/zi Ca
Rezultate:

 O crestere semnificativa a aportului de ascorbat la

pacientii cu hiperoxalurie (178mg/zi vs 103mg/zi)
 Acesta este un precursor al oxalatului estimandu-se ca
35-50% din oxalatul urinar provine din conversia
acestuia
 Aportul de vitamina C in lotul cu hiperoxalurie a fost
cu 80 % mai mare fata de recomandarea zilnica actuala
 FOSFATUL

 Fosforul joaca un rol foarte important in organism.

 In mare parte este combinat cu oxigen de unde rezulta
fosfatul.
 85% din acesta se afla in os, 14% in tesuturi moi si
restul de 1% extracelular.
 In os acesta face parte din hidroxiapatita ce se
depoziteaza in matricea organica in timpul procesului de
mineralizare. Raportul P la Ca in osul normal este de 1:2
 In tesuturi acesta este un component structural, un factor
in metabolism si un component al materialului genetic.
Ca
Calcium should not be restricted, unless there are strong reasons for doing so,
due to the inverse relationship between dietary calcium and stone formation.
The daily requirement for calcium is 1,000 to 1,200 mg. Calcium supplements are
not recommended except in enteric hyperoxaluria, when additional calcium
should be taken with meals to bind intestinal oxalate. Older adults who do not
have a history of renal stones but who take calcium supplements should ensure
adequate fluid intake since it may prevent increases in urine calcium
concentration, and thereby reduce or eliminate any increased risk of renal stones
formation associated with calcium supplement use.
Committee to Review Dietary Reference Intakes for Vitamin D and Calcium,
Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes
for Calcium and Vitamin D. Washington, DC: National Academy Press, 2010.
 UN APORT CRESCUT DE Ca
SCADE INCIDENTA LITIAZEI
 S-a urmarit influenta ingestiei a diferite forme si doze de calciu asupra
absorbtiei de oxalat si excretia acestuia
 In primul experiment s-a evaluat diferenta asupra incarcarii cu oxalat
(oxalate load = OL) : baza (OL), carbonat de calciu + OL si malat citrat de
calciu + OL
 Sarurile de calciu utilizate contin 300mg Ca esential iar OL reprezinta
198mg acid oxalic
 Experimentul 2 a comparat baza (OL) si administrarea concomitenta a
bazei cu 100, 200 si 300mg Ca
 Probe de urina au fost prelevate din 2 in 2h in primele 6h si apoi la 9h
pana la terminarea a 24h
 In experimentul 1 au fost inclusi 10 subiecti fara antecedente litiazice si 4
formatori de calculi
 Studiul 2 a inclus 9 subiecti sanatosi
 REZULTATE:

 S-a decelat o cantitate mai mare de Ca excretata dupa

administrarea de malat citrat de calciu ceea ce sugereaza ca,
dintre sarurile testate, aceasta a furnizat Ca cu o
biodisponibilitate mai mare
 Ambele saruri de Ca au fost la fel de eficiente in reducerea
absorbtiei de oxalat
 Nu s-a observat o relatie intre doza de Ca administrata si Ca
excretat
 200 sau 300 mg Ca au fost la fel de eficiente in reducerea
absorbtia oxalatului de la 11.3% in cazul bazei la 5.9% si 7.6%
 Calciul din alimentatie pare sa precipite oxalatul formand
saruri de oxalat in tubul digestiv astfel limitand absorbtia si
excretia de oxalat
 The Health Professionals Follow-up Study din care au
fost inclusi 45,619 barbati, fara antecedente litiazice
 Pe baza chestionarelor a fost estimat consumul de
calciu
 Reevaluare la 2 ani si 4 ani prin chestionare
 Daca a fost raaportat un episod litiazic atunci a fost
trimis un chestionar suplimentar
 Au fost evaluate dosarele medicale aleator a 60 dintre
acestia pentru a valida acuratetea datelor furnizate
 Diagnosticul a fost confirmat in 97% din cazuri
 REZULTATE:

 Au fost documentate 505 cazuri de litiaza simptomatica

 25.7% (130) au raportat antecedente litiazice in familie
 Durerea a fost cel mai frecvent simptom – 90.5%
 Din cei 221 pacienti ce au putut furniza informatii asupra
compozitiei calculului, 71.5% au raportat si prezenta calciului
 Incidenta maxima a fost intre 40 si 59 ani
 Aportul alimentar de Ca a fost semnificativ mai scazut in cazul
pacientilor ce au dezvoltat litiaza (o crestere cu 34 % a riscului
intre extreme)
 Nu a fost descoperita o asociere intre utilizarea suplimentelor
de Ca si aparitia calculilor
 Datele sugereaza ca un aport crescut de Ca scade incidentaa
litiazei simptomatice
 In 1989, 96245 femei cu varsta intre 25 si 42 ani, fara
antecedente litiazice, incluse in NHS II
 Analiza aportului de calciu pe baza chestionarului
alimentar
 Chestionarele au fost trimise la fiecare 2 ani, pe o
perioada de 8 ani
 REZULTATE:

 1223 incidente simptomatice de litiaza au fost raportate

 ITU prezenta in momentul evenimentului litiazic a fost raportata de
17.5% din femei, dar o relatie intre cele 2 evenimente a fost suspicionata
in 6.6% din cazuri
 Antecedente familiale de litiaza au fost raportate de 36.4%
 Durerea a fost simptomul de debut in 95.2% din cazuri
 Din cele 439 femei ce au putut furniza informatii cu privire la
compozitie, in 87.5% a fost implicat Ca
 Incidenta a fost mai mare intre 27 si 34 ani, scade intre 35 si 44 dar
creste iar peste 45 ani
 Un aport mai crescut de Ca a fost corelat cu o reducere a riscului de
litiaza
 Ca din suplimente a fost asociat cu o crestere nesemnificativa a riscului
de litiaza
 O analiza a 3 studii importante: Health Professionals
Follow-up Study (HPFS- 30,762barbati) , Nurses’ Health
Study (NHS I si II - 94,164 si 101,701 femei)
 5,270 cazuri litiazice
 A fost estimat aportul de Ca din surse non-lactate: 41% pt
HPFS, 46% pt NHS I si 38% la NHS II
 Nu se observa o modificare a incidentei in functie de
sursa aportului de Ca
 Indiferent de sursa aportului, un consum mai mare de Ca
a fost asociat cu un risc mai scazut al incidentei ltiazei
 UN APORT CRESCUT DE Ca
DIN SUPLIMENTE POATE CRESTE INCIDENTA
LITIAZEI
 32 militari, fara antecedente litiazice
 Critedii de excludere: functie renala modificata, boli gastro-
intestinale sau sindrom de malabsorbtie
 Faza 1: o saptamana cu o dieta prestabilita, prelevarea urinei pe 24
ore in ziua 6 si 7
 In saptamana 2 au fost impartiti in 2 grupuri: A – o capsula de
650mg carbonat de Ca imediat dupa fiecare masa, iar grupul B a
luat 3 comprimate de carbonat de Ca la culcare cu prelevarea urinei
in ziua 6 si 7
 Dupa aceasta au urmat o perioada de pauza de 4 saptamani, cu
reinitierea testului in faza 2
 Dieta consta in 2000-2500kcal/zi, carbohidrati 350g/zi, proteine
80g/zi, grasimi 60 g/zi, Ca 10-15mmol/zi si oxalat 0.6-1.2mmol/zi
 REZULTATE:

 Excretia de Ca a crescut semnificativ in ambele cazuri, fara

a fi o diferenta semnificativa intre cele 2 regimuri
 Oxalatul urinar a scazut semnificativ, cu o crestere a
citratului doar in cazul administrarii suplimentelor cu
alimentele
 Prin contrast, administrarea suplimentului la culcare a dus la
o crestere a activitatii oxalatului. Aceasta a rezultat din
cresterea Ca urinar fara o reducere compensatorie a
oxalatului urinar si o crestere mai putin evidenta a citratului
 Pentru pacientii formatori de calculi, al caror oxalurie este
semnificativa, administrarea de suplimente la culcare este
inoportuna.
GRASIMI
 UN APORT CRESCUT DE LIPIDE
INFLUENTEAZA INCIDENTA LITIAZEI
 13 pacienti cu ileopatie dintre care 2 cu antecedente
litiazice
 S-a administrat 100g grasimi pentru 8-16 zile urmat de 12-24
zile cu un aport de 40g grasimi, dieta fiind la alegerea
pacientului, fiind ulterior incurajat sa o continue la
domiciliu
 La reevaluare dupa 3- 27 luni
 S-a observat o corelatie intre acizii grasi eliminati fecal si
excretia de oxalat urinar
 Se presupune ca prin reducerea scaunelor diareice si
cresterea diurezei se produce o dilutie a factorilor lithogeni
 Un numar de 58 barbati (medie varsta 43.9 ani) cu litiaza de
oxalat de Ca, in prezent stone-free, au fost inrolati
 A fost investigata dieta acestora dupa metoda auto-evaluaarii
 Se preleveazaa urina pe 24ore
 Au fost investigate relatiile intre aportul de grasimi, grasimi
animale si excretia de oxalat
 REZULTATE:

 39 au prezentat hiperoxalurie
 Doar grasimea de origine animala a putut fi asociata cu oxalatul
urinar, fiind o excretie mai mare in cazul unui aport > 60g/zi
 Obiectivul a fost investigarea influentei dietei asupra
excretiei de oxalat la pacientii formatori de calculi
renali pe baza de calciu
 Au fost evaluati cu ajutorul chestionarelor alimentare
si urina pe 24 ore, 60 pacienti formatori idiopatici de
calculi calcici
 Aportul de grasimi si proteine a fost corelat cu o
crestere a excretiei de oxalat
 De asemenea aportul de grasimi a fost corelat cu
aportul de proteine
 UN APORT CRESCUT DE LIPIDE
NU INFLUENTEAZA INCIDENTA LITIAZEI
 476 pacienti (305 barbati si 171 femei) alesi aleator de un
calculator din randurile pacientilor ce s-au adresat unui
ambulator specializat in litiaza
 Nu au fost supusi inainte unei educatii cu privire la alimentatie
 142 prezentau un prim episod de litiaza, 334 - recurenta
 Compozitia afost analizata direct sau estimata prin metode
radiologice
 Acestia au furnizat date cu privire la alimentatia lor pe
parcursul a 4 zile consecutive, daca se putea impreuna cu
gramaje
 In ultimile 2 zile s-a prelevat urina pe 24h
 REZULTATE:

 Media de aport pentru grasimi a fost de 105.6g in

randul barbatilor si 78.1g in randul femeilor
 Nu s-a putut determina o legatura intre aportul de
grasimi si modificari ale rezultatului urinei pe 24 ore, in
cazul barbatilor si a femeilor
 Grasimile au fost analizate ca saturate,
monosaturaate sau polisaturate pentru a incerca sa se
gaseasca o legatura
GLUCIDE
 7 voluntari sanatosi
 Au fost studiati in 2 zile, spatiate la o saptamana
 A jeun se amplaseazaa cate o linie venoasa la ambele
brate si se preleveaza probe de urina si sange, ulterior
se administreaza o perfuzie cu glucoza sau fructoza
 Calciuria, oxaluria a crescut dupa infuzia de fructoza,
dar nu au aparut modificari in cazul glucozei
 Uratii au crescut atat dupa administrarea de fructoza
cat si dupa glucoza
 Evaluate NHS I, NHS II si HPFS

 Aportul de carbohidrati non-fructoza nu a fost asociat

cu o crestere a incidentei litiazice
 7 adulti sanatosi
 Evaluati initial metabolic si s-au colectat 2 probe de urina 24h
 Diete controlate, cu un aport scazut de oxalat (51mg/zi) si 3
nivele stabilite de fructoza (4, 13, 21% din caloriile zilnice
2000-2500)
 Perioada alocata fiecarei diete – 7 zile, in ultimele 4 zile
colectarea urinei pe 24 ore

 Nu s-au observat modificari in excretia oxalatului, calciului si

acidului uric
 12 subiecti sanatosi
 Fara istoric litiazic, afectiuni gastro-intestinale sau diabet
 Dieta normocalorica ce contine 250g carbohidrati, 1g calciu
initiata cu o saptamana anterior evaluarii si pe perioada
acesteia
 Testele efectuate a jeun; dupa colectare de urina si probe
biologice se administra oral o solutie de 75g glucoza sau
fructoza dizolvata in 250 ml apa minerala
 Fructoza a provocat o crestere a calciuriei si calcemiei cu o
scadere a oxaluriei
 Dupa administrarea de glucoza apare o crestere a oxaluriei