Diet and Alternative Therapies in the Management of Stone Disease

Although nonnutritional factors affect the risk for renal stone development, nutrition is widely viewed as contributory and is frequently included as part of the therapeutic regimen in secondary stone prevention. In this article, the therapeutic application of nutritional recommendations to address specific risk factors of urolithiasis is reviewed. The article focuses on calcium-containing and uric acid stones. The general approach to nutrition therapy is addressed first, and empiric and tailored approaches are discussed. How to assess a patient’s nutrition risk for lithogenesis is reviewed, and the implementation or practice of nutrition therapy is discussed.

Key points

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Nutrition therapy, widely used for secondary prevention of urolithiasis, is the application of nutritional assessment, diagnosis, intervention, and counseling to prevent or manage disease.
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Nutrition therapy for prevention of kidney stone recurrence is based primarily on the idea that the reduction of known lithogenic risk factors reduces or prevents calculus formation and growth.
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After assessment of the nutritional intake of the patient, urinary and other risk factors are evaluated with respect to their cause and whether or not nutrition intervention is likely to address them.

Introduction

Therapeutic nutrition recommendations for the secondary prevention of urolithiasis are widely used. General nutrition guidelines are useful in promoting public health and for developing nutrition plans that reduce the risk for or attenuate the effects of diseases that are affected by nutrition. Examples of such guidelines are the dietary reference intake values (which include the recommended dietary allowance (RDA), adequate intake, and the tolerable upper intake level for individual nutrients) and the dietary guidelines for Americans. However, general guidelines are insufficient in developing interventions to address specific disease conditions in individual patients. Nutrition therapy is the application of nutritional assessment, diagnosis, intervention, and counseling to prevent or manage disease.

Food and nutrition are inherently complex. Plants grow in different soils and conditions throughout the world and therefore have variations with respect to their nutrient and molecular profiles. Animalia of all types eat different foods and are subject to different management techniques, rendering their nutrient profiles variable. People from different cultures and backgrounds may derive the same essential nutrients but from vastly different foods and preparation methods. Conversely, the intake of certain nutrients and biologically active nonnutrients is also known to vary between cultures, between individuals, and even within individuals over time. The intake of individual nutrients or food components rarely, if ever, occurs in isolation; a single food item may contain hundreds of biologically active compounds. In the context of an entire meal, thousands of nutrients and nonnutrients are consumed. Certain micronutrients and other food constituents interact in antagonistic, synergistic, or benign ways. Individuals vary with respect to their consumption, digestion, and absorption of foods and their components, even within an individual over the course of the life span. Moreover, a single food-derived compound may affect hundreds of molecular systems and even cause epigenomic changes.

General nutritional influences on stone disease are difficult to characterize. Although interest for nutrition interventions is high among patients, evidence-based data from well-designed research studies to support specific recommendations are lacking. A recent systematic review of published randomized trials on nutritional prevention of urolithiasis collectively identified 8 trials with reasonable but variable quality, all but one reporting reduced stone recurrence ( Table 1 ). Few studies have been designed to assess the effects of a whole diet intervention or of multiple, simultaneous nutrition interventions. Many more studies have evaluated the effects of single nutrients or individual food components, but most of these have assessed effects on stone risk factors, not stone formation. The use of stone risk factors as outcomes is attractive because it is accomplished in a shorter time frame than assessment of stone formation and growth and may be evaluated with a single diagnostic test, such as a 24-hour urine analysis. Although risk reduction alone has not been definitively tied to reduced recurrence, much of what we believe and practice about nutrition interventions to prevent recurrence comes from this assumption.

Table 1

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