Is There an Association between Childhood Obesity and Pediatric Kidney Stone Disease? A Literature Review
Abstract
:1. Introduction
2. Materials and Methods
3. Epidemiology
4. Diet, Nutrition, Obesity
- Diet, Nutrition, and Obesity—The relationship between diet, obesity, sugar-sweetened beverages, and diabetes in children has been demonstrated by several epidemiological trials [22]. The intake of sugar-sweetened beverages, such as soda and juice, have continued to increase in the United States [23]. Providing children and adolescents with proper knowledge of nutrition is a necessary primary preventative measure, to reduce obesity and subsequent downstream sequalae, such as kidney stone disease [24]. Additionally, the makeup of our food continues to change, with increased processing and chemical use, which must be considered as the diet of pediatric patients continues to change [25].
- Low Fluid Intake—Decreased fluid intake led to an increase in the supersaturation of stone-forming salts, a surrogate for kidney stone risk [26,27]. Children spend more time exercising and playing outdoors than adults, thus requiring more water on average per body pound. Additionally, children do not meet their daily water intake requirements. Cambareri et al. [28,29] demonstrated that overweight and obese children have lower urinary volumes than their normal weight counterparts [30]. The first study to document significant increases in juice intake was Dennison et al. in 1996, who then reported preschooler juice intake had increased in recent years from 3.2 fluid ounces per day to 5.5 [31]. They also noted a decrease in milk intake but did not look at changes in water intake.
- High Sodium Intake—High-sodium diets predispose to stone formation by way of decreasing the renin–angiotensin–aldosterone axis and thus decreasing proximal tubule calcium reabsorption [16]. BMI directly correlates with increases in urinary sodium, calcium, uric acid, magnesium, and calcium oxalate, while also with decreased urinary pH [32]. In addition to higher void volumes and low dietary sodium, weight reduction may be useful when counseling stone formers [33]. National Health and Nutrition Examination Survey (NHANES) data have demonstrated that the average sodium consumption for the pediatric population is 3387 mg/day, nearly 1100 mg/day over the recommended daily limit of 2300 mg/day [34]. Adult studies have demonstrated that a dietary intake of greater than 10 g/day of salt correlates to an increased prevalence of hypercalciuria [35].
- High Protein Intake—Proteins are an essential component of the human diet, yet are known to have a negative effect on the tubules of chronic kidney stone formers [36]. Excess protein is known to cause a negative calcium balance, decrease urine pH, and decrease urinary excretion of citrate, potassium, and magnesium, which are well-described stone inhibitors [37,38]. Additionally, animal proteins breakdown into purines, thus also contributing to hyperuricosuria in both uric acid and calcium stones [39].
- High Sugar Intake—Feeding mice a diet rich in both sodium and fructose yielded both an increase in uric acid in the urine and a decrease in stone inhibitors, such as magnesium and citrate [40]. Of all demographics, adolescents, aged 12–18, have the greatest consumption of fructose (73 g/day), more than any other age group [41]. Johnson et al., in an adult randomized controlled study, found that with increased fructose intake came increased serum uric acid, decreased urinary pH, increased urine oxalate, and decreased urinary magnesium. With an increase in stone-forming risk factors (increased uric acid, increased urine oxalate, and decreased urine pH) and a decrease in stone inhibitors (urinary magnesium), fructose may very well play a contributing role in stone formation [42].
- Other Factors—Factors such as low magnesium intake, low citrate intake, and high oxalate intake must all be considered as contributing factors to stone disease as well. Fruits and vegetables are a primary source of magnesium, which inhibits calcium oxalate formation by binding up free oxalate and increasing its solubility [43]. Citrate plays a well described role in alkalinizing the urine and inhibiting the crystallization of calcium crystals [44]. Lastly, oxalate-rich foods, such as spinach and chocolate, increase oxalate intake, subsequently requiring the kidneys to filter more oxalate, which supersaturates with calcium, resulting in calcium oxalate crystallization [45]. An ideal, daily diet should consist of fruits and vegetables for magnesium, low calorie orange juice for citrate, and to be mindful of oxalate-rich food intake [46].
5. The 24 h Urine Collection
- Urinary Risk Factors—Certain disease states, such as hypocitraturia or metabolic syndrome, affect urinary parameters, thereby theoretically increasing the risk of pediatric stone formation [53]. For example, pediatric patients diagnosed with metabolic syndrome have specific urine findings: decreased urinary pH and increased relative saturation ratio of calcium oxalate [54]. The 24 h urine studies have also demonstrated that pediatric kidney stone formers have lower urine volume, higher calcium excretion and increased in the relative supersaturation of calcium phosphate and calcium oxalate. Murphy et al. [55] demonstrated that obese pediatric patients do have lower levels of citrate, potassium, and urine pH compared to their normal-weight counterparts [18].
- Dietary Risk Factors—Updated nutritional guidelines have been published that suggest increasing fluid intake to 3 liters, maintaining 2 liters of daily urine output to prevent supersaturation of calcium, and increasing urinary citrate with lemon and orange juices [56]. Additionally, limiting sodium intake per child age group (to less than <2 g of sodium per day) and increasing intake of fruits and vegetables to alkalinize the urine all help prevent stone formation in pediatric patients [57]. Other guidelines broadly suggest low-protein (<20 g daily) and low-salt (<2 g daily) intake, and adequate hydration (3 L daily) [58] (Table 2).
- Regional variations in the United States—24 h urine studies are not unanimous in their variation. When examining studies on a regional basis in the United States, there were few risk factors that were clearly established. Internationally, some studies were contradictory in their findings: Eisner et al., in California, finding decreased oxalate in stone formers and Sarica et al., in Turkey, finding increased oxalate in stone formers [32,59]. Based on the variation seen in these studies, the etiology underlying these stones may not be solely from obesity, but rather multifactorial, unidentified risk factors, such as environmental, geographical, and familial (Table 3).
6. Stone Composition
7. Treatment
- Medical Expulsion Therapy (MET)—Observation is the mainstay of treatment for first-time stone formers. For stones less than 5 mm, 62% passed merely with observation. For stones greater than 5 mm, the stone-free rate was 35% [68]. Randomized controlled trials have shown that alpha blocker therapy for distal ureteral stones provides significant benefit, with an overall odds ratio of being stone free of 4.0 (95% CI 1.1–14.8) [69]. Alpha blocker therapy is typically tried for up to four to six weeks until definitive therapy is indicated. The role of alpha blockers in proximal and middle ureteral stones remains poorly defined in pediatric patients [70].
- Surgical—The two surgical methods, as outlined below, would be non-invasive endourological or invasive, open procedures.
- Non-invasive—Should a pediatric patient fail observation or MET, or the stone is larger than 10 mm, shockwave lithotripsy (SWL) is the preferred non-invasive modality. SWL is typically preferred in certain pediatric populations, such as very small children, in which ureteroscopy access may be limited or challenging [71].
- Invasive—Once more, should the patient fail observation or MET, or the stone burden be too significant for SWL, ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) are two choices for invasive, definitive treatment [72]. URS is typically indicated for stones up to 20 mm and when patient anatomy is amenable to ureteroscopy access [73]. SWL and URS have similar stone-free rates. For stones greater than 20 mm, a non-contrast CT should be obtained, followed by PCNL. Children are particularly susceptible to ionizing radiation due to their rapidly developing tissues, thus exposure should be kept as low as reasonably achievable (“ALARA” principle) [74] (Table 5).
8. Conclusions
Limitations
How to Apply This Knowledge
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Conflicts of Interest
References
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Risk Factors in Pediatric Stone Formers | Note |
---|---|
Decreased fluid intake | <3 L/day |
Increased salt intake | >2300 mg/day |
Metabolic Abnormalities | Hypercalciuria, hypocitraturia |
Environmental | Temperature, relative humidity |
Medications | Topiramate, calcitriol, steroids |
Type of Stone | Dietary Risk Factors | Dietary Reccomendation |
---|---|---|
Calcium Oxalate | ↑ oxalate, ↑ sodium | ↓ oxalate, ↓ sodium, limit animal protein |
Calcium Phosphate | ↑ sodium | ↓ sodium, limit animal protein |
Uric Acid | ↑ animal proteins | ↓ animal proteins |
Cystine | ↓ water intake | ↑ water intake |
Author | Region | # of Patients | Prospective vs. Retrospective | % of Study Patients Who Are Overweight/Obese | Risk Factors |
---|---|---|---|---|---|
Bandari | Northeast (Pennsylvania) | 110 | Retrospective | 26% | ↑ urine Ca2+ ↓ citrate ↓ urine PO4 ↓ urine Mg2+ |
Murphy | South (Kentucky) | 111 | Retrospective | 37% | ↓ citrate ↓ potassium ↓ urine pH |
Roddy | Midwest (Wisconsin) | 117 | Retrospective | 100% | no differences (vs. National Survey of Children’s Health 2007) |
Eisner | West Coast (California) | 43 | Retrospective | 33% | ↑ urine CaPO4 ↓ oxaluria |
Cambareri | “four institutions” | 206 | Retrospective | 35% | ↑ uricosuria ↓ urine volume |
Sarica | Turkey | 94 | Prospective | 46% | ↑ oxaluria ↑ urinary Ca2+ ↓ citraturia |
Governing Body | First-Line Workup | MET | Surgical | Diet/Fluids | Other Reccomendations |
---|---|---|---|---|---|
AUA |
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EAU |
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BAUS |
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Type of Surgical Approach | Pros | Cons |
---|---|---|
Shockwave Lithotripsy | Non-invasive | Lower success rate, post-operative HTN |
Ureteroscopy | Better stone clearance, advancing technology | Ureteral stenting, dependent on available tech |
Percutaneous Nephrolithotomy | High success rate | Invasive, increased surgical complications |
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Paiste, H.J.; Moradi, L.; Assimos, D.G.; Wood, K.D.; Dangle, P.P. Is There an Association between Childhood Obesity and Pediatric Kidney Stone Disease? A Literature Review. Uro 2021, 1, 108-117. https://doi.org/10.3390/uro1030014
Paiste HJ, Moradi L, Assimos DG, Wood KD, Dangle PP. Is There an Association between Childhood Obesity and Pediatric Kidney Stone Disease? A Literature Review. Uro. 2021; 1(3):108-117. https://doi.org/10.3390/uro1030014
Chicago/Turabian StylePaiste, Henry J., Luke Moradi, Dean G. Assimos, Kyle D. Wood, and Pankaj P. Dangle. 2021. "Is There an Association between Childhood Obesity and Pediatric Kidney Stone Disease? A Literature Review" Uro 1, no. 3: 108-117. https://doi.org/10.3390/uro1030014