Post on 05-Feb-2016
description
InstitutBMK
Medizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
Effect of a bicabonate-rich mineral water
in patients with recurrent renal stone
formation – a controlled double-blind
study
Chr. Gutenbrunner, U. Smorag, O. Karagülle, F. Candir, H.
Becker, U. Jonas
Professor Christoph Gutenbrunner, MD, PhD,
Clinic for Physical Medicine and Rehabilitation
Hanover Medical School
Carl-Neuberg-Str. 1
D-30625 Hannover
gutenbrunner.christoph@mh-hannover.de
InstitutBMK
Introduction
In the industrialised countries urolithiasis is a frequent
disease
Prevalence in Germany: 4.7%
Incidence: 1.47%
The rate of relapses is high: 50-60%
The extra-corporal shock-wave therapy is not free of
complications
For that reason an effective metaphylaxis is of major
importance
Medizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
InstitutBMK
Introduction
A basic principle of the metaphylaxis of urolitioasis is the
dilution of the urine by an increase of the fluid intake
Additional principles are
the reduction of the excretion of stone forming
substances in the urine: calcium, oxalate, uric
acid and others
the enhancement of the excretion of inhibitors:
magnesium, citrate and others
the reduction of the crystallisation risk by influencing
the pH of the urine (dependent on the type of
renal stones)
Medizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
InstitutBMK
Introduction
From experimental studies it is known that
bicarbonate waters increase the urinary pH and the
citrate excretion
magnesium-rich waters increase the urinary excretion
of magnesium
the increase of calcium-excretion is over-
compensated by the increase of diuresis
Only a few studies were performed in patients
Most studies dealt with the problem of calcium-waters
Therefore we studied the effect of a magnesium- and
bicarbonate-rich mineral water
Medizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
InstitutBMK
Material and MethodsMedizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
Design of the Study:
- double-blind controlled study
- cross-over-design
Patients:
- Patients with multi-episodic CaOx-urolithiasis (n=34)
- males/females: 30/4
- number of stone episodes: 3.0 ± 1.6
Setting:
- Everyday activities
- no standardisation of the diet
- nutrition protocol
InstitutBMK
Material and MethodsMedizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
Interventions:
- 1.5 l/d bicarbonated water (2,673 mg HCO3-/l;
175 mg Mg++/l; 116 mg Ca++/l)
- 1.5 l/d low-mineralized water (98 mg HCO3-/l
8 mg Mg++/l; 38 mg Ca++/l)
- 1.400 ml of each water for three consecutive days
- all waters in the same type of bottles, colour code
- distance between drinking periods: one week
Main Outcome Parameters:
- 24-h-urine samples before drinking, 3rd day of drinking
- urinary pH (24-h-urine)
- magnesium- and citrate-excretion
- supersaturation CaOx and of other types of urinary stones
InstitutBMK
ResultsMedizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
4
5
6
7
8
***
Patients with Recurrent Urolithiasis (n = 34)
Calcium-Excretion
30
40
50
60
70
*
Oxalate-Excretion
3
4
5
6
7
***
Magnesium-Excretion
400
500
600
700
800
900
1000
1100
***
Citrate-Excretion
InstitutBMK
ResultsMedizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
1,0
1,5
2,0
2,5
3,0
3,5
4,0
******
[l]
Patients with Recurrent Urolithiasisn = 34
UrinaryVolume
Baseline Controls Baseline Bicarbonate Water
5,5
6,0
6,5
7,0
***
*
UrinarypH
1,0
1,5
2,0
2,5
3,0
3,5
4,0
4,5
******
SupersaturationCaOx
InstitutBMK
ResultsMedizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
Supersaturation CaOx
Supersaturation Uric acid
Supersaturation CaPO4
Controls
Baseline 3,41 ± 0,31 1,22 ± 0,13 1,33 ± 0,19
Drinking 2,44 ± 0,28 0,70 ± 0,07 1,01 ± 0,15
Bicarbonate Water
Baseline 3,39 ± 0,34 1,03 ± 0,12 1,44 ± 0,23
Drinking 2,42 ± 0,29 0,24 ± 0,04 2,01 ± 0,24
p (controls vs. bicarbonate water)*)
0,801 0,001 0,001
p (baseline vs. Drinking)**)
Controls 0,001 0,001 0,014
Bicarbonate Water
0,001 0,001 0,023
InstitutBMK
Patients with high riskMedizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
Low mineralised water bicarbonate rich water
Baseline Intervention Baseline Intervention Significance
Citrate-concentration
(mmol/l)
1,73 ± 0,88 1,18 ± 0,43 1,61 ± 0,72 1,60 ± 0,56p1 = 0,016**
p2 = 0,001*** p2 = 0,884
Magnesium-concentration
(mmol/l)
2,18 ± 0,92 1,53 ±0,49 2,09 ± 0,88 1,99 ± 065p1 = 0,033*
p2 = 0,001*** p2 = 0,961
Calcium-concentration
(mmol/l)
3,15 ± 1,68 2,17 ± 1,08 3,07 ± 1,37 2,57 ± 1,27p1 = 0,245
p2=0,001*** p2=0,007**
Oxalate-concentration
(mmol/l)
0,29 ± 0,09 0,21 ± 0,10 0,28 ± 0,12 0,21 ± 0,09p1 = 0,879
p2 = 0,002** p2 = 0,001***
Uric acid-concentration
(mmol/l)
1,77 ± 0,67 1,21 ± 0,32 1,49 ± 0,37 1,36 ± 0,40p1 = 0,152
p2 = 0,001*** p2 = 0,140
Phosphate-concentration
(mmol/l)
15,79 ± 6,48 10,86 ± 3,29 16,12 ± 3,29 9,80 ± 3,42p1 = 0,231
p2 = 0,001*** p2 = 0,001***
p1 = Significance between verum and controls p2 = Significance between baseline and drinking period
InstitutBMK
ConclusionMedizinische Hochschule Hannover
InstitutBalneologieMedizinische Klimatologie
für
und
Both waters significantly reduce the renal stone formation
risk in patients with relapsing CaOx-urolithiasis
The mineral water additionally increases the urinary pH as
well as the excretion of magnesium and citrate
The mineral water is effective even in cases with high risk of
stone formation (hypercalciuria, hyperoxaluria)
Bicarbonated waters should be used in patients with
combined stones containing CaOx and uric acid or in
uric acid stones but not in in patients with phosphate
stones