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Year : 2016 | Volume : 4 | Issue : 2 | Page : 93 - 96  


Original Articles
Role of non- dietary factors in the causation of Urolithiasis

AA Kameswar Rao1, A SaiRam2, Ch. Hiranmayee3, A. Navatha4

1Professor of Community Medicine, Malla Reddy Institute of Medical Sciences, Hyderabad

2Assistant Professor, Kamineni Academy of Medical Sciences, Hyderabad

3Resident, Prathima Institute of Medical Sciences, Karimangar

4Resident, Prathima Institute of Medical Sciences, Karimangar

Corresponding Author:

Dr. AA Kameswar Rao

Email: avasarala46@gmail.com

 

Abstract:

Background: Urolithiasis is a well known cause of morbidity in Indian population.

Objective: To know the Non-dietary factors causing Urolithiasis among the patients in Karimnagar district and to compare the extent of awareness, attitude and practices by the patients about non- dietary and dietary factors.

Methods: Two resident doctors interviewed 1400 patients (720 urban, 680 rural) attending urban and rural hospitals in Karimnagar district using predesigned questionnaire regarding the non-dietary factors causing urolithiasis.

Results: Overall prevalence of Urolithiasis was 7.7% seen among 109 patients. Patients with kidney stones were 92 (84.4%), with ureteric stones 14 (12.8%) while patients having both were 3 (2.8%). Significant Non- dietary factors include Age predilection for the age group of 15-45 years 74 patients (68%),   Male sex predilection (p value < 0.00790961) , Family history 47 ( 43%), illiteracy(p value = 0.0001) , the presence of Urinary tract infections 51(47%), Less daily water intake 18(16.5%), obesity 13(12%), and Catheterization 9(8%) and Excess use of antacids 10(9%). Awareness and preventive care practices were less with non- dietary factors when compared with those of dietary factors.

Conclusion: Some non- dietary   factors were significantly associated with urolithiasis. But the patients were not aware of the significance of their role as they do with dietary factors. Hence poor attention was paid by the patients to the non dietary factors.

Key-words: Non dietary factors, Urinary stones, Awareness and practices, Karimnagar district

INTRODUCTION:

 

Urolithiasis is a worldwide urological problem ranging 1-5% in Asia, 5-9%in Europe, 13%in North America and 20% in Saudi Arabia. [1] While the prevalence has reached its peak and plateaued in Europe and North America, it is still rising in the underdeveloped countries. Kidney stones are more prevalent than those in lower urinary tract. [2] Their significance lies in causing painful suffering and loss of work and quality of life. It has become customary to stress mainly on diet as the cause for urolithiasis. [3] Dietary theory was well supported by scientific community and very familiar with the public and submerged the role played by non- dietary factors like age, sex, occupation , literacy status, social status, obesity, family history, chronic alcoholism, presence of urinary tract infections, history of catheterization, pelvic inflammatory disease, gout, primary hyperparathyroidism, urinary tract anomalies, presence of dehydrated states due to diarrheas, vomiting , chronic usage of thiazide diuretics, corticosteroids, antacids, colchicines, anti-epileptic drugs etc,   physical activity ,smoking and unemployment etc.

The present study was conducted to find out the non- dietary factors causing urolithiasis and also the extent of awareness and adoption of preventive practices regarding non dietary factors by the patients.

 

 

 

MATERIAL AND METHODS

 

Period of study: August and December 2007

Setting & Design:   Urban and rural hospitals setting: Cross sectional descriptive study.

Sampling: About 1400 patients who attended a teaching hospital and a private nursing home in Karimnagar city was the reference population. About 109 patients who were diagnosed as having urinary stones, as and when they come during those five months, were enrolled purposively for the study.

Statistical techniques: Proportions; X2test. Epi-info version 3.5

The study was conducted in between August and December 2007 after duly obtaining the ethical committee permission from the institute. Two resident doctors lead by one Lecturer from the department of community medicine screened 1400 patients (720 urban, 680 rural) attending teaching hospital and a nursing home in the city. About 109 patients confirmed by ultrasonography to be suffering from urinary stones were selected for the study. . Diagnosis by ultrasonography was chosen as it is highly accurate and utilized by several studies. [3]

They enquired about dietary factors (DF) and non- dietary factors (NDF) using a predesigned questionnaire. DF information included vegetarian or non vegetarian diet, excess consumption of oxalate containing foods like tomato, spinach etc, hard water consumption, less daily water intake and high salt intake etc was enquired.

Non dietary factors ( NDF) like age, sex, occupation , literacy status, social status, obesity, family history, chronic alcoholism, presence of urinary tract infections, history of catheterization, pelvic inflammatory disease, gout, primary hyperparathyroidism, urinary tract anomalies, presence of dehydrated states due to diarrheas, vomiting , chronic usage of thiazide diuretics, corticosteroids, antacids, colchicines, anti-epileptic drugs etc, physical activity, smoking and unemployment were enquired. The following operational criteria were used while gathering the information from patients:

Body mass index above 30 as obesity; monthly earnings up to 10 000 rupees as lower class, 10000- 20000 rupees as middle class and above 20000 as high class (modified B.G.Prasad’s scale); consumption of meat products more than thrice a week as non vegetarians with high intake of animal proteins; eating more than 5 times a week of tomatoes and spinach as oxalate excess diet; daily intake of alcohol regularly since years as chronic alcoholism; more than 5 grams of salt daily in the diet as excess salt intake; positive urinary culture for microorganisms and previous history of repeated urinary tract symptoms as urinary tract infections; clinical and laboratory diagnosis in the case sheets in the case of gout, hyperparathyroidism, pelvic inflammatory disease and urinary tract anomalies; usage of drugs regularly for years as chronic drug usage and physical activity less than 2 hours per day as poor, 2-5 hours as moderate and 5-8 hours as heavy exercise, regular smoking for years as smoking, unemployment, and summer incidence etc. The data was analyzed using Epi info –version 3.5.

RESULTS

 

Overall prevalence of disease was 7.7%. (Out of reference population of 1400 patients, about 109 patients (7.7%) were suffering from urinary stones.

Sex distribution: Males were more affected (57.7%) than females (42.3%) (Table.1). Patients with kidney stones were 92 (84.4%), ureteric stones 14(12.8%) while patients having both   were 3 (2.8%)

Dietary factors (DF): Patients with Excess non vegetarian diet consumption 97 (89%), Excess tomato consumption 83(76%), Spinach21 (9), High salt consumption 35(32%), Hard water consumption 38 (35%) were observed. (Table 2)

Non- dietary factors (NDF): Age predilection for 15-45 years age group is 74 patients (68%),   Male sex predilection (p value < 0.00790961) , positive Family history 47 ( 43%), illiteracy(p value = 0.0001) , poor physical activity 73(67% ) (P=0.0838286), poor and middle social status 107 (98%) (P = 0.167480); the presence of Urinary tract infections 51(47%), obesity 13(12%),   Less daily water intake during summer   18 (16.5%), Catheterization 9 (8%), Excess use of antacids 10 (9%), smoking 16 (14.7%) and unemployment 22 (20% ) were observed (Table 3).

Awareness about non- dietary factors was less when compared to that of dietary factors. (Table.4&5)

 

DISCUSSION

 

The overall prevalence of urinary stones in this study was 7.7%, a little excess than the   Asian prevalence of 1-5% found by Ramello A and his colleagues. [1] Kidney stones were more common than ureteric stones in the present study and also in the study by Bakane BC study. [2] But here it was very high in this study (84%) while it was less in the later (6%).

Four dietary factors like Excess non- vegetarian diet consumption, Excess tomato and Spinach consumption, High salt consumption, Hard water consumption were significantly associated with urolithiasis as seen in other studies.[4,5,6,7,8]

Fifteen non- dietary factors like age, sex, illiteracy, occupation, familial history, obesity, alcoholism, smoking, poor and middle social status, antacids intake, urinary tract infection, less water in intake during summer ,catheterization, less physical activity and even unemployment were found associated with uorolithiasis. While the prevalence was decreasing with age in this study (68% in the age group of 15-45 years and 29% in 46-65 years), it was increasing with age (0.9% in 15-29years age group and 8.2% in 60-69 years) in Safarinejad study and very less. [9]. Males were more affected in this study as was the case with several studies. [1, 9, 10]. This might be due to sex differences in excretion of lithogenic substances both promoters and inhibitors as postulated by Sarada B in her study. [11].Family history of urolithiasis was very commonly observed among the patients. Robertson WG et al, Lerolle N et al and Nayar D [10, 12, 13] in their studies also found familial incidence. While poor and middle social status patients to the maximum extent (70%) and poor class patients about 28% were affected in this study, only middle class patients were affected in study by Nair D. [13] Most of the sufferers were illiterates. Illiteracy, a precursor of ignorance of the causation of urolithisasis was playing a significant role in this study and that by Akinci M and his colleagues. [14] About half of the patients (47%) developed stones due to repeated urinary tract infections. Holmegren .K [15] and Miano R [16] in their studies found similar association. About 12% of the patients were obese. Ramello A, Siener R, Obligado SH and Lee SC [1, 17, 18, 19] also noticed obesity as a commonest predisposing factor for urolithiasis in their studies. Ten patients gave history of over- consumption antacids. It was not known whether antacids caused stones or not, but literature was available that drugs like Indinavir. [20] Sulfadiazine and antibiotics can cause urolithiasis. Alcoholism, smoking, catheterization, Unemployment and less physical activity though associated with stones in this study, they were not significant. But Nayar D found alcoholism and smoking as significant contributors. [8] Safarinejad MR observed unemployed people suffered from urinary stones. [4]

The practical usage of this study lies in application of the fact that non dietary factors can contribute substantially to urolithiasis and cannot be ignored. Their prevention at the individual, family and community levels can reduce the occurrence and recurrence of urolithiasis in populations at risk. Urolithiasis is a life style disease and fortunately a preventable disease. But the main problem is less awareness about NDF which makes the prevention difficult. A person with positive family history or obese or aging or suffering from urinary tract infections or consuming drugs for longer periods must be more cautious of urolithiasis than the one without these risk factors. Medical community must advice regarding the NDF along with DF while counseling their patients. Then only it will be a comprehensive preventive counseling.

CONCLUSION:

 

To conclude, Non- dietary factors were also found to be significant contributors for urolithiasis and peoples’ awareness was poor regarding their role .People are not trying to prevent or take care of these non dietary factors. Community sensitization, by increasing the peoples’ awareness and preventive practices about Non dietary factors along with dietary factors through intensive information, education & communication activities can only reduce this preventable human suffering.

REFERENCES:

 

  1. Ramello A, Vitale C, Marangella M. Epidemiology of nephrolithiasis. Pol Merkur Lekarski. 2000 Apr; 8(46):170-1.
  2. Bakane BC, Nagtilak SB, Patil B, Urolithiasis: A tribal scenario. Indian journal of pediatrics, 1999, Nov-Dec.; 66(6) 863-5.
  3. Knönagel H, Müntener M. Urolithiasis and ultrasound diagnosis. Value of ultrasound in diagnosis of urolithiasis. J Rheumatol. 2005 Nov; 32(11):2189-91.
  4. Stanley Goldfarb, Diet and Nephrolithisis;Annual.Rev.med.1994.45:235-43
  5. Schwartz BF, Schenkman NS, Bruce JE, Leslie W, Stoller ML. Calcium Nephrolithiasis: effect of water hardness on urinary electrolytes. Journal of urology,2002, July: 60 (1) : 23-7
  6. Hesse A, Siener R, Heynck H, Jahen A, The influence of dietary factors on the risk of urinary stone formation .Scanning Microscopy 1993,SEP 7(3)11 19-27
  7. Bellizzi V, De Nicola L, Minutolo R, Russo D, Cianciaruso B, Andreucci M, Conte G, Andreucci VE. Effects of water hardness on urinary risk factors for kidney stones in patients with idiopathic nephrolithiasis. Arch Ital Urol Androl. 2008 Mar;80(1):5-12
  8. Mittal RD, Kumar R. Gut-inhabiting bacterium Oxalobacter formigenes: role in calcium oxalate urolithiasis. J Endourol. 2005 Jan-Feb; 19(1):102-6.
  9. Safarinejad MR. Adult urolithiasis in a population-based study in Iran: prevalence, incidence, and associated risk factors. Urology. 2002 Apr; 59(4):517-21.
  10. Robertson WG, Peacock M, Baker M, Marshall DH, Pearlman B, Speed R, Seargent V, Smith A, Studies on the Prevalence and Epidemiology of Urinary stone disease in men in Leeds. British journal of urology, 1983, 55; 595-598.
  11. Sarada B, Satyanarayan U. Influence of sex and age in the risk of urolithiasis-A Biochemical evaluation in Indian subjects. Annual Clinical biochemistry 1991 July; 28 Pf 4365-7.
  12. Lerolle N, Lantz B, Paillard F, Gattegno B, Flahault A, Ronco P, Houillier P, Rondeau E Risk factors for nephrolithiasis in patients with familial idiopathic hypercalciuria. Am J Med. 2002 Aug 1; 113(2):99-103.  
  13. Nayar D; Kapil U; Dogra PN. Risk factors in urolithiasis;the Indian practitioner,.1997 mar;50(3):209-14
  14. Akinci M.Esen T. Tellaloglu S. Urinary stone disease in Turkey: An updated Epidemiological study. European urology, Volume 44, Issue 6, PP709-713.
  15. Holmegren .K. Urinary calculi and urinary tract infection. A clinical and Microbiological study. Scandinavian journal of urology and nephrology, suppl: 1986,98: 171
  16. Miano R, Germani S, Vespasiani G. Stones and urinary tract infections. Nephron. 1999; 81 Suppl 1:66-70.
  17. Siener R. Impact of dietary habits on stone incidence. Urol Int. 2002; 68(3):172-7.
  18. Obligado SH, Goldfarb DS, The association of nephrolithiasis with hypertension and obesity: a review. American J Hypertension. 2008 Mar; 21(3):257-64. Epub 2008 Jan 24.
  19. Lee SC, Kim YJ, Kim TH, Yun SJ, Lee NK, Kim WJ. Impact of obesity in patients with urolithiasis and its prognostic usefulness in stone recurrence. Urologiia. 2007 Mar-Apr;(2):9-13
  20. Wu DS, Stoller ML. Indinavir urolithiasis. Vet Clin North Am Small Anim Pract. 1999 Jan;29(1):251-66, xiv

Table 1: Age and sex distribution of the patients with Urinary stones:

Age group (yrs)

Male (%)

Female (%)

Total

0-14

1(1.58)

2(4.3)

3(2.7)

15-30

30(47.6)

8(17.4)

38(34.9)

31-45

19(30.1)

17(36.9)

36(33.8)

46-50

5(7.9)

12(26.2)

17(15.6)

51-65

8(12.6)

7(15.2)

15(13.7)

Total

63(57.7)

46(42.3)

109 ( 100)

         X2 = 13.81, d.f. = 4, p value < 0.00790961(significant)

Table 2: Dietary factors prevalent among the patients with urinary stones

Type

Factor present (%)

Factor absent (%)

Total

Non vegetarians

97(89)

12(11)

109

Tomato & spinach

83( 76)

26(24)

109

Hard water

38 (35)

71(65)

109

High Salt

35 (32)

74(68)

109

X2 =   111.68, d.f. = 3,   p value < 0.00000000 ( significant)

Table 3: Non dietary factors prevalent among the patients with urinary stones

Factor

Present     (%)

Absent (%)

Statistical test

Familial history

28(25.7)

81(74.3)

X2 =   264.63, d.f. = 8, p value < 0.00000000

95% CI -77.75 to 9.97

 

illiteracy

52(47)

57(53)

Related   to occupation

13(12)

96 (88)

unemployment

36 (33)

73 (67)

Poor Social status

68 (62)

41(38)

Excess of drugs /antacids

10 (9.1)

99(90.9)

smoking

23(21)

86(79)

alcoholism

44 (40)

65(60)

catheterization

9 (8.2)

100(91.8)

Less daily intake of water

91(83.5)

18(16.5)

Increasing age

32(29)

77(71)

Male sex preference

63(57.7%)

46(42.3%)

obesity

13 (12)

96(88)

Urinary tract infections

51(46.8)

58(53.2)

Less physical activity

73(67%)

27%(33%)

 

Table 4: Awareness that dietary factors can cause urolithiasis

Factor as cause of   urolithiasis

Aware ( % )

Not aware ( %)

Non vegetarian diet

96 (88.07)

13 (11.92)

Tomato spinach

67 (61.46)

42 (38.53)

High salt diet

91 (83.48)

18 (16.51)

Hard water

74 (67.88)

35 (32.11)

X2 = 27.87, d.f. = 3, p value < 0.00000388, 95% CI 11.28 to 98.71

Table 5: Awareness that Non- dietary factors can cause urolithiasis

Factor

Aware (% )

Not aware (%)

Statistical test

Familial history

6 (5.5)

103(94.49)

X2 =   244.75, d.f.= 8, p value < 0.00000000

95%

CI -97.30 to -23.36

 

illiteracy

18 (16.51)

91 (83.48)

occupation

14 (12.84)

95 (87.15)

Social status

16 (14.67)

93 (85.32)

Excess of drugs /antacids

22 (20.18)

87 (79.81)

smoking

19 (17.43)

90 (82.56)

alcoholism

7 (6.42)

102 (93.57)

catheterization

32 (29.35)

77 (70.64)

Less daily intake of water

85 (77.98)

24 (22.01)

Increasing age

18 (16.51)

91 (83.48)

Male sex

9 (8.25)

100 (91.74)

unemployment

8 (7.33)

101 (92.66)

obesity

46 (42.20)

63 (57.79)

Urinary tract infections

34 (31.19)

75 (68.8)

Less physical activity

11 (10.09)

98 (89.9)





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