|Year : 2014 | Volume
| Issue : 2 | Page : 83-87
Renal stone disease in the border regions of Karnataka, Maharashtra and Goa: Role of diet, urinary pH and body mass index
RB Nerli1, Shivagouda Patil1, MB Hiremath1, RA Patil2
1 Department of Urology, JNMC, Belgaum, Karnataka, India
2 Department of Urology, KLES Dr. Prabhakar Kore Hospital, JNMC Campus, Belgaum, Karnataka, India
|Date of Web Publication||7-Jan-2015|
Dr. R A Patil
Department of Urology, 21, KLES Dr. Prabhakar Kore Hospital, Nehrunagar, JNMC campus, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Although surgical treatments remove the offending stone, do little to alter the course of the disease. The incidence of stone disease is on the rise, a thorough understanding of the etiology, epidemiology and pathogenesis of urinary tract stone disease is necessary so as to develop an effective medial prophylactic program. We took up this study to analyze geographical factors, diet, body mass index (BMI) in patients from North West Karnataka, South coastal Maharashtra and Goa.
Materials and Methods: Patients with renal stones for surgical management at our hospital formed study group. A detailed history of these patients was recorded. The patient's data in relation to diet, BMI, urinary pH, chemical composition of the stone were collected and analyzed.
Results: A total of 250, of these 160 patients were from north western Karnataka, 43 from the state of Goa and 47 were from south coastal Maharashtra. Male: Female ratio was 2.33:1. When compared with patients from North West Karnataka and South coastal Maharashtra the mean BMI of the patients from Goa was significantly high, P < 0.042 and < 0.00000035 respectively. The mean urinary pH of urine was significantly lower in patients from Goa when compared with patients from North West Karnataka, and South coastal Maharashtra that is, P < 0.009 and < 0.022 respectively. Twenty-nine (11.6%) patients were diabetics, and the percentage of diabetics was similar from all the three regions. The incidence of uric acid calculi among the diabetics was high in patients from South coastal Maharashtra (50%) and Goa (60%).
Conclusions: Nonvegetarian diet was most commonly seen amongst patients from Goa (74.4%) and south coastal Maharashtra (65.6%) when compared to patients from North West Karnataka (38.2%). Calcium stones were the most common in all the three regions, though the incidence of uric acid calculi was the highest in patients from Goa (37.3%). The urinary pH was significantly lower in patients from Goa when compared with patients from North West Karnataka and South coastal Maharashtra.
Keywords: Body mass index, calcium stones, diabetes mellitus, uric acid stones, urolithiasis
|How to cite this article:|
Nerli R B, Patil S, Hiremath M B, Patil R A. Renal stone disease in the border regions of Karnataka, Maharashtra and Goa: Role of diet, urinary pH and body mass index. Indian J Health Sci Biomed Res 2014;7:83-7
|How to cite this URL:|
Nerli R B, Patil S, Hiremath M B, Patil R A. Renal stone disease in the border regions of Karnataka, Maharashtra and Goa: Role of diet, urinary pH and body mass index. Indian J Health Sci Biomed Res [serial online] 2014 [cited 2020 Jun 4];7:83-7. Available from: http://www.ijournalhs.org/text.asp?2014/7/2/83/148805
| Introduction|| |
Stone disease is one of the most common afflictions of modern society and has been described since antiquity.  With changing times, the site of stone formation has migrated from the lower to the upper urinary tract and the disease once limited to men is increasingly gender blind.  Revolutionary advances in the minimally invasive and noninvasive management of stone disease over the past few decades have greatly facilitated the ease with which stones are removed. Although surgical techniques remove the offending stone, they do little to alter the course of the disease. It is estimated that the lifetime prevalence of kidney stone disease varies between 1% to 15%, with a probability of having a stone varying according to age, gender, race, and geographic location. 
Stone disease affects more adult men than adult women. By a variety of indicators including inpatient admissions, out-patient office visits, and emergency department visits, men are affected 2-3 times more often than women.  The geographic distribution of stone disease tends to roughly follow environmental risk factors; a higher prevalence of stone disease is found in hot, arid, or dry climates such as the mountains, desert, or tropical areas. However, genetic factors and dietary influences may outweigh the effects of geography. Several studies have investigated the association of body size and incidence of stone disease. In two large prospective cohort studies of men and women, the prevalence and incident risk of stone disease were directly correlated with weight and body mass index (BMI) in both sexes, although the magnitude of the association was greater in women than men. , We took up this study to analyze geographical factors, diet, BMI in patients with renal calculi from North west Karnataka, South coastal Maharashtra and Goa, which are neighboring areas of each other.
| Materials and Methods|| |
Patients presenting with renal stones for surgical management at our hospital formed the study group. A detailed history of these patients was recorded which included residential address, source of water, details of diet, previous history of stones and their treatment. All patients underwent routine blood and the urinary examination. Urinary pH was noted, and urine was also sent for culture and sensitivity. Imaging of stones was done both with ultrasonography and X-rays. Computed tomography was done whenever felt necessary. Body mass index was calculated by noting the weight and height of the patient. All these patients underwent surgical treatment to extract the renal calculi. Surgical procedures included open surgery, percutaneous nephrolithotomy and retrograde intrarenal surgery. The extracted stone/stone fragments were analyzed to note the chemical composition.
| Results|| |
During the study period January 2012 to December 2012, a total of 250 adult patients underwent surgical treatment for renal calculi. Of these 160 patients were from North western Karnataka, 43 from the state of Goa and 47 were from South coastal Maharashtra. The overall male: female ratio was 2.33:1. The mean age, BMI and dietary characteristics of the patients were as shown in [Table 1]. The mean BMI of the patients from different regions were as follows, North West Karnataka 23.59 ± 3.54, South Coastal Maharashtra 22.8 ± 4.02, and Goa 25.17 ± 4.13. When compared with patients from North West Karnataka and South Coastal Maharashtra the mean BMI of the patients from Goa was significantly high, P < 0.042 and < 0.00000035 respectively. The mean BMI of patients From North West Karnataka and South coastal Maharashtra was similar P < 0.132.
The mean urinary pH [Table 2] was 6.04 ± 1.01 of patients from North West Karnataka, 5.99 ± 0.90 from south coastal Maharashtra and 5.83 ± 0.97 from Goa. The mean urinary pH of urine was significantly lower in patients from Goa when compared with patients from North West Karnataka and South coastal Maharashtra i.e. P < 0.009 and < 0.022 respectively.
The main component of the stones on analysis was as follows, 90% of patients from North west Karnataka and 93.6% of patients from South coastal Maharashtra had calcium stones, whereas only 62.7% of the stones were calcium stones in patients from Goa. Uric acid stones formed 37.3% of stones in patients from Goa [Figure 1] and [Figure 2].
The incidence of diabetes mellitus in the patients was similar from all the three regions. However the incidence of diabetic patients [Table 3] developing uric acid calculi was 16.66%, 50%, and 60% from North West Karnataka, South Coastal Maharashtra and Goa respectively.
| Discussion|| |
Kidney stone disease varies in frequency and stone type between different climates and racial groups. It is important to understand the epidemiology of stones disease so as to determine the significance of the disease at the community level, the associations and risk factors for individuals and the likelihood of stone recurrence.  The prevalence and incidence of nephrolithiasis are reported to be increasing across the world. In the United States, overall stone prevalence has doubled since the 1964-1972 period, and appears to have stabilized since the early 1980s. ,, Other countries with documented increases in prevalence include Germany, Spain, and Italy. ,,, The frequencies of different stone types as reported in a large prospective cohort study performed in the United States, in men were calcium 71.5%, uric acid 23.1%, struvite 5% and cystine 0.5% (44% of stones were available for analysis).  In women, the composition of stones (45% were available for analysis) were calcium 86.2%, uric acid 11.3%, struvite 1.3% and cystine 1.3%. 
Men are at greatest risk of developing kidney stones with incidence and prevalence rates between 2 and 4 times that of women. , The sex ratios range from 2.5:1 in Japan to 1.15:1 in Iran. , Romero et al.  reported on stone incidence as stratified by age in Iran, Japan, and the United States. Incidence rates reported by age group consistently showed rise- and-fall pattern as the population aged. Age at peak incidence was similar among these 3 countries: Age at peak incidence was similar among these 3 countries, ranging from 40 to 49 years, except for Japanese women for whom the peak incidence occurred between ages 50 and 59 years. The actual incidence rate was similar for men age 40-49 years in the United States and Japan but lower in Iran.  In our study 70% of the patients were males and the male: female ratio was 2.33:1. The mean age of the patients was 40.58 ± 12.4 years from North West Karnataka, 42.34 ± 11.7 from South Coastal Maharashtra and 49.6 ± 9.9 from the state of Goa.
Environmental factors are known to influence stone risk. Environmental factors are varied and complex, but their influence is more apparent as changes in these factors occur over much shorter intervals. Two of the most important environmental factors, diet and climate, have the most significant impact on these trends.  There has been historical evidence of the influence of diet on stone formation. The first documented increase in stone disease occurred during the 16 th century when European Stein-Schneiders (stone cutters) found that their services were more in demand.  Improvements in food production was noted during those times and corn became a popular food staple.  The increased consumption of starchy foods derived from corn promoted obesity, currently a known risk factor for stone formation. ,,
The impact of agricultural modernization is reflected by the epidemic in obesity seen in many countries, including India. The prevalence of obesity in the United States in adults has risen from 14.6% in the 1971 through 1974 period to 35.2% in the 2005 through 2006 period.  A similar trend was observed among the children, with 11-17.8% being in the overweight category in the 2005 through 2006 period.  The consumption of fast foods and high fructose corn syrup preparations has been thought to promote this epidemic. In the United States alone, the percentage of meals coming from fast-food eateries or restaurants rose from 9.6% to 23.5% during the timeframe of 1977-1996.  These dietary changes have also been reported in many other countries, including China, India, Egypt, Russia, and the Philippines. ,,, High fructose consumption has been demonstrated to be a risk factor for stone formation. 
Several other dietary risk factors have also been identified. There is strong evidence that diminished fluid and calcium consumption are risk factors. ,,, Increased the oxalate consumption has also been demonstrated to promote stone formation. , Epidemiologic studies have demonstrated that increased sodium and animal protein intake have an equivocal impact on stone risk. There is evidence that the consumption of animal protein has increased in a number of countries, paralleling the acceleration of stone disease. ,,, There are also studies that demonstrate an increased intake of sodium and sodium-rich foods in certain cohorts.  In our study, 38.2% of patients from north western Karnataka, 65.6% from south coastal Maharashtra and 74.4% from Goa consumed animal protein. Rice and fish remain the staple diet both in coastal Maharashtra as well as in Goa. However, the consumption of red meat (pork and beef) is significantly higher in the population from Goa. In our study, 37.3% of stones in patients from Goa were uric acid calculi, as compared to 10% from North West Karnataka and 5.4% from South Coastal Maharashtra.
Global climate change is another environmental factor which increases the risk of stone disease. The concept of global warming has been debated for many years, and today it is accepted as a legitimate phenomenon. Studies have documented an association between increased environmental temperatures and increased kidney stone rates.  Brikowski and associates  examined global warming patterns and predicted that the percentage of people living in areas designated as high risk for kidney stone formation would increase from 40% in 2000 to 56% by 2050, and up to 70% by 2095. This would result in a significant "climate-related" increase in kidney stone events. North West Karnataka has a tropical savanna climate (Köppen climate classification Aw).  Year-round the climate is pleasant. The average year round humidity is 63.3%, though high humidity > 80% is seen during the months of June to September. Daily mean temp is 24.28°C. Goa and South coastal Maharashtra feature a tropical monsoon climate under the Köppen climate classification. Goa and South coastal Maharashtra, being in the tropical zone and near the Arabian Sea, have a hot and humid climate for most of the year. The month of May is the hottest, seeing day temperatures of over 35°C (95°F) coupled with high humidity.  The high temperatures coupled with high humidity may contribute toward risk of urolithiasis in these regions.
Two large prospective cohort studies of men and women reported that the prevalence and incident risk of stone disease directly correlated with the weight and BMI in both sexes, , although the magnitude of the association was greater in women. Obesity has been associated with insulin resistance and compensatory hyperinsulinemia that may lead to the formation of calcium-containing kidney stones. A recent metabolic trial demonstrated that insulin resistance was associated with defects in renal ammonium production,  and an examination of more than 4500 patients with a history of kidney stones showed that urinary pH was inversely related to body weight.  A defect in renal acid excretion could lead to hypocitraturia, an important risk factor for calcium nephrolithiasis.  Hyperinsulinemia may contribute to the development of calcium stones by increasing the urinary excretion of calcium. ,,
Type 2 diabetes mellitus is characterized by insulin resistance,  a metabolic derangement that may increase the risk of kidney stone formation. Metabolic trials have demonstrated that insulin resistance is associated with defects in renal ammonium production, , and stone formers with diabetes may have more acidic urine than stone formers without diabetes.  Although a low urinary pH plays a major role in the formation of uric acid kidney stones, , a defect in renal acid excretion also could lead to hypocitraturia, an important risk factor for calcium stones.  In addition, the compensatory hyperinsulinemia of insulin resistance  may increase the urinary excretion of calcium.  In our study, 29 (11.6%) patients were diabetics, and the percentage of diabetics was similar from all the three regions. The incidence of uric acid calculi among the diabetics was high in patients from South coastal Maharashtra (50%) and Goa (60%). Diabetes mellitus is associated with an increased risk of kidney stone formation, may be due to subclinical insulin resistance, and it may be reasonable to screen new stone formers for diabetes.
| Conclusions|| |
Urolithiasis is a common disorder affecting the population of the neighboring regions of North West Karnataka, Goa and South coastal Maharashtra. Nonvegetarian diet was most commonly seen among patients from Goa (74.4%) and South Coastal Maharashtra (65.6%) when compared to patients from north west Karnataka (38.2%). Calcium stones were the most common in all the three regions, though the incidence of uric acid calculi was the highest in patients from Goa (37.3%). The urinary pH was significantly lower in patients from Goa when compared with patients from North West Karnataka and South coastal Maharashtra.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]