CHAPTER 35 Medical Nutrition Therapy for Renal Disorders
Formation of a stone in a person with IH can be triggered by
an excessive dietary calcium intake, increased intestinal absorp-
tion of calcium that may or may not be vitamin D–mediated,
decreased renal tubular reabsorption of calcium, or prolonged
bed rest. Increased gut absorption of calcium even when on
a restricted calcium, sodium and animal protein diet is noted
particularly in patients with absorptive hypercalciuria. Urinary
calcium levels higher than normal at any level of net calcium
absorption suggests that some of the urine calcium is derived
from the bone. Negative calcium balance appears to be greater in
stone formers than in non–stone formers.
When challenged with a very-low-calcium diet, the loss of
more calcium in the urine than is in the diet indicates a net loss
of total body calcium. The source of this additional calcium is the
skeleton (Krieger and Bushinsky, 2013). Patients with IH tend
toward negative phosphorus balance even on normal intakes.
The defective phosphate metabolism may lead to increased
1,25(OH)2D3 levels, and increased intestinal calcium absorption.
Bone loss can be high in patients with IH in whom low
calcium intake exaggerates bone loss from increased net acid
excretion (NAE). For decades low-calcium diets were recom-
mended to reduce the hypercalciuria in these stone formers.
However, chronic prolonged calcium restriction, deficient cal-
cium intake, and increased losses from hypercalciuria decrease
bone mineral density. The decreased BMD also correlates with
CLINICAL INSIGHT
Acid and Alkaline Diets
by Sheila Dean, DSc, RDN, LD, CCN, CDE
Dietary intake can influence the acidity or alkalinity of the urine (Berardi
et al, 2008). It has been shown that excessive dietary protein (particularly
high in sulfur-containing amino acids such as methionine and cysteine),
and chloride, phosphorous, and organic acids are the main sources of di-
etary acid load. When these animal proteins, such as meat and cheese, are
eaten concomitantly with other acid-producing foods and not balanced
with alkaline-producing foods, such as fruit and vegetables, there is an in-
creased risk of chronic acidosis. Acidosis (which is not to be confused with
acidemia) has been linked to inflammatory-related chronic diseases such
as urolithiasis, hypertension, insulin resistance, low immune function, and
osteoporosis (Adeva and Souto, 2011; Minich and Bland, 2007).
Consequently, when working with higher protein intakes it is important
to provide a diet balanced in high alkaline foods. The most abundant alka-
line foods are plant-based foods; particularly vegetables and fruit abundant
in alkalinizing micronutrients such as magnesium, calcium, sodium, and
potassium. A more alkaline diet consisting of a higher fruit and vegetable
intake is associated with a low potential renal acid load (PRAL) (Remer and
Manz, 1995). Lower consumption of meat, which is also associated with a
lower PRAL, may thus ameliorate not only the elevated blood pressure of
hypertension but also the concurrent excess of morbidity and mortality of
the concurrent cardiac, vascular, and metabolic aspects of the hyperten-
sive state. Although acute acid loading may only temporarily disrupt acid-
base equilibrium, a chronic perturbation occurs when metabolism of the
diet repeatedly releases acids into the systemic circulation in amounts that
exceed the amount of base released at the same time. To overcome the
imbalance, the skeleton, which serves as the major reservoir of base,
provides the buffer needed to main blood pH and plasma bicarbonate
concentrations. To some degree, skeletal muscle also acts as a buffer.
Other compensatory mechanisms occur as well, all in response to the
acidic load (Pizzorno et al, 2010).
Remer and Manz developed a physiologically based model to calculate
the PRAL of selected, frequently consumed foods. By means of these
PRAL data, the daily net acid excretion can be calculated, allowing for an
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an increase in markers of bone turnover as well as increased
fractures (Krieger and Bushinsky, 2013). Vertebral fracture risk
increases fourfold among urolithiasis patients in comparison
with the general population.
Undesirable bone resorption may be enhanced by a high
protein intake of nondairy origin. An inadequate calcium in-
take along with high protein intake induces metabolic acidosis,
increases calcium excretion, and lowers urinary pH. This acid
load inhibits the renal reabsorption of calcium. A reduction in
nondairy animal protein may be recommended (see Clinical
Insight: Urinary pH—How Does Diet Affect It?).
Calcium supplements do not have the same protective effect
against stone formation as dietary calcium. Widespread use
of calcium supplements to prevent osteoporosis corresponds to
an increase in kidney stones in women. A trial of combined
calcium–vitamin D supplementation to prevent bone loss and
fractures led to a 17% increase in new stone formation in
women who increased their calcium intake to 2000 mg a day by
adding a 1000 mg calcium supplement to their baseline diet
(Wallace et al, 2011).
If calcium is taken as a supplement, timing is important.
Calcium supplements taken with meals increase urinary cal-
cium and citrate, but decrease urinary oxalate; thus the increase
in citrate and decrease in oxalate counterbalance the effects of
elevated urinary calcium. Therefore, if used by patients who
accurate prediction of the effects of diet on acid load. This has been a
reason to recommend animal protein limited diets, to control the dietary
source of acids (Kiwull-Schone et al, 2008). The following food lists serve
as a guide to influencing potential renal acid load (PRAL).
Potentially Acid Foods
Protein: meat, fish, fowl, shellfish, eggs, all types of cheese, peanut butter,
peanuts
Fat: bacon, butternuts, walnuts, pumpkin seeds, sesame seeds, sunflower
seeds, creamy salad dressings
Carbohydrate: all types of bread including cornbran, oats, macaroni, rice-
bran, rye, wheat, and especially wheat gluten
Sweets: gelatin desserts (dry mix with and without aspartame), pudding
(instant, dry mix)
Potentially Basic or Alkaline Foods
Fat: dried beechnuts, dried chestnuts, acorn
Vegetables: all types including legumes but especially beets, beet greens,
Swiss chard, dandelion greens, kale, leeks, mustard greens, spinach,
turnip greens
Fruit: all types, especially currants, dates, figs, bananas, dried apricots,
apples, prunes, raisins
Spices/Herbs: all types, especially fresh dill weed and dried spices/herbs
such as spearmint, basil, coriander, curry powder, oregano, parsley
Sweets: sorghum syrup, sugar (brown), molasses, cocoa (dry powder)
Beverages: coffee
Neutral Foods
Fats: butter, margarine, oils
Dairy: milk
Vegetables: corn
Sweets: sugar (white), most syrups, honey
Beverages: water, tea