Scandinavian Journal of Urology

ISSN: 2168-1805 (Print) 2168-1813 (Online) Journal homepage: http://www.tandfonline.com/loi/isju20

Impact of food quantity and quality on the

biochemical risk of renal stone formation

Francesco Esperto, Roberto Miano, Martino Marangella & Alberto Trinchieri

To cite this article: Francesco Esperto, Roberto Miano, Martino Marangella & Alberto Trinchieri
(2018): Impact of food quantity and quality on the biochemical risk of renal stone formation,
Scandinavian Journal of Urology, DOI: 10.1080/21681805.2018.1453868

To link to this article: https://doi.org/10.1080/21681805.2018.1453868

Published online: 01 Apr 2018.

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SCANDINAVIAN JOURNAL OF UROLOGY, 2018
https://doi.org/10.1080/21681805.2018.1453868

ARTICLE

Impact of food quantity and quality on the biochemical risk of renal

stone formation
Francesco Espertoa, Roberto Mianob, Martino Marangellac and Alberto Trinchierid
a
Department of Urology, Ospedale Sant’Andrea, University La Sapienza, Rome, Italy; bDivision of Urology, Department of Experimental
Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy; cFondazione Scientifica Mauriziana Onlus Torino, Torino, Italy; dUrology
Unit, Manzoni Hospital, Lecco, Italy

ABSTRACT ARTICLE HISTORY

Objective: This study evaluated the role of body mass index (BMI) and dietary potential renal acid Received 14 January 2018
load (PRAL) with urinary saturation for calcium oxalate (US-CaOx), calcium phosphate (US-CaP) and uric Revised 11 February 2018
acid (US-UA) in renal stone formers. Accepted 13 March 2018
Materials and methods: A retrospective analysis was conducted of laboratory data collected on 442
KEYWORDS
renal stone-forming patients. Demographic information, BMI and 24 h urinary samples were collected Body mass index (BMI);
from patients on their regular diets. PRAL was calculated as the Load of Acid to Kidney Evaluation diet; potential renal acid
(LAKE) score through a short questionnaire. load (PRAL); urinary calculi;
Results: Urinary risk factors, but also inhibitors of calcium stone formation such as magnesium, tended urinary saturation
to increase in relation to BMI (p ¼ .000). Urinary pH (p ¼ .002) and ammonium/sulfate ratio (p ¼ .000)
were negatively related to BMI. This resulted in a positive correlation between BMI and US-UA
(p ¼ .000), whereas US-CaOx and US-CaP were not influenced by BMI. LAKE score was positively corre-
lated with US-CaOx (p ¼ .022) and US-CaP (p ¼ .000) as a consequence of the inverse relationship
between LAKE score and citrate (p ¼ .000). Multiple linear regression analysis identified BMI (p ¼ .009)
and male gender (p ¼ .002) as independent predictors of US-UA, and LAKE score (p ¼ .004) and age
(p ¼ .001) as independent predictors of US-CaP.
Conclusions: BMI, which depends on excessive intake of energy from food, is not related to an
increased biochemical risk of calcium stone formation, which is more dependent on the renal acid
load of the diet. In contrast, obesity is associated with an increased risk of uric acid stone formation
due to insulin resistance, impaired ammoniagenesis and low urinary pH.

Introduction Materials and methods

Obesity is the result of an imbalance between the energy
intake from food and energy expenditure in physical activity.
Obese patients have an increased risk of developing chronic
medical conditions such as diabetes mellitus, hypertension
and coronary artery disease. According to some studies [1–3],
obesity and overweight increase the risk of formation of kid-
ney stones through the modification of some urinary risk fac-
tors, although a 2017 study in a Mediterranean population
was not able to confirm this finding [4]. A possible explan-
ation for this latter finding could be the lower acid load
related to the Mediterranean dietary pattern. An increased
acid load in the diet is a dietary pattern that may increase
the risk of kidney stone formation [5]. Urinary saturation is a
reliable measure of the propensity of urine to form crystals
of different types, which represent the first step in the pro-
cess of kidney stone formation. The aim of this study was to
evaluate, in a large cohort of renal stone formers, the cumu-
lative effect of some demographic and nutritional factors,
such as age, gender, body mass index (BMI) and potential
renal acid load (PRAL), in predicting urinary saturation values
for calcium oxalate (US-CaOx), calcium phosphate (US-CaP)
and uric acid (US-UA).
This cross-sectional analysis studied 442 patients with renal
stones, drawn from urology and nephrology practices making
use of one laboratory service (Lithotest; Biohealth, Turin,
Italy) from September 2008 to October 2010. Demographic
information, including body weight and height values, was
obtained by the patients filling in a short questionnaire.
BMI was computed from the weight and height of each
subject. Underweight was defined as a BMI <18.5 kg/m2, nor-
mal weight as a BMI of 18.5 to 24.9 kg/m2, overweight as a
BMI of 25–30 kg/m2 and obesity as a BMI of >30 kg/m2,
according to the WHO classification [6].
Urinary 24 h samples were collected from patients on their
regular diets, in two separate bottles containing a preserva-
tive against bacterial growth or acid. Urine samples were
sent by express courier to Biohealth (Turin, Italy), where the
laboratory tests were performed. Sodium, potassium, calcium,
magnesium, ammonia, phosphate, sulfate, citrate, oxalate,
urate, chloride, cystine, pH and urine volume were
measured. Calcium, magnesium, creatinine and uric acid
were measured by colorimetric or enzymic methods using an
automated analyzer (Konelab; Sclavo Diagnostics, Milan,
Italy). Phosphate, sulfate, oxalate and citrate were measured

CONTACT Alberto Trinchieri a.trinchieri@asst-lecco.it Urology Unit, Manzoni Hospital, via dell’Eremo 9/11, 23900 Lecco, Italy
ß 2018 Acta Chirurgica Scandinavica Society
2 F. ESPERTO ET AL.

by ion chromatography (Dionex ICS-1000; Thermo Scientific,
Sunnyvale, CA, USA). Sodium and potassium were deter-
mined directly by ion-selective electrodes, and urine pH by a
specific electrode (Hanna Instruments, Woonsocket, RI ,USA).
The original software LithoRisk [7] was used to compute the
relative supersaturation (beta) according to a scale where
beta =1 is saturation, beta <1 undersaturation and beta >1
oversaturation.
The dietary patterns of the patients were evaluated by the
administration of a semi-quantitative questionnaire, which
made it possible to estimate the PRAL of the diet as the
Load of Acid to Kidney Evaluation (LAKE) score [8]. The LAKE
score is a rapid food screener that assesses the potential acid
load of the diet by scoring the consumption of grains, meats,
cured meats, eggs, cheeses, legumes, potatoes, vegetables,
fruits, milk and other dairy products, and bread.
The rates of overweight and obesity by gender and age
groups were calculated and compared. Linear correlations of
urinary risk factors with BMI and LAKE score were calculated.
Multivariate analysis was performed by logistic regression,
taking into account US-CaOx, US-CaP and Ca-UA as depend-
ent variables and age, gender, BMI and LAKE score as predic-
tors. Statistical analysis was performed using SPSS version
11.5 (SPSS, Chicago, IL, USA).
Results
Of the 442 patients included in the study (240 male, 202
female), 14 (3.2%) had a BMI <18.5 kg/m2. The BMI was
18.5–24.9 kg/m2 in 214 patients (48.5%), 25–29.9 kg/m2 in 156
patients (35.4%) and >30 kg/m2 in 57 patients (12.9%).
Overweight and obesity were present in 112 (46.7%) and 33
(13.8%) of the men, respectively, and in 44 (22%) and 24
(11.9%) of the women. The occurrence of overweight and
obesity tended to be higher in men (p ¼ .000) and to
increase with age in both genders, although there was a
slight decrease in >65-year-old patients (p ¼ .000) (Table 1).
BMI was positively correlated with daily urinary excretion of
calcium (r ¼ 0.162; p ¼ .001), magnesium (r ¼ 0.206; p ¼ .000),
potassium (r ¼ 0.261; p ¼ .000), sodium (r ¼ 0.309; p ¼ .000),
oxalate (r ¼ 0.244; p ¼ .000), urate (r ¼ 0.294; p ¼ .000), phos-
phate (r ¼ 0.303; p ¼ .000), sulfate (r ¼ 0.307; p ¼ .000), chloride
(r ¼ 0.339; p ¼ .000) and US-UA (r ¼ 0.191; p ¼ .000), and
inversely related to urinary pH (r ¼ –0.149; p ¼ .002) and
ammonium/sulfate ratio (r ¼ –0.205; p ¼ .000) (Table 2).
LAKE score was positively correlated with urate (r ¼ 0.114;
p ¼ .016), phosphate (r ¼ 0.109; p ¼ .022), sulfate (r ¼ 0.111;
p ¼ .019), US-CaOx (r ¼ 0.109; p ¼ .022) and US-CaP (r ¼ 0.171;
p ¼ .000), and inversely related to citrate (r ¼ –0.194;
p ¼ .000), potassium (r ¼ –0.127; p ¼ .008) and ammonium/sul-
fate ratio (r ¼ –0.102; p ¼ .031) (Table 2).
Multiple linear regression analysis identified BMI
(p ¼ .009) and male gender (p ¼ .002) as independent predic-
tors of US-UA, and LAKE score (p ¼ .004) and age (p ¼ .001)
as independent predictors of US-CaP. The ammonium/
sulfate ratio tended to decrease with the increase in
BMI (p ¼ .007).
Supersaturation with respect to uric acid (beta >1) was
observed in the urine of 45 patients (10.2%), while supersat-
uration with respect to calcium oxalate and calcium phos-
phate was observed in the urine of 429 (97%) and 295
(66.7%) patients, respectively.
No difference in the percentage of urine with calcium
oxalate (100%, 96%, 97% and 93%, p ¼ .41) or calcium phos-
phate (57%, 69%, 62% and 74%, p ¼ .25) supersaturation was
observed in the four different BMI classes, whereas the rate
of patients with urine supersaturation with respect to uric
acid tended to increase progressively in the higher BMI
classes (0%, 7%, 13% and 16%, p ¼ .05).
Discussion
Some previous studies have identified specific derangements
on 24 h urine from overweight and obese patients. All studies
agree that values of the excretion of oxalate, urate, phos-
phate, sodium and creatinine are higher and urinary pH is
lower in overweight or obese renal stone formers [9–13].
Urinary ammonium, urinary sulfate and cystine were also
reported by some authors to be higher in patients with

Table 1. Body mass index (BMI) categories by gender and age class in renal stone-forming patients.
BMI category (kg/m2)
Age (years), gender Underweight (<18.5) Normal (18.5–24.9) Overweight (25–29.9) Obesity (>30) Total
All
18–24 5 (15.6) 16 (50) 9 (28.1) 2 (6.2) 32
25–44 8 (4.5) 102 (57.3) 46 (25.8) 22 (12.3) 178
45–64 1 (0.5) 76 (41.1) 82 (43.8) 27 (14.6) 185
>65 0 20 (43.5) 20 (43.5) 6 (13) 46
Total 14 (3.2) 214 (48.5) 157 (35.4) 57 (12.9) 442
Males
18–24 1 (7.1) 7 (50) 4 (28.6) 2 (14.3) 14
25–44 1 (1) 43 (46.2) 39 (41.9) 10 (10.7) 93
45–64 0 35 (32.4) 56 (51.9) 17 (15.7) 108
>65 0 8 (32) 13 (52) 4 (16) 25
Total 2 (0.8) 93 (38.7) 112 (46.7) 33 (13.8) 240
Females
18–24 4 (22.2) 9 (50) 5 (27.8) 0 18
25–44 7 (8.2) 59 (69.4) 7 (8.2) 12 (14.1) 85
45–64 1 (1.2) 41 (52.6) 26 (33.3) 10 (12.8) 78
>65 0 12 (57.1) 7 (33.3) 2 (9.5) 21
Total 12 (5.9) 121 (59.9) 45 (22.3) 24 (11.9) 202
Data are shown as n (%).
 SCANDINAVIAN JOURNAL OF UROLOGY 3

higher BMI [9,10]. However, data on calcium, magnesium and rich in animal protein [14]. However, the enlarged adipose
citrate excretion and urinary volume in obese renal stone for- tissue mass that defines obesity causes systemic insulin
mers are controversial. Urinary calcium excretion was found resistance, which is linked to a wide array of pathophysio-
to be increased [9], unchanged [13] or unchanged after cor- logical sequelae including an excessively acidic urine [15]. In
rection for sodium excretion [11], or increased only in obese patients with metabolic syndrome, differences in alkali con-
males and not in females [11]. Urinary volumes in obese sumption were considered not relevant to explain acidic
renal stone formers were reportedly either increased [9] or urine, and lower urinary pH persisted after adjustment for
unchanged [10]. Similarly, magnesium and citrate excretion urinary sulfate (as a marker of animal protein intake), sug-
were reported to be increased [9,13] or unchanged [10]. The gesting that dietary factors alone cannot account for the
present study confirmed that BMI was positively correlated overly acidic urine observed in those patients [16,17]. On the
with the major urinary risk factors for calcium stone formers, other hand, ammonia excretion is a major determinant of
i.e. calcium, oxalate, urate and phosphate, but also with an urinary pH by acting as a buffer in the urine, which tends to
inhibitor of calcium crystallization, i.e. magnesium, and be acidic when ammoniagenesis is affected, as in insu-
inversely related to urinary pH and to the ammonium/sulfate lin resistance.
ratio. The increased excretion of some urinary risk factors for In the present study, ammonium excretion tended to
stone formation in relation to increased BMI values can be increase with BMI, but less than the concomitant increase in
explained by the increased intake of nutrients and energy sulfate, so the ratio of urinary ammonium to urinary sulfate
that is associated with being overweight or obese. In this was inversely related to BMI. A similar finding has previously
study, sodium and sulfate excretion, which are reliable been observed in uric acid stone formers by Bobulescu et al.
markers of sodium and protein intake, tended to increase [18], who demonstrated a blunted urine ammonium excre-
with BMI. tion in response to an acute acid load. No relation between
The increased intake of nutrients can influence the excre- BMI and US-CaOx or US-CaP was found in the present study,
whereas US-UA tended to increase with BMI. US-CaOx and
tion of urinary risk factors either directly or indirectly through
US-CaP are not influenced by the increase in BMI because it
alteration of their metabolism. Uric acid, oxalate and phos-
implies an increase in the risk factors for stone formation
phate seem to be strictly dependent on dietary intake,
that is counteracted by the concomitant increase in inhibitors
whereas this relationship is weaker for other nutrients, such
of calcium crystallization. In contrast, overweight or obese
as calcium and citrate, which are more affected by metabolic
patients tend to have higher mean levels of US-UA, although
alterations or variations in renal handling. Calcium urinary
in this population only 13% of the overweight patients and
excretion depends on the dietary intake of sodium and cal-
16% of the obese patients presented with supersaturated
cium, but in stone-forming subjects it is also strongly influ-
urine for uric acid. Accordingly, the rate of uric acid stones in
enced by a number of heterogeneous pathophysiological
obese patients has been previously found to be higher than
anomalies that may be stronger than the effect of diet. The
in the general population of renal stone formers. Daudon
influence of dietary citrate on urinary citrate is limited
et al. showed that the proportion of uric acid stones grad-
because citrate excretion is much more dependent on the ually increased with the BMI of patients, from 7.1% in normal
intracellular pH of the proximal tubular cells, which may be BMI to 28.7% in obese male subjects and from 6.1% in nor-
influenced by the acid load of the urine. Urinary pH depends mal BMI to 17.1% in female obese patients [19]. Although
on a complex interplay of dietary and metabolic factors. The metabolic syndrome, which includes the presence of obesity
acid load of the diet has an effect on urinary pH, as demon- in its definition, has also been associated with calcium stone
strated by the finding of higher urinary pH value in people formation [20], renal stone formers with metabolic syndrome
consuming a vegetarian diet than in those who eat a diet have a higher prevalence of uric acid stones than patients
without metabolic syndrome [21,22]. Therefore, the tendency
Table 2. Correlation of urinary risk factors and urinary saturations by body for overweight and obese patients to have an increased risk
mass index (BMI) and Load of Acid to Kidney Evaluation (LAKE) score values.
of stone formation seems to be limited to patients who form
BMI LAKE score
uric acid stones or mixed calcium oxalate/uric acid stones.
r p r p However, in the present study population, levels of US-CaOx
Urinary calcium (mg/24 h) 0.162 .001 –0.045 NS and US-CaP seem to be more dependent on other nutritional
Urinary phosphate (mmol/24 h) 0.303 .000 0.109 .022
Urinary urate (mg/24 h) 0.294 .000 0.114 .016 patterns. A previous study demonstrated that PRAL in renal
Urinary oxalate (mmol/24 h) 0.244 .000 0.027 NS calcium stone formers was higher than in gender- and age-
Urinary citrate (mg/24 h) 0.034 NS –0.194 .000 matched controls [5], and found an inverse relationship
Urinary magnesium (mg/24 h) 0.206 .000 –0.090 NS
Urinary potassium (mEq/24 h) 0.261 .000 –0.127 .008 between urinary citrate and PRAL [23]. In multiple linear
Urinary sodium (mEq/24 h) 0.309 .000 0.020 NS regression analysis of the data, BMI, together with male gen-
Urinary chloride (mEq/24 h) 0.339 .000 0.038 NS der, was an independent predictor of US-UA, but not of US-
Urinary sulfate (mmol/24 h) 0.307 .000 0.111 .019
Urinary ammonium (mmol/24 h) 0.046 NS 0.002 NS CaOx or US-CaP. In contrast, US-CaP was predicted by LAKE
Urinary volume (ml/24 h) 0.073 NS –0.045 NS score, a measure of dietary PRAL, owing to its inverse correl-
Urinary pH –0.149 .002 –0.028 NS ation with the urinary excretion of citrate.
Urinary saturation CaOx 0.060 NS 0.109 .022
Urinary saturation CaP 0.014 NS 0.171 .000 This study has some possible limitations. First, the risk of
Urinary saturation UA 0.191 .000 0.004 NS stone formation was measured by the levels of urinary satur-
NS: not significant. ation in 24 h samples. A more robust approach could be the
4 F. ESPERTO ET AL.
prospective evaluation of stone formation in the follow-up in
relation to the dietary variables measured. The role of urinary
supersaturation as the main driving force in the formation of
urinary stones was highlighted by Robertson et al. more than
40 years ago [24]. More recently, on the basis of detailed
renal physiological studies and with the advent of the digital
endoscope, a deeper insight into the mechanisms of renal
stone formation has been achieved. In particular, calcium
oxalate stone growth over sites of Randall's plaque and at
the ends of Bellini duct plugs has been described [25]. Thus,
the role of urinary supersaturation in the mechanism of renal
stone formation has been questioned. Rodgers [26] exten-
sively reviewed studies in which urinary compositional data
had been determined in terms of urinary supersaturation. He
concluded that urinary supersaturation cannot distinguish
stone formers from healthy individuals, although urinary
supersaturation can be used in research settings for relative
comparisons. Another limitation of the approach taken in the
current study is the evaluation of urinary saturation in 24 h
urine pooled samples rather than timed urine samples taken
throughout the day. There is some evidence that levels of
urinary saturation fluctuate during the day, with peaks after
meals or overnight when fluid intake is restricted [27]. In par-
ticular, it is well known that urinary pH is variable throughout
the day and that diurnal variation in urinary pH has an
important role in determining stone composition [28]. The
role of the diurnal pattern of urinary pH is crucial in patients
who form uric acid stones, who have similar patterns of
change to healthy controls but whose urine pH is always
lower throughout the day compared with controls [29]. A sig-
nificant variability between 24 h urine pH and fasting urine
pH was observed in individual patients, although these two
parameters correlated moderately in a large cohort of renal
stone formers and controls [30]. Although the effects of these
confounding factors would certainly be crucial in the evalu-
ation of the single individual, they should be attenuated by
the large number of subjects in the present series.
In conclusion, the overweight and obese patients in this
study did not show an increased biochemical risk of calcium
stone formation, but only a limited group of them was at risk
of uric acid stone formation. Overweight and obesity are not
related to a specific food pattern but rather to the imbalance
between the energy intake from food and the energy
expenditure linked to physical activity. An increased intake of
food, by itself, does not imply urinary modifications that
could lead to an increased risk of calcium stone formation.
The quality of foods consumed, specifically their acid load,
has a more relevant impact on the risk of calcium stone for-
mation. The risk of stone formation in obese patients is
modulated by the pattern of their diets, where a diet rich in
meat and poor in vegetables and fruits may lead to an
increased risk of calcium stone formation owing to the high
acid load associated with this specific dietary pattern. In con-
trast, a dietary pattern associated with a lower acid load,
such as the Mediterranean diet of this population, could
imply a lower risk of calcium stones, even in the presence of
overweight and obesity.
Disclosure statement
Biohealth Italia (consultant for educational courses) gave free access to
its files and supported the input of data in a database for statistical ana-
lysis. The authors declare no other conflicts of interest in relation to the
content of this article.
ORCID
Alberto Trinchieri http://orcid.org/0000-0002-9394-8292
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