A summary of the epidemiology and pathophysiology of kidney stones, and scientific review on water intake for the prevention and reduction of health costs in stone disease.

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Water intake and Kidney stones

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3. Epidemiology
Risk factors
Pathophysiology
Focus on chronic dehydration as a major risk factor
High water intake benefits on secondary prevention of kidney stones
High water intake benefits on primary prevention of kidney stones
Hypothetical impact of adequate water intake on health costs
General measures for the prevention of kidney stones recurrence
EFSA recommendations for total water intake
Key facts
References– References are sorted by slide, at the end of the presentation
Content
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4. Epidemiology of kidney stones
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40 to 60% of stone formers will relapse within 5 years following a first episode
Detailed on
next page
= €590 million
(year 2011)
> $2.1 billion
(year 2000)
Prevalence: 10% worldwide and increasing
Kidney stones are also called lithiasis or urolithiasis, while nephrolithiasis refers
more precisely to stones located in the kidney.
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Urolithiasis is more prevalent among men than among women
Health costs are considerable
More common in adults aged 30 to 50 years old
Increasing trend in children

5. Epidemiology of kidney stones
World map of kidney stones lifetime prevalence in the general population
Lifetime prevalence in men Mean lifetime prevalenceLifetime prevalence in women
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6. 5
Risk factors for kidney stones
A multifactorial disease
Environmental factors
Family history
Ethnicity
Age and Gender
Diet
Dehydration
Overweight, obesity,
diabetes, hypertension
Lifestyle related factors
Occupation
Intense physical activity
Geography
Climate & Temperature
Individual factors
Non modifiable factors
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7. 6
Pathophysiology
A misbalance between urine volume and composition
Low urine
volume
Urine pH
alteration
Promoters
in high
concentration
Inhibitors in low
concentration
Urinary risk factors
of lithogenesis
Lithogenesis
About 60 to 80% of stones are composed
of calcium oxalate
Individual & environmental
risk factors
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8. Chronic dehydration
A major risk factor for kidney stones
Conditions related to chronic dehydration predisposing
to a low urine volume
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Higher urinary compounds concentration
Low urine volume
Work in hot
environment
Intense physical
activity
High sunlight
exposure
Hot climate Low fluid intake
Uncompensated water losses
risk of kidney stones7,10,33
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9. High water intake benefits on secondary
prevention of kidney stones
Increasing water intake to reduce the risk of kidney stones recurrence:
Borghi et al, 1996
12,1%
27%
5-year
follow-up
5-year
follow-up
Recruitment of
300 stone formers
after 1st episode
Increased fluid intake is an effective preventive measure
for kidney stones recurrence.
8
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A
199 subjects
B
101 subjects
Total urine:
2,0L/day
Intervention:
↗ water intake
No instruction on fluid
intake

10. A
1406 subjects
High water intake benefits on primary
prevention of kidney stones
To date, only one remote study from 1966 suggests that increasing water intake
could help reduce the incidence of kidney stones:
Frank et al, 1966
0,28%
0,85%
3-year
follow-up
3-year
follow-up
Stone
prevalence
5385 subjects
with no history of
kidney stones,
from 2 towns in
arid desert
Stronger evidence is needed to assess the role of increased
water intake on prevention of first episodes of kidney stones.
9
Urine
volume
B
3979 subjects
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Intervention:
Education to increase
fluid intake
No instruction on fluid
intake

11. Hypothetical estimation model of cost savings by French Health care system
through stones prevention by increased water intake.
Recurrence
prevention
First time
prevention
% of compliance to adequate
water intake of 2L 100% 25% 100% 25%
Number of stones prevented 11,572 2,893 9,625 2,316
Cost savings in million € 49 10 273 68
Prevention of first stones and stones recurrence,
with an adequate water intake of 2.0L per day could be cost-effective
and could reduce the economic burden of urolithiasis.
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Cost savings were calculated with a Markov statistical model for an adequate
water intake of 2.0L/d
Hypothetical impact of adequate water intake
on health costs of kidney stones

12. General measures for the prevention of kidney
stones recurrence
Based on the EAU guidelines for nephrolithiasis patients
Increased fluid intake
Urine volume > 2,0L/d
Urine Specific Gravity < 1,010
Balanced diet
Normal calcium intake (1,000-1,200 mg/d)
Limit salt intake (4-5 g/d)
Limit animal protein intake (0,8-1 g/kg/d)
Lifestyle
BMI 18-25
Limit stress
Adequate physical activity
Balancing excessive fluid loss
(adapted from Tiselius et al. 2001)
11
Water is essential and should be at the core of everyone’s daily intake.
To prevent recurrence, official guidelines include a fluid intake sufficient
to achieve a urine volume of at least 2.0L per day.
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13. EFSA Recommendations
for Total Water Intake (TWI) in Europe
1-2
years
2-3
years
4-8
years
9-13
years
14-18
years
Adults
Pregnant
women
Lactating
women
Recommended
TWI
(EFSA 2010)
1,1-
1,2L/d
1,3L/d 1,6L/d
Girls
1,9L/d
Women 2L/d
2,3L/d 2,7L/d
Boys
2,1L/d
Men 2,5L/d
12
EFSA recommendations for TWI for adults:
Are in line with EAU guidelines to prevent kidney stones recurrence
If followed, could help reduce the economic burden of urolithiasis
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14. Key facts to keep in mind
Recommendation
for total water
intake
EFSA
14-18
years
Adults
Women 2L/d
Men 2,5L/d
Prevalence 10%
Guidelines to
prevent recurrence
> 2L/ dayUrine volume
13
Low urine
volume
Risk of
kidney stones
Chronic
dehydration
Urine
Supersaturation
Costs are considerable$
Adequate water intake is:
cost-effective
can help reduce the economic
burden of kidney stones.
2L
Fluid intake
Kidney stones recurrence
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15. Access Kidney stones Monograph online
To learn more
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Visit the kidney facts website
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academy/hydration-lab/
More information on kidney and kidney stones
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16. Shah J, Whitfield HN. (2002) Urolithiasis through the ages. BJU.Int. 89:801-810.
Ettinger B. (1979) Recurrence of nephrolithiasis. A six-year prospective study. Am J Med 67:245-248.
Hosking DH, Erickson SB, Van den Berg CJ, Wilson DM, Smith LH. (1983) The stone clinic effect in patients with idiopathic
calcium urolithiasis. J Urol. 130:1115-1118.
Sutherland JW, Parks JH, Coe FL. (1985) Recurrence after a single renal stone in a community practice. Miner.Electrolyte.
Metab 11:267-269.
Brenner B and Rector JRF. (2008) Nephrolithiasis. In: Brenner and Rector’s: The Kidney. Philadelphia (PA): Saunders, 1299-
1349.
Ramello A, Vitale C, Marangella M. (2000) Epidemiology of nephrolithiasis. J Nephrol. 13 Suppl 3:S45-S50.
Trinchieri A, Cappoli S, Esposito N, Acquati P. (2008) Epidemiology of renal colic in a district general hospital. Arch.Ital.Urol.
Androl. 80:1-4.
Ferrari P, Piazza R, Ghidini N, Bisi M, Galizia G, Ferrari G. (2007) Lithiasis and risk factors. Urol.Int. 79 Suppl 1:8-15.
Sas DJ. (2011) An update on the changing epidemiology and metabolic risk factors in pediatric kidney stone disease Clin.J
Am.Soc.Nephrol. 6:2062-2068.
Clayton DB, Pope JC. (2011) The increasing pediatric stone disease problem. Ther.Adv.Urol. 3:3-12.
Lopez M, Hoppe B. (2010) History, epidemiology and regional diversities of urolithiasis. Pediatr Nephrol. 25:49-59.
Lotan Y, Buendia J, I, Lenoir-Wijnkoop I, Daudon M, Molinier L, Tack I, Nuijten MJ. (2012) Primary prevention of nephrolithiasis
is cost-effective for a national healthcare system. BJU.Int. 110:E1060-E1067.
Pearle MS, Calhoun EA, Curhan GC. (2005) Urologic diseases in America project: urolithiasis. J Urol. 173:848-857.
Bibliographic references
15
Slide 3 – Epidemiology of kidney stones

17. Bibliographic references
16
Slide 5 – Risk factor of kidney stones (1/2)
Brenner B and Rector JRF. (2008) Nephrolithiasis. In: Brenner and Rector’s: The Kidney. Philadelphia (PA): Saunders, 1299-1349.
Ramello A, Vitale C, Marangella M. (2000) Epidemiology of nephrolithiasis. J Nephrol. 13 Suppl 3:S45-S50.
Trinchieri A, Cappoli S, Esposito N, Acquati P. (2008) Epidemiology of renal colic in a district general hospital. Arch.Ital.Urol. Androl.
80:1-4.
Ferrari P, Piazza R, Ghidini N, Bisi M, Galizia G, Ferrari G. (2007) Lithiasis and risk factors. Urol.Int. 79 Suppl 1:8-15.
Coe FL, Parks JH, Moore ES. (1979) Familial idiopathic hypercalciuria. N Engl J Med 300:337-340.
Curhan GC, Willett WC, Rimm EB, Stampfer MJ. (1997a) Family history and risk of kidney stones. J Am Soc.Nephrol. 8:1568-1573.
Serio A, Fraioli A. (1999) Epidemiology of nephrolithiasis. Nephron. 81 Suppl 1:26-30.
Soucie JM, Thun MJ, Coates RJ, McClellan W, Austin H. (1994) Demographic and geographic variability of kidney stones in the
United States. Kidney.Int. 46:893-899.
Stamatelou KK, Francis ME, Jones CA, Nyberg LM, Curhan GC. (2003) Time trends in reported prevalence of kidney stones in the
United States: 1976-1994. Kidney.Int. 63:1817-1823.
Scales CD, Jr., Smith AC, Hanley JM, Saigal CS. (2012) Prevalence of kidney stones in the United States. Eur.Urol. 62:160-165.
Borghi L, Meschi T, Schianchi T, Briganti A, Guerra A, Allegri F, Novarini A. (1999c) Urine volume: stone risk factor and preventive
measure. Nephron. 81 Suppl 1:31-37.
Curhan GC, Willett WC, Rimm EB, Stampfer MJ. (1993) A prospective study of dietary calcium and other nutrients and the risk of
symptomatic kidney stones. N Engl J Med 328:833-838.
Curhan GC, Willett WC, Speizer FE, Spiegelman D, Stampfer MJ. (1997b) Comparison of dietary calcium with supplemental calcium
and other nutrients as factors affecting the risk for kidney stones in women. Ann.Intern.Med 126:497-504.

18. Bibliographic references
17
Slide 5 – Risk factor of kidney stones (2/2)
Bartoletti R, Cai T, Mondaini N, Melone F, Travaglini F, Carini M, Rizzo M. (2007) Epidemiology and risk factors in urolithiasis. Urol.Int. 79
Suppl 1:3-7.
Embon OM, Rose GA, Rosenbaum T. (1990) Chronic dehydration stone disease. Br.J Urol. 66:357-362.
Brenna I, Dogliotti E, Terranegra A, Raspini B, Soldati L. (2013) Nephrolithiasis: nutrition as cause or therapeutic tool. J Transl.Med
11:178.
Daudon M, Traxer O, Jungers P. (2012). Lithiase Urinaire. Paris: Lavoisier.
Borghi L, Meschi T, Guerra A, Briganti A, Schianchi T, Allegri F, Novarini A. (1999b) Essential arterial hypertension and stone disease.
Kidney.Int. 55:2397-2406.
Atan L, Andreoni C, Ortiz V, Silva EK, Pitta R, Atan F, Srougi M. (2005) High kidney stone risk in men working in steel industry at hot
temperatures. Urology. 65:858-861.
Irving RA, Noakes TD, Rodgers AL, Swartz L. (1986) Crystalluria in marathon runners. 1. Standard marathon--males. Urol. Res 14:289-294.
Milvy P, Colt E, Thornton J. (1981) A high incidence of urolithiasis in male marathon runners. J Sports Med Phys.Fitness 21:295-298.
Frank M, ATSMON A, SUGAR P, De VA. (1963) Epidemiological investigation of urolithiasis in the hot arid Southern region of Israel.
Urol.Int. 15:65-76.
Brikowski TH, Lotan Y, Pearle MS. (2008) Climate-related increase in the prevalence of urolithiasis in the United States.
Proc.Natl.Acad.Sci.U.S.A. 105:9841-9846.
Soucie JM, Coates RJ, McClellan W, Austin H, Thun M. (1996) Relation between geographic variability in kidney stones prevalence and
risk factors for stones. Am.J Epidemiol 143:487-495.
Chauhan V, Eskin B, Allegra JR, Cochrane DG. (2004) Effect of season, age, and gender on renal colic incidence. Am.J Emerg.Med 22:560-
563.

19. Bibliographic references
18
Slide 6 – Pathophysiology
Curhan GC, Willett WC, Rimm EB, Stampfer MJ. (1993) A prospective study of dietary calcium and other nutrients and the risk of
symptomatic kidney stones. N Engl J Med 328:833-838.
Daudon M, Traxer O, Jungers P. (2012). Lithiase Urinaire. Paris: Lavoisier.
Finlayson B. (1978) Physicochemical aspects of urolithiasis. Kidney.Int. 13:344-360.
Coe FL, Evan A, Worcester E. (2011) Pathophysiology-based treatment of idiopathic calcium kidney stones. Clin J Am Soc.
Nephrol. 6:2083-2092.
Curhan GC, Willett WC, Speizer FE, Stampfer MJ. (2001) Twenty-four-hour urine chemistries and the risk of kidney stones among
women and men. Kidney.Int. 59:2290-2298.
Peres LA, Molina AS, Galles MH. (2003) Metabolic investigation of patients with urolithiasis in a specific region. Int.Braz.J Urol.
29:217-220.
Elaine M. Worcester, MD & Fredric L. Coe, MD. (2010) Clinical Practice Calcium Kidney Stones. N Engl J Med. 363(10): 954–963.
Vadim A. Finkielstein* and David S. Goldfarb†. (2006) Strategies for preventing calcium oxalate stones CMAJ. 174(10): 1407–
1409.

20. Bibliographic references
19
Slide 7 – Chronic dehydration (1/2)
Brenner B and Rector JRF. (2008) Nephrolithiasis. In: Brenner and Rector’s: The Kidney. Philadelphia (PA): Saunders, 1299-1349.
Trinchieri A, Cappoli S, Esposito N, Acquati P. (2008) Epidemiology of renal colic in a district general hospital. Arch.Ital.Urol. Androl.
80:1-4.
Soucie JM, Thun MJ, Coates RJ, McClellan W, Austin H. (1994) Demographic and geographic variability of kidney stones in the United
States. Kidney.Int. 46:893-899.
Bartoletti R, Cai T, Mondaini N, Melone F, Travaglini F, Carini M, Rizzo M. (2007) Epidemiology and risk factors in urolithiasis.
Urol.Int. 79 Suppl 1:3-7.
Embon OM, Rose GA, Rosenbaum T. (1990) Chronic dehydration stone disease. Br.J Urol. 66:357-362.
Borghi L, Meschi T, Guerra A, Briganti A, Schianchi T, Allegri F, Novarini A. (1999b) Essential arterial hypertension and stone disease.
Kidney.Int. 55:2397-2406.
Atan L, Andreoni C, Ortiz V, Silva EK, Pitta R, Atan F, Srougi M. (2005) High kidney stone risk in men working in steel industry at hot
temperatures. Urology. 65:858-861.
Irving RA, Noakes TD, Rodgers AL, Swartz L. (1986) Crystalluria in marathon runners. 1. Standard marathon--males. Urol. Res 14:289-
294.
Frank M, ATSMON A, SUGAR P, De VA. (1963) Epidemiological investigation of urolithiasis in the hot arid Southern region of Israel.
Urol.Int. 15:65-76.
Brikowski TH, Lotan Y, Pearle MS. (2008) Climate-related increase in the prevalence of urolithiasis in the United States.
Proc.Natl.Acad.Sci.U.S.A. 105:9841-9846.
Soucie JM, Coates RJ, McClellan W, Austin H, Thun M. (1996) Relation between geographic variability in kidney stones prevalence
and risk factors for stones. Am.J Epidemiol 143:487-495.

21. Borghi L, Meschi T, Schianchi T, Briganti A, Guerra A, Allegri F, Novarini A. (1999c) Urine volume: stone risk factor and preventive
measure. Nephron. 81 Suppl 1:31-37.
Curhan GC. (2007) Epidemiology of stone disease. Urol.Clin North Am 34:287-293.
Curhan GC, Taylor EN. (2008) 24-h uric acid excretion and the risk of kidney stones. Kidney.Int. 73:489-496.
Pak CY, Sakhaee K, Crowther C, Brinkley L. (1980) Evidence justifying a high fluid intake in treatment of nephrolithiasis.
Ann.Intern.Med 93:36-39.
Bibliographic references
20
Slide 7 – Chronic dehydration (2/2)
Slide 8 – High water intake benefits on secondary prevention of kidney stones
Borghi L, Meschi T, Amato F, Briganti A, Novarini A, Giannini A. (1996) Urinary volume, water and recurrences in idiopathic
calcium nephrolithiasis: a 5-year randomized prospective study. J Urol. 155:839-843

22. Frank M, De VA. (1966) Prevention of urolithiasis. Education to adequate fluid intake in a new town situated in the Judean
Desert Mountains. Arch.Environ.Health 13:625-630.
Bibliographic references
21
Slide 9 - High water intake benefits on primary prevention of kidney stones
Slide 10 – Hypothetical impact of adequate water intake on health costs of kidney stones
Primary prevention
Lotan Y, Buendia J, I, Lenoir-Wijnkoop I, Daudon M, Molinier L, Tack I, Nuijten MJ. (2012) Primary prevention of
nephrolithiasis is cost-effective for a national healthcare system. BJU.Int. 110:E1060-E1067.
Secondary prevention
Lotan Y, Buendia J, I, Lenoir-Wijnkoop I, Daudon M, Molinier L, Tack I, Nuijten MJ. (2013) Increased water intake as a
prevention strategy for recurrent urolithiasis: major impact of compliance on cost-effectiveness. J Urol. 189:935-939.

23. Tiselius HG, Ackermann D, Alken P, Buck C, Conort P, Gallucci M. (2001) Guidelines on urolithiasis. Eur Urol. 40:362-371.
Bibliographic references
22
Slide 11 - General measures for the prevention of kidney stones recurrence
Slide 13 – EFSA Recommendations for Total Water Intake (TWI) in Europe
EFSA Panel on Dietetic Products Nutrition and Allergies (NDA). (2010) Scientific Opinion on Dietary Reference Values for
water. EFSA Journal. 8(3): 1459-1507.

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