Urolithiasis as a complication of chronic diarrheal disease

Urolithiasis in patients with inflammatory bowel disease: A systematic review and meta-analysis of 13,339,065 individuals

BACKGROUND

This study aimed to summarize the current literature regarding the prevalence of renal stones in patients with inflammatory bowel disease (IBD). Moreover, we aimed to evaluate the risk factors of urolithiasis in patients with IBD and the difference between patients with IBD and healthy controls in terms of urinary profile.

METHODS

On February 23, 2022, a computerized search was conducted on PubMed, OVID via MEDLINE, Web of Science, and Scopus using relevant keywords. Three independent reviewers performed 2-stage screening and data extraction. The National Institutes of Health tools were employed for quality assessment. Review Manager 5.4 software was used to calculate the mean difference (MD) between IBD patients and non-IBD in terms of urine profile using the Inverse-variance model and to estimate the odds ratio of reported risk factors for renal stones with the Generic Inverse-Variance model.

RESULTS

Thirty-two articles (n = 13,339,065 patients) were included. The overall prevalence of renal stones in patients with IBD was 6.3%, 95% Confidence interval (4.8%-8.3%). The prevalence of urolithiasis was more common in Chron's disease vs Ulcerative colitis (7.9% vs 5.6%) and in old studies (1964-2009) than in more recent studies (2010-2022) (7.3% vs 5.2%), respectively. Compared to non-IBD patients, patients with IBD were associated with significantly lower urine volume (MD = -518.84 mL/day, P < .00001), calcium 24-hour urine (MD = -28.46 mg/day, P < .0001), citrate 24-hour urine (MD = -144.35 mg/day, P < .00001), sodium 24-hour urine (MD = -23.72 mg/day, P = .04), and magnesium 24-hour urine (MD = -33.25 mg/day, P < .00001).

CONCLUSION

The overall prevalence of renal stones in patients with IBD was comparable to the general population. Patients with Chron's disease were associated with a higher prevalence of urolithiasis compared to Ulcerative colitis. Drugs that induce renal calculi should be stopped in high-risk patients.

Risk of Urolithiasis in Patients With Inflammatory Bowel Disease: A Nationwide Danish Cohort Study 1977-2018

BACKGROUND AND AIMS

Patients with inflammatory bowel disease (IBD) are suggested to be at increased risk of urolithiasis, but the magnitude of risk and the impact of medical and surgical treatment on this risk remain unknown. We therefore aimed to determine overall and treatment-related risk of urolithiasis in patients with IBD in a nationwide population-based cohort study.

METHODS

Using national registers, we identified all patients with IBD and all cases of urolithiasis in Denmark during 1977-2018. We obtained information on all IBD medications and surgical procedures during 1995-2018. IBD cases were matched 1:10 on age and sex to non-IBD individuals.

RESULTS

In total, 2,549 (3%) of 75,236 IBD patients and 11,258 (2%) of 767,403 non-IBD individuals developed urolithiasis, resulting in a 2-fold increased risk of urolithiasis (HR, 2.27; 95% CI, 2.17-2.38) in patients with IBD. The patients were also at increased risk of repetitive urolithiasis events (RR, 1.09; 95% CI: 1.04-1.15) and had increased risk of urolithiasis prior to IBD diagnosis (OR, 1.42; 95% CI: 1.34-1.50). After IBD diagnosis, risk of urolithiasis was associated with anti-TNF therapy and surgery.

CONCLUSION

Patients with IBD had a 2-fold increased risk of urolithiasis after IBD diagnosis and a 42% increased risk prior to IBD diagnosis. Risk was increased in anti-TNF exposed patients, and after surgery, suggesting that IBD severity per se and surgery, with altered intestinal absorption, increase risk of urolithiasis. Since stone formation is associated with adverse outcomes including sepsis, subpopulations of IBD patients, especially those undergoing strong immunosuppression might benefit from additional urolithiasis screening.

Uric acid nephrolithiasis: An update

Uric acid nephrolithiasis appears to increase in prevalence. While a relationship between uric acid stones and low urinary pH has been for long known, additional association with various metabolic conditions and pathophysiological basis has recently been elucidated. Some conditions such as diabetes and metabolic syndrome disease, excessive dietary intake, and increased endogenous uric acid production and/or defect in ammoniagenesis are associated with low urinary pH. In addition, the phenomenon of global warming could result in an increase in areas with greater climate risk for uric acid stone formation. There are three therapeutic steps to be taken for management of uric acid stones: identification of urinary pH profiles, assessment of urinary volume status, and identification of disorders leading to excessive uric acid production. However, the most important factor for uric acid stone formation is acid urinary pH, which is a prerequisite for uric acid precipitation. This article reviews recent insights into the pathophysiology of uric acid stones and their management.

Recent advances in the pathophysiology of nephrolithiasis

Over the past 10 years, major progress has been made in the pathogenesis of uric acid and calcium stones. These advances have led to our further understanding of a pathogenetic link between uric acid nephrolithiasis and the metabolic syndrome, the role of Oxalobacter formigenes in calcium oxalate stone formation, oxalate transport in Slc26a6-null mice, the potential pathogenetic role of Randall's plaque as a precursor for calcium oxalate nephrolithiasis, and the role of renal tubular crystal retention. With these advances, we may target the development of novel drugs including (1) insulin sensitizers; (2) probiotic therapy with O. formigenes, recombinant enzymes, or engineered bacteria; (3) treatments that involve the upregulation of intestinal luminal oxalate secretion by increasing anion transporter activity (Slc26a6), luminally active nonabsorbed agents, or oxalate binders; and (4) drugs that prevent the formation of Randall's plaque and/or renal tubular crystal adhesions.

Metabolic syndrome and uric acid nephrolithiasis

The metabolic syndrome describes a cluster of metabolic features that increases the risk for type 2 diabetes mellitus and cardiovascular disease. The prevalence of uric acid nephrolithiasis is higher among stone-forming patients with features of the metabolic syndrome such as obesity and/or type 2 diabetes mellitus. The major determinant in the development of idiopathic uric acid stones is an abnormally low urinary pH. The unduly urinary acidity in uric acid stone formers increasingly is recognized to be one of the features observed in the metabolic syndrome. Two major abnormalities have been implicated to explain this overly acidic urine: (1) increased net acid excretion, and (2) impaired buffering caused by defective urinary ammonium excretion, with the combination resulting in abnormally acidic urine. New information is emerging linking these defects to changes in insulin signaling in the kidney. This article reviews the epidemiologic and metabolic studies linking uric acid nephrolithiasis with the metabolic syndrome, and examines the potential mechanisms underlying the unduly acidic urine in these conditions.

Uric Acid Nephrolithiasis

Uric acid nephrolithiasis may be the final manifestation of various pathophysiological processes. Recent advances in renal urate transport have elucidated mechanisms by which hyperuricosuria occurs. However, in most uric acid stone formers the primary pathophysiologic defect is an excessively acidic urine pH rather than hyperuricosuria. Insulin resistance may contribute to the development of acidic urine by augmenting endogenous acid production and decreasing renal ammonium excretion. Medical management strategies focus primarily on alkali treatment or decreasing hyperuricosuria.

Urologic manifestations of nonurologic diseases gastrointestinal disorders

A variety of common, gastrointestinal diseases result in significant genitourinary tract pathology. In general, knowledge of these associated disease processes permit rapid and accurate diagnosis and treatment. The underlying thread is the recognition of one pathophysiological process to explain patterns of a single disease.

Urine stone risk factors in nephrolithiasis patients with and without bowel disease

BACKGROUND

The prevalence of nephrolithiasis among patients with bowel disease is higher than in the general population. We examined urine stone risk factors and clinical characteristics of these patients, contrasted with a large group of stone forming patients without systemic disease.

METHODS

A total of 180 patients with bowel disease were compared with a group of 2048 nephrolithiasis patients with calcium or uric acid stones and without systemic diseases. Bowel diseases included inflammatory bowel disease with and without bowel resections, bowel resections from cancer or trauma, and bypass procedures for obesity or hypercholesterolemia. Urine stone risk factors, stone rates, stone compositions, and creatinine clearance were measured.

RESULTS

Compared to ordinary stone forming patients, bowel patients formed stones higher in rate of recurrence and in uric acid content. Uric acid content was highest when colon surgery had occurred. Urine volumes were low among all bowel patients except those with a bypass. Average creatinine clearance values were low among all bowel patients. Urine oxalate excretion was modestly elevated after small bowel resection, but very high with bypass. Supersaturations were increased mainly by low urine volume and-for uric acid-low pH. Patients with no surgery were indistinguishable from routine stone formers.

CONCLUSIONS

Low urine volume and pH are the main stone-forming abnormalities in bowel disease patients. Hyperoxaluria is extreme after bypass, but only modest after small bowel surgery. In the absence of surgery, bowel disease patients with stones cannot be distinguished from common stone formers by comprehensive stone risk measurements.

The physiologic approach to the medical management of stone disease

The cause of urinary stone disease can now be detected in approximately 80% of patients. Effective treatment can substantially reduce the recurrence of urinary calculi. Proper therapy depends on a thorough understanding of the physiology of calcium, oxalate, uric acid, cystine, and struvite formation and the medication developed for prevention. This article reviews the physiologic basis of urinary stone management in a straightforward, understandable fashion.

Uric acid-related nephrolithiasis

Abnormalities in uric acid metabolism are associated with uric acid and calcium oxalate urolithiasis. Clinical stone formation depends on multiple identifiable risk factors that affect uric acid and calcium oxalate solubility. The understanding of urinary pH is critical to direct appropriate treatment of uric acid-related nephrolithiasis. Understanding uric acid metabolism and the pathophysiology of uric acid and calcium oxalate stone formation leads to a rational treatment approach to uric acid and hyperuricosuric calcium oxalate stone disease.

Relationship between bisacodyl-induced urolithiasis and rat urinary bladder tumorigenesis

Dietary supplementation with bisacodyl at concentrations ranging from 1 to 0.3% was found to induce both calculi and epithelial proliferative lesions, including a transitional-cell carcinoma, in the urinary bladder of F344/DuCrj rats. In order to clarify the relationship between the bisacodyl-associated urinary bladder calculi and the development of proliferative lesions in the urinary bladder, male and female rats were administered bisacodyl-diets at concentrations of 0.3, 0.1, and 0.03% for 32 wk. Both sexes of animals treated with bisacodyl suffered from diarrhea throughout the experimental period. Epithelial proliferative lesions and calculus formation were observed only in the urinary bladder of male rats given the 0.3% bisacodyl diet. Proliferative lesions and increases of bromouracil deoxyriboside (BUdR) labeling indices were found only in the urinary bladder epithelium of rats with calculi, the severity of the former correlating with the calculus weight and being most marked in the dome areas, which are susceptible to physical stimulation. These findings indicate a close relationship between the development of proliferative lesions and the existence of calculi in the urinary bladder, and suggest that bisacodyl-induced proliferative lesions are not caused directly by bisacodyl per se but are secondary to calculus formation.

Tests of renal function in patients with quiescent colitis: effects of drug treatment

Mesalazine has structural similarities to aspirin and phenacetin and is nephrotoxic when given intravenously in high doses to rats. A number of cases of nephrotoxicity has been reported recently in patients taking oral mesalazine. Sensitive indicators of renal function in a group of patients maintained on long term, delayed release mesalazine and a comparable group on sulphasalazine have been studied. Sixty two patients (32 men, aged 28-82 years) with quiescent colitis were studied. Thirty four had been maintained on delayed release mesalazine 1.6 (0.8-2.4) g/day for 2.9 (0.5-6.9) years and 28 on sulphasalazine 2 (2-3) g/day. Groups were comparable for age, sex, disease duration, and disease extent. Renal function was assessed by: urine microscopy; creatinine clearance; the urinary excretion of two markers of glomerular toxicity, albumin and transferrin; and the urinary excretion for two markers of tubular toxicity, N-acetyl-beta-D-glucosaminidase (NAG) and alpha 1-microglobulin. There were no significant differences in renal function between the two treatment groups. Furthermore, no correlations were found between measures of renal function and either cumulative mesalazine dose or mesalazine treatment duration. In this study, long term maintenance treatment with delayed release mesalazine was no more nephrotoxic than continued treatment with sulphasalazine.

Prophylaxis of uric acid stone in patients with inflammatory bowel disease following extensive colonic resection

Seven patients (13.0%) among 54 patients with inflammatory bowel disease treated by extensive colonic resection were complicated by renal stone. The mean urinary pH value in cases complicated by renal stones (5.3 +/- 0.4) was significantly lower than among those without stones (6.1 +/- 0.3, P less than 0.01). Sodium bicarbonate (4 gm/day, q.i.d.) was given to 11 patients with renal stones and/or hematuria, whose urinary pH was lower than 5.0 or whose urinary sediments were positive for uric acid crystals since Oct. 1985. Their urinary pH and Na concentration increased significantly and no renal stone complication has been seen in the treated group.

Prevention of uric acid stone formation by sodium bicarbonate in an ileostomy patient--a case report

A 38 year old female underwent a proctocolectomy and ileostomy for ulcerative colitis in February, 1974. For 8 year post-operatively, she excreted innumerable renal stones, mainly composed of uric acid. Her urine was highly acidic and hyperuricosuric with a low concentration of sodium. Sodium bicarbonate 4 gm/day, t.i.d., was started in October 1985, after which her renal stone excretion completely ceased (up until March, 1987), except for one incidence of stone excretion when she discontinued therapy for a week. During the sodium bicarbonate therapy, her urinary pH and Na concentration were elevated. Furthermore, sodium bicarbonate significantly elevated the urinary pH and Na concentration of other ileostomy patients. Thus, sodium bicarbonate could be used for the possible prophylaxis of uric acid formation in selected ileostomy patients.

Urinary stones in subjects with a permanent ileostomy

The prevalence of urinary stones in a group of subjects living with a permanent ileostomy has been determined by intravenous urography. Thirty-nine of the ileostomists had previously suffered from ulcerative colitis, while the remaining 12 suffered from Crohn's disease. Four of the ileostomists who had had ulcerative colitis had urinary stones (10.3 per cent). These four subjects were all male, so that among the 23 male ileostomists who had had ulcerative colitis 17.4 per cent had urinary stones. No urinary stones were found in the ileostomists with Crohn's disease. Various factors thought to be associated with a liability to urolithiasis have been examined in the ileostomists and also in a control group of 39 healthy subjects matched for age and sex with the ileostomists who had had ulcerative colitis. The ileostomists commonly showed a reduced urinary volume, a low urinary sodium and magnesium content and low urinary pH. The ileostomists were much more prone to be hyperuricaemic than the controls, and hyperuricaemia was strongly associated with the presence of urinary stones.

[Pathogenic significance of bile acids (author's transl)]

Because of their amphiphilic properties, bile acids have important physiological functions. However, they can also be pathogenetically active. Some recent findings on the biochemistry and enterohepatic circulation of bile acids are presented. In contrast to the adult liver where the only primary bile acids formed are cholic- and chenodeoxycholic acid, the foetal liver is able to synthesise a variety of "atypical" bile acids. Under certain circumstances, a retrograde differentiation is possible in the adult. The very effective transport systems in gut and in the sinusoidal and canalicular membrane of the liver cell limit the bile acids almost exclusively to the enterohepatic circulation. During transport in blood, through biomembranes and in the liver cytosol, bile acids are bound to carrier proteins. The carrier has been detected using photoaffinity labelling. Following biotransformation (sulphation and glucuronidation) pathogenetically active bile acids can be converted into derivatives which can be rapidly eliminated. Disturbances of these mechanisms result in functional defects and diseases. The pathological significance of bile acids in hepato-biliary diseases is represented with regard to the cholestatic and proliferative effect of individual bile acids. The significance of bile acids in chologenic diarrhea, steatorrhea and enteral hyperoxaluria are presented as examples of the pathogenetic effects of bile acids on the gut. In these diseases it is possible to recognise the specific effects of certain bile acids on the colon mucosa. Recent studies have demonstrated that bile acids are possibly of pathogenetic significance in the case of epidemiologically proven relationship between colon carcinoma and high fat, high cholesterol and low fibre diets.

Urolithiasis in chronic inflammatory bowel disease

In a selected material of 228 patients with chronic inflammatory bowel disease (CIBD) the incidence of urolithiasis was 15% (95% confidence limit 11-21). The tendency to urolithiasis is significantly correlated to small-bowel resection and its extent and to obstruction in the urinary tract. On the other hand, there is no definite correlation to the duration or extent of the bowel disease. The significant correlation between urolithiasis and ileal resection is in agreement with the hyperabsorption of oxalate as an important cause of stone formation demonstrated by others. That local factors too play an essential role in the formation of urinary calculi is apparent from the increased incidence of urolithiasis in obstruction of the urinary tract. The incidence of urolithiasis was particularly high (22-25%) among patients with ileostomies. The few and negligible symptoms of and sequelae to, urolithiasis in CIBD encourage a conservative attitude.

Urologic complications of inflammatory bowel disease

Urologic complications occurred in 54 of 233 patients with inflammatory bowel disease followed during a 15-year period. Urinary calculi, enterovesical fistulas and ureteral obstruction were the most common problems. Urinary tract complications may arise many years after primary bowel disease has been diagnosed. Symptoms frequently may be absent or obscured by those of the gastrointestinal disorder. We recommend that urologic evaluation be included periodically in the long-term management of patients with inflammatory bowel disease.

Ileostomy and excisional surgery for chronic inflammatory disease of the colon: A survey of one hospital region: Part II The health of ileostomists

To the ileostomist who asks, ;Am I as healthy as the rest of the population', the answer can be a qualified affirmative. There is probably an increased likelihood of his developing calculi in the urinary tract but, apart from this, there is no suggestion of diseases of a general nature to which he is more subject than another individual of comparable age. If the surgery has been undertaken for ulcerative colitis in the absence of malignant change and the patient has survived one postoperative year, then an assurance can be given that life expectancy is little less than that in the general population.