Calcium Supplementation and Incident Kidney Stone Risk: A Systematic Review

Prevalence of osteoporosis in patients with nephrolithiasis and vice versa: a cumulative analysis

Purpose

Nephrolithiasis is thought to be a risk factor for osteoporosis, but data assessing if osteoporosis predisposes to the risk of nephrolithiasis are lacking. The present study aims to investigate whether patients with nephrolithiasis have a prominently higher prevalence of osteoporosis than the controls and vice versa via a cumulative analysis.

Methods

Four databases were used to detect the eligible studies. We calculated the relative risk (RR) with a 95% confidence interval (CI) to assess the combined effect. The methodologies for conducting this study followed the PRISMA guidelines and were registered in the PROSPERO (ID: CRD42023395875).

Results

Nine case-control or cohort studies with a total of 454,464 participants were finally included. Combined results indicated that there was a significantly higher prevalence of osteoporosis in patients with nephrolithiasis as compared to the general population without nephrolithiasis (overall RR from six studies= 1.204, 95%CI: 1.133 to 1.28, P< 0.001; heterogeneity: I2 = 34.8%, P= 0.162). Conversely, osteoporosis was significantly correlated to an increased risk of nephrolithiasis as compared to the controls without osteoporosis (overall RR from four studies= 1.505, 95%CI: 1.309 to 1.731, P< 0.001; I2 = 89.8%, P< 0.001). Sensitivity analysis on the two categories validated the above findings. No significant publication bias was identified in this study.

Conclusions

The present study highlighted a significantly high prevalence of osteoporosis in patients with nephrolithiasis and vice versa. This reciprocal association reminded the clinicians to conduct a regular follow-up assessment when managing patients with nephrolithiasis or osteoporosis, especially for the elderly.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/#searchadvanced, identifier CRD42023395875.

The Reciprocal Relationship between Osteoporosis and Renal Stones

Previous studies have proposed an association between osteoporosis and renal stones. The current analyses intended to investigate the bidirectional relationship between osteoporosis and renal stones. The ≥40-year-old population in the National Health Insurance Service-Health Screening cohort (2002-2015) was analyzed. In study I, 67,811 patients with osteoporosis and 67,811 control I participants were matched. The hazard ratio (HR) of osteoporosis for renal stones was calculated using stratified Cox proportional hazard models. In study II, 25,261 patients with renal stones and 101,044 control II participants were matched. The HR of renal stones for osteoporosis was estimated using stratified Cox proportional hazard models. In study I, 3.4% (2276/67,811) of osteoporosis patients and 2.5% (1696/67,811) of control I participants had renal stones. Osteoporosis patients had a 1.36 times higher HR for renal stones than control I participants (95% confidence intervals [CI] = 1.28-1.45). In study II, 9.2% (2319/25,261) of renal stone patients and 7.6% (7658/101,044) of control II participants had osteoporosis. Renal stone patients had a 1.26 times higher HR for osteoporosis than control II participants (95% CI = 1.21-1.32). Adults with osteoporosis had a higher risk of renal stones. Moreover, adults with renal stones had a higher risk of osteoporosis.

Relationships between Dairy and Calcium Intake and Mental Health Measures of Higher Education Students in the United States: Outcomes from Moderation Analyses

Background: The prevalence of mental health concerns among university students in the United States (U.S.) continues to increase, while current treatments, including medication and counseling, present shortcomings. Higher dairy and calcium intakes are associated with protective effects on mental health; however, previous studies have focused on investigating singular relationships between dairy and calcium intakes and mental health measures. A more complex exploration of these relationships is warranted to better examine whether increasing dairy and calcium intakes could serve as an intervention to improve mental health. The present study sought to further characterize the relationships between dairy and calcium intake, perceived stress, and a variety of mental health measures using linear regression and moderation analyses. Methods: The present cross-sectional study involved students studying at three large U.S. universities, and data collection occurred from April to May 2020 when students were learning remotely due to the COVID-19 pandemic. An online survey comprising validated tools was distributed among students to assess dairy and calcium intake, perceived stress, anxiety, negative and positive moods, rumination, and resilience, sleep quality and duration, dietary risk, and physical activity. Results: A total of 1233 students completed the study. Higher dairy and calcium intake was coincident with lower perceived stress and higher positive mood scores, while higher calcium intake was also coincident with lower anxiety, rumination, and higher resilience scores. Additionally, as calcium intake increased, the relationship between perceived stress and anxiety and the relationship between perceived stress and negative mood weakened. Dairy intake did not have this effect. Conclusions: Based on the results, and considering that calcium is a shortfall nutrient, universities should consider initiating programs and public health campaigns to promote dairy and calcium intake among this population.

Nutritional Approaches as a Treatment for Impaired Bone Growth and Quality Following the Consumption of Ultra-Processed Food

The severe impairment of bone development and quality was recently described as a new target for unbalanced ultra-processed food (UPF). Here, we describe nutritional approaches to repair this skeletal impairment in rats: supplementation with micro-nutrients and a rescue approach and switching the UPF to balanced nutrition during the growth period. The positive effect of supplementation with multi-vitamins and minerals on bone growth and quality was followed by the formation of mineral deposits on the rats' kidneys and modifications in the expression of genes involved in inflammation and vitamin-D metabolism, demonstrating the cost of supplementation. Short and prolonged rescue improved trabecular parameters but incompletely improved the cortical parameters and the mechanical performance of the femur. Cortical porosity and cartilaginous lesions in the growth-plate were still detected one week after rescue and were reduced to normal levels 3 weeks after rescue. These findings highlight bone as a target for the effect of UPF and emphasize the importance of a balanced diet, especially during growth.

The Effect of Calcium Supplementation on Body Weight Before and During Pregnancy in Women Enrolled in the WHO Calcium and Preeclampsia Trial

INTRODUCTION

Obesity is a major and challenging public health problem. The aim of this substudy is to evaluate the effect of calcium supplementation on body weight in women recruited in the Calcium and Preeclampsia trial.

METHODS

Women were recruited before pregnancy and randomized to receive a calcium supplement containing 500 mg of elemental calcium or placebo until 20 weeks' gestation; all women received 1.5 g from 20 weeks until delivery.

RESULTS

A total of 630 women conceived during the study, 322 allocated to calcium and 308 to placebo. Among these, 230 allocated to calcium and 227 allocated to placebo had information on body weight at baseline and at 8 weeks' gestation. During the study period, women allocated to calcium had a mean weight increase of 1.1 (SD ±5.5) kg, whereas those allocated to placebo had a mean increase of 1.5 (SD ±6.1) kg, a mean difference of 0.4 kg (95% -0.4 (-1.4 to 0.6); P = .408). Women classified as obese at the start of the trial had a lower body weight gain at 8 weeks' gestation (1.0 kg; 95% CI: -3.2 to 1.2; P = .330) and at 32 weeks' gestation (2.1 kg; 95% CI: 5.6-1.3; P = .225) if they received calcium as compared to placebo. However, none of these differences were statistically significant.

CONCLUSION

The smaller increase in body weight found in women supplemented with 500 mg elemental calcium daily is quantitatively consistent with previous studies. However, in this study, the difference was not statistically significant.

Contribution of calcium in drinking water from a South American country to dietary calcium intake

Objective

To describe the calcium concentration of tap and bottled waters from Argentina and to estimate the contribution of drinking water to calcium recommendations.

Results

Calcium concentrations provided by water authorities ranged from 6 to 105 mg/L. The mean calcium level of samples analysed at the Laboratorio de Ingeniería Sanitaria, National University of La Plata was 15.8 (SD ± 13.2) mg/L and at the Bone Biology Laboratory of the National University of Rosario was 13.1 (± 10.0) mg/L. Calcium values of samples from supply systems and private wells was similar. Most bottled waters had calcium levels well below 50 mg/L. The intake of one litre of drinking water from Argentina could represent in average between 1.2 and 8.0% of the calcium daily values for an adult.

Calcium Intake and Health

There are striking inequities in calcium intake between rich and poor populations. Appropriate calcium intake has shown many health benefits, such as reduction of hypertensive disorders of pregnancy, lower blood pressure particularly among young people, prevention of osteoporosis and colorectal adenomas, lower cholesterol values, and lower blood pressure in the progeny of mothers taking sufficient calcium during pregnancy. Studies have refuted some calcium supplementation side effects like damage to the iron status, formation of renal stones and myocardial infarction in older people. Attention should be given to bone resorption in post-partum women after calcium supplementation withdrawal. Mechanisms linking low calcium intake and blood pressure are mediated by parathyroid hormone raise that increases intracellular calcium in vascular smooth muscle cells leading to vasoconstriction. At the population level, an increase of around 400-500 mg/day could reduce the differences in calcium intake between high- and middle-low-income countries. The fortification of food and water seems a possible strategy to reach this goal.

Beta-thalassemia: renal complications and mechanisms: a narrative review

OBJECTIVES

Beta-thalassemias are a group of recessively autosomal inherited disorders of hemoglobin synthesis, which, due to mutations of the beta-globin gene, lead to various degrees of defective beta-chain production, an imbalance in alpha/beta-globin chain synthesis, ineffective erythropoiesis, and anemia. Improved survival in thalassemic patients has led to the emergence of previously unrecognized complications, such as renal disease.

METHODS

A comprehensive literature review through PubMed was undertaken to summarize the published evidence on the epidemiology and pathophysiology of renal disease in thalassemia. Literature sources published in English since 1990 were searched, using the terms beta-thalassemia, renal disease.

RESULTS

Renal disease is considered to be the 4th cause of morbidity among patients with transfusion dependent thalassemia. Chronic anemia, hypoxia and iron overload are the main mechanisms implicated in development of renal injury, whereas several studies also suggested a contributive role of iron chelators.

DISCUSSION AND CONCLUSION

Kidney disease may develop through progressive renal tubular and glomerular damage; thus, its early recognition is important in order to prevent and/or reverse deterioration. This review will provide an insight on the involved mechanisms implicated in kidney disease in thalassemic patients and will discuss the updates on diagnosis and prevention of renal complications in thalassemia.

Urolithiasis is prevalent and associated with reduced bone mineral density in β-thalassaemia major

Asymptomatic urolithiasis is common and of mixed composition in patients with β-thalassaemia major. Twenty-seven subjects were imaged using dual-energy computer tomography to determine the presence and composition of urolithiasis. The prevalence of urolithiasis was 59% and affected patients generally had multiple stones, often with more than one component: struvite (33%), calcium oxalate (31%) and cystine (22%). Hypercalciuria was present in 78% of subjects and calcium-containing urolithiasis was associated with reduced femoral neck Z scores.

Clinical importance of chemokines and inflammatory cytokines for patient care following percutaneous nephrolithotripsy

Chemokines are a class of proteins with low molecular weight that serve important roles in the progression of inflammation. Percutaneous nephrolithotripsy is a surgical technique in which lasers or ultrasound are utilized to break down and/or remove kidney stones. In order to ensure a full recovery following surgery, effective patient care and nursing are required. In the present study, a total of 348 patients with kidney stones were recruited and the clinical importance of chemokines and inflammatory cytokines for the nursing of patients during perioperative period was investigated. Plasma levels of inflammatory cytokines, as well as chemokines in the C, CC and CXC families, were analyzed in patients following percutaneous nephrolithotripsy. Correlations between chemokines and inflammatory cytokines and the urinary concentration of calcium oxalate were also investigated. The results indicated that plasma levels of C and CC chemokines were downregulated in patients following percutaneous nephrolithotripsy, whereas the plasma concentrations of CXC chemokines were upregulated. Plasma concentration levels of inflammatory cytokines interleukin (IL)-8, IL-1, IL-17 and tumor necrosis factor (TNF)-α were significantly downregulated in patients following percutaneous nephrolithotripsy; however, no significant differences were observed in plasma levels of IL-6 and IL-10 pre- and post-surgery. Regression analysis revealed that plasma concentration levels of chemokine C motif ligand, which is a C chemokine, chemokine ligand 2, which is a CC chemokine, and TNF-α were positively correlated with the urinary concentration of calcium oxalate during the perioperative period. The results of the present study indicate that plasma levels of chemokines and inflammatory cytokines are clinically important for nursing of patients who experienced percutaneous nephrolithotripsy.

Nephrolithiasis, bone mineral density, osteoporosis, and fractures: a systematic review and comparative meta-analysis

Our meta-analysis demonstrates that people with nephrolithiasis have decreased bone mineral density, an increased odds of osteoporosis, and potentially an elevated risk of fractures.

INTRODUCTION

People with nephrolithiasis might be at risk of reduced bone mineral density (BMD) and fractures, but the data is equivocal. We conducted a meta-analysis to investigate if patients with nephrolithiasis have worse bone health outcomes (BMD), osteoporosis, and fractures versus healthy controls (HCs).

METHODS

Two investigators searched major databases for articles reporting BMD (expressed as g/cm² or a T- or Z-score), osteoporosis or fractures in a sample of people with nephrolithiasis, and HCs. Standardized mean differences (SMDs), 95 % confidence intervals (CIs) were calculated for BMD parameters; in addition odds (ORs) for case-control and adjusted hazard ratios (HRs) in longitudinal studies for categorical variables were calculated.

RESULTS

From 1816 initial hits, 28 studies were included. A meta-analysis of case-control studies including 1595 patients with nephrolithiasis (mean age 41.1 years) versus 3402 HCs (mean age 40.2 years) was conducted. Patients with nephrolithiasis showed significant lower T-scores values for the spine (seven studies; SMD = -0.69; 95 % CI = -0.86 to -0.52; I ² = 0 %), total hip (seven studies; SMD = -0.82; 95 % CI = -1.11 to -0.52; I ² = 72 %), and femoral neck (six studies; SMD = -0.67; 95 % CI = --1.00 to -0.34; I ² = 69 %). A meta-analysis of the case-controlled studies suggests that people with nephrolithiasis are at increased risk of fractures (OR = 1.15, 95 % CI = 1.12-1.17, p < 0.0001, studies = 4), while the risk of fractures in two longitudinal studies demonstrated trend level significance (HR = 1.31, 95 % CI = 0.95-1.62). People with nephrolithiasis were four times more likely to have osteoporosis than HCs (OR = 4.12, p < 0.0001).

CONCLUSIONS

Nephrolithiasis is associated with lower BMD, an increased risk of osteoporosis, and possibly, fractures. Future screening/preventative interventions targeting bone health might be indicated.

Indications and Outcomes of Osteoporosis and Bone Modulation Therapies

Osteoporosis is a disorder of bone strength that leads to an increased risk of fractures. It is most commonly seen in patients aged 50 or older, although it can sometimes occur at a younger age if there are other comorbidities present. The most common cause of osteoporosis by far is menopause, although it also occurs in men, usually with higher morbidity rates than those seen in women. There are many treatment options available, such as anabolics and antiresorptives, with many more currently being developed. However, osteoporosis remains grossly unrecognized and untreated, resulting in a significant strain on the American economy.

Building healthy bones throughout life: an evidence-informed strategy to prevent osteoporosis in Australia

Osteoporosis imposes a tremendous burden on Australia: 1.2 million Australians have osteoporosis and 6.3 million have osteopenia. In the 2007–08 financial year, 82 000 Australians suffered fragility fractures, of which > 17 000 were hip fractures. In the 2000–01 financial year, direct costs were estimated at $1.9 billion per year and an additional $5.6 billion on indirect costs. Osteoporosis was designated a National Health Priority Area in 2002; however, implementation of national plans has not yet matched the rhetoric in terms of urgency. Building healthy bones throughout life, the Osteoporosis Australia strategy to prevent osteoporosis throughout the life cycle, presents an evidence-informed set of recommendations for consumers, health care professionals and policymakers. The strategy was adopted by consensus at the Osteoporosis Australia Summit in Sydney, 20 October 2011. Primary objectives throughout the life cycle are: to maximise peak bone mass during childhood and adolescence to prevent premature bone loss and improve or maintain muscle mass, strength and functional capacity in healthy adults to prevent and treat osteoporosis in order to minimise the risk of suffering fragility fractures, and reduce falls risk, in older people. The recommendations focus on three affordable and important interventions — to ensure people have adequate calcium intake, vitamin D levels and appropriate physical activity throughout their lives. Recommendations relevant to all stages of life include: daily dietary calcium intakes should be consistent with Australian and New Zealand guidelines serum levels of vitamin D in the general population should be above 50nmol/L in winter or early spring for optimal bone health regular weight-bearing physical activity, muscle strengthening exercises and challenging balance/mobility activities should be conducted in a safe environment.

Calcium revisited: part II calcium supplements and their effects

Calcium supplements were tested in pregnancy and lactation, in childhood and adolescence, in pre- and postmenopausal women and in elderly persons with various effects on bone density and fracture incidence. They must be properly chosen and adequately used. In this case, the reported minor negative side-effects do not restrict their use. All these aspects are reviewed here.

25-Hydroxyvitamin D in the range of 20 to 100 ng/mL and incidence of kidney stones

OBJECTIVES

Increasing 25-hydroxyvitamin D serum levels can prevent a wide range of diseases. There is a concern about increasing kidney stone risk with vitamin D supplementation. We used GrassrootsHealth data to examine the relationship between vitamin D status and kidney stone incidence.

METHODS

The study included 2012 participants followed prospectively for a median of 19 months. Thirteen individuals self-reported kidney stones during the study period. Multivariate logistic regression was applied to assess the association between vitamin D status and kidney stones.

RESULTS

We found no statistically significant association between serum 25-hydroxyvitamin D and kidney stones (P = .42). Body mass index was significantly associated with kidney stone risk (odds ratio = 3.5; 95% confidence interval = 1.1, 11.3).

CONCLUSIONS

We concluded that a serum 25-hydroxyvitamin D level of 20 to 100 nanograms per milliliter has no significant association with kidney stone incidence.

Thalassemia bone disease: the association between nephrolithiasis, bone mineral density and fractures

Thalassemia bone disease is well described, but the prevalence of nephrolithiasis has not been characterized. The association between nephrolithiasis, reduced bone density, and increased fractures has been demonstrated through this retrospective study of 166 participants with transfusion-dependent thalassemia. The findings support the need for increased vigilance of kidney and bone disease in this cohort.

INTRODUCTION

Previous studies have revealed that thalassemia is associated with reduced bone mineral density (BMD) and fractures. Many causes are implicated including hypogonadism, growth hormone deficiency, marrow expansion, and iron overload. Nephrolithiasis is associated with reduced BMD and increased fractures in the general population. However, the prevalence of nephrolithiasis and its association with bone density and fractures have not been characterized in thalassemia.

METHODS

We have addressed this question by performing a retrospective cohort study of 166 participants with transfusion-dependent thalassemia who had undergone dual-energy X-ray absorptiometry between 2009 and 2011. Logistic regression modeling was used to adjust for potential confounders.

RESULTS

We found a high prevalence of kidney stones (18.1 %) which was greater in males compared to females (28.7 vs 9.7 %, respectively). Renal stones were associated with reduced femoral neck Z-score and fractures in men after adjusting for potential confounders. These results indicate that nephrolithiasis is highly prevalent in patients with transfusion-dependent thalassemia and is significantly associated with reduced BMD and increased fractures.

CONCLUSIONS

The findings from this study strongly support the need for ongoing surveillance of BMD, fractures, and nephrolithiasis in the management of transfusion-dependent thalassemia.

Vitamin D, calcium, and cardiovascular mortality: a perspective from a plenary lecture given at the annual meeting of the American Association of Clinical Endocrinologists

OBJECTIVE

To examine data showing associations between serum 25-hydroxyvitamin D levels and calcium intake and cardiovascular mortality.

METHODS

The articles reviewed include those published from 1992-2011 derived from search engines (PubMed, Scopus, Medscape) using the following search terms: vitamin D, calcium, cardiovascular events, cardiovascular mortality, all-cause mortality, vascular calcification, chronic kidney disease, renal stones, and hypercalciuria. Because these articles were not weighted (graded) on the level of evidence, this review reflects my own perspective on the data and how they should be applied to clinical management.

RESULTS

For skeletal health, vitamin D and calcium are both needed to ensure proper skeletal growth (modeling) and repair (remodeling). Nutritional deficiencies of either vitamin D or calcium may lead to a spectrum of metabolic bone disorders. Excessive consumption of either nutrient has been linked to a variety of medical disorders, such as hypercalcemia or renal stones. There have also been associations between vitamin D or calcium intake and cardiovascular disease. However, neither of these associations have established evidence nor known causality for increasing cardiovascular risk or all-cause mortality in patients with creatinine clearances greater than 60 mL/min. In patients with more severe chronic kidney disease, stronger data link excess calcium (or phosphorus) intake and increase in vascular calcification, but not mortality. The safe upper limit for vitamin D intake is at least 4000 IU daily and probably 10 000 IU daily; for calcium, the safe upper limit is between 2000 and 3000 mg daily.

CONCLUSIONS

While no solid scientific evidence validates that serum vitamin D levels between 15 and 70 ng/mL are associated with increased cardiovascular disease risk, stronger but inconsistent evidence shows an association between calcium supplementation greater than 500 mg daily and an increase in cardiovascular disease risk. Most professional societies suggest that replacement levels of these nutrients be personalized with the goal of reaching a 25-hydroxyvitamin D concentration between 30 and 50 ng/mL and a calcium intake of 1200 mg daily.

Proceedings of the 2011 Santa Fe Bone symposium

The 11th Santa Fe Bone Symposium was held in Santa Fe, NM, USA, on August 6-7, 2010. This annual event addresses the clinical relevance of recent scientific advances in the fields of osteoporosis and metabolic bone disease. The symposium format included plenary presentations, oral abstracts, and interactive panel discussions, with participation of clinicians, researchers, and bone densitometry technologists. Among the many topics included in the symposium were new developments in nutritional therapy for osteoporosis, parathyroid hormone for the assessment and treatment of skeletal disease, osteoporosis in men, new and emerging concepts in osteoporosis therapy, report on the 2010 International Society for Clinical Densitometry (ISCD)-International Osteoporosis Foundation FRAX Initiative and the ISCD Position Development Conference, balancing benefits and risks of bisphosphonate therapy, and an advanced bone densitometry workshop for clinicians and technologists.

Complementary medicine and safety: a systematic investigation of design and reporting of systematic reviews

OBJECTIVES

The objective of this study was to examine the methods used in systematic reviews of safety across a range of complementary therapies to assess the variation in approach and the potential for developing guidance on conduct and reporting.

DESIGN

Systematic reviews focusing on safety were retrieved from NHS Evidence and searches of major databases. A pre-prepared template was used for data extraction. Information extracted included details of search strategies, sources, participants, interventions, reported adverse event/effect(s) and causality assessment. Data extraction was carried out by one researcher and a check for accuracy by a second researcher. Methods were assessed against criteria based on guidance provided by the Cochrane Adverse Effects Methods Group.

RESULTS

A total of 2563 citations were screened and 88 systematic reviews were selected for inclusion. The majority focused on the safety of herbs and nutritional supplements. Approximately half the reviews covered all aspects of safety; other reviews addressed specific adverse effects or interactions. Types of data included in the reviews did not always reflect the focus of the review. Search strategies, sources used, quality assessment and assessment of causality also varied.

CONCLUSIONS

Detailed examination and comparison of the methods has highlighted several areas in which there is potential for development of guidelines and consensus on standards. These include search strategies, sources of information, data extraction and assessment of causality. The value of systematic reviews in relation to large outcome studies requires further consideration.

[Are calcium and vitamin D supplements for everyone?: Cons]

Calcium and vitamin D supplements are one of the most widely used treatments in the field of bone metabolism and, especially due to its frequency, in the case of the osteoporosis. Sometimes the use of these treatments can be easily justified because there is plenty of evidence or because prescription is mandatory. But other times, not only because of the possibility of adverse events, the indication of these therapies is more controversial. Furthermore, and particularly in the context of osteoporosis, it may be suggested that prescribing calcium and vitamin D supplements to the general population may reduce the impact of disease.

Calcium: An Essential Mineral

This review of calcium discusses briefly the role of the parathyroid glands, the gastrointestinal system, and the renal system in maintaining calcium homeostasis that is required for normal bone health, nerve and muscle function, and blood coagulation in the human body. The new recommendations for calcium intake by the United States Institute of Medicine are discussed. The concerns by the Institute of Medicine regarding adverse effects from excess calcium intake, especially hypercalcemia, nephrolithiasis (kidney stones), milk alkali syndrome, prostate cancer, and coronary heart disease, are reviewed.

Is excess calcium harmful to health?

Most current guidelines recommend that older adults and the elderly strive for a total calcium intake (diet and supplements) of 1,000 to 1,300 mg/day to prevent osteoporosis and fractures. Traditionally, calcium supplements have been considered safe, effective and well tolerated, but their safety has recently been questioned due to potential adverse effects on vascular disease which may increase mortality. For example, the findings from a meta-analysis of randomized controlled trials (currently published in abstract form only) revealed that the use of calcium supplements was associated with an ~30% increased risk of myocardial infarction. If high levels of calcium are harmful to health, this may alter current public health recommendations with regard to the use of calcium supplements for preventing osteoporosis. In this review, we provide an overview of the latest information from human observational and prospective studies, randomized controlled trials and meta-analyses related to the effects of calcium supplementation on vascular disease and related risk factors, including blood pressure, lipid and lipoprotein levels and vascular calcification.

Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society

OBJECTIVE

To update the evidence-based position statement published by The North American Menopause Society (NAMS) in 2006 regarding the management of osteoporosis in postmenopausal women.

METHODS

NAMS followed the general principles established for evidence-based guidelines to create this updated document. A panel of clinicians and researchers expert in the field of metabolic bone diseases and/or women's health was enlisted to review the 2006 NAMS position statement, compile supporting statements, and reach consensus on recommendations. The panel's recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Osteoporosis, which is especially prevalent among older postmenopausal women, increases the risk of fractures. Hip and spine fractures are associated with particularly high morbidity and mortality in this population. Given the health implications of osteoporotic fractures, the primary goal of osteoporosis therapy is to prevent fractures, which is accomplished by slowing or stopping bone loss, maintaining bone strength, and minimizing or eliminating factors that may contribute to fractures. The evaluation of postmenopausal women for osteoporosis risk requires a medical history, physical examination, and diagnostic tests. Major risk factors for postmenopausal osteoporosis (as defined by bone mineral density) include advanced age, genetics, lifestyle factors (such as low calcium and vitamin D intake, smoking), thinness, and menopause status. The most common risk factors for osteoporotic fracture are advanced age, low bone mineral density, and previous fracture as an adult. Management focuses first on nonpharmacologic measures, such as a balanced diet, adequate calcium and vitamin D intake, adequate exercise, smoking cessation, avoidance of excessive alcohol intake, and fall prevention. If pharmacologic therapy is indicated, government-approved options are bisphosphonates, selective estrogen-receptor modulators, parathyroid hormone, estrogens, and calcitonin.

CONCLUSIONS

Management strategies for postmenopausal women involve identifying those at risk for fracture, followed by instituting measures that focus on reducing modifiable risk factors through dietary and lifestyle changes and, if indicated, pharmacologic therapy.

Medical care for the final years of life: "When you're 83, it's not going to be 20 years"

The case of an 83-year-old man who has had a fall-related injury and continues to be the sole caregiver for his wife who has dementia exemplifies a common situation that clinicians face--planning for the final years of an elderly individual's life. To appropriately focus on the patient's most pressing issues, the approach should begin with an assessment of life expectancy and incorporation of evidence-based care whenever possible. Short-term issues are focused on efforts to restore the patient to his previous state of health. Mid-range issues address providing preventive care, identifying geriatric syndromes, and helping him cope with the psychosocial needs of being a caregiver. Long-term issues relate to planning for his eventual decline and meeting his goals for the end of life. Unfortunately, the workload and inefficiencies of primary care practice present barriers to providing optimal care for older patients. Systematic approaches, including team care, are needed to adequately manage chronic diseases and coordinate care.

Gastric band placement for obesity is not associated with increased urinary risk of urolithiasis compared to bypass

PURPOSE

Obesity is associated with multiple health risks. Bariatric surgery is a treatment for clinically severe obesity and is known to increase urolithiasis risk. However, trends in risk over time are not well characterized. Moreover little attention has been devoted to laparoscopic gastric band placement. A comparison of urinary risk of urolithiasis after the Roux-en-Y and gastric banding procedures was performed.

MATERIALS AND METHODS

We evaluated 24-hour urine collections from 39 subjects (11 male and 28 female, mean age 51 years) after bariatric surgery. Of these subjects 27 underwent Roux-en-Y gastric bypass and 12 had gastric banding procedures. Mean time since surgery was 3.4 and 2.1 years for the Roux-en-Y gastric bypass and gastric banding groups, respectively.

RESULTS

Urine volume was low in both groups (less than 1.5 l daily). Urinary calcium excretion was lower (p = 0.001) in the Roux-en-Y gastric bypass (100 mg daily) vs the gastric banding group (191 mg daily). After Roux-en-Y gastric bypass surgery 48% had a urinary oxalate of 45 mg daily or more compared to 25% after gastric banding. Urinary citrate was less than 370 mg daily for 14 subjects in the Roux-en-Y gastric bypass and 1 in the gastric banding group. All patients were taking calcium supplements. Dietary intake of high oxalate foods did not correlate with urinary oxalate excretion or with hyperoxaluria.

CONCLUSIONS

Our study confirms the risk of urinary stones following the Roux-en-Y gastric bypass procedure as a result of hyperoxaluria, low urine volume and hypocitraturia. Those with gastric banding placement had low urine volumes. Future studies should elucidate the effect of nutrition and/or pharmacological therapy on stone risk of both surgeries as their incidence increases.

Diet, fluid, or supplements for secondary prevention of nephrolithiasis: a systematic review and meta-analysis of randomized trials

CONTEXT

Although numerous trials have evaluated efficacy of diet, fluid, or supplement interventions for secondary prevention of nephrolithiasis, few are included in previous systematic reviews or referenced in recent nephrolithiasis management guidelines.

OBJECTIVE

To determine efficacy and safety of diet, fluid, or supplement interventions for secondary prevention of nephrolithiasis.

EVIDENCE ACQUISITION

Systematic review and meta-analysis of trials published January 1950 to March 2008. Sources included Medline and bibliographies of retrieved articles. Eligible trials included adults with a history of nephrolithiasis; compared diet, fluids, or supplements with control; compared relevant outcomes between randomized groups (eg, stone recurrence); had > or = 3 mo follow-up; and were published in the English language. Data were extracted on participant and trial characteristics, including study methodologic quality.

EVIDENCE SYNTHESIS

Eight trials were eligible (n=1855 participants). Study quality was mixed. In two trials, water intake > 2 l/d or fluids to achieve urine output > 2.5 l/d reduced stone recurrence (relative risk: 0.39; 95% confidence interval: 0.19-0.80). In one trial, fewer high soft drink consumers assigned to reduced soft drink intake had renal colic than controls (34% vs 41%, p=0.023). Content and results of multicomponent dietary interventions were heterogeneous; in one trial, fewer participants assigned increased dietary calcium, low animal protein, and low sodium had stone recurrence versus controls (20% vs 38%, p=0.03), while in another trial, more participants assigned diets that included low animal protein, high fruit and fiber, and low purine had recurrent stones than controls (30% vs 4%, p=0.004). No trials examined the independent effect of altering dietary calcium, sodium, animal protein, fruit and fiber, purine, oxalate, or potassium. Two trials showed no benefit of supplements over control treatment. Adverse event reporting was poor.

CONCLUSIONS

High fluid intake decreased risk of recurrent nephrolithiasis. Reduced soft drink intake lowered risk in patients with high baseline soft drink consumption. Data for other dietary interventions were inconclusive, although limited data suggest possible benefit from dietary calcium.

Nutritional therapies (including fosteum)

Nutrition is important in promoting bone health and in managing an individual with low bone mass or osteoporosis. In adult women and men, known losses of bone mass and microarchitecture occur, and nutrition can help minimize these losses. In every patient, a healthy diet with adequate protein, fruits, vegetables, calcium, and vitamin D is required to maintain bone health. Recent reports on nutritional remedies for osteoporosis have highlighted the importance of calcium in youth and continued importance in conjunction with vitamin D as the population ages. It is likely that a calcium intake of 1200 mg/d is ideal, and there are some concerns about excessive calcium intakes. However, vitamin D intake needs to be increased in most populations. The ability of soy products, particularly genistein aglycone, to provide skeletal benefit has been recently studied, including some data that support a new medical food marketed as Fosteum (Primus Pharmaceuticals, Scottsdale, AZ).