Increased sulfate as an etiological factor in the hypercalciuria associated with total parenteral nutrition

Causal assessment of dietary acid load and bone disease: a systematic review & meta-analysis applying Hill's epidemiologic criteria for causality

Background

Modern diets have been suggested to increase systemic acid load and net acid excretion. In response, alkaline diets and products are marketed to avoid or counteract this acid, help the body regulate its pH to prevent and cure disease. The objective of this systematic review was to evaluate causal relationships between dietary acid load and osteoporosis using Hill's criteria.

Methods

Systematic review and meta-analysis. We systematically searched published literature for randomized intervention trials, prospective cohort studies, and meta-analyses of the acid-ash or acid-base diet hypothesis with bone-related outcomes, in which the diet acid load was altered, or an alkaline diet or alkaline salts were provided, to healthy human adults. Cellular mechanism studies were also systematically examined.

Results

Fifty-five of 238 studies met the inclusion criteria: 22 randomized interventions, 2 meta-analyses, and 11 prospective observational studies of bone health outcomes including: urine calcium excretion, calcium balance or retention, changes of bone mineral density, or fractures, among healthy adults in which acid and/or alkaline intakes were manipulated or observed through foods or supplements; and 19 in vitro cell studies which examined the hypothesized mechanism. Urine calcium excretion rates were consistent with osteoporosis development; however calcium balance studies did not demonstrate loss of whole body calcium with higher net acid excretion. Several weaknesses regarding the acid-ash hypothesis were uncovered: No intervention studies provided direct evidence of osteoporosis progression (fragility fractures, or bone strength as measured using biopsy). The supporting prospective cohort studies were not controlled regarding important osteoporosis risk factors including: weight loss during follow-up, family history of osteoporosis, baseline bone mineral density, and estrogen status. No study revealed a biologic mechanism functioning at physiological pH. Finally, randomized studies did not provide evidence for an adverse role of phosphate, milk, and grain foods in osteoporosis.

Conclusions

A causal association between dietary acid load and osteoporotic bone disease is not supported by evidence and there is no evidence that an alkaline diet is protective of bone health.

Meta-analysis of the quantity of calcium excretion associated with the net acid excretion of the modern diet under the acid-ash diet hypothesis

BACKGROUND

The acid-ash diet hypothesis of osteoporosis suggests that acid from the modern diet causes a demineralization of the skeleton, and mobilized bone calcium is excreted. A systematic approach has not been used to summarize the findings of the numerous studies about the hypothesis.

OBJECTIVES

The purpose of this meta-analysis was to estimate the quantity of net acid excretion and calciuria associated with the modern diet, to assess the association between acid excretion and calcium excretion, and to assess the influence of urine preservatives on calcium measurement.

DESIGN

We systematically searched for trials of the acid-ash hypothesis and conducted a meta-analysis.

RESULTS

Twenty-five of 105 studies met the inclusion criteria. The estimated quantity of net acid excretion from the weighted average of the control diets from 11 studies was 47 mEq/d. The increase in urinary calcium with a change in renal net acid excretion depended on whether the urine was acidic or alkaline (P < 0.001). A significant linear relation was observed between net acid excretion and calcium excretion for both acidic and alkaline urine (P < 0.001). The estimated change in urine calcium associated with a change of 47 mEq of net acid excretion in acidic urine was 1.6 mmol/d (66 mg/d) of calcium.

CONCLUSION

Evidence suggests a linear association between changes in calcium excretion in response to experimental changes in net acid excretion. However, this finding is not evidence that the source of the excreted calcium is bone or that this calciuria contributes to the development of osteoporosis.

The clinical chemistry of inorganic sulfate

Although inorganic sulfate is an essential and ubiquitous anion in human biology, it is infrequently assayed in clinical chemistry today. Serum sulfate is difficult to measure accurately without resorting to physicochemical methods, such as ion chromatography, although many other techniques have been described. It is strongly influenced by a variety of physiological factors, including age, diet, pregnancy, and drug ingestion. Urinary excretion is the principal mechanism of disposal for the excess sulfate produced by sulfur amino acid oxidation, and the kidney is the primary site of regulation. In renal failure, sulfoesters accumulate and hypersulfatemia contributes directly to the unmeasured anion gap characteristic of the condition. In contrast, sulfate in urine is readily assayed by a number of means, particularly nephelometry after precipitation as a barium salt. Sulfate is most commonly assayed today as part of the clinical workup for nephrolithiasis, because sulfate is a major contributor to the ionic strength of urine and alters the equilibrium constants governing saturation and precipitation of calcium salts. Total sulfate deficiency has hitherto not been described, although genetic defects in sulfate transporters have been associated recently with congenital osteochondrodystrophies that may be lethal. New insights into sulfate transport and its hormonal regulation may lead to new clinical applications of sulfate analysis in the future.

Quantitation of sulfate and thiosulfate in clinical samples by ion chromatography

For assay of serum sulfate, quantitation by ion conductimetry after separation by anion-exchange chromatography is the method of choice. In comparison to classical barium precipitation methods, chromatographic methods demonstrate increased precision, specificity and sensitivity, and they may be superior to spectrophotometric methods that rely on organic cation precipitation of sulfate. The increased sensitivity and specificity, as well as the inherent capacity of chromatographic methods for simultaneous determination of other anions, has led to its increasing use in the determination of excreted sulfate in clinical profiles of urinary anion composition. Ion chromatography can also be used to quantitate free sulfate in other clinical samples, including cerebrospinal fluid, sweat, saliva, breast milk and human tissues. Finally, ion chromatography shows promise as a more precise and sensitive method for measurement of total acid-labile sulfoesters and thiosulfate.

Manipulation of dietary cation-anion difference on nutritionally related production diseases, productivity, and metabolic responses of dairy cows

Dietary cation-anion difference has been defined as milliequivalents of (Na+K)-(Cl+S) per kilogram of DM and has a direct impact on blood acid-base metabolism. As this difference decreases, one or more of the following blood parameters change: increased H+, decreased HCO3-, and decreased pH. These changes are accompanied by reduced urinary HCO3- excretion and pH as compensatory mechanisms. Although other minerals have an impact on acid-base metabolism, the four minerals used in dietary cation-anion difference have the greatest effect. Manipulation of acid-base balance can be used to manipulate other biological functions to benefit health and productivity of cows. Low cation-anion difference prepartum can mitigate hypocalcemia peripartum via increased urinary Ca, blood-ionized Ca, and responsiveness to Ca homeostatic hormones. These changes reduced the incidence of paresis and increased productivity by reducing the severity and length of hypocalcemia in all cows (periparturient), regardless of the occurrence of paresis. Reduced cation-anion differences prepartum have been related to a reduced severity of udder edema, likely related to increased renal loss of water and unchanged water intake. However, the effects on acid-base balance cannot be ruled out because of effects on biochemical and transport processes. Elevated cation-anion difference in lactation has been shown to increase DMI and production and to mitigate the effects of heat stress. Because production and heat stress are acidogenic, elevated cation-anion difference improves blood-buffering capacity to cope with H+. In heat stress, elevated water intake with elevated cation-anion difference cannot be ignored. Other diseases related to metabolic acid, such as laminitis and ketoacidosis, may be influenced by elevated cation-anion difference in lactation; however, research in these areas has not been forthcoming.

Changes in acid-base balance and calcium metabolism after urinary diversion through ileal segments. II. Treatment with nicotinic acid

Investigations in animals have shown that nicotinic acid, an intestinal cyclic-AMP inhibitor, partially corrects the metabolic changes associated with urinary diversion through intestinal segments. Blood and serum chemistry were studied in patients before and 3 to 5 months after undergoing urinary diversion through ileal segments, both with and without nicotinic acid treatment. It was found that diverted patients had metabolic acidosis, an increased anion gap and increased levels of serum alkaline phosphatase; there were no significant changes in serum PTH and vitamin D levels, calcaemia and phosphoraemia. There was a tendency towards dehydration, hypernatraemia, hyperchloraemia and secondary hyperaldosteronism produced by ileal secretion of a hypotonic fluid. Nicotinic acid 3 g/day significantly reduced the chloraemia but did not correct the metabolic acidosis, although it reduced its severity, since blood pH decreased when treatment was suspended. Nicotinic acid cannot be recommended for routine use in the management of metabolic acidosis after urinary diversion, and patients with a marginal renal reserve should not be considered for trans-intestinal urinary diversion.

Effect of parenteral calcium and phosphorus therapy on mineral retention and bone mineral content in very low birth weight infants

HYPOTHESIS

If calcium and phosphorus are administered to very low birth weight infants in amounts larger than those currently used in standard parenteral nutrition solutions, apparent retention of calcium and phosphorus (intake minus urinary excretion) will increase and bone mineralization will improve.

DESIGN

Randomized, controlled, double-blind trial.

SETTING

Neonatal intensive care unit.

PATIENTS

Twenty-four very low birth weight infants (< 1.2 kg) expected to receive parenteral nutrition exclusively for approximately 3 weeks beginning 3 days after birth.

INTERVENTIONS

Infants received parenteral nutrition solutions, either the standard mixture containing 1.25 mmol calcium and 1.5 mmol phosphorus per deciliter (group STAND: n = 12, birth weight 921 +/- 171 gm, gestational age 27 +/- 2 weeks (mean +/- SD)) or 1.7 mmol calcium and 2.0 mmol phosphorus per deciliter (group HIGH: n = 12, 857 +/- 180 gm, 27 +/- 2 weeks).

MAIN OUTCOME MEASURES

Intake, urinary excretion, and apparent retention of calcium, phosphorus, and magnesium every 3 days during parenteral nutrition therapy. Serum indexes of mineral status twice during therapy. Bone mineral content of the distal segment of the left radius at 1, 4, 8, and 26 weeks.

RESULTS

Apparent calcium retention (1.2 +/- 0.2 vs 1.6 +/- 0.2 mmol.kg-1.d-1) and phosphorus retention (1.4 +/- 0.2 vs 1.8 +/- 0.4 mmol.kg-1.d-1) differed significantly (p < 0.01) between groups STAND and HIGH, respectively; neither changed with the duration of parenteral nutrition therapy. Serum calcium, magnesium, parathyroid hormone, 25-hydroxyvitamin D, and osteocalcin concentrations were similar in both groups. Serum phosphorus concentration was significantly higher in group HIGH than in group STAND (p = 0.025). The absolute bone mineral content and the rate of increase in bone mineral content between 1 and 4, 1 and 8, and 1 and 26 weeks were significantly greater in group HIGH than in group STAND.

CONCLUSIONS

Increased parenteral intakes of calcium and phosphorus resulted in greater retention of these minerals during parenteral nutrition therapy and in greater bone mineral content after therapy.

Role of the source of phosphate salt in improving the mineral balance of parenterally fed low birth weight infants

Because the monobasic potassium phosphate salt (monobasic) improves the solubility of calcium and phosphorus in amino acid plus dextrose solutions, compared with the current mixtures of monobasic plus dibasic salts (dibasic), we tested the bioavailability and clinical effects of monobasic in 16 parenterally fed low birth weight infants at standard (n = 8) and high levels (n = 8) of mineral intakes. A constant infusion of macronutrients and vitamin D was provided in a crossover design of two four-day periods. With standard intakes of calcium (35 mg/kg/day, 0.9 mmol/kg/day) and phosphorus (30 mg/kg/day, 1 mmol/kg/day), there was no difference between monobasic and dibasic regimens on balance data or plasma biochemical monitoring (calcium, phosphorus, pH, carbon dioxide pressure, base excess, 1,25-dihydroxyvitamin D, 25-hydroxyvitamin D). With the use of the monobasic regimen, the mineral intakes were doubled without precipitation in the infusate: calcium, 70 mg/kg/day (1.8 mmol/kg/day), and phosphorus, 55 mg/kg/day (1.7 mmol/kg/day). This led to increased apparent retention of both calcium (63 +/- 5 mg/kg/day, 1.58 +/- 0.12 mmol/kg/day) and phosphorus (52 +/- 4 mg/kg/day, 1.67 +/- 0.14 mmol/kg/day) compared with that for standard levels of mineral intake. The improvement of calcium-phosphorus balance was accompanied by more severe calciuria (9 +/- 2 mg/kg/day, 0.2 +/- 0.05 mmol/kg/day) and by metabolic compensation for an increased acid load. In addition to the possibility of exceeding the buffering capacity of the infant, this relative acidosis could also be evidence of improved bone mineralization.

Effect of dietary protein and minerals on calcium and zinc utilization

The utilization of most minerals can be altered not only by varying the dietary levels of protein, carbohydrate, fiber, fat, and vitamins but also by varying the forms of macronutrients fed. Interactions among minerals are frequent and sometimes complex. Thus, all assessments of mineral requirements should include discussions of the effects of interactions on mineral bioavailability. Some of these interactions occur in the gut and affect the absorption of minerals. Other interactions affect the metabolism, transport and storage of minerals, and ultimately their excretion in urine or in endogenous gut secretions.

Effect of sulfate on calcium and magnesium homeostasis following urinary diversion

The present investigation was undertaken to elucidate the mechanisms of renal calcium and magnesium wastage in patients with urinary diversion through intestinal segments. Patients with urinary intestinal diversions demonstrated a hyperchloremic metabolic acidosis, increased serum sulfate and phosphate, and increased urinary excretion of calcium, phosphate, sulfate, and magnesium. A study was conducted in rats utilizing oral or intravenous loads of various solutes to investigate the possible mechanisms of these findings in patients. Ammonium enhances renal sulfate excretion and intestinal sulfate absorption. Increased filtered loads of sulfate inhibit renal tubule sodium and calcium reabsorption. Dietary ammonium and sulfate result in increased serum phosphorous concentrations. Ammonium appears to directly inhibit renal magnesium reabsorption. Renal tubule dysfunction resulting from relieved obstruction appears to enhance the inhibitory effect of sulfate on renal sodium and calcium reabsorption but does not alter the effect of ammonium on renal magnesium excretion. Taken together, these findings suggest that patients with hyperchloremic metabolic acidosis from the chronic reabsorption of ammonium chloride by intestinal urinary diversions may also reabsorb urinary sulfate. This load of ammonium and sulfate inhibits renal calcium and magnesium reabsorption.

A key to the literature of total parenteral nutrition: update 1987

This comprehensive bibliography is intended to enhance the education of the practitioner, student, and academician in the area of parenteral nutrition. This bibliography is not all-inclusive but serves as an update from the original published in 1983. Of particular note in this work is the addition of topics that reflect a growing interest in medical specialties with regard to patient nutritional status and support.

Increased urinary excretion of inorganic sulfate in premature infants fed bovine milk protein

We report measurements of urinary inorganic sulfate (iSO4) in 38 very low birth weight (VLBW) premature infants receiving various protein intakes in the first 2 months of life. The primary source of urinary iSO4 is the metabolism of amino acids containing sulfur (methionine, cysteine, taurine). It was hypothesized that urinary iSO4 excretion would be increased in VLBW infants fed the relatively high concentrations of protein in mother's own milk (HM), mother's own milk fortified with 0.85 gm/dl bovine whey (fortified HM), and a special formula for premature infants (Similac Special Care, 20 cal/oz), and that urinary iSO4 excretion would correlate with calcium excretion. VLBW premature infants fed HM (protein intake 3.3 gm/kg day) excreted very small amounts of urinary iSO4 compared with infants fed fortified HM (4.5 gm/kg/day protein), Similac SC (2.9 gm/kg/day protein), or Similac (2.7 gm/kg/day protein), all three of which contain bovine whey. Unlike the case in adults, there was no correlation between either total protein intake and urinary calcium excretion or urinary iSO4 excretion. There was, however, a significant correlation between methionine intake and urinary iSO4 excretion (r = 0.48). We speculate that increased urinary iSO4 excretion is indicative of an overload of sulfur-containing amino acids, namely methionine, present in bovine whey protein. The data also support the ability of premature infants to catabolize relatively large quantities of sulfur-containing amino acids after 2 weeks of age.

Optimized calcium/phosphorus solubility in a parenteral nutrition solution containing dicarboxylic amino acids and cysteine

The solubility of calcium and phosphorus was studied in neonatal parenteral nutrition solutions containing dicarboxylic amino acids and cysteine. Experimental amino acid solutions containing aspartic acid, glutamic acid, and cysteine in concentrations from 0.5% to 2.0% were studied with dextrose concentrations of 5-20% plus standard electrolyte, vitamin, and trace element additives. Solutions were held at room temperature for 24 hr prior to incubation in a 37 degrees C water bath for 30 min. The pH of each solution was determined. Precipitation was detected by light scattering on a Cobas Bio centrifugal analyzer. An absorbance greater than 0.015 at 600 nm was considered evidence of precipitation. The pH of test solutions ranged between 5.7 and 6.4. Increasing amino acid concentration produced an improvement in calcium/phosphate solubility. Change in dextrose concentration had a lesser effect. Solutions of 10% dextrose with 2% amino acids contained 40 mEq/liter calcium and 17 mmol/liter phosphorus without precipitation. Administered at 150 ml/kg/day, such a solution would provide 120 mg/kg body weight/day calcium and 80 mg/kg/day phosphorus, approximately the daily in utero accretion rates during the last trimester. This is not readily achieved in comparable solutions of previous amino acid formulations.