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Foerster RH, Lamprecht G, Rischmüller K, Berlin P, Rousing AQ, Sørensen MV, Leipziger J, Berg P. Urinary acid-base excretion deciphers high acid load from colonic bicarbonate loss in intestinal failure patients with ileocolonic anastomosis - Guidance for composition of parenteral support. Clin Nutr 2024; 43:1043-1050. [PMID: 38554476 DOI: 10.1016/j.clnu.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/03/2024] [Accepted: 03/12/2024] [Indexed: 04/01/2024]
Abstract
BACKGROUND & AIMS Acid-base disturbances are common in short bowel (SB) patients due to increased intestinal bicarbonate loss. However, the resulting systemic acid load has not been quantified. Base excess is used to monitor metabolic acid-base disturbances but inadequately reflects the acid load. Our aim was to investigate the systemic acid/base load in SB-patients to obtain quantitative estimates to guide the composition of parenteral support. METHODS We calculated total acid load in SB patients by summing 24-h urinary net acid excretion (NAE) and the provision of base equivalents in parenteral support. We then compared differences among anatomical SB-types: jejunostomy (SB-J), jejunocolostomy (SB-JC), and jejunoileostomy (SB-JIC). 47 urine samples from 34 SB patients were analyzed for bicarbonate (HCO3-), ammonium (NH4+), and titratable acid (TA) concentrations. NAE was calculated as (TA + NH4+) - HCO3-. Mixed-effects repeated-measures models were used to statistically examine differences between SB-types and associations with parenteral nutrition and NAE. A healthy cohort served as control. RESULTS In comparison to SB-J, SB-JC patients had a 4.1 mmoL/l lower base excess (95% CI: -6.3 to -1.8) and an 84.5 mmol/day higher total acid load (CI: 41.3 to 127.7). There were no significant differences between SB-JIC and SB-J regarding base excess, NAE, or total acid load. Higher amounts of infused acetate, sodium, and chloride, but not the acetate/chloride ratio, were associated with lower NAE and higher base excess. CONCLUSIONS Due to increased colonic bicarbonate loss, patients with SB-JC have a ∼4.4-fold higher acid load than healthy controls. The ion transport mechanisms mediating this bicarbonate loss from the remaining colon need further experimental investigation. NAE could be a useful tool to adjust base infusion in SB.
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Affiliation(s)
- Robert H Foerster
- Rostock University Medical Center, Department of Medicine II, Division of Gastroenterology and Endocrinology, Rostock, Germany
| | - Georg Lamprecht
- Rostock University Medical Center, Department of Medicine II, Division of Gastroenterology and Endocrinology, Rostock, Germany.
| | - Karen Rischmüller
- Rostock University Medical Center, Department of Medicine II, Division of Gastroenterology and Endocrinology, Rostock, Germany
| | - Peggy Berlin
- Rostock University Medical Center, Department of Medicine II, Division of Gastroenterology and Endocrinology, Rostock, Germany
| | - Amalie Q Rousing
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark
| | - Mads V Sørensen
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark
| | - Jens Leipziger
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark
| | - Peder Berg
- Department of Biomedicine, Health, Aarhus University, Aarhus, Denmark
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Siener R, Ernsten C, Speller J, Scheurlen C, Sauerbruch T, Hesse A. Intestinal Oxalate Absorption, Enteric Hyperoxaluria, and Risk of Urinary Stone Formation in Patients with Crohn's Disease. Nutrients 2024; 16:264. [PMID: 38257157 PMCID: PMC10821467 DOI: 10.3390/nu16020264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 01/13/2024] [Accepted: 01/14/2024] [Indexed: 01/24/2024] Open
Abstract
Nephrolithiasis is a common urologic manifestation of Crohn's disease. The purpose of this study was to investigate the clinical characteristics, intestinal oxalate absorption, and risk factors for urinary stone formation in these patients. In total, 27 patients with Crohn's disease and 27 healthy subjects were included in the present study. Anthropometric, clinical, and 24 h urinary parameters were determined, and the [13C2]oxalate absorption test was performed. Among all patients, 18 had undergone ileal resection, 9 of whom had a history of urinary stones. Compared to healthy controls, the urinary excretion values of calcium, magnesium, potassium, sulfate, creatinine, and citrate were significantly lower in patients with Crohn's disease. Intestinal oxalate absorption, the fractional and 24 h urinary oxalate excretion, and the risk of calcium oxalate stone formation were significantly higher in patients with urolithiasis than in patients without urolithiasis or in healthy controls. Regardless of the group, between 83% and 96% of the [13C2]oxalate was detected in the urine within the first 12 h after ingestion. The length of ileum resection correlated significantly with the intestinal absorption and urinary excretion of oxalate. These findings suggest that enteric hyperoxaluria can be attributed to the hyperabsorption of oxalate following extensive ileal resection. Oral supplementation of calcium and magnesium, as well as alkali citrate therapy, should be considered as treatment options for urolithiasis.
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Affiliation(s)
- Roswitha Siener
- University Stone Center, Department of Urology, University Hospital Bonn, 53127 Bonn, Germany; (C.E.); (A.H.)
| | - Charlotte Ernsten
- University Stone Center, Department of Urology, University Hospital Bonn, 53127 Bonn, Germany; (C.E.); (A.H.)
| | - Jan Speller
- Department of Medical Biometry, Informatics and Epidemiology, Medical Faculty, University of Bonn, 53127 Bonn, Germany;
| | - Christian Scheurlen
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany; (C.S.); (T.S.)
| | - Tilman Sauerbruch
- Department of Internal Medicine I, University Hospital Bonn, 53127 Bonn, Germany; (C.S.); (T.S.)
| | - Albrecht Hesse
- University Stone Center, Department of Urology, University Hospital Bonn, 53127 Bonn, Germany; (C.E.); (A.H.)
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Ekmeiro-Salvador JE, Storz MA. The Impact of Plant-Based Diets on Dietary Acid Load Metrics in Venezuela: A Cross-Sectional Study. Nutrients 2023; 15:2745. [PMID: 37375649 DOI: 10.3390/nu15122745] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
Dietary acid load (DAL) is an important determinant of the acid-base balance in humans and has been associated with several chronic non-communicable diseases. Plant-based diets, including vegetarian and vegan diets, decrease DAL-although their alkalizing potential varies substantially. Their net effect on common DAL scores, including potential renal acid load and net endogenous acid production, has been insufficiently quantified and is poorly understood-particularly in populations outside of Europe and North America. We assessed the associations between three plant-based dietary patterns (flexitarian vs. lacto-ovo-vegetarian vs. vegan diet) and DAL scores in a healthy Venezuelan population in the metropolitan area of Puerto La Cruz, Venezuela. Substantial differences in DAL scores were observed, whereby the vegan diet yielded the highest alkalizing potential, followed by the lacto-ovo-vegetarian and the flexitarian diet. DAL scores were substantially lower in comparison to European and North American plant-based populations, probably due to the higher potassium intake (exceeding 4000 mg/d in vegans), the higher magnesium intake (390.31 ± 1.79 mg/d in vegans) and the lower intake of protein in vegans and lacto-ovo-vegetarians. Additional studies in other non-industrialized populations are warranted to allow for a better understanding of the (numeric) impact of plant-based dietary patterns on DAL scores, potentially allowing for an establishment of reference ranges in the near future.
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Affiliation(s)
| | - Maximilian Andreas Storz
- Department of Internal Medicine II, Centre for Complementary Medicine, Freiburg University Hospital Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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Stamatelou K, Goldfarb DS. Epidemiology of Kidney Stones. Healthcare (Basel) 2023; 11:healthcare11030424. [PMID: 36766999 PMCID: PMC9914194 DOI: 10.3390/healthcare11030424] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/25/2023] [Accepted: 01/29/2023] [Indexed: 02/05/2023] Open
Abstract
In the past two decades, major breakthroughs that improve our understanding of the pathophysiology and therapy of kidney stones (KS) have been lacking. The disease continues to be challenging for patients, physicians, and healthcare systems alike. In this context, epidemiological studies are striving to elucidate the worldwide changes in the patterns and the burden of the disease and identify modifiable risk factors that contribute to the development of kidney stones. Our expanding knowledge of the epidemiology of kidney stones is of paramount importance and largely upgrades the modern management of the disease. In this paper, we review the variables affecting prevalence and incidence, including age, gender, race, ethnicity, occupation, climate, geography, systemic diseases, diabetes, vascular disease, chronic kidney disease, and dietary risk factors relevant to kidney stones.
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Affiliation(s)
- Kyriaki Stamatelou
- “MESOGEIOS” Nephrology Center, Haidari and Nephros.eu Private Clinic, 11527 Athens, Greece
| | - David S. Goldfarb
- Nephrology Division, NYU Langone Health and NYU Grossman School of Medicine, NY Nephrology Section, NY Harbor VA Healthcare System, New York, NY 10016, USA
- Correspondence: ; Tel.: +1-212-686-7500 (ext. 3877); Fax: +1-212-951-6842
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Uribarri J, Goldfarb DS, Raphael KL, Rein JL, Asplin JR. Beyond the Urine Anion Gap: In Support of the Direct Measurement of Urinary Ammonium. Am J Kidney Dis 2022; 80:667-676. [PMID: 35810828 DOI: 10.1053/j.ajkd.2022.05.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/10/2022] [Indexed: 02/02/2023]
Abstract
Ammonium is a major urinary buffer that is necessary for the normal excretion of the daily acid load. Its urinary rate of excretion (UNH4) may be increased several fold in the presence of extrarenal metabolic acidosis. Therefore, measurement of UNH4 can provide important clues about causes of metabolic acidosis. Because UNH4 is not commonly measured in clinical laboratories, the urinary anion gap (UAG) was proposed as its surrogate about 4 decades ago, and it is still frequently used for that purpose. Several published studies strongly suggest that UAG is not a good index of UNH4 and support the concept that direct measurement of UNH4 is an important parameter to define in clinical nephrology. Low UNH4 levels have recently been found to be associated with a higher risk of metabolic acidosis, loss of kidney function, and death in persons with chronic kidney disease, while surrogates like the UAG do not recapitulate this risk. In order to advance the field it is necessary for the medical community to become more familiar with UNH4 levels in a variety of clinical settings. Herein, we review the literature, searching for available data on UNH4 under normal and various pathological conditions, in an attempt to establish reference values to interpret UNH4 results if and when UNH4 measurements become available as a routine clinical test. In addition, we present original data in 2 large populations that provide further evidence that the UAG is not a good predictor of UNH4. Measurement of urine NH4 holds promise to aid clinicians in the care of patients, and we encourage further research to determine its best diagnostic usage.
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Affiliation(s)
- Jaime Uribarri
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
| | | | - Kalani L Raphael
- Oregon Health & Science University and VA Portland Health Care System, Portland, Oregon
| | - Joshua L Rein
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John R Asplin
- Litholink Corporation, Laboratory Corporation of America Holdings, Chicago, Illinois
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Emmett M. Review of Clinical Disorders Causing Metabolic Acidosis. Adv Chronic Kidney Dis 2022; 29:355-363. [PMID: 36175073 DOI: 10.1053/j.ackd.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/28/2022] [Accepted: 07/12/2022] [Indexed: 01/25/2023]
Abstract
The various mechanisms responsible for the development of metabolic acidosis are briefly reviewed, and the metabolic acidoses are categorized both by mechanism and by the presence or absence of an increased anion gap. When a diagnosis of metabolic acidosis is established, it becomes imperative to identify the primary causative etiology as quickly as possible. This is often readily apparent from the history and physical exam (ie, diabetic ketoacidosis when the glucose is very high in a patient with diabetes mellitus; lactic acidosis in a patient with sepsis and hypotension, etc.). However, when the etiology is not obvious, it is very helpful to determine if the metabolic acidosis is of the hyperchloremic or high-anion-gap type (or a combination of both). Once this categorization has been established, a stepwise consideration of each of the potential causative etiologies will usually direct the clinician to order the appropriate diagnostic studies.
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Affiliation(s)
- Michael Emmett
- Department of Internal Medicine, Baylor University Medical Center, Dallas, TX.
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Wesson DE. The Importance of Recognizing and Addressing the Spectrum of Acid Stress. Adv Chronic Kidney Dis 2022; 29:364-372. [PMID: 36175074 DOI: 10.1053/j.ackd.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/01/2022] [Accepted: 06/09/2022] [Indexed: 01/25/2023]
Abstract
Acid accumulation sufficient to reduce plasma bicarbonate concentration, thereby recognized as chronic metabolic acidosis, harms bones and muscles and appears to enhance progression of CKD. Evolving evidence supports that progressive acid accumulation that is not enough to cause chronic metabolic acidosis nevertheless has deleterious effects. Measurable acid retention without reduced plasma bicarbonate concentration, called eubicarbonatemic acidosis, also appears to cause kidney injury and exacerbate CKD progression. Furthermore, chronic engagement of mechanisms to mitigate the ongoing acid challenge of net acid-producing diets of developed societies also appears to be deleterious, including for kidney health. This review challenges clinicians to consider the growing evidence for a spectrum of acid-accumulation disorders that include lesser degrees of acid accumulation than metabolic acidosis yet are harmful. Further research will develop clinically useful tools to identify individuals suffering from these earlier stages of acid stress and determine if the straightforward and comparatively inexpensive intervention of dietary acid reduction relieves or eliminates the harm they appear to cause.
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Affiliation(s)
- Donald E Wesson
- The University of Texas at Austin Dell Medical School, Austin, TX; Donald E Wesson Consulting LLC, Dallas, TX.
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