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Medizinische Hochschule Hannover

InstitutBalneologieMedizinische Klimatologie

für

und

Effect of a bicabonate-rich mineral water

in patients with recurrent renal stone

formation – a controlled double-blind

study

Chr. Gutenbrunner, U. Smorag, O. Karagülle, F. Candir, H.

Becker, U. Jonas

Professor Christoph Gutenbrunner, MD, PhD,

Clinic for Physical Medicine and Rehabilitation

Hanover Medical School

Carl-Neuberg-Str. 1

D-30625 Hannover

gutenbrunner.christoph@mh-hannover.de

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Introduction

In the industrialised countries urolithiasis is a frequent

disease

Prevalence in Germany: 4.7%

Incidence: 1.47%

The rate of relapses is high: 50-60%

The extra-corporal shock-wave therapy is not free of

complications

For that reason an effective metaphylaxis is of major

importance

Medizinische Hochschule Hannover

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Introduction

A basic principle of the metaphylaxis of urolitioasis is the

dilution of the urine by an increase of the fluid intake

Additional principles are

the reduction of the excretion of stone forming

substances in the urine: calcium, oxalate, uric

acid and others

the enhancement of the excretion of inhibitors:

magnesium, citrate and others

the reduction of the crystallisation risk by influencing

the pH of the urine (dependent on the type of

renal stones)

Medizinische Hochschule Hannover

InstitutBalneologieMedizinische Klimatologie

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Introduction

From experimental studies it is known that

bicarbonate waters increase the urinary pH and the

citrate excretion

magnesium-rich waters increase the urinary excretion

of magnesium

the increase of calcium-excretion is over-

compensated by the increase of diuresis

Only a few studies were performed in patients

Most studies dealt with the problem of calcium-waters

Therefore we studied the effect of a magnesium- and

bicarbonate-rich mineral water

Medizinische Hochschule Hannover

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Material and MethodsMedizinische Hochschule Hannover

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Design of the Study:

- double-blind controlled study

- cross-over-design

Patients:

- Patients with multi-episodic CaOx-urolithiasis (n=34)

- males/females: 30/4

- number of stone episodes: 3.0 ± 1.6

Setting:

- Everyday activities

- no standardisation of the diet

- nutrition protocol

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Material and MethodsMedizinische Hochschule Hannover

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und

Interventions:

- 1.5 l/d bicarbonated water (2,673 mg HCO3-/l;

175 mg Mg++/l; 116 mg Ca++/l)

- 1.5 l/d low-mineralized water (98 mg HCO3-/l

8 mg Mg++/l; 38 mg Ca++/l)

- 1.400 ml of each water for three consecutive days

- all waters in the same type of bottles, colour code

- distance between drinking periods: one week

Main Outcome Parameters:

- 24-h-urine samples before drinking, 3rd day of drinking

- urinary pH (24-h-urine)

- magnesium- and citrate-excretion

- supersaturation CaOx and of other types of urinary stones

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ResultsMedizinische Hochschule Hannover

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und

4

5

6

7

8

***

Patients with Recurrent Urolithiasis (n = 34)

Calcium-Excretion

30

40

50

60

70

*

Oxalate-Excretion

3

4

5

6

7

***

Magnesium-Excretion

400

500

600

700

800

900

1000

1100

***

Citrate-Excretion

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ResultsMedizinische Hochschule Hannover

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und

1,0

1,5

2,0

2,5

3,0

3,5

4,0

******

[l]

Patients with Recurrent Urolithiasisn = 34

UrinaryVolume

Baseline Controls Baseline Bicarbonate Water

5,5

6,0

6,5

7,0

***

*

UrinarypH

1,0

1,5

2,0

2,5

3,0

3,5

4,0

4,5

******

SupersaturationCaOx

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ResultsMedizinische Hochschule Hannover

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Supersaturation CaOx

Supersaturation Uric acid

Supersaturation CaPO4

Controls

Baseline 3,41 ± 0,31 1,22 ± 0,13 1,33 ± 0,19

Drinking 2,44 ± 0,28 0,70 ± 0,07 1,01 ± 0,15

Bicarbonate Water

Baseline 3,39 ± 0,34 1,03 ± 0,12 1,44 ± 0,23

Drinking 2,42 ± 0,29 0,24 ± 0,04 2,01 ± 0,24

p (controls vs. bicarbonate water)*)

0,801 0,001 0,001

p (baseline vs. Drinking)**)

Controls 0,001 0,001 0,014

Bicarbonate Water

0,001 0,001 0,023

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Patients with high riskMedizinische Hochschule Hannover

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Low mineralised water bicarbonate rich water

Baseline Intervention Baseline Intervention Significance

Citrate-concentration

(mmol/l)

1,73 ± 0,88 1,18 ± 0,43 1,61 ± 0,72 1,60 ± 0,56p1 = 0,016**

p2 = 0,001*** p2 = 0,884

Magnesium-concentration

(mmol/l)

2,18 ± 0,92 1,53 ±0,49 2,09 ± 0,88 1,99 ± 065p1 = 0,033*

p2 = 0,001*** p2 = 0,961

Calcium-concentration

(mmol/l)

3,15 ± 1,68 2,17 ± 1,08 3,07 ± 1,37 2,57 ± 1,27p1 = 0,245

p2=0,001*** p2=0,007**

Oxalate-concentration

(mmol/l)

0,29 ± 0,09 0,21 ± 0,10 0,28 ± 0,12 0,21 ± 0,09p1 = 0,879

p2 = 0,002** p2 = 0,001***

Uric acid-concentration

(mmol/l)

1,77 ± 0,67 1,21 ± 0,32 1,49 ± 0,37 1,36 ± 0,40p1 = 0,152

p2 = 0,001*** p2 = 0,140

Phosphate-concentration

(mmol/l)

15,79 ± 6,48 10,86 ± 3,29 16,12 ± 3,29 9,80 ± 3,42p1 = 0,231

p2 = 0,001*** p2 = 0,001***

p1 = Significance between verum and controls p2 = Significance between baseline and drinking period

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ConclusionMedizinische Hochschule Hannover

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Both waters significantly reduce the renal stone formation

risk in patients with relapsing CaOx-urolithiasis

The mineral water additionally increases the urinary pH as

well as the excretion of magnesium and citrate

The mineral water is effective even in cases with high risk of

stone formation (hypercalciuria, hyperoxaluria)

Bicarbonated waters should be used in patients with

combined stones containing CaOx and uric acid or in

uric acid stones but not in in patients with phosphate

stones