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V. Biourge, DVM PhD Dip ACVN&ECVCN Royal Canin, Centre de Recherche, Aimargues (France) Dietary management of (reccurent) urolithiasis.

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Presentation on theme: "V. Biourge, DVM PhD Dip ACVN&ECVCN Royal Canin, Centre de Recherche, Aimargues (France) Dietary management of (reccurent) urolithiasis."— Presentation transcript:

1 V. Biourge, DVM PhD Dip ACVN&ECVCN Royal Canin, Centre de Recherche, Aimargues (France) Dietary management of (reccurent) urolithiasis.

2 Plan Lower urinary tract diseases (LUTD) Work-up of reccurent urolithiasis Urinary stones How to determine their composition ? Urinary Supersaturation Dietary management of stone reccurence.

3 LUTD: definition Buffington Dr. Rosama Pusoonthornthum LUTD Syndrome Frequent urination: pollakiuria Painful urination: dysuria Blood in urine: hematuria Urination outside litter box: periuria Urethral blockade

4 LUTD

5 LUTD: older cats Most frequent causes 81 cats > 10 yr with hematuria and dysuria UTI % Urolith + UTI % Uroliths % Urethral plugs % Trauma % Idiopathic % Bartges, 1997

6 Reccurence of LUTDs Diagnostic work-up Clinical and dietary History Clinical exam –Palpation –Other clinical signs Urine analysis –pH (at home, pH meter) –Specific gravity, Glucose –Hematuria –Bacteria/leucocytes –Crystals (agregates, cystine, urate) Urine culture –If risk factors Radiology ou echography Blood biochemistry –Diabetes, hyperthyroïdism, cushing, renal disease, hypercalcemia, … Cystine CVUC

7 Reccurence of stones To have in mind Stone composition might differ between episodes. Easy to miss a stone during surgery (CaOx, urate) Foreign bodies (suture material in 9.4% of reccurent stones) Urinary crystals do not allow to predict stone composition (except cystine, xanthine and urate in Dalmatian) CVUC

8 Urinary stones Struvite Calcium oxalate Courtesy of Dr Buffington Urate Courtesy of Dr Deschamps XanthineSilicaPhosphate de CaCystine CVUCWCPN 40-45% 6-15%0.6 Ct-5Cn %< 0.01 %Cn %Cn <0.01 %Cn-Ct

9 Simple Vs mixed stones Simple –One major mineral (>70%) –Mineral = 100% % of stones Mixed stones –< 70 % –Nidus CVUC CaOx Struvite

10 Urinary stone composition CVUC

11 Urinary stone composition CVUC

12 Urinary stone composition Optical crystallography X-ray diffraction IR Spectrography, HPLC, … UC Davis: Minnesota Urolith Center: Canadian veterinary urolith center: sion_form_EN%2006_10.pdf

13 A problem of small dogs Canadian Veterinary urolith Center Submissions

14 Breed effect - dogs a b a a a b b b AE Stevenson, 2002 Breed panel composition will affect CaOx RSS

15 Urine supersaturation Crystal formation P O- O - Mg Ca Sulfate C C O O O O - - Citrate Urine C C O O O O Ca Calcium Oxalate Na + K +

16 Urinary pH and concentrations (mmol/l): calcium, magnesium, sodium, potassium, phosphate, sulfate, ammonium, oxalate, citrate and uric acid Struvite and Calcium Oxalate Relative Supersaturation (RSS) Supersat ®, Equil ® RSS Calculation Ionic chromatography (Dionex, Sunnyvale, CA, USA) Cations methanesulfonic acid Anions KOH

17 RSS a tool to measure urine supersaturation and risk crystal formation METASTABLE SUPERSATURATION Spontaneous crystallization Rapid crystal growth UNDERSATURATION LABILE SUPERSATURATION Solubility product No crystal dissolution No crystallization Crystal dissolution Formationproduct Formation product RSS 1 (71-99 mg/L) CaOx 12 (900 mg/L) MAP 2.5

18 How do we test the influence of the diet on RSS. Adaptation (9 d)Collection (5 d) Supersat ® RSS Struvite RSS CaOx 6-8 X As of June 30, 2008 Feline diets: 341 dry diets 25 moist diets Canine diet: 53 dry diets 2881 urine samples analyses or Titration pH =2 -20°C Chlorhexidine 20% Volume SG

19 To promote urine diuresis (689) (95)(15)(33) Dry < 0,8% Na/DM Dry > 0,8% Na/DM Wet < 0,8% Na/DM Wet > 0,8% Na/DM mL/kg/d

20 Reccurence of struvite stones

21 Struvite: Physiopathology (cats) JP Cotard Concentrated urine Mg, NH4+, PO4 Dry diet Nacl ? Dietary fiber pH > 6.5 Sulfur Aa Alkalizing minerals Alkaline tide If pH < 6.5 If diluted urine

22 Struvite: Physiopathology UTI Positive-urease bacteria Staphylococcus spp. (S. Intermedius) Proteus Spp Antibiotherapy validated by urine culture. Stérile: rare Dogs

23 Avoid struvite reccurence (cats) RSS struvite < 1 Dietary change Urinary pH Precursors Diuresis

24 Acidifying diets High in sulfur amino-acids –Methionine, Cystine –Animal proteins, Corn gluten Low in alkalinizing minerals –CaCO 3,... Use of acidifying mineral sources –CaCl 2, CaSO 4, … Other acidifiers –Phosphoric Acid, NH 4 Cl, Methionine pH RSS Struvite < 1 Time of dissolution median 18 d (10-55 d) Dissolution and prévention Acidifying diets Houston et al BJN 2011

25 RSS struvite Struvite stones: cumulative weight loss (%) Same pH but different RSS RSS = 0.45 RSS=0,4 RSS=0,2 pH = 6.1 Same RSS but different pH

26 Avoid struvite reccurence (dogs) Disappearance of clinical signs < 10 d Time of dissolution: 3 mo No dissolution:- Antibio-resistance - no struvite or mixed stones ATBQ : 4 wks after disappearance of stones + control after Trt (7 d and 4 mo). Acidifying diets UTI Antibiotics/ NSAID diuresisUrinary pH No UTI Dietary Manage- ment

27 Reccurence of Calcium oxalate stones

28 Factors affecting CaOx RSS Diets ? pH urinaire protein, Ca, P, Mg, Na, K, Cl Protein level, source Fiber level, source Energy density Mineral bioavailability Calcium/Phosphorus Oxalate Sodium Vitamin D Vitamin C, B 6 …. Cats/dogs Hypercalciuria (HyperPTH, cushing, renal acidosis, idiopathique,..) Hyperoxaluria (chats) Genetics/Size Oxalobacter Promotors/ inhibitors …. Diuresis Canned food Sodium Dietary fiber …. JP Cotard Environnement Indoor Heat Neutering Stress

29 Solubility product Formation product RSS CaOx Individual data on 341 dry feline diets Urinary pH does not allow to predict CaOx urine saturation

30 Urinary pH & RSS struvite Individual data on 341 feline dry diets RSS Solubility Product

31 Dietary Sodium and high dietary moisture decreased Struvite and Calcium Oxalate RSS. Cats: NaCl and RSS Dietary Na (%/DM) Formation Product Usual level of Na in petfood

32 Stone-formers - dogs (Stevenson et al, 2004)

33 Metabolic dysfunction Treatments Diet diuresis Wet food NaCl Mictions RSS CaOx Oxalate, Vit C Vit D Ca/P ?urinary pH RSS CaOx Oxalate, Vit C Vit D Ca/P ?urinary pH Hyperparathyroidism Cushing syndrome Renal acidosis Low enzyme activity (hyperoxaluria I or II) Citrate deficiency B6 deficiency Avoid Glucocorticoids Vitamin D Vitamin C Furosemide ? Antibiotics Indicated Hydrochloro- thiazides K Citrate Prevention of reccurrences CaOX Regular check-up Xrays - ultrasound post-op Urinary sediments Xrays or ultrasound follow-up

34 Endogenous purines Dietary purines PURINE BODY POOL: Catabolism synthesissalvage degradation Guanine Hypoxanthine Xanthine Adenine Uric acid Allantoin uricase Uric acid Allantoin English Bulldog, Schnauzers, Shih Tzu, Yorkshire Allopurinol Giesecke et al, J Nutr 1982, 112, Bannasch, 2004; Safra, 2005 SLC2A9 Urate stones

35 Stevenson et Rutgers, 2006 Medical management Diet low in purines Organ meat, fishes, poultry, cheese, yeast Soy isolate, wheat gluten, casein, egg, rice Diet moderate in protein % protein ammonium (metabolic acidosis – UTI) Alkalinizing diet pH = > 6.5 animal protein, sulfur amino-acids Sodium bicarbonate, K citrate Promote diuresis (SG=1.025) Xanthine oxydase inhibitor Allopurinol Low purine diets Dissolution 4-40 wks (moyenne = 14 wks) JY Deschamps

36 Cystine stones Stevenson et Rutgers, 2006 Medical management Physiopathology aa reabsorption in renal tubules Very low solubility of cystine Hereditary - male Moderate to low protein diet % proteins – MET - CYS Taurine, carnitine supplementation Alkalinizing diet pH = ± 7.5 Sodium bicarbonate, K Citrate Promote diuresis N-(2mercaptopropionyl)-glycine (2-MPG) Thiol groups Diet low in methionine + cystine Dissolution 1-3 mo D Houston

37 Calcium phosphate stones Stevenson et Rutgers, 2006 Medical management Physiopathology Hyperparathyroïdism Renal tubular acidosis Idiopathic hypercalciuria ? Severe UTI with very high pH 4 mineral types HydroxyapatiteCa10(PO4)6(OH)2 BrushiteCaHPO42H2O Carbonate de calcium Whitlockite & octacalcium phosphate Management Treat the cause Stimulate diuresis pH Réduce dietary Ca/P, Vit D

38 Silica stones Stevenson et Rutgers, 2006 Prevention of reccurence Physiopathology Urinary hyperexcretion of silica ? Pica ? Poor quality vegetable ingredients Management ? Higher quality petfood Promote diuresis Houston

39 Conclusions Diuresis + Urine dilution: RSS + Miction + Wet diet + NaCl + Promote water intake Dietary management ++ Struvite (Cats ++, Dogs+) + Urate, cystine + CaOx ? (dilution, pH, other) ? Calcium phosphate, Silica Reccurence + Confirm the occurrence of stone(s) + ? UTI + If struvite suspected: dissolution + Others: identification + trt + Follow-up Animal + UTI (Struvite, urate) + Metabolism (CaOx, urate, CaP) + Inhibitors Crystallization Agregation

40 Bibliography Wetropp J et al; Lower urinary tract disorders in cats. et Adams LG et al Canine ureteral and lower urinary tract diseases. Textbook of Veterinary Internal Medicine 7 th edition, 2010, Saunders, St Louis;

41 Thank you … Merci … Obrigado …


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