Preventive fluid and dietary therapy for urolithiasis: An appraisal of strength, controversies and lacunae of current literature

Regulation of fluid and dietary intake habits is essential in comprehensive preventive management of urolithiasis. However, despite large body of epidemiological database, there is dearth of good quality prospective interventional studies in this regard. Often there is conflict in pathophysiological basis and actual clinical outcome. We describe conflicts, controversies and lacunae in current literature in fluid and dietary modifications in prevention of urolithiasis. Adequate fluid intake is the most important conservative strategy in urolithiasis-prevention; its positive effects are seen even at low volumes. Of the citrus, orange provides the most favorable pH changes in the urine, equivalent to therapeutic alkaline citrates. Despite being richest source of citrate, lemon does not increase pH significant due to its acidic nature. Fructose, animal proteins and fats are implicated in contributing to obesity, which is an established risk factor for urolithiasis. Fructose and proteins also contribute to lithogenecity of urine directly. Sodium restriction is commonly advised since natriuresis is associated with calciuresis. Calcium restriction is not advisable for urolithiasis prevention. Adequate calcium intake is beneficial if taken with food since it reduces absorption of dietary oxalate. Increasing dietary fiber does not protect against urolithiasis. Evidence for pyridoxine and magnesium is not robust. There is no prospective interventional study evaluating effect of many dietary elements, including citrus juices, carbohydrate, fat, dietary fiber, sodium, etc. Due to lack of good-quality prospective interventional trials it is essential to test the findings of pathophysiological understanding and epidemiological evidence. Role of probiotics and phytoceuticals needs special attention for future research