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2 AUTHORS:
Yige Bao
Qiang Wei
Sichuan University
Sichuan University
10 PUBLICATIONS 28 CITATIONS
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This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2012, Issue 6
http://www.thecochranelibrary.com
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 2.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 3.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Increased water intake versus standard water intake, Outcome 1 Stone recurrence.
. .
Analysis 1.2. Comparison 1 Increased water intake versus standard water intake, Outcome 2 Average interval for
recurrence. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
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[Intervention Review]
Contact address: Qiang Wei, Department of Urology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu,
Sichuan, 610041, China. wq933@hotmail.com.
Editorial group: Cochrane Renal Group.
Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 6, 2012.
Review content assessed as up-to-date: 18 April 2012.
Citation: Bao Y, Wei Q. Water for preventing urinary stones. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.:
CD004292. DOI: 10.1002/14651858.CD004292.pub3.
Copyright 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
Urinary stones are a common condition characterised by high incidence and high recurrence rate. For a long time, increased water
intake has been the main preventive measure for the disease and its recurrence. This is an update of a review originally published in
2004.
Objectives
To assess the effectiveness of increased water intake for the primary and secondary prevention of urinary stones.
Search methods
We searched the Cochrane Renal Groups specialised register, CENTRAL, MEDLINE, EMBASE, and the Chinese Biomedical Disk
using a search strategy developed in conjunction with Cochrane Renal Groups Trials Search Co-ordinator. No language restriction was
applied.
Date of last search: April 2012.
Selection criteria
Randomised controlled trials (RCTs) and quasi-RCTs of increased water intake for the prevention of urinary stones and its recurrence
were included.
Data collection and analysis
Two authors independently assessed risk of bias and extracted data. Statistical analyses were performed using the random effects model
and the results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95%
confidence intervals (CI).
Main results
No studies of increased water intake for the primary prevention of urinary stones met the inclusion criteria. One study with 199
patients provided results of increased water intake for the recurrence of urinary stones. The stone recurrence was lower in the increased
water intake group than that of the no intervention group (12% versus 27%; RR 0.45, 95% CI 0.24 to 0.84). The average interval for
recurrence was 3.23 1.1 years in increased water intake group and 2.09 1.37 years in the no intervention group (MD 1.14, 95%
CI 0.33 to 1.95). There were insufficient data to assess selection, performance, detection or attrition bias.
Water for preventing urinary stones (Review)
Copyright 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Authors conclusions
The evidence from only one study indicates that increased water intake reduces the risk of recurrence of urinary stones and prolongs
the average interval for recurrences. However further research is required. Due to the lack of appropriate RCTs, no conclusions can be
drawn on increased water intake for the primary and secondary prevention of urinary stones.
BACKGROUND
volume of urine, which is less saturated and theoretically benefits all stone-formers. Historical data suggests that increased water
intake is effective in preventing stone formation. Blacklock 1969
reported that stone formation rates dropped by 86% in the British
Navy when the average urinary output was increased from 800
to 1200 mL/d. Experimental evidence (Pak 1980) indicated that
high fluid intake resulted in the reduction of the saturation of
calcium phosphate, calcium oxalate and monosodium urate, and
increased the threshold at which calcium oxalate crystallised. The
authors concluded that there was a protective effect of urine dilution by increased water intake.
OBJECTIVES
This review aims to look at the benefits and harms of:
1. increased water intake for the primary prevention of urinary
stones in a population without a history of the disease; and
METHODS
Types of studies
All RCTs and quasi-RCTs (RCTs in which allocation to treatment was obtained by alternation, use of alternate medical records,
date of birth or other predictable methods) looking at the benefits
and harms of increased water intake for the prevention of urinary
stones and its recurrence. The first period of randomised crossover studies will be included.
Types of participants
All patients with or without a history of urinary stones (all types).
Types of interventions
Increased water intake (any kind of water) versus routine care, no
intervention or drugs given for more than three months.
Review update
The Cochrane Renal Groups specialised register was searched for
the update of the review in June 2011. The Specialised Register
contains studies identified from sources.
1. Quarterly searches of the Cochrane Central Register of
Controlled Trials CENTRAL
2. Weekly searches of MEDLINE (OVID SP)
3. Handsearching of renal-related journals and the
proceedings of major renal conferences
4. Searching of the current year of EMBASE (OVID SP)
5. Weekly current awareness alerts for selected renal journals
6. Searches of the International Clinical Trials Register
(ICTRP) Search Portal & ClinicalTrials.gov
Studies contained in the specialised register are identified through
search strategies for CENTRAL, MEDLINE, and EMBASE based
on the scope of the Cochrane Renal Group. Details of these strategies as well as a list of handsearched journals, conference proceedings and current awareness alerts are available in the Specialised
Register section of information about the Cochrane Renal Group.
Initial search
Relevant studies were obtained, with the assistance of the Trials
Search Co-ordinator, from the following sources without language
restriction (see Appendix 1 for electronic search strategies).
1. Cochrane Renal Group Specialised Register of Randomised
Controlled Trials (January 2004)
2. Cochrane Central Register of Controlled Trials
(CENTRAL in The Cochrane Library Issue 2, 2004) for any
New records not yet incorporated into the specialised register.
Selection of studies
The search strategy described was used to obtain titles and abstracts of studies that may be relevant to the review. The titles
and abstracts were screened independently by two authors, who
discarded studies that were not applicable. However studies and
reviews that might include relevant data or information on studies
were retained initially. Disagreements were resolved via discussion
with a third author.
If sufficient RCTs were identified, publication bias was to be investigated using a funnel plot (Higgins 2011).
Data synthesis
Data was to be pooled using the random effects model but the
fixed effects model was also to be analysed to ensure robustness of
the model chosen and susceptibility to outliers
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies; Characteristics of ongoing studies.
Despite extensive literature searching, no study of increased water intake for the primary prevention of urinary stones met our
inclusion criteria. Only one RCT of increased water intake for
preventing the recurrence of urinary stones fulfilled our inclusion
criteria (Borghi 1996). This study randomised 220 patients to
control group (just drink water as usual) and intervention group
(a high water intake which would give a urine volume equal to or
greater than 2 L/d). The number of patients that completed the
study with a follow-up of five years was 199 (99 in the intervention
group and 100 in control group).
Further information about the electronic searching is presented in
the study flow diagram (Figure 1).
Figure 2. Risk of bias graph: review authors judgements about each risk of bias item presented as
percentages across all included studies.
Figure 3. Risk of bias summary: review authors judgements about each risk of bias item for each included
study.
Effects of interventions
Adverse effects
Adverse effects where not reported.
DISCUSSION
AUTHORS CONCLUSIONS
Implications for practice
No evidence is available for the benefit of increasing water intake
for the primary prevention of urinary stones. There is inconclusive
evidence of the benefit of increasing water intake for the secondary
prevention of urinary stones. However no implications for practice
are warranted in light of the small amount of available evidence.
ACKNOWLEDGEMENTS
The authors would like to thank Zhang Ke who
contributed to the design, quality assessment, data collection,
entry, analysis and interpretation, and writing of the initial
version (Ke 2004) of this review.
The authors are grateful for the help and support of Narelle
Willis, Managing Editor; and Gail Higgins, Trials Search Coordinator, and all the personnel from Cochrane Renal Group.
REFERENCES
Additional references
Blacklock 1969
Blacklock NJ. The pattern of urolithiasis in the Royal Navy.
In: Hodgkinson A, Nordin BEC editor(s). Proceedings of
the renal stone research symposium. London: J&A Churchill
LTD, 1969:3347.
Dickersin 1994
Dickersin K, Scherer R, Lefebvre C. Identifying relevant
studies for systematic reviews. BMJ 1994;309(6964):
128691. [MEDLINE: 7718048]
Higgins 2003
Higgins JP, Thompson SG, Deeks JJ, Altman DG.
Measuring inconsistency in meta-analyses. BMJ 2003;327
(7414):55760. [MEDLINE: 12958120]
Higgins 2011
Higgins JPT, Green S (editors). Cochrane Handbook
for Systematic Reviews of Interventions Version 5.1.0
[updated March 2011]. The Cochrane Collaboration,
2011. Available from www.cochrane-handbook.org.
Kohnmann 1993
Kohrmann KU, Rassweiler J, Alken P. The recurrence rate
of stones following ESWL. World Journal of Urology 1993;
11(1):2630. [MEDLINE: 93258437]
Lefebvre 1996
Lefebvre C, McDonald S. Development of a sensitive
search strategy for reports of randomised controlled trials
10
CHARACTERISTICS OF STUDIES
Participants
Interventions
Group 1
A high water intake which would give a urine volume equal to or greater than 2L/d
Group 2
No treatment
Outcomes
Notes
Recurrence
Average interval for recurrence
Baseline of the intervention group, including urine volume, creatine, urea etc, is equal
to that of the control group
During the study period, urine volume of the intervention group was significantly greater
than that of the control group (2621 443 mL/24 h versus 1014 195 mL/24 h, P <
0.0001)
Risk of bias
Bias
Authors judgement
Unclear risk
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Borghi 1996
(Continued)
Unclear risk
Unclear risk
Study
Curhan 1993
Not RCT
de La Guronnire 2011
Di Silverio 1994
Di Silverio 2000
Wrong comparator
Frank 1966
Not RCT
Karagulle 2007
Wrong comparator
Lorentzen 1979
Wrong comparator
Marangella 1996
Not RCT
Neimark 2003
Wrong comparator
Rodgers 1998
Valli 2000
Wrong comparator
12
The Links Between Water and Salt Intake, Body Weight, Hypertension and Kidney Stones: a Difficult Puzzle
Methods
Participants
Interventions
Outcomes
Primary outcome
Normalization of urinary stone risk factors
Secondary outcomes
urinary sodium/calcium relationship
blood pressure reduction
relationship between 24h-calciuria and blood pressure
stone rate reduction
correlation BMI-urinary stone risk factors
compliance
Starting date
May 2010
Contact information
Notes
13
No. of
studies
No. of
participants
1
1
Statistical method
Effect size
Analysis 1.1. Comparison 1 Increased water intake versus standard water intake, Outcome 1 Stone
recurrence.
Review:
Study or subgroup
Borghi 1996
Increased intake
Standard intake
n/N
n/N
12/99
27/100
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
0.45 [ 0.24, 0.84 ]
0.2
0.5
Favours increased
Favours standard
14
Analysis 1.2. Comparison 1 Increased water intake versus standard water intake, Outcome 2 Average
interval for recurrence.
Review:
Study or subgroup
Increased intake
Borghi 1996
Mean
Difference
Standard intake
Mean(SD)[years]
Mean(SD)[years]
12
3.23 (1.1)
27
2.09 (1.37)
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1.14 [ 0.33, 1.95 ]
-2
-1
Favours increased
Favours standard
APPENDICES
Appendix 1. Electronic search strategies
DATABASE
Search terms
CENTRAL
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
MEDLINE (OVID)
1.
2.
3.
4.
5.
15
(Continued)
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Mineral Waters/
fluid$.tw.
drink$.tw.
water.tw.
or/1-9
exp Urinary Calculi/
Urolithiasis/
urolithiasis.tw.
((calcul$ or stone$) and urin$).tw.
or/11-14
and/10,15
Assessment criteria
16
(Continued)
17
(Continued)
Low risk of bias: The study protocol is available and all of the
studys pre-specified (primary and secondary) outcomes that are of
interest in the review have been reported in the pre-specified way;
the study protocol is not available but it is clear that the published
reports include all expected outcomes, including those that were
pre-specified (convincing text of this nature may be uncommon)
High risk of bias: Not all of the studys pre-specified primary outcomes have been reported; one or more primary outcomes is reported using measurements, analysis methods or subsets of the
data (e.g. subscales) that were not pre-specified; one or more reported primary outcomes were not pre-specified (unless clear justification for their reporting is provided, such as an unexpected
adverse effect); one or more outcomes of interest in the review are
reported incompletely so that they cannot be entered in a metaanalysis; the study report fails to include results for a key outcome
that would be expected to have been reported for such a study
Unclear: Insufficient information to permit judgement
Other bias
Bias due to problems not covered elsewhere in the table
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WHATS NEW
Last assessed as up-to-date: 18 April 2012.
Date
Event
Description
18 April 2012
New citation required but conclusions have not changed One ongoing study identified
18 April 2012
Updated electronic search strategies; risk of bias assessment tool used; PRISMA flowchart included
HISTORY
Protocol first published: Issue 3, 2003
Review first published: Issue 3, 2004
Date
Event
Description
15 October 2008
Amended
CONTRIBUTIONS OF AUTHORS
BY: updating the review, selection of studies, risk of bias assessment, data extraction, data analysis
WQ: writing and updating review, selection of studies, risk of bias assessment, data extraction, data analysis
DECLARATIONS OF INTEREST
We certify that we have no affiliations with or involvement in any organization or entity with a direct financial interest in the subject
matter of the review (e.g. employment, consultancy, stock ownership).
SOURCES OF SUPPORT
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Internal sources
Chinese Cochrane Centre, Chinese Centre of Evidence-based Medicine, West China Hospital of Sichuan University, China.
External sources
China Medical Board of New York (Grant number:98-680), USA.
INDEX TERMS
Medical Subject Headings (MeSH)
Drinking; Drinking Water; Recurrence [prevention & control]; Urinary Calculi [ prevention & control]
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