My Opera
The Dish On Oxalates
Tuesday, September 4, 2012 7:57:18 PM
When I was first diagnosed with MSK, I was devastated to find I have something wrong with my kidneys. I then started doing some research, like most people might do when diagnosed with a rare disease, and I went to the internet for answers. I found there was no cure, no easy fix, and no simple surgery to repair what didn’t form properly from the beginning. What I did find, however, were many different diet changes that I could make to help better protect my kidneys. Two of the major substances, I discovered, that required balancing are calcium and oxalates. The information I found on these two items went WAY over my head, though, and frankly the idea of taking certain foods out of my life was not something I was looking forward to. I quickly realized that if I wanted to keep myself from building a massive amount of kidney stones in a very short amount of time, I need to figure out how I could not take food away, but modify it so that I can enjoy the things I love to eat. To try to figure out this balance, I turned to a fellow MSKer and whom many consider the “Oxalate Queen” Jennifer Francisco. Jennifer is a wife of 23 years and a mother of two college-aged children. She was diagnosed 6 years ago at the age of 37 and has been gracious enough to share with us, in her own words, the dish on oxalates.
“The Dish” on the Low-Oxalate Diet
So what’s the big deal about Medullary Sponge Kidney and a low-oxalate diet? Only a kidney full of stones and a real pain in the...! That is, if the stones you form are calcium-oxalate stones. If you are like me, you may never have heard the word “oxalate” prior to your MSK diagnosis, much less know to avoid it. But before I give you “the dish” on the low-oxalate diet, let me be technical for a moment and explain what oxalate is.
Oxalate is a “salt” that is formed in the body when oxalic acid from the plant foods in our diet binds to minerals such as sodium, potassium, and calcium. Oxalic acid converted to oxalate is excreted through the urinary system. Sodium and potassium oxalate salts are water-soluble, but calcium oxalate salts are practically insoluble. When calcium oxalate salts are found in concentrated levels in the body, they can precipitate (solidify) in the kidneys or urinary tract to form calcium oxalate crystals. Calcium oxalate crystals are very small and very sharp, and can be large enough to be irritating to the body, and in high concentrations can contribute to the formation of calcium-oxalate kidney stones. But how does all this relate to MSK and is it really all that important?
Medullary Sponge Kidney is caused by a congenital defect of the kidneys in which cysts form in the collecting tubules of the renal pyramids of the kidney. The resulting dilation of the tubules causes abnormal drainage of urine, allowing it to concentrate in the tubules. MSKers who form kidney stones, according to kidneystoners.org, commonly have “other metabolic abnormalities that predispose someone to form stones...including hypercalciuria (high calcium levels in the urine)....” It is this abnormal concentration of calcium that leaks through our kidneys and binds to the oxalic acid from our diet to form gross amounts of calcium oxalate crystals. Combine this with the sluggish transport of urine through the collecting tubules, and you have the perfect storm for “an astounding number of stones developing throughout the kidneys.” (((shudder)))
Can you see the importance of following a low-oxalate diet as it relates to the management of calcium-OXALATE kidney stone formation? If so, here’s "the dish" on the low-oxalate diet from my vantage point.
Like most MSKers, my kidney stones are primarily calcium-oxalate kidney stones. To help slow down the formation of these stones, I’ve been prescribed a hydrochlorothiazide diuretic to help slow down calcium loss through my kidneys. Because this addresses only half of the calcium-oxalate kidney stone “equation”, my nephrologist wants me to keep my oxalate intake limited to 40-50 milligrams per day. All plant foods contain oxalic acid, but in varying amounts; that’s is why it’s so important to know which foods fall into which category (low/moderate/high) and to stay within the daily limit.
My nephrologist recommended the low-oxalate diet developed by the University of Pittsburgh Medical Center to get me started and help keep me on track (link can be found in “References” below). The diet provided by the UPMC offered a food list which made it easy to see at a glance which foods I could enjoy liberally (“low-oxalate” foods that contain 2 milligrams or less oxalate per serving, such as cucumbers, bananas, and wild rice), which foods I should limit to 2-3 servings per day (“moderate-oxalate” foods that contain 2-10 milligrams of oxalate per serving, such as broccoli, oranges, and brown rice), and which foods I should more strictly ration or avoid altogether (“high-oxalate” foods that contain more than 10 milligrams of oxalate per serving, such as spinach, berries, and whole wheat).
I was astonished to realize how many, many foods that I enjoyed on a daily basis fell under the “moderate” and “high” categories! Foods like dark, leafy or richly-colored fruits and vegetables, whole grains, dry beans, and (((gasp))) chocolate! I was used to these nutritious and immensely beneficial foods being a part of my healthy lifestyle, and now I was being told to limit or restrict them; I was stunned. After the initial shock wore off (and I got past my “La-la-la, I can’t hear you,” rebellious stage), I realized that I’m going to have to try it to find out if it really works. Pain is a good motivator and I was weary with the pain of being a chronic kidney stone-former; I was now ready to make the necessary adjustments. But the “all-or-nothing” kind of person that I am took it to the far other extreme. I thought that in order to know if it works, I must live exclusively from the “low-oxalate” food list. This worked for the first couple weeks until I realized how limited, unhealthy, and dull my diet had become. I was tired of bland vegetables that were limited to cabbage, cauliflower, cucumbers, kohlrabi, mushrooms, peas, and water chestnuts; the only leafy green vegetable listed was endive. The starches that were available to me were even worse with only barley and wild rice for whole grains, leaving white rice and refined flour products (pastas, graham crackers, English muffins, and some breakfast cereals) to fill in the gaps. Grocery shopping became a depressing and dreaded chore; I actually fought tears as I chose vibrant, flavorful fruits and vegetables for my family. I remained diligent because I would never know what a low-oxalate diet could do for me if I didn’t follow it consistently.
At my three-month follow-up with my nephrologist after I began the diet, I was excited to find that my urine oxalate levels had reached an all-time low! My doctor was so pleased, at least until I told her what I had done to reach my goal. After she recovered from shock that I could follow such a limited diet for three months, she told me that no one can live healthfully on a strictly low-oxalate, low-fiber, nutrient-deficient diet as that. What I had failed to realize was that a low-oxalate diet meant limiting my oxalate intake to 40-50 milligrams per day, not living exclusively on low-oxalate foods. She said I must find a way to get a variety of healthful foods in my daily diet while at the same time staying within the daily oxalate limit. This did not mean that I could never enjoy an occasional higher-oxalate food now and then (chocolate!!!), it just meant I needed to enjoy it in moderation. (As we all know, chocolate is an essential nutrient!)
Once I figured out what 40-50 milligrams of oxalate per day looked like "on a plate" in a day's worth of meals, it wasn’t hard to stick to it! If I wanted to enjoy something that’s higher in oxalate, I would just swap it for two lower oxalate-containing foods. I just love a loaded baked potato, but potatoes are so high in oxalates! Instead of making a meal out of it, I baked smaller potatoes to serve as a side and traded this high-oxalate serving for two moderate-oxalate foods from other meals. Another way I enjoy a high-oxalate food is to use it as a garnish instead of a side. Berries and nuts go on top of cereal or ice cream; nuts and chocolate chips go into a trail mix made with raisins and low-oxalate cereals; and for a real treat on a rare occasion, a little rhubarb gets mixed with lots of apples in a fruit pie or crisp. Any time I indulge in a high-oxalate food, regardless of the amount, I always chase it with a glass of milk (this allows the oxalates to bind to the calcium in the GI tract instead of the urinary tract and evacuate it out the "back door", if you know what I mean!).
Besides limiting dietary oxalate, there are other factors that contribute to hyperoxaluria (high oxalate levels in the urine) to be aware of. Too much protein in our diet increases oxalate excretion and excess amounts of vitamin C converts to oxalate. Even a diet deficient in calcium can reflect high oxalate levels in a 24-hour urine lab like Litholink.
In the six years since I was diagnosed with MSK, I've learned from my nephrologist that managing stone formation is not limited to lowering urine oxalate; there are many factors that contribute to stone formation. I am so very thankful for my nephrologist who understands MSK and has skillfully identified those factors, bringing my MSK under better control. I have told her how thankful I am, but she is quick to remind me that it is a team effort; I would not be where I am today if I did not follow her treatment plan. I have learned by trial and error (i.e. the “hard way”!) that managing MSK is very much like the links of a chain--if one link is weak or fails, the whole thing falls apart!...
• If I don't pay attention to how many oxalates I'm consuming, this allows too much oxalate to become available in my urine to bind to all the calcium my kidneys dump to form stones.
• If I eat in too much protein, I excrete too much oxalate to form stones.
• If I indulge in too much sodium, this accelerates calcium excretion which makes more calcium available to form stones.
• If I don't drink enough water, my defective kidneys concentrate all this stuff to form stones.
• If I forget to take my meds, then I start dumping too much calcium again which makes more calcium available to form stones.
• If I do absolutely none of these things to help manage stone formation, I'm back in the ER on a regular basis passing stones!!![/ALIGN]
By living within these boundaries, I've been able to stay out of the ER for three years! Unfortunately none of these things can change calcification that has already formed, but making these a part of my daily routine has made a HUGE difference in slowing down the factors that contribute to further calcification. Also, MSK is progressive so meds will eventually need adjusting.
Now you’ve got “the dish” on the low-oxalate diet. In a future post, I will share what the low-oxalate diet looks like “on a plate”. I hope you can see for yourself the importance of following a low-oxalate diet as it relates to MSK and this information helps you in your quest to slow down calcium-oxalate kidney stone formation!
REFERENCES:
http://www.thevpfoundation.org/vpfoxalate.htm
http://oxalicacidinfo.com/
http://www.upmc.com/patients-visitors/education/nutrition/Pages/low-oxalate-diet.aspx
http://www.litholink.com/downloads/Stone_LowOxalateDiet.pdf
http://www.litholink.com/en/DietInformation
The information given here is in no way intended to replace medical advise. Please consult with your physician or a member of you care team to see what best fits your needs before making any changes in diet.
“The Dish” on the Low-Oxalate Diet
So what’s the big deal about Medullary Sponge Kidney and a low-oxalate diet? Only a kidney full of stones and a real pain in the...! That is, if the stones you form are calcium-oxalate stones. If you are like me, you may never have heard the word “oxalate” prior to your MSK diagnosis, much less know to avoid it. But before I give you “the dish” on the low-oxalate diet, let me be technical for a moment and explain what oxalate is.
Oxalate is a “salt” that is formed in the body when oxalic acid from the plant foods in our diet binds to minerals such as sodium, potassium, and calcium. Oxalic acid converted to oxalate is excreted through the urinary system. Sodium and potassium oxalate salts are water-soluble, but calcium oxalate salts are practically insoluble. When calcium oxalate salts are found in concentrated levels in the body, they can precipitate (solidify) in the kidneys or urinary tract to form calcium oxalate crystals. Calcium oxalate crystals are very small and very sharp, and can be large enough to be irritating to the body, and in high concentrations can contribute to the formation of calcium-oxalate kidney stones. But how does all this relate to MSK and is it really all that important?
Medullary Sponge Kidney is caused by a congenital defect of the kidneys in which cysts form in the collecting tubules of the renal pyramids of the kidney. The resulting dilation of the tubules causes abnormal drainage of urine, allowing it to concentrate in the tubules. MSKers who form kidney stones, according to kidneystoners.org, commonly have “other metabolic abnormalities that predispose someone to form stones...including hypercalciuria (high calcium levels in the urine)....” It is this abnormal concentration of calcium that leaks through our kidneys and binds to the oxalic acid from our diet to form gross amounts of calcium oxalate crystals. Combine this with the sluggish transport of urine through the collecting tubules, and you have the perfect storm for “an astounding number of stones developing throughout the kidneys.” (((shudder)))
Can you see the importance of following a low-oxalate diet as it relates to the management of calcium-OXALATE kidney stone formation? If so, here’s "the dish" on the low-oxalate diet from my vantage point.
Like most MSKers, my kidney stones are primarily calcium-oxalate kidney stones. To help slow down the formation of these stones, I’ve been prescribed a hydrochlorothiazide diuretic to help slow down calcium loss through my kidneys. Because this addresses only half of the calcium-oxalate kidney stone “equation”, my nephrologist wants me to keep my oxalate intake limited to 40-50 milligrams per day. All plant foods contain oxalic acid, but in varying amounts; that’s is why it’s so important to know which foods fall into which category (low/moderate/high) and to stay within the daily limit.
My nephrologist recommended the low-oxalate diet developed by the University of Pittsburgh Medical Center to get me started and help keep me on track (link can be found in “References” below). The diet provided by the UPMC offered a food list which made it easy to see at a glance which foods I could enjoy liberally (“low-oxalate” foods that contain 2 milligrams or less oxalate per serving, such as cucumbers, bananas, and wild rice), which foods I should limit to 2-3 servings per day (“moderate-oxalate” foods that contain 2-10 milligrams of oxalate per serving, such as broccoli, oranges, and brown rice), and which foods I should more strictly ration or avoid altogether (“high-oxalate” foods that contain more than 10 milligrams of oxalate per serving, such as spinach, berries, and whole wheat).
I was astonished to realize how many, many foods that I enjoyed on a daily basis fell under the “moderate” and “high” categories! Foods like dark, leafy or richly-colored fruits and vegetables, whole grains, dry beans, and (((gasp))) chocolate! I was used to these nutritious and immensely beneficial foods being a part of my healthy lifestyle, and now I was being told to limit or restrict them; I was stunned. After the initial shock wore off (and I got past my “La-la-la, I can’t hear you,” rebellious stage), I realized that I’m going to have to try it to find out if it really works. Pain is a good motivator and I was weary with the pain of being a chronic kidney stone-former; I was now ready to make the necessary adjustments. But the “all-or-nothing” kind of person that I am took it to the far other extreme. I thought that in order to know if it works, I must live exclusively from the “low-oxalate” food list. This worked for the first couple weeks until I realized how limited, unhealthy, and dull my diet had become. I was tired of bland vegetables that were limited to cabbage, cauliflower, cucumbers, kohlrabi, mushrooms, peas, and water chestnuts; the only leafy green vegetable listed was endive. The starches that were available to me were even worse with only barley and wild rice for whole grains, leaving white rice and refined flour products (pastas, graham crackers, English muffins, and some breakfast cereals) to fill in the gaps. Grocery shopping became a depressing and dreaded chore; I actually fought tears as I chose vibrant, flavorful fruits and vegetables for my family. I remained diligent because I would never know what a low-oxalate diet could do for me if I didn’t follow it consistently.
At my three-month follow-up with my nephrologist after I began the diet, I was excited to find that my urine oxalate levels had reached an all-time low! My doctor was so pleased, at least until I told her what I had done to reach my goal. After she recovered from shock that I could follow such a limited diet for three months, she told me that no one can live healthfully on a strictly low-oxalate, low-fiber, nutrient-deficient diet as that. What I had failed to realize was that a low-oxalate diet meant limiting my oxalate intake to 40-50 milligrams per day, not living exclusively on low-oxalate foods. She said I must find a way to get a variety of healthful foods in my daily diet while at the same time staying within the daily oxalate limit. This did not mean that I could never enjoy an occasional higher-oxalate food now and then (chocolate!!!), it just meant I needed to enjoy it in moderation. (As we all know, chocolate is an essential nutrient!)
Once I figured out what 40-50 milligrams of oxalate per day looked like "on a plate" in a day's worth of meals, it wasn’t hard to stick to it! If I wanted to enjoy something that’s higher in oxalate, I would just swap it for two lower oxalate-containing foods. I just love a loaded baked potato, but potatoes are so high in oxalates! Instead of making a meal out of it, I baked smaller potatoes to serve as a side and traded this high-oxalate serving for two moderate-oxalate foods from other meals. Another way I enjoy a high-oxalate food is to use it as a garnish instead of a side. Berries and nuts go on top of cereal or ice cream; nuts and chocolate chips go into a trail mix made with raisins and low-oxalate cereals; and for a real treat on a rare occasion, a little rhubarb gets mixed with lots of apples in a fruit pie or crisp. Any time I indulge in a high-oxalate food, regardless of the amount, I always chase it with a glass of milk (this allows the oxalates to bind to the calcium in the GI tract instead of the urinary tract and evacuate it out the "back door", if you know what I mean!).
Besides limiting dietary oxalate, there are other factors that contribute to hyperoxaluria (high oxalate levels in the urine) to be aware of. Too much protein in our diet increases oxalate excretion and excess amounts of vitamin C converts to oxalate. Even a diet deficient in calcium can reflect high oxalate levels in a 24-hour urine lab like Litholink.
In the six years since I was diagnosed with MSK, I've learned from my nephrologist that managing stone formation is not limited to lowering urine oxalate; there are many factors that contribute to stone formation. I am so very thankful for my nephrologist who understands MSK and has skillfully identified those factors, bringing my MSK under better control. I have told her how thankful I am, but she is quick to remind me that it is a team effort; I would not be where I am today if I did not follow her treatment plan. I have learned by trial and error (i.e. the “hard way”!) that managing MSK is very much like the links of a chain--if one link is weak or fails, the whole thing falls apart!...
• If I don't pay attention to how many oxalates I'm consuming, this allows too much oxalate to become available in my urine to bind to all the calcium my kidneys dump to form stones.
• If I eat in too much protein, I excrete too much oxalate to form stones.
• If I indulge in too much sodium, this accelerates calcium excretion which makes more calcium available to form stones.
• If I don't drink enough water, my defective kidneys concentrate all this stuff to form stones.
• If I forget to take my meds, then I start dumping too much calcium again which makes more calcium available to form stones.
• If I do absolutely none of these things to help manage stone formation, I'm back in the ER on a regular basis passing stones!!![/ALIGN]
By living within these boundaries, I've been able to stay out of the ER for three years! Unfortunately none of these things can change calcification that has already formed, but making these a part of my daily routine has made a HUGE difference in slowing down the factors that contribute to further calcification. Also, MSK is progressive so meds will eventually need adjusting.
Now you’ve got “the dish” on the low-oxalate diet. In a future post, I will share what the low-oxalate diet looks like “on a plate”. I hope you can see for yourself the importance of following a low-oxalate diet as it relates to MSK and this information helps you in your quest to slow down calcium-oxalate kidney stone formation!
REFERENCES:
http://www.thevpfoundation.org/vpfoxalate.htm
http://oxalicacidinfo.com/
http://www.upmc.com/patients-visitors/education/nutrition/Pages/low-oxalate-diet.aspx
http://www.litholink.com/downloads/Stone_LowOxalateDiet.pdf
http://www.litholink.com/en/DietInformation
The information given here is in no way intended to replace medical advise. Please consult with your physician or a member of you care team to see what best fits your needs before making any changes in diet.
