Vol. 115, June
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
STUDIES ON UROLITHIASIS IN ISRAEL JACOB L. ZAIDMAN
AND
NELLY PINTO
From the Institute of Biochemical Pathology, Assaf Haro/eh Government Hospital, Tel-Aviv University Medical School, Zerifin, Israel
ABSTRACT
The composition of 1,000 kidney stones in our area of Israel was analyzed. The predominant stones were a combination of calcium oxalate and calcium phosphate, and uric acid. We used chemical analysis to determine the relative incidence of urinary calculi in 500 patients of various ages and ethnic groups. The incidence of calcium oxalate and calcium phosphate calculi (44 per cent) in Jews born in Israel was lower than in other ethnic groups (54 to 64 per cent). The incidence of uric acid stones in Jews born in Israel, Lebanon, Iran, Iraq and Syria, and the Ashkenazim (16 to 29 per cent) was 2 to 3 times higher than in other groups. In more than 60 per cent of the patients urolithiasis developed after they were 20 years old. The age at onset was significantly younger in Jews born in Israel (25.7 per cent) and North Africa (13.8 per cent), and in Arabs (18 per cent).
Knowledge of the composition of urinary stones is a necessity for all physicians treating patients with kidney stones. Urolithiasis is a recurrent disease in many people and preventive measures must be based on such information. There are substantial historical and geographical variations in the incidence of urinary calculi. 1- 9 In Israel, which is a country of continuous immigration and a part of the known Middle East stone belt, 7 a number of surveys on urinary calculi were published, 1• 7 - 9 the first of which is credited to Rosenthal and Launer. 8 However, actual data on the composition of stones according to age and ethnic group in Israel are not known.
DISCUSSION
Stone formation is alleged to be more common among patients whose occupations are associated with dehydration or reduced mobility. 11 Israeli climatic conditions involve much sweating, which causes conditions of dehydration but we were unable to draw any definite conclusions.
TABLE
1. Distribution of urinary calculi by chemical analysis in Israel Relative Incidence (%)
MATERIALS AND METHODS
Analysis
Our criteria for the diagnosis of urinary calculus were based exclusively on the stones collected after they were passed or removed. The stones were examined by Henry's method of qualitative chemical analysis. 10 RESULTS
Calcium oxalate and calcium phosphate Uric acid pure Calcium oxalate, calcium phosphate and uric acid Apatite (calcium phosphate and calcium carbonate) Calcium oxalate pure Triple phosphate and apatite Calcium oxalate and apatite Calcium oxalate and triple phosphate Triple phosphate (struvite, magnesium ammonium phosphate) Cystine pure and mixed
Israel (1,000 pts.)
Literature (approx. 8,000 pts.)
57.0
33.7*
13.3 8.9
5.7 1.1
5.9
3.4
The chemical composition of 1,000 stones collected in our 5.5 4.8 15.5 hospital between 1966 and 1975 is presented in table 1. 3.2 34.3t Calcium oxalate-calcium phosphate and uric acid stones were 1.2 3.2t the most common types found. The relative incidence of urinary calculi in 500 patients 0.6 0.3 determined by chemical analysis in various ethnic groups 0.5 2.9 (table 2) and ages (table 3) is presented. Urinary stones in most ethnic groups were a combination of calcium oxalate and * Calcium oxalate pure and mixed. calcium phosphate stones (54 to 65 per cent), whereas in t Apatite plus calcium oxalate pure and mixed. t Triple phosphate, calcium oxalate plus apatite. Israeli born Jews the incidence was only 44 per cent. In Jews born in Israel, Lebanon, Iran, Iraq and Syria, and the Ashkenazim uric acid stones accounted for more than 15 per cent of the total, 3 times higher than in other groups. In Jews born in Israel apatite stones accounted for 15 per cent of the total, 2 to 3 The onset of urolithiasis in childhood or adolescence in times higher than in other groups. Israeli born Jews is considered part of the general world In more than 60 per cent of the patients urolithiasis trend 12- 14 and an outcome of low fluid intake and excessive developed after the patient was 20 years old in most ethnic sweating. 1 groups. The age at onset was younger in Jews born in Israel The relative frequency of uric acid stones among Jews in (25.7 per cent), North Africa (13.8 per cent), Lebanon, Iraq, Israel (34.6 per cent) as estimated by Frank and associates• was Iran and Syria (8 per cent) and in Arabs (18 per cent). not confirmed in this series. The prevalence of uric acid stones calculated on the basis of our criteria was 22 per cent, 3 times Accepted for publication September 19, 1975. higher than mentioned in the literature. 9 • 15 626
11 --- ... 627
STUDIES ON UROLITHIASIS IN ISRAEL
'I TABLE
2. Relative incidence of urinary calculi by chemical analysis in various ethnic groups in Israel Jews
Israel (51 pts.)
Ashkenazim (200 pts.)
(%)
(%)
Bulgaria, Greece and T urkey (76 pts.) (%)
Calcium oxalate and calcium phosphate Uric acid pure Calcium oxalate, calcium phosphate and uric acid Apatite* Calcium oxalate pure Triple phosphate and apatite Calcium oxalate and apatite Calcium oxalate and triple phosphate Triple phosphate (struvite, magnesium ammonium phosphate) Cystine pure and mixed
Arabs North Africa (83 pts.) (%)
Lebanon, Iran, Iraq and Syria (61 pts.)
Yemen (17 pts.) (%)
(12 pts.) (%)
Israel Total Sample (1,000 pts.) (%)
(%)
Combined Ethnic Groups (500 pts.) (%)
44 .0
54.0
64.0
61.0
56.0
62.4
59.0
57.0
57.2
5.5 10.0
18.0 8.4
6.2 6.2
4.3 7.2
15.0 14.0
6.1 6.1
8.3 8.3
13.3 8.9
12.7 8.7
15.0 7.5 11.5
5.4 6.0 4.1 1.8 0.6
6.2 3.1 4.9 6.6 1.8
7.2 5.8 4.3 1.4 3.0
3.0 2.0 2.0 2.0 3.0
6.1 13.2
8.3
6.1
7.3 8.3
5.9 5.5 4.8 3.2 1.2
6.2 6.0 4.7 2.0 1.5
5.0
1.8
4.3
3.0
0.6
0.4
0.5
0.6
6 .5
0.6
1.4
• Calcium phosphate and calcium carbonate.
TABLE 3.
Distribution of urinary calculi by age in various ethnic groups in Israel Age (yrs.) Less Than 20
21 to 50 (%)
(%)
Jews: Israel Ashkenazim Bulgaria, Greece and Turkey North Africa Lebanon, Iran, Iraq and Syria Yemen Arabs
More Than 51
No. Pts.
(%)
25.7 1.7
55.5 34.4 42.0
18.6 64.0 58.0
46 187 70
13.8 8.0
51.7 69 .0
34.5 23.0
75 55
72.0 82.0
28.0
l8.0
16 12
REFERENCES
~1 '1
:'
1. Frank, M ., De Vries, A., Atsmon, A., Lazebnik, J. and Kochwa, S.: Epidemiological investigation of urolithiasis in Israel. J. Urol., 81: 497, 1959. 2. Eckstein, H. B.: Endemic urinary lithiasis in Turkish children. Arch. Dis. Child., 36: 1.37, 1961. 3. Gershoff, S. N., Prien, E. L. and Chandrapanond, A.: Urinary stones in Thailand. J. Urol., 90: 285, 1963. 4. Lavan, J. N., Neale, F. C. and Posen, S. : Urinary calculi. Clinical, biochemical and radiological studies in 619 patients. Med. J. Aust., 2: 1049, 1971. 5. Sutor, D. J ., Wooley, S. E. and Illingworth, J. J.: A geographical and historical survey of the composition of urinary stones. Brit. J. Urol., 46: 393, 1974.
6. Herbstein, F . H ., Kleeberg, J., Shalitin, Y., Wartski, E. and Wielinski, S.: Chemical and x-ray diffraction analysis of urinary stones in Israel. Isr. J. Med. Sci., 10: 1493, 1974. 7. Butt, A. J.: Etiologic factors in renal lithiasis. Springfield, Illinois: Charles C Thomas, Publisher, 1956. 8. Rosenthal, G. and Launer, J.: The chemical composition of urinary calculi. Harefuah, 56: 109, 1959. 9. Frank, M., Lazebnik, J. and De Vries, A.: Uric acid lithiasis-a study of six hundred and twenty two patients. Urol. Int., 25: 32, 1970. 10. Henry, R. J.: Clinical Chemistry, Principles and Technics. New York: Harper & Row, Publishers, Inc., p . 913, 1966. 11. Lonsdale, K.: Human stones. Science, 159: 1199, 1968. 12. Epstein, F. H.: Calcium and the kidney. Amer. J. Med., 45: 700, 1968. 13. Gharib, R.: Lithiasis in the urinary tract of children. General review based on observations in 167 affected Iranian children. Clin. Pediat., 9: 157, 1970. 14. Ghazali, S., Barratt, T. M. and Williams, D. I.: Childhood urolithiasis in Britain. Arch. Dis. Child., 48: 291, 1973. 15. Prien, E. L.: Crystallographic analysis of urinary calculi: a 23-year ·survey study. J. Urol., 89: 917, 1963.
COMMENT This paper represents a monumental compilation of stone analyses in a country where climate and heredity are probably contributing factors to nephrolithiasis. The large number of mixed composition stones points to the important interplay between different stone salts and the probable role o~ pita6:} whereby 1 type of stone crystal serves as the nucleating surface or mducing the precipitation of a second type of stone crystal. W.B.G.
h,i.e
~!ttf I ~
r~~," 4=-,z;;,,
11 I
II
THE JOURNAL OF UROLOGY
Copyright© 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
STUDIES ON UROLITHIASIS IN ISRAEL JACOB L. ZAIDMAN
AND
NELLY PINTO
From the Institute of Biochemical Pathology, Assaf Haro/eh Government Hospital, Tel-Aviv University Medical School, Zerifin, Israel
ABSTRACT
The composition of 1,000 kidney stones in our area of Israel was analyzed. The predominant stones were a combination of calcium oxalate and calcium phosphate, and uric acid. We used chemical analysis to determine the relative incidence of urinary calculi in 500 patients of various ages and ethnic groups. The incidence of calcium oxalate and calcium phosphate calculi (44 per cent) in Jews born in Israel was lower than in other ethnic groups (54 to 64 per cent). The incidence of uric acid stones in Jews born in Israel, Lebanon, Iran, Iraq and Syria, and the Ashkenazim (16 to 29 per cent) was 2 to 3 times higher than in other groups. In more than 60 per cent of the patients urolithiasis developed after they were 20 years old. The age at onset was significantly younger in Jews born in Israel (25.7 per cent) and North Africa (13.8 per cent), and in Arabs (18 per cent).
Knowledge of the composition of urinary stones is a necessity for all physicians treating patients with kidney stones. Urolithiasis is a recurrent disease in many people and preventive measures must be based on such information. There are substantial historical and geographical variations in the incidence of urinary calculi. 1- 9 In Israel, which is a country of continuous immigration and a part of the known Middle East stone belt, 7 a number of surveys on urinary calculi were published, 1• 7 - 9 the first of which is credited to Rosenthal and Launer. 8 However, actual data on the composition of stones according to age and ethnic group in Israel are not known.
DISCUSSION
Stone formation is alleged to be more common among patients whose occupations are associated with dehydration or reduced mobility. 11 Israeli climatic conditions involve much sweating, which causes conditions of dehydration but we were unable to draw any definite conclusions.
TABLE
1. Distribution of urinary calculi by chemical analysis in Israel Relative Incidence (%)
MATERIALS AND METHODS
Analysis
Our criteria for the diagnosis of urinary calculus were based exclusively on the stones collected after they were passed or removed. The stones were examined by Henry's method of qualitative chemical analysis. 10 RESULTS
Calcium oxalate and calcium phosphate Uric acid pure Calcium oxalate, calcium phosphate and uric acid Apatite (calcium phosphate and calcium carbonate) Calcium oxalate pure Triple phosphate and apatite Calcium oxalate and apatite Calcium oxalate and triple phosphate Triple phosphate (struvite, magnesium ammonium phosphate) Cystine pure and mixed
Israel (1,000 pts.)
Literature (approx. 8,000 pts.)
57.0
33.7*
13.3 8.9
5.7 1.1
5.9
3.4
The chemical composition of 1,000 stones collected in our 5.5 4.8 15.5 hospital between 1966 and 1975 is presented in table 1. 3.2 34.3t Calcium oxalate-calcium phosphate and uric acid stones were 1.2 3.2t the most common types found. The relative incidence of urinary calculi in 500 patients 0.6 0.3 determined by chemical analysis in various ethnic groups 0.5 2.9 (table 2) and ages (table 3) is presented. Urinary stones in most ethnic groups were a combination of calcium oxalate and * Calcium oxalate pure and mixed. calcium phosphate stones (54 to 65 per cent), whereas in t Apatite plus calcium oxalate pure and mixed. t Triple phosphate, calcium oxalate plus apatite. Israeli born Jews the incidence was only 44 per cent. In Jews born in Israel, Lebanon, Iran, Iraq and Syria, and the Ashkenazim uric acid stones accounted for more than 15 per cent of the total, 3 times higher than in other groups. In Jews born in Israel apatite stones accounted for 15 per cent of the total, 2 to 3 The onset of urolithiasis in childhood or adolescence in times higher than in other groups. Israeli born Jews is considered part of the general world In more than 60 per cent of the patients urolithiasis trend 12- 14 and an outcome of low fluid intake and excessive developed after the patient was 20 years old in most ethnic sweating. 1 groups. The age at onset was younger in Jews born in Israel The relative frequency of uric acid stones among Jews in (25.7 per cent), North Africa (13.8 per cent), Lebanon, Iraq, Israel (34.6 per cent) as estimated by Frank and associates• was Iran and Syria (8 per cent) and in Arabs (18 per cent). not confirmed in this series. The prevalence of uric acid stones calculated on the basis of our criteria was 22 per cent, 3 times Accepted for publication September 19, 1975. higher than mentioned in the literature. 9 • 15 626
11 --- ... 627
STUDIES ON UROLITHIASIS IN ISRAEL
'I TABLE
2. Relative incidence of urinary calculi by chemical analysis in various ethnic groups in Israel Jews
Israel (51 pts.)
Ashkenazim (200 pts.)
(%)
(%)
Bulgaria, Greece and T urkey (76 pts.) (%)
Calcium oxalate and calcium phosphate Uric acid pure Calcium oxalate, calcium phosphate and uric acid Apatite* Calcium oxalate pure Triple phosphate and apatite Calcium oxalate and apatite Calcium oxalate and triple phosphate Triple phosphate (struvite, magnesium ammonium phosphate) Cystine pure and mixed
Arabs North Africa (83 pts.) (%)
Lebanon, Iran, Iraq and Syria (61 pts.)
Yemen (17 pts.) (%)
(12 pts.) (%)
Israel Total Sample (1,000 pts.) (%)
(%)
Combined Ethnic Groups (500 pts.) (%)
44 .0
54.0
64.0
61.0
56.0
62.4
59.0
57.0
57.2
5.5 10.0
18.0 8.4
6.2 6.2
4.3 7.2
15.0 14.0
6.1 6.1
8.3 8.3
13.3 8.9
12.7 8.7
15.0 7.5 11.5
5.4 6.0 4.1 1.8 0.6
6.2 3.1 4.9 6.6 1.8
7.2 5.8 4.3 1.4 3.0
3.0 2.0 2.0 2.0 3.0
6.1 13.2
8.3
6.1
7.3 8.3
5.9 5.5 4.8 3.2 1.2
6.2 6.0 4.7 2.0 1.5
5.0
1.8
4.3
3.0
0.6
0.4
0.5
0.6
6 .5
0.6
1.4
• Calcium phosphate and calcium carbonate.
TABLE 3.
Distribution of urinary calculi by age in various ethnic groups in Israel Age (yrs.) Less Than 20
21 to 50 (%)
(%)
Jews: Israel Ashkenazim Bulgaria, Greece and Turkey North Africa Lebanon, Iran, Iraq and Syria Yemen Arabs
More Than 51
No. Pts.
(%)
25.7 1.7
55.5 34.4 42.0
18.6 64.0 58.0
46 187 70
13.8 8.0
51.7 69 .0
34.5 23.0
75 55
72.0 82.0
28.0
l8.0
16 12
REFERENCES
~1 '1
:'
1. Frank, M ., De Vries, A., Atsmon, A., Lazebnik, J. and Kochwa, S.: Epidemiological investigation of urolithiasis in Israel. J. Urol., 81: 497, 1959. 2. Eckstein, H. B.: Endemic urinary lithiasis in Turkish children. Arch. Dis. Child., 36: 1.37, 1961. 3. Gershoff, S. N., Prien, E. L. and Chandrapanond, A.: Urinary stones in Thailand. J. Urol., 90: 285, 1963. 4. Lavan, J. N., Neale, F. C. and Posen, S. : Urinary calculi. Clinical, biochemical and radiological studies in 619 patients. Med. J. Aust., 2: 1049, 1971. 5. Sutor, D. J ., Wooley, S. E. and Illingworth, J. J.: A geographical and historical survey of the composition of urinary stones. Brit. J. Urol., 46: 393, 1974.
6. Herbstein, F . H ., Kleeberg, J., Shalitin, Y., Wartski, E. and Wielinski, S.: Chemical and x-ray diffraction analysis of urinary stones in Israel. Isr. J. Med. Sci., 10: 1493, 1974. 7. Butt, A. J.: Etiologic factors in renal lithiasis. Springfield, Illinois: Charles C Thomas, Publisher, 1956. 8. Rosenthal, G. and Launer, J.: The chemical composition of urinary calculi. Harefuah, 56: 109, 1959. 9. Frank, M., Lazebnik, J. and De Vries, A.: Uric acid lithiasis-a study of six hundred and twenty two patients. Urol. Int., 25: 32, 1970. 10. Henry, R. J.: Clinical Chemistry, Principles and Technics. New York: Harper & Row, Publishers, Inc., p . 913, 1966. 11. Lonsdale, K.: Human stones. Science, 159: 1199, 1968. 12. Epstein, F. H.: Calcium and the kidney. Amer. J. Med., 45: 700, 1968. 13. Gharib, R.: Lithiasis in the urinary tract of children. General review based on observations in 167 affected Iranian children. Clin. Pediat., 9: 157, 1970. 14. Ghazali, S., Barratt, T. M. and Williams, D. I.: Childhood urolithiasis in Britain. Arch. Dis. Child., 48: 291, 1973. 15. Prien, E. L.: Crystallographic analysis of urinary calculi: a 23-year ·survey study. J. Urol., 89: 917, 1963.
COMMENT This paper represents a monumental compilation of stone analyses in a country where climate and heredity are probably contributing factors to nephrolithiasis. The large number of mixed composition stones points to the important interplay between different stone salts and the probable role o~ pita6:} whereby 1 type of stone crystal serves as the nucleating surface or mducing the precipitation of a second type of stone crystal. W.B.G.
h,i.e
~!ttf I ~
r~~," 4=-,z;;,,
11 I
II
