Water For Preventing Urinary Stones

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discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/225305223
Water for preventing urinary stones

ARTICLE in COCHRANE DATABASE OF SYSTEMATIC REVIEWS (ONLINE) JANUARY 2012
Impact Factor: 5.94 DOI: 10.1002/14651858.CD004292.pub3 Source: PubMed
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2 AUTHORS:
Yige Bao
Qiang Wei
Sichuan University
Sichuan University
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Retrieved on: 21 June 2015
Water for preventing urinary stones (Review)

Bao Y, Wei Q
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

Copyright 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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]

Yige Bao1 , Qiang Wei1
1 Department
of Urology, West China Hospital, Sichuan University, Chengdu, China
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.
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.
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.
PLAIN LANGUAGE SUMMARY

Increased water intake may help reduce the risk of recurrence of kidney stones but more studies are needed
Kidney stones (also known as calculi) are masses of crystals and protein and are common causes of urinary tract obstruction in adults.
For a long time, increased water intake has been the main preventive measure for the disease and its recurrence. In this review only
one study was found that looked at the effect of increase water intake on recurrence and time to recurrence. Increased water intake
decreased the chance of recurrence and increased the time to recurrence. Further studies are needed.
BACKGROUND
Description of the condition

Urinary stones are a very common urological disease, with the
prevalence in the general population estimated to be between 2%
and 3%. In China, nationwide surveys held in 1977 and 1983
showed that urinary stones accounted for 26% of all urological
patients.
Urinary stones can be divided into upper urinary tract (kidney
and ureter) and lower urinary tract (bladder and urethra) stones.
Stone formation is a very complex process, and the pathophysiological mechanism is still not fully understood. Currently the
treatment options for urinary stones include drug therapy, surgical removal and extracorporeal shock wave lithotripsy (ESWL).
However a major problem is the high recurrence rate, even after
surgery or ESWL. The natural recurrence rate is reported to be
31.5% after five years and 72% after 20 years (Ljunghall 1975).
The average recurrence rate after surgery and ESWL is 40% after
11 years and 20% after four years (Kohnmann 1993; Sutherland
1982). The high prevalence and high recurrence rates underscore
the importance of a preventive programme.
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.
Why it is important to do this review

Few urologists have tested in a controlled study the preventive effective of increased water intake. Frank 1966 illustrated its importance in a general population living in a village in a hot desert region, and Borghi 1996 demonstrated in a randomised controlled
trial (RCT) that a high water intake without dietary change could
prolong the interval for recurrence in patients with a history of
urinary stones.
How the intervention might work

One of the prevailing assumptions in the literature is that increased
water intake and increased urine volume, decreases the incidence
of urinary stones in those patients predisposed to the disease. The
rationale is that supersaturation of the urinary environment with
stone-forming compounds is considered a prerequisite for stone
formation. Increased water intake results in excretion of a higher
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

2. increased water intake for the secondary prevention of

urinary stones in patients with a history of the disease.
METHODS
Criteria for considering studies for this review
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.
Types of outcome measures

1. Incidence of urinary stones
2. Stone recurrence
3. Average interval for recurrence
4. Incidence rate/patient/year
5. Recurrence rate/patient/year
6. Serious adverse effects of the intervention (e.g. water
intoxication)
Search methods for identification of studies
3. MEDLINE and Pre-MEDLINE (1966 - January 2004).

This will be combined with the Cochrane highly sensitive search
strategy for identifying RCTs in MEDLINE (Dickersin 1994),
and a similar strategy for EMBASE (Lefebvre 1996). Please see
Cochrane Renal Group Module for details of these strategies
4. EMBASE (1980 - January 2004)
5. Reference lists of nephrology textbooks, review articles and
relevant studies.
6. Conference proceedings from nephrology and urology
meetings.
7. Letters seeking information about unpublished or
incomplete studies to investigators known to be involved in
previous studies.
8. The Chinese Biomedical Disk (CBM disk) was also
searched to include the Chinese studies.
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.
Data collection and analysis
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.

Data extraction and management
Assessment of reporting biases
Two authors independently assess retrieved abstracts and, where

necessary the full text, of these studies to determine which studies
satisfied the inclusion criteria. Data extraction was independently
carried out using standard data extraction forms. Studies not reported in English or Chinese language journals were translated before assessment. To avoid duplication bias, we focused on checking the authors name, publication date and main results. Where
necessary, we extracted data from different publications to obtain
all the outcomes. Where more than one publication of one study
existed, reports were to be grouped together and the publication
with the most complete data used in the analyses. Disagreements
were resolved via discussion.
If sufficient RCTs were identified, publication bias was to be investigated using a funnel plot (Higgins 2011).
Assessment of risk of bias in included studies

The following items will be independently assessed by two authors
using the risk of bias assessment tool (Higgins 2011) (see Appendix
2).
Was there adequate sequence generation (selection bias)?
Was allocation adequately concealed (selection bias)?
Was knowledge of the allocated interventions adequately
prevented during the study (detection bias)?
Participants and personnel
Outcome assessors
Were incomplete outcome data adequately addressed
(attrition bias)?
Are reports of the study free of suggestion of selective
outcome reporting (reporting bias)?
Was the study apparently free of other problems that could
put it at a risk of bias?
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
Subgroup analysis and investigation of heterogeneity

Subgroup analysis were to be used to explore possible sources of
heterogeneity (e.g. with or without a history of urinary stones;
different volumes of water intake; different types of water (e.g.
tap water, mineral water); different types of stones (e.g. calcium,
uric acid)). Adverse effects were to be tabulated and assessed with
descriptive techniques, as they were likely to be different for the
various agents used. Where possible, the risk difference (RD) with
95% CI was to be calculated for each adverse effect, either compared to no treatment or to another agent. We also planned to conduct calculation of absolute risk reductions (ARR) for increased
water intake versus no intervention or a different intervention.
Subgroup analysis were to be performed if sufficient data was provided for patients with hyperthyroidism, hyperparathyroidism,
metabolic stones (e.g. cystinuria, oxalosis), Cushings syndrome,
severe diabetes, gout, urinary infections or other decalcification
diseases, as these factors are considered to promote the stone formation process.
Measures of treatment effect

For dichotomous outcomes (e.g. stones or no stones) results were
expressed as risk ratio (RR) with 95% confidence intervals (CI).
Where continuous scales of measurement were used to assess the
effects of treatment (e.g. time to stones or interval for recurrence),
the mean difference (MD) was used, or the standardised mean
difference (SMD) if different scales were used.
Dealing with missing data
Any further information required from the original author was
to be requested and any relevant information obtained was to be
included in the review.
Assessment of heterogeneity
Heterogeneity was to be analysed using a Chi test on N-1 degrees
of freedom, with an alpha of 0.05 used for statistical significance
and with the I test (Higgins 2003). I values of 25%, 50% and
75% correspond to low, medium and high levels of heterogeneity.
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 1. Study flow diagram.
Risk of bias in included studies

Allocation
The method of random sequence generation and allocation concealment was not described.
Blinding
Blinding was not possible for participants and investigators and
not reported for outcome assessors.
Incomplete outcome data
The dropout was 9.5%. No intention-to-treat analysis was performed.

Selective reporting
Only two of our six of our predefined outcomes were reported, and
further information could not be obtained from the investigators.
Other potential sources of bias
Insufficient information was provided to determine if there were
any other potential sources of bias.
Risk of bias assessment is summarised in Figure 2 and Figure 3.

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
The other planned outcomes and subgroup analyses could not be

performed because of the lack of appropriate studies.
Stone recurrence and average time to recurrence

Stone recurrence was lower in the increased water intake group
(12%) than that of the no intervention group (27%) (Analysis 1.1:
RR 0.45, 95% CI 0.24 to 0.84). The average time to recurrences
was 3.23 1.1 years in increased water intake group and 2.09
1.37 years in the control group (Analysis 1.2: MD 1.14, 95% CI
0.33 to 1.95).
Adverse effects
Adverse effects where not reported.
DISCUSSION
Summary of main results

Despite the fact that increased water intake has been widely used
to prevent urinary stones and its recurrence, no RCTs were found
investigating increased water intake for the prevention of urinary
stones.

With regard to the prevention of recurrences in stone formers,

only one study met our inclusion criteria. It reported stone recurrence was lower (RR 0.45, 95% CI 0.24 to 0.84) and average
time to recurrence was longer for the increased water intake group
(MD 1.14, 95% CI 0.33 to 1.95). Blinding and the method of
randomisation were unclear and so the results must be considered
with some caution. Confirmatory research is required.
Overall completeness and applicability of

evidence
Borghi 1996 applied no restrictions with respect to age, body
weight, occupation or comorbidities. However this conclusion
need further conformation with more RCTs.
Urinary stones are a global health issue permeating all geographic
regions and socioeconomic classes, and have an increasing incidence and high recurrence rate. Drinking water remains a simple and cost-effective preventive method, and is recommended by
most healthcare facilities. This review sought to confirm these recommendations by analysing RCT evidence and to determine the
direction and strength of this evidence.
Quality of the evidence

Only one RCT enrolling 220 participants with a follow-up period
of five years was included. The method of randomisation and allocation concealment was not described; blinding of participants
and investigators was not possible, and blinding of outcome assessors was not reported. Eleven patients dropped out without explanation (dropout rate 9.5%) and intention-to-treat analysis was not
performed. There was no evidence of selective outcome reporting,
although no potential adverse events were reported.
Potential biases in the review process

We followed the Cochrane Collaboration guidelines for conducting this systematic review and meta-analysis. Strengths of our review include the searching of several databases with no language
restrictions. Study selection, assessment of risk of bias, and data
extraction were performed by two authors, which reduced the risk
of error and bias. Although efforts were made to collect relevant
data, the possibility of missing data cannot be excluded. Publication bias remains a possible source of important bias. Meanwhile,
interpretation of the result should be done cautiously because the
number of studies included in relation to our selection criteria was
limited.
Agreements and disagreements with other

studies or reviews
We are not aware of any other systematic reviews on this topic;

however two observational studies support the effectiveness of increased water intake for the prevention of urinary stones (Curhan
1993; Frank 1966). Frank 1966 compared the incidence of urinary
stones in two desert towns after an educational program had been
run in one of them for increasing water intake as a preventive measure against the risk of urinary stones. After three years the prevalence of urinary stones was lower in the intervention town (0.28%
versus 0.85%, P < 0.001). This finding has been confirmed in a
wide ranging, long-term study in the US (Curhan 1993). In this
study, a total of 45,619 male health professionals aged 40 to 75
years with no history of urinary stones were enrolled. Daily fluid
intake was divided into quintiles and the RR of kidney stone development decreased with increased fluid consumption: (< 1275
mL, RR = 1.0; 1275 to 1669 mL, RR = 1.05; 1670 to 2049 mL,
RR = 0.82; 2050 to 2537 mL, RR = 0.72; > 2537 mL, RR = 0.52).
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.
Implications for research

Large, multi-centre long-term RCTs of good quality are
required to answer the questions concerning increased water
intake for the primary and secondary prevention of urinary
stones.
Future studies should be designed to evaluate how much
water and what kind of water is best for the primary and
secondary prevention of urinary stones.
The effect of increased water intake on different kinds of
stone formers should also be evaluated.
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
References to studies included in this review
calcium nephrolithiasis. Clinical Science 1996;91(3):3138.

[MEDLINE: 8869414]
Borghi 1996 {published data only}

Borghi L, Meschi T, Amato F, Briganti A, Novarini A,
Giannini A. Urinary volume, water and recurrences in
idiopathic calcium nephrolithiasis: a 5-year randomized
prospective study. Journal of Urology 1996;155(3):83943.
[MEDLINE: 8583588]
Neimark 2003 {published data only}

Neimark AI, Davydov AV. Use of Serebrianyi Kliuch
mineral water in the postoperative treatment of patients with
nephrolithiasis after extracorporeal shock-wave lithotripsy.
Urologiia (Moscow, Russia) 2003, (4):446. [MEDLINE:
12942727]
References to studies excluded from this review
Rodgers 1998 {published data only}

Rodgers AL. The influence of South African mineral
water on reduction of risk of calcium oxalate kidney stone
formation. South African Medical Journal 1998;88(4):
44851. [MEDLINE: 9594989]
Curhan 1993 {published data only}

Curhan GC, Willett WC, Rimm EB, Stampfer MJ. A
prospective study of dietary calcium and other nutrients and
the risk of symptomatic kidney stones. New England Journal
of Medicine 1993;328(12):8338. [MEDLINE: 8441427]
de La Guronnire 2011 {published data only}
de La Guronnire V, Le Bellego L, Jimenez IB, Dohein
O, Tack I, Daudon M. Increasing water intake by 2 liters
reduces crystallization risk indexes in healthy subjects.
Archivio Italiano di Urologia, Andrologia 2011; Vol. 83,
issue 1:4350. [MEDLINE: 21585170]
Valli 2000 {published data only}

Valli PP, Cesaroni M, Mearini L, Rociola W, Cervelli B,
Porena M. Hyperhydration with low mineral Rocchetta
water after extracorporeal lithotripsy. Archivio Italiano di
Urologia, Andrologia 2000;72(1):2931. [MEDLINE:
10875164]
References to ongoing studies
Di Silverio 1994 {published data only}

Di Silverio F, DAngelo AR. Prevention of renal calculosis:
efficacy of Fiuggi water cure. Research Group on Renal
Calculosis. Archivio Italiano di Urologia, Andrologia 1994;
66(5):2538. [MEDLINE: 7812305]
Borghi 2010 {published data only}

Borghi L. The links between water and salt intake, body
weight, hypertension and kidney stones: a difficult puzzle.
clinicaltrials.gov/ct2/show/NCT01100580 (accessed 18
April 2012).
Di Silverio 2000 {published data only}

Di Silverio F, Ricciuti GP, DAngelo AR, Fraioli A,
Simeoni G. Stone recurrence after lithotripsy in patients
with recurrent idiopathic calcium urolithiasis: Efficacy of
treatment with Fiuggi water. European Urology 2000;37(2):
1458. [EMBASE: 2000069669]
Additional references
Frank 1966 {published data only}

Frank M, De Vries A, Tikva P. Prevention of urolithiasis.
Education to adequate fluid intake in a new town situated
in the Judean Desert Mountains. Archives of Environmental
Health 1966;13(3):62530. [MEDLINE: 5925636]
Karagulle 2007 {published data only}
Karagulle O, Smorag U, Candir F, Gundermann G, Jonas
U, Becker AJ, et al.Clinical study on the effect of mineral
waters containing bicarbonate on the risk of urinary stone
formation in patients with multiple episodes of CaOxurolithiasis. World Journal of Urology 2007;25(3):31523.
[MEDLINE: 17333204]
Lorentzen 1979 {published data only}
Lorentzen JE, Lund F, Andersen B, Dorph S. Effect of
Radison water in treatment of patients with renal calculi.
A randomized double-blind method. Ugeskrift for Laeger
1979;141(9):57981. [MEDLINE: 371092]
Marangella 1996 {published data only}
Marangella M, Vitale C, Petrarulo M, Rovera L, Dutto F.
Effects of mineral composition of drinking water on risk
for stone formation and bone metabolism in idiopathic
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

in EMBASE. Fourth International Cochrane Colloquium;

1996 Oct 20-24; Adelaide (Australia) 1996.
Ljunghall 1975
Ljunghall S, Hedstrand H. Epidemiology of renal stones in
a middle-aged male population. Acta Medica Scandinavica
1975;197(6):43945.
Pak 1980
Pak CY, Sakhaee K, Crowther C, Brinkley L. Evidence
justifying a high fluid intake in treatment of nephrolithiasis.
Annals of Internal Medicine 1980;93(1):369. [MEDLINE:
80240234]
Sutherland 1982
Sutherland JW. Recurrence following operative treatment of
upper urinary tract stone. Journal of Urology 1982;127(3):

4724. [MEDLINE: 82145743]
References to other published versions of this review

Ke 2004
Ke Z, Wei Q. Water for preventing urinary calculi. Cochrane
Database of Systematic Reviews 2004, Issue 3. [DOI:
10.1002/14651858.CD004292.pub2]
Wei 2003
Wei Q, Zhang K. Water for preventing urinary calculi.
Cochrane Database of Systematic Reviews 2003, Issue 3.
[DOI: 10.1002/14651858.CD004292]
Indicates the major publication for the study

10
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Borghi 1996
Methods
Study design: prospective RCT

Study duration: started 1996, with 5 year follow-up
Participants
Setting: Single centre

Country: Italy
Patients with first episode of idiopathic calcium nephrolithiasis (calculus found at
the chemical examination to be composed of pure calcium oxalate or mixed with traces
of calcium phosphate),absence of other retained calculi (renal echography and IVP)
and absence of arterial hypertension or other metabolic pathology that requires regular
dietary measures or drug therapy
Number: 220 enrolled, 199 analysed
Group 1: 99
Group 2: 100
Mean age SD years: group 1 (42.2 11.6); group 2 (40.4 13.2)
Sex (M/F): group 1 (70/29); group 2 (64/36)
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
Support for judgement
Random sequence generation (selection Unclear risk

bias)
Insufficient information about the sequence generation process
Allocation concealment (selection bias)
Method of concealment is not described
Unclear risk
Blinding of participants and personnel Unclear risk

(performance bias)
All outcomes

Insufficient information to permit judgement of Low risk or High risk
11
Borghi 1996
(Continued)
Blinding of outcome assessment (detection Unclear risk

bias)
All outcomes
Insufficient information to permit judgement of Low risk or High risk
Incomplete outcome data (attrition bias)

All outcomes
Unclear risk
Dropout rate < 10%, intention-to-treat

analysis was not performed
Selective reporting (reporting bias)
Unclear risk
Only two of our six predefined outcomes

were reported and we were unable to obtain
any additional data from the authors
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Curhan 1993
Not RCT
de La Guronnire 2011
Intervention given for only 6 days
Di Silverio 1994
Results not presented for recurrence
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
Results not presented for recurrence
Valli 2000
Wrong comparator

12
Characteristics of ongoing studies [ordered by study ID]

Borghi 2010
Trial name or title
The Links Between Water and Salt Intake, Body Weight, Hypertension and Kidney Stones: a Difficult Puzzle
Methods
Prospective, randomised, open label, Interventional study
Participants
For stone formers main inclusion criteria

age between 20 and 70 years
Caucasian race
idiopathic calcium stone disease
normal renal function (creatininemia <1.2 mg/dL)
Interventions
Dietary supplement: low salt diet + water therapy
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
Prof Loris Borghi +390521703375 loris.borghi@unipr.it
Notes
Study not yet recruiting (March 2012)

13
DATA AND ANALYSES
Comparison 1. Increased water intake versus standard water intake
No. of
studies
Outcome or subgroup title

1 Stone recurrence
2 Average interval for recurrence
No. of
participants
1
1
Statistical method
Effect size
Risk Ratio (M-H, Random, 95% CI)

Mean Difference (IV, Random, 95% CI)
Totals not selected

Totals not selected
Analysis 1.1. Comparison 1 Increased water intake versus standard water intake, Outcome 1 Stone
recurrence.
Review:
Comparison: 1 Increased water intake versus standard water intake

Outcome: 1 Stone recurrence
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:
Comparison: 1 Increased water intake versus standard water intake

Outcome: 2 Average interval for recurrence
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.
MeSH descriptor Water, this term only

MeSH descriptor Drinking, this term only
MeSH descriptor Fluid Therapy, this term only
MeSH descriptor Body Water, this term only
MeSH descriptor Beverages, this term only
(water*):ti,ab,kw in Clinical Trials
(fluid*):ti,ab,kw in Clinical Trials
(drink*):ti,ab,kw in Clinical Trials
(#1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8)
MeSH descriptor Urinary Calculi explode all trees
MeSH descriptor Urolithiasis, this term only
(urolithiasis):ti,ab,kw in Clinical Trials
(urin* stone*):ti,ab,kw or (urin* calcul*):ti,ab,kw in Clinical Trials
(#10 OR #11 OR #12 OR #13)
(#9 AND #14)
Water/
Drinking/
Fluid Therapy/
Body Water/
Beverages/

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
Appendix 2. Risk of bias assessment tool
Potential source of bias
Assessment criteria
Random sequence generation

Low risk of bias: Random number table; computer random numSelection bias (biased allocation to interventions) due to inade- ber generator; coin tossing; shuffling cards or envelopes; throwing
quate generation of a randomised sequence
dice; drawing of lots; minimization (minimization may be implemented without a random element, and this is considered to be
equivalent to being random)
High risk of bias: Sequence generated by odd or even date of birth;
date (or day) of admission; sequence generated by hospital or
clinic record number; allocation by judgement of the clinician; by
preference of the participant; based on the results of a laboratory
test or a series of tests; by availability of the intervention
Unclear: Insufficient information about the sequence generation
process to permit judgement
Allocation concealment
Low risk of bias: Randomisation method described that would not
Selection bias (biased allocation to interventions) due to inade- allow investigator/participant to know or influence intervention
quate concealment of allocations prior to assignment
group before eligible participant entered in the study (e.g. central
allocation, including telephone, web-based, and pharmacy-controlled, randomisation; sequentially numbered drug containers of
identical appearance; sequentially numbered, opaque, sealed envelopes)
High risk of bias: Using an open random allocation schedule (e.g. a
list of random numbers); assignment envelopes were used without
appropriate safeguards (e.g. if envelopes were unsealed or nonopaque or not sequentially numbered); alternation or rotation;
date of birth; case record number; any other explicitly unconcealed
procedure

16
(Continued)
Unclear: Randomisation stated but no information on method

used is available
Blinding of participants and personnel
Low risk of bias: No blinding or incomplete blinding, but the rePerformance bias due to knowledge of the allocated interventions view authors judge that the outcome is not likely to be influenced
by participants and personnel during the study
by lack of blinding; blinding of participants and key study personnel ensured, and unlikely that the blinding could have been
broken
High risk of bias: No blinding or incomplete blinding, and the
outcome is likely to be influenced by lack of blinding; blinding
of key study participants and personnel attempted, but likely that
the blinding could have been broken, and the outcome is likely
to be influenced by lack of blinding
Unclear: Insufficient information to permit judgement
Blinding of outcome assessment
Low risk of bias: No blinding of outcome assessment, but the review
Detection bias due to knowledge of the allocated interventions by authors judge that the outcome measurement is not likely to be
outcome assessors
influenced by lack of blinding; blinding of outcome assessment
ensured, and unlikely that the blinding could have been broken
High risk of bias: No blinding of outcome assessment, and the
outcome measurement is likely to be influenced by lack of blinding; blinding of outcome assessment, but likely that the blinding
could have been broken, and the outcome measurement is likely
to be influenced by lack of blinding
Incomplete outcome data
Low risk of bias: No missing outcome data; reasons for missing
Attrition bias due to amount, nature or handling of incomplete outcome data unlikely to be related to true outcome (for survival
outcome data
data, censoring unlikely to be introducing bias); missing outcome
data balanced in numbers across intervention groups, with similar
reasons for missing data across groups; for dichotomous outcome
data, the proportion of missing outcomes compared with observed
event risk not enough to have a clinically relevant impact on the
intervention effect estimate; for continuous outcome data, plausible effect size (difference in means or standardized difference in
means) among missing outcomes not enough to have a clinically
relevant impact on observed effect size; missing data have been
imputed using appropriate methods
High risk of bias: Reason for missing outcome data likely to be
related to true outcome, with either imbalance in numbers or reasons for missing data across intervention groups; for dichotomous
outcome data, the proportion of missing outcomes compared with
observed event risk enough to induce clinically relevant bias in
intervention effect estimate; for continuous outcome data, plauWater for preventing urinary stones (Review)
17
(Continued)
sible effect size (difference in means or standardized difference in

means) among missing outcomes enough to induce clinically relevant bias in observed effect size; as-treated analysis done with
substantial departure of the intervention received from that assigned at randomisation; potentially inappropriate application of
simple imputation
Selective reporting
Reporting bias due to selective outcome reporting
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
Other bias
Bias due to problems not covered elsewhere in the table
Low risk of bias: The study appears to be free of other sources of

bias.
High risk of bias: Had a potential source of bias related to the specific study design used; stopped early due to some data-dependent
process (including a formal-stopping rule); had extreme baseline
imbalance; has been claimed to have been fraudulent; had some
other problem
Unclear: Insufficient information to assess whether an important
risk of bias exists; insufficient rationale or evidence that an identified problem will introduce bias

18
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
New search has been performed
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
Converted to new review format.
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

19
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.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

Risk of bias assessment tool has replaced the quality assessment checklist (Wei 2003).
I statistic was used to assess heterogeneity (Higgins 2003)
INDEX TERMS
Medical Subject Headings (MeSH)
Drinking; Drinking Water; Recurrence [prevention & control]; Urinary Calculi [ prevention & control]
MeSH check words

Humans

20

Water For Preventing Urinary Stones

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156 PUBLICATIONS 422 CITATIONS

Available from: Yige Bao

Water for preventing urinary stones (Review)

Water for preventing urinary stones (Review)

Water for preventing urinary stones (Review)

Water for preventing urinary stones

of Urology, West China Hospital, Sichuan University, Chengdu, China

PLAIN LANGUAGE SUMMARY

Description of the condition

Why it is important to do this review

How the intervention might work

Water for preventing urinary stones (Review)

2. increased water intake for the secondary prevention of

Criteria for considering studies for this review

Types of outcome measures

Search methods for identification of studies

3. MEDLINE and Pre-MEDLINE (1966 - January 2004).

Data collection and analysis

Water for preventing urinary stones (Review)

Data extraction and management

Assessment of reporting biases

Two authors independently assess retrieved abstracts and, where

Assessment of risk of bias in included studies

Subgroup analysis and investigation of heterogeneity

Measures of treatment effect

Water for preventing urinary stones (Review)

Figure 1. Study flow diagram.

Risk of bias in included studies

The dropout was 9.5%. No intention-to-treat analysis was performed.

Water for preventing urinary stones (Review)

Water for preventing urinary stones (Review)

The other planned outcomes and subgroup analyses could not be

Stone recurrence and average time to recurrence

Summary of main results

Water for preventing urinary stones (Review)

With regard to the prevention of recurrences in stone formers,

Overall completeness and applicability of

Quality of the evidence

Potential biases in the review process

Agreements and disagreements with other

We are not aware of any other systematic reviews on this topic;

Implications for research

Water for preventing urinary stones (Review)

References to studies included in this review

calcium nephrolithiasis. Clinical Science 1996;91(3):3138.

Borghi 1996 {published data only}

Neimark 2003 {published data only}

References to studies excluded from this review

Rodgers 1998 {published data only}

Curhan 1993 {published data only}

Valli 2000 {published data only}

References to ongoing studies

Di Silverio 1994 {published data only}

Borghi 2010 {published data only}

Di Silverio 2000 {published data only}

Frank 1966 {published data only}

Water for preventing urinary stones (Review)

in EMBASE. Fourth International Cochrane Colloquium;

upper urinary tract stone. Journal of Urology 1982;127(3):

References to other published versions of this review