Chronic stress and calcium oxalate stone disease: is it a potential recurrence risk factor?

Abstract

Chronic emotional stress is associated with increased cortisol release and metabolism disorders. However, few studies have evaluated the influence of chronic stress on calcium oxalate (CaOx) stone disease and its recurrence. A total of 128 patients were enrolled in this case-control study over a period of 20 months. All patients were CaOx stone formers with a recent stone episode (<3 months); 31 were first-time stone formers (FS) and 33 recurrent stone formers (RS). Dimensions of chronic stress were evaluated with self-reported validated questionnaires measuring stressful life events, perceived stress, anxiety, depression, burnout and satisfaction with life. An ad hoc self-reporting questionnaire was designed to evaluate stress-related specifically to stone episodes. Blood and urine samples were collected to determine cortisol levels and urinary composition. In addition, epidemiological data, socioeconomic information, diet and incidences of metabolic syndrome (MS) were reported. Overall, no significant differences were observed in the scores of cases and controls on any of the questionnaires dealing with stress. The number (p < 0.001) and the intensity (p < 0.001) of perceived stressful life events were higher in RS than in FS, but there were no differences between the two groups in other dimensions of stress. RS had higher glucose (p = 0.08), uric acid (p = 0.02), blood cortisol (p = 0.01), and urine calcium levels (p = 0.01) than FS. RS also had lower economic levels (p = 0.02) and more frequent incidences of MS (p = 0.07) than FS. Although no differences were observed in cases and controls among any dimension of chronic stress, the number and intensity of stressful life events were higher in RS than in FS. These differences correlate with variations in blood and urinary levels and with metabolic disorders, indicating an association between chronic stress and risk of recurrent CaOx stone formation.

Stress–stones–stress–recurrent stones: a self-propagating cycle? Difficulties in solving this dichotomy

“…Some studies have shown alterations which are consistent with an increase in stone risk in certain parameters [11,12,[15][16][17], but a simultaneous decrease in risk in other parameters [16,17]. Reported urinary alterations which support the hypothesis that urine chemistry becomes more lithogenic under stressful conditions are elevations in urinary calcium [11,15], oxalate [15], phosphorus [16] and uric acid [15] and decreases in Mg [17] and Cit [17]. The latter finding is supported by the observation that urinary magnesium is associated with life satisfaction [12].…”

“…Stone formers were out-patients in the Urology Department at Hospital Germans Trias I Pujol, Badalona, Spain while controls were persons with no history of stones who accompanied patients on their hospital visits in the Urology Department for causes not related to stone disease [11].…”

“…Stress has been listed among the so-called lifestyle factors [7]. Examination of the literature reveals that while several studies have established an associative link between stress and stones, none have demonstrated a causal link between them [8][9][10][11][12][13][14]. Moreover, only a few of the studies in which associations have been observed, Abstract Numerous studies have reported an association between stress and urolithiasis.…”

“…In a previous study, we compared chronic stress dimensions and urine and blood chemistries in first time (FS) and recurrent (RS) stone formers and suggested that there is an association between chronic stress and the risk of recurrence [11]. As a continuation of our ongoing interest in this relationship and of our ongoing objective to find evidence in support of a causal effect rather than an associative one, we undertook the present study to revisit and interrogate all of the urinary and stress data obtained in our previous study, in terms of the more holistic approach described above.…”

“…All subjects had been previously assessed for chronic stress dimensions, as well as for stress caused by their stone episodes per se. Conditional and unconditional logistic regression (with a Bonferroni correction for multiple tests) have attempted to identify by laboratory measurements of blood and urine chemistries, the biochemical mechanisms and pathways by which stress, in whatever form, might induce stone formation [11,12,[15][16][17]. A credible hypothesis suggests that in stress conditions, the fight or flight response is triggered, setting in motion several processes ultimately leading to a change in urine chemistries which include hypercalciuria [7].…”