Study Type - Prevalence (retrospective cohort)
Level of Evidence 2b
What's known on the subject? and What does the study add?
Shockwave lithotripsy is a common and effective treatment method for kidney stones, but has been associated with long-term complications, namely hypertension and diabetes. We compared the prevalence of these two disease in patients treated with lithotripsy to the background provincial population. Our analyses did not find an association between lithotripsy and the development of these diseases.
Shockwave lithotripsy is an effective treatment modality for urolithiasis. The mechanism of stone communition during lithotripsy as well as the acute complications that occur following this treatment have been well described; however, the long-term consequences of this procedure have not been clearly defined. Diabetes and hypertension have been associated with lithotripsy at 19 years follow-up, though this relationship is controversial. This issue is further complicated by the interrelatedness of metabolic dysfunction and stone disease.
Our data show that there is no association between lithotripsy and the development of either hypertension or diabetes. Patients treated for urolithiasis 20 years ago with shockwave lithotripsy were contacted, and their prevalence of diabetes and hypertension in these subjects was compared to the background population of British Columbia. The analysis also considered whether the properties of shockwaves delivered by the original Dornier HM-3 versus a modified Dornier HM-3 differentially affected the risk of our subjects developing these diseases. We did not find that lithotripsy, let alone the type of lithotriptor, was a risk factor for developing hypertension and diabetes. We postulate that the development of renal calculi in our subjects is more indicative of an overall metabolic syndrome where there is increasing evidence that patients with kidney stones get hypertension and diabetes and vice-versa. The development of these diseases is not related to shockwave lithotripsy, but rather to a systemic metabolic dysfunction.
OBJECTIVES: To compare the prevalence of hypertension and diabetes mellitus (DM) in patients treated with an unmodified HM-3 lithotripter (USWL) and a second-generation modified HM-3 lithotripter (MSWL) 20 years ago at our Centre with that in the provincial population. To determine whether the type of lithotripter was differentially associated with the development of these sequelae.
PATIENTS AND METHODS: Retrospective review of 727 patients at Vancouver General Hospital who underwent shock-wave lithotripsy (SWL) between 1985 and 1989. Our study group was compared with Statistics Canada data describing the provincial prevalence of these diseases. Multivariate analysis was performed.
RESULTS: The response rate was 37.3%. There was a greater proportion of overweight and obese individuals in the study group compared with the provincial average. In univariate analysis, lithotripsy with an unmodified HM-3 (USWL) was associated with a higher rate of DM than the provincial rate, whereas lithotripsy with the modified HM-3 (MSWL) was not. Hypertension was more prevalent in all lithotripsy subjects. On multivariate analysis the type of lithotripter was not associated with the development of either sequela.
CONCLUSIONS: No association between lithotripsy and the development of either DM or hypertension in a multivariate analysis Metabolic syndrome may have elevated the prevalence of DM and hypertension observed in our subjects on univariate analysis, which is in keeping with the fact that our study population had statistically higher body mass indices than the provincial rate. Lithotripsy using the HM-3 was not associated with increased DM or hypertension.
© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.
BJU Int. 2012 Feb;109(3):444-9. doi: 10.1111/j.1464-410X.2011.10291.x. Epub 2011 Jun 2
PMID: 21635683 [PubMed - as supplied by publisher]
After several conflicting reports on the long term consequences of SWL the paper published by Krambeck AE et al. in 2006 seemed to clarify things: “Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of followup.” Their conclusion made it into the lay press and, turned into gossip, caused some confusion among patients and physicians. Their publication set the pace. But it is difficult to compare results of similar studies on that subject because of the differences in material and methods. An easier way is to have a look at the conclusions only:
(Krambeck et al. Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of followup. J Urol. 2006 May; 175(5):1742-7)
CONCLUSIONS: “In this case-control study treating renal and proximal ureteral calculi with the HM-3 lithotriptor was associated with DM (Diabetes Mellitus) and hypertension at 19 years of followup.”
(Krambeck AE, et al. Long-term outcomes of percutaneous nephrolithotomy compared to shock wave lithotripsy and conservative management. J Urol. 2008 Jun; 179 (6):2233-7)
CONCLUSIONS: “PCNL was not associated with a higher rate of adverse medical conditions at long-term followup compared to those treated with SWL and those treated conservatively. Based on these results we conclude that PCNL is a safe treatment for appropriately selected renal calculi with minimal long-term effects.”
(Krambeck AE, et al. Shock wave lithotripsy is not predictive of hypertension among community stone formers at long-term followup. J Urol. 2011 Jan; 185(1):164-9)
CONCLUSIONS: “This study in a large population based cohort of incident stone formers failed to demonstrate an increased risk of hypertension after SWL for urolithiasis. These findings are reassuring that the use of at least 1 SWL treatment does not subject most patients with urolithiasis to an increased risk of hypertension. However, it is still possible that multiple SWL treatments may increase the subsequent risk of hypertension or that certain subgroups (e.g. those with chronic kidney disease) might be more susceptible.
The present paper offers a good way out of the confusion: The metabolic syndrome is more important for stone formation and the development of Diabetes and Hypertension than the kind of treatment of stones. (Chew BH, et al. BJU Int. 2011 Jun. Twenty-year prevalence of diabetes mellitus and hypertension in patients receiving shock-wave lithotripsy for urolithiasis.)
CONCLUSIONS: “We did not find that lithotripsy, let alone the type of lithotriptor, was a risk factor for developing hypertension and diabetes. The development of these diseases is not related to shockwave lithotripsy, but rather to a systemic metabolic dysfunction. THIS IS WHAT WE CAN TELL OUR PATIENTS.
The interested Urologists who want to come closer to the truth may spend some time to read a paper by another Krambeck (Multiple gossip statements and their effect on reputation and trustworthiness. Sommerfeld RD, Krambeck H-J, Milinski M. Proc. R. Soc. B 2008 275, 2529-2536)
CONCLUSIONS:” … Apparently, the real world is different … “