Hyperoxaluria and Genitourinary Disorders in Children Ingesting Almond Milk Products

doi:10.1016/j.jpeds.2015.08.029

The Journal of Pediatrics

Volume 167, Issue 5, November 2015, Pages 1155-1158

https://doi.org/10.1016/j.jpeds.2015.08.029 Get rights and content

We describe 3 children presenting with hematuria, dysuria or kidney stones, and hyperoxaluria believed to be related to ingestion of excessive amounts of almond milk products. Our investigation of the oxalate content of several popular plant-based milk substitutes indicates that almond milk products are a particularly rich source of dietary oxalate. All genitourinary and urinary metabolic disturbances resolved after discontinuation of almond milk ingestion. Therefore, pediatricians should be aware of this potential link.

Section snippets

Clinical Presentation

Two girls (9 and 10 years of age) and 1 boy (3 years of age) were developmentally appropriate and healthy except for constipation in both girls. All 3 children presented with dysuria. Both girls had periumbilical or costovertebral colicky pain and intermittent gross hematuria; all 3 had persistent, isolated microscopic hematuria. One child's mother saw a “white powder” at the urethral meatus on several occasions. In addition to non-dysmorphic red blood cells, urine microscopy revealed mild

Methods

Validation of adequacy of 24-hour urine collections was ascertained by the amount of creatinine excreted per kg of lean body weight. Pre-intervention studies demonstrating hyperoxaluria were first performed at the clinical laboratory of our facility and then confirmed by a second urine collection analyzed at Litholink Corporation (Chicago, Illinois). Urinary oxalate was measured by an oxalate oxidase kit (Trinity Biotech, Bray, Ireland).6, 7 For purposes of uniformity of data comparison pre-

Discussion

We evaluated three young children presenting with hematuria and genitourinary symptoms. All 3 consumed an excessive amount of almond milk products and had marked hyperoxaluria. A tendency to low fluid intake and a hereditary predisposition to calcium-based nephrolithiasis may have been contributing factors in these children. Our children did not consume other foods with high oxalate content.¹⁴

After complying with standard dietary guidelines aimed at minimizing the risk for nephrolithiasis and

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Citation Excerpt :
Prospective data from the Health Professionals Follow-up Study and Nurses’ Health Studies showed that increased calcium intake from dairy or nondairy dietary sources is associated with a lower risk of incident symptomatic kidney stones.4 However, there is concern that some nut-based milks may have a high oxalate content.5 This could have implications for patients with kidney stones.
Patients with kidney stones are counseled to eat a diet low in animal protein, sodium, and oxalate and rich in fruits and vegetables, with a modest amount of calcium, usually from dairy products. Restriction of sodium, potassium, and oxalate may also be recommended in patients with chronic kidney disease. Recently, plant-based diets have gained popularity owing to health, environmental, and animal welfare considerations. Our objective was to compare concentrations of ingredients important for kidney stones and chronic kidney disease in popular brands of milk alternatives.
Sodium, calcium, and potassium contents were obtained from nutrition labels. The oxalate content was measured by ion chromatography coupled with mass spectrometry.
The calcium content is highest in macadamia followed by soy, almond, rice, and dairy milk; it is lowest in cashew, hazelnut, and coconut milk. Almond milk has the highest oxalate concentration, followed by cashew, hazelnut, and soy. Coconut and flax milk have undetectable oxalate levels; coconut milk also has comparatively low sodium, calcium, and potassium, while flax milk has the most sodium. Overall, oat milk has the most similar parameters to dairy milk (moderate calcium, potassium and sodium with low oxalate). Rice, macadamia, and soy milk also have similar parameters to dairy milk.
As consumption of plant-based dairy substitutes increases, it is important for healthcare providers and patients with renal conditions to be aware of their nutritional composition. Oat, macadamia, rice, and soy milk compare favorably in terms of kidney stone risk factors with dairy milk, whereas almond and cashew milk have more potential stone risk factors. Coconut milk may be a favorable dairy substitute for patients with chronic kidney disease based on low potassium, sodium, and oxalate. Further study is warranted to determine the effect of plant-based milk alternatives on urine chemistry.

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: The authors declare no conflicts of interest.

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Clinical and Laboratory ObservationsHyperoxaluria and Genitourinary Disorders in Children Ingesting Almond Milk Products

Section snippets

Clinical Presentation

Methods

Discussion

J Am Diet Assoc

J Urol

Kidney Int

Kidney Int

Urology

J Urol

Kidney Int

Kidney Int

Kidney Int

Kidney Int

Am J Clin Nutr

J Cryst Growth

Kidney Int

J Urol

J Urol

Clinical and Laboratory Observations
Hyperoxaluria and Genitourinary Disorders in Children Ingesting Almond Milk Products