Editorial Comment on: Successful Diabetic Control as Measured by Hemoglobin A1c Is Associated with Lower Urine Risk Factors for Uric Acid Calculi by Maciolek et al. (From: Maciolek KA,Penniston KL,Jhagroo RA,et al.J Endourol 2018;32:771–776)

I read with great interest the article ¹ by Maciolek and colleagues who reported an uncommonly studied phenomenon. The authors retrospectively collected data of 183 stone formers (SFs) with 459 acceptable 24 hours urine collections and who had hemoglobin A1c (HgbA1c) measures from within 3 months of the urine collection. The authors concluded that effective glycemic control may be associated with reduced urinary risk factors for uric acid (UA) stone formation. Excellent glycemic control may negate the increased risk of UA nephrolithiasis typically associated with type 2 diabetes mellitus (DM) and confer lower risk that is comparable with SFs without DM. The authors should be congratulated for performing a well-designed study and with the current emphasis to promotion of glycemic control as a target of the multidisciplinary medical management of stone disease.

UA stone comprises 8%–10% of all kidney stones in the United States, especially in patients with metabolic syndrome (type 2 DM and obesity). ² Duvdevani et al. reported a higher incidence of UA stones in patients with diabetes (41%). ³ Insulin resistance type 2 DM results in lower urine pH through impaired ammonium excretion. A low urine pH plays a major role of UA stone formation.

To date, previous studies have identified that DM may be associated with higher risk for nephrolithiasis. ^1,2 The increasing prevalence of kidney stones, as well as the burden of stone disease on society, is enormous. Therefore, understanding the pathophysiologic underpinnings of urolithiasis formation will contribute to establish a more rational and economical approach for nephrolithiasis management, with greater emphasis on stone prevention being imperative rather than symptomatic treatment. The correction of impaired glucose tolerance could obviously reduce kidney stone risk. ⁴