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Chyluria - Case Reports and Review of Literature

Chyluria, also called chylous urine, is a medical condition involving the presence of chyle in the urine stream, which results in urine appearing milky white. The condition is usually classified as being either parasitic or non-p…

Chyluria, also called chylous urine, is a medical condition involving the presence of chyle in the urine stream, which results in urine appearing milky white. The condition is usually classified as being either parasitic or non-parasitic. Subsequent local inflammation of the area leads to dilation of the lymph vessels and the development of a urinary fistulae due to rupture of the lymphatic vessel, redirecting the lymph flow from the intestinal lymphatic vessels into the lymphatic vessels of the kidney and ureter Because of obstruction   there is passage of white blood cells, fat, and fat-soluble vitamins into the urine

Treatment of chyluria will depend on cause some cases like congenital causes or tumors may not me able to be treated with diet n medical treatment but have to surgically treated

A BRIEF REVIEW OF FAT DIGESTION AND ABSORPTION

 Majority of dietary fat is in the form of long chain fats (LCF).

Once absorbed across the intestinal mucosa, the fatty acids and monoglycerides are re-esterified into triglycerides combining with cholesterol, protein and other substances to form chylomicrons. Chylomicrons enter the lymphatic system as chyle via lacteals  Chylomicrons are returned to the blood stream via the thoracic duct, the final common pathway for all lymphatic flow. and subclavian veins. Two to four liters of chyle are transported through the thoracic duct each day. Fat-soluble vitamins are also absorbed into the lymphatic system by this route, the protein content of lymph has about the same content as the interstitial fluid.  Short and medium chain triglycerides (MCT) are more easily absorbed[GK1]  than LCT 

MCT’s are primarily absorbed directly across the intestinal mucosa and delivered to the portal vein.

Abstract

Case presentation

Ten  male patients with chyluria and complaint of passing milky urine for  more than 6 months , pedal edema (in 2 cases) , fatigue, nausea and loss of appetite with more than 5 kg  weight loss over a six month period, of unknown etiology were assessed. Eventually diagnosed chyluria.  Patients were advised low fat high protein diet with fats in form of MCT.  Follow-up of 10 days showed a decrease in hazy urine, weight gain, increased albumin and less fatigue. At next visit there was significant change in patients weight , protein levels and chyle leak in urine However, the chyluria relapsed after few days because of patients dietary changes and noncompliance and  also  shift to LCT  .A low-fat/high-protein content diet   was consumed   again  by most patients .Although. Incorporating LCTs  and full fat milk  diet met   the calorie requirement   but milky urine relapsed.  Patients  were  again counciled and diet pattern changed once more  to   diet  with MCT. Coconut oil(2 Tablespoons of extra virgin oil  ) as alternative to prepare food was started  and low fat dairy products with 2 tablespoon add on of MCT oils   and  seeds were incorporated. Few weeks later the patients returned reporting consistent improvement. the milky urine appearance related with the use of the diet. Although the diet was tasteless and time consuming to prepare, some patients complained little gastrointestinal tolerance but  they  reported   better compliance to diet with MCT and the milky urine was fewer . MCT was   continued, since then the chyluria remains in remission.


Discussion

Chyluria indicates the presence of abnormal communication between intestinal lymphatic and the urinary tract The analysis of chyluria can be classified as either parasitic or non-parasitic

Most dietary fat is in the form of LCTs which are digested by pancreatic enzymes in the small bowel and emulsified by bile salts before being absorbed and converted to chylomicrons; Chylomicrons enter the lymphatic system through lacteals found in the villi. 70% of ingested fat will pass through the lymphatic system, high intake of LCTs increases flow chyle flow, decreased intake of LCTs decreases chyle

This is the basis for substituting LCTs with Medium-chain triglycerides (MCTs) as part of the MNT for this condition.

Nutritional management and goals of Therapy

The primary goals of nutritional management of chyle leaks are to:

1. Reduce production of chyle fluid in order to avoid milky urine

2. Replace fluid and electrolytes; and

3. Maintain or replete nutritional status and prevent malnutrition, create a diet that meets protein and calorie requirement.

RESULTS

There were no  much nutritional differences between the cases  Substantial  differences were found in severity but all cases had same outcomes with low LCT rich diet and high MCT diet The span  of time that nutrition therapy is pursued  varied from 1st week till 5 weeks

CONCLUSION

Chyle leaks are infrequent complications seen in the clinical setting. However, because of the direct effect oral nutrition plays, this complication can be challenging for the clinician. Treatment and monitoring is factual in many cases, but the treatment may be problematic due to expense, palatability, compliance.

The effective improvement of the milky urine with a low-fat/high-protein diet with MCT and its proper compliance is  our study

Keywords: LCT (Long-chain triglycerides), MCT(Medium chain triglycerides)

REFERENCES

1. Yamauchi S. Chyluria: clinical, laboratory and statistical study of 45 personal cases observed in Hawaii. J Urol 1945; 54: 318–347.. Diamond E, Schapira HE. Chyluria – a review of the literature. Urolog

2. Steward W, Hunter WA, O’Byrne, Snowden J. Chemotherapy and haemopoietic stem cell transplantation. In: Intestinal failure.mNightingale J (ed). Greenwich Medical Media Limited, London, m2001:73.

3. Good response of low-fat/high-protein diet in a patient with chyluria. Triffoni-Melo AT1, Diez-Garcia RW, Barros Silva GE, Garcia Caldas Fde F, Wichert-Ana L, Corte Denardi R, Kato M, Júnior Lucca L, Dantas M.

4. The absorption of fat study in patient with chyluria ROLF BLOMSTRAND AND EDWAIZD H. AHRENS, JR. Hashin S, Rohol HB, Babayan VK, Vanitallie TB. 5Treatment of chyluria and chylothorax with medium chain triglyceride. N Eng J Med 1964;270:756-61. 

About Authors
Guljeet Kaur (Sr. Dietician, Fortis Escorts Amritsar) Dr. Sagar Sabharwal (Consultant Urology Dep’t Fortis Escorts Amritsar), Dr Aashish Jain (Consultant Critical Care Fortis Escorts Amritsar)

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