Chyluria is a clinical manifestation resulting from a shunt of chyle from the small intestine to the renal pelvis.[12] This manifestation usually reflects a filarial background in endemic zones like India though a lymphourinary fistula which may result from a retroperitoneal lymphatic obstruction resulting from any other cause like congenital, trauma, tuberculosis or malignancy.[23456]
Filariasis has a worldwide distribution but it is mainly prevalent in tropical countries. In India, about 45 million people are suffering from filariasis. Uttar Pradesh alone has the highest number of people (about 7 million) affected by filariasis.[7] Chyluria is usually a late manifestation of filariasis. About 10% of the patients with filariasis ultimately develop chyluria.
Chyluria is characterized by passage of milky urine. Actually chyluria is the result of excretion of chyle from blood into the urine through a fistulous communication between the lymphatic and urinary system.[8] It has been noted that, if a patient with chyluira is kept on fat free diet, the urine rapidly losses its milky appearance.[910] We have evaluated the relationship between the quantity and quality of fat intake and the degree of lipid loss in the urine of patients with chyluria.
PATIENTS AND METHODS
This study was performed among 40 patients with chyluria between March 1983 and June 1984, in two phases but this work remained unpublished for more than two decades. In the phase I, 20 patients were included to evaluate the effect of the quantity of fat intake and the degree of lipid loss in urine. Initially 24 h urine sample was collected from all the patients, keeping them on usual normal diet (Control sample). Then the basal loss of urinary lipid was determined by keeping the patient on a fat free diet for 3 days (basal sample). This was taken as the minimum loss of lipid in urine when dietary intake of fat is negligible. Then, 20 patients included in phase I study were subdivided into two subgroups, each containing 10 patients. In the subgroup 1 (short-term study group), daily urinary lipid loss was measured on increasing the amount of dietary fat in a stepwise manner everyday for 4 days from 25 to 100 g and on further 3 days on a fat free diet. The serum lipid level was also measured on the first day and at the beginning and end of fat load and at the last day of study.
In the subgroup two patients (long-term study group), each patient was fed with 25 g of fat daily for 4 days and urinary and serum lipids were measured at the end of fourth day. For the next 3 days, these patients were again put on fat free diet to bring urinary lipids to the basal level. Then during second feeding period for the next 4 days daily 50 g fat was taken by each patient, urinary and serum lipids were again estimated on last day. In same manner further booster amounts of 75 and 100 g of fat was given according to the protocol and in similar way, urinary and serum lipids were estimated.
In phase II study, 20 patients were included, and there was no subgrouping. Initially control and basal sample of 24 h urine were collected from each patient as in phase I study. Then each patient was kept on one type of cooking fat (mustard oil) 50 g daily for 7 days followed by another type of fat (ghee) 50 g daily for next 7 days. Urinary and serum lipids were measured on Day-1, 4, 8, 11 and 14, respectively. Levels of cholesterol, triglyceride, phospholipid and free fatty acids were measured in both serum and urine to assess their total lipid level.
RESULTS
The present study was conducted on 20 controls and 40 chylurics. The break up of chylurics in different phases and subgroups were as follows:
Phase I (20 patients)
l Subgroup 1 (Short-term study) - 10 patients
l Subgroup 2 (Long-term study) - 10 patients
Phase II (20 patients)
l Mustard oil consumption - 10 patients
l Ghee consumption - 10 patients
Serum lipid profiles in controls and chylurics
In 20 controls, serum triglycerides, cholesterols, phospholipids and free fatty acids values ranged between 122-280, 140-256, 200-388 and 15.86-35.34 mg% with mean values of 185.87 ± 47.00, 190.33 ± 4469, 254.00 ± 57.91 and 23.99 ± 7.50 mg%, respectively.
In 40 chylurics, serum triglycerides, cholesterols, phospholipids and free fatty acids levels ranged between 32-333, 80-250, 56.25-363 and 5.12-19.96 mg% with mean values of 171.65 ± 102.21, 179.25 ± 47.52, 143.43 ± 79.62 and 12.87 ± 5.59 mg%, respectively.
All four values were on the lower side in chylurics as compared to the controls, serum phospholipids and free fatty acids were significantly lowered (P < 0.001).
Quantity of dietary fats and lipiduria
Short-term study
Urinary losses
Triglycerides: Urinary losses of triglycerides on home diet, fat free diet and diets with 25, 50, 75 and 100 g fat loads per day ranged between 672-1743, 440-1485, 1150-3660, 706-2359, 875-3300 and 900-3180 mg per 24 h with mean values of 1322.20 ± 438.29, 764.00 ± 515.03, 1950.00 ± 1003.26, 1254.00 ± 669.77, 1919.80 ± 1024.48 and 1987.20 ± 1004.66 mg per 24 h, respectively.
Minimum urinary loss was observed with 50 g/day fat load.
Cholesterols: Urinary losses of cholesterol on home diet, fat free diet and diets with 25, 50, 75 and 100 g/day fat load ranged between 96-167, 75-175, 126-184, 85-126, 108-192 and 144-216 mg per 24 h with mean values or 142.40 ± 30.89, 106.00 26.79, 147.00 ± 23.56 m, 103.60 ± 16.53, 156.00 ± 38.94 and 160.80 ± 37.57 mg per 24 h, respectively.
Minimum urinary loss was observed with 50 g/day fat load.
Phospholipids: Urinary losses of phospholipids on home diet, fat free diet and diets with 25, 50, 75 and 100 g/day fat load ranged between 108-390, 81.25-337.5, 132.25-450.00, 76.50-472.50, 120.00-500.00 and 138.80-480.00 mg per 24 h with mean values of 224.40 ± 132.80, 161.75 ± 101.23, 394.60 ± 236.34, 226.30 ± 169.33, 264.35 ± 175.99 and 276.00 ± 173.07 mg per 24 h, respectively.
Minimum urinary loss was observed with 50 g/day fat load.
Free fatty acids: Urinary losses of free fatty acids on home diet, fat free diet and diets with 25, 50, 75 and 100 g/day fat load ranged between 46.15-223.07, 35.89-256.40, 56.40-299.90, 35.89-238.40, 76.90-374.30 and 84.60-289.70 mg per 24 h with mean values of 168.68 ± 70.24, 135.34 79.14, 159.96 ± 88.31, 136.88 ± 84.56, 202.52 ± 126.94 and 172.26 ± 89.29 mg per 24 h, respectively.
Minimum urinary loss was observed with 50 g/day fat load.
Serum lipid profiles Triglycerides: Serum triglyceride levels on home diet, fat free diet and diets with 25 and 100 g/day fat load ranged between 32-322, 22-333, 26-200 and 34-244 mg% with mean values of 155.20 ± 104.52, 126.20 ± 119.61, 161.80 ± 85.13 and 164.20 ± 79.87 mg%, respectively.
Rise in serum level was observed on 100 g/day fat load as compared to 25 g/day.
Cholesterols: Serum cholesterol levels on home diet, fat free diet and diets with 25 and 100 g/day fat load ranged between 140-170, 135-180, 150-190, and 170-200 mg% with mean values of 159.00 ± 11.40, 142.00 ± 17.88, 176.00 ± 16.73 and 200.00 ± 21.21 mg%, respectively.
Rise in serum level was observed on 100 g/day fat load as compared to 25 g/day.
Phospholipids: Serum phospholipids levels on home diet, fat free diet and diets with 25 and 100 g/day fat load ranged between 56.25-125.00, 50.00-87.50, 87.50-120.00, and 100-175 mg% with mean values of 90.00 ± 32.65, 70.00 ± 16.77, 97.05 ± 13.82 and 122.50 ± 31.12 mg%, respectively.
Rise in serum level was observed on 100 g/day fat load as compared to 25 g/day.
Free fatty acids: Serum free fatty acids levels on home diet, fat free diet and diets with 25 and 100 g/day fat load ranged between 5.12-22.70, 4.35-18.43, 8.79-25.60 and 8.70-27.13 mg% with mean values of 17.24 ± 6.92, 12.23 ± 6.10, 14.49 ± 7.04 and 16.67 ± 7.18 mg%, respectively.
Rise in serum level was observed on 100 g/day fat load as compared to 25 g/day.
Long-term study
1. Urinary losses
Triglycerides: Urinary losses triglycerides on home diet, fat free diet and diets with 25, 50, 75 and 100 g fat load ranged between 286-840, 854-2442, 544-1760, 594-2040 and 420-2106 mg per 24 h with mean values of 999.20 ± 233.11, 589.40 ± 260.40, 1804.20 ± 696.86, 1045.20 478.91, 1254.00 ± 567.25 and 1336.40 ± 693.99 mg per 24 h, respectively.
Minimum urinary loss was observed on 50 g/day fat feeding period.
Cholesterols: Urinary losses cholesterols on home diet, fat free diet and diets with 25, 50, 75 and 100 g fat load ranged between 69-176, 26-120, 888-224, 54-240, 54-221 and 60-125 mg per 24 h with mean values of 115.80 ± 43.37, 58.60 ± 38.31, 135.80 ± 55.71, 113.80 74.80, 124.20 ± 63.26 and 127.40 ± 42.47 mg per 24 h, respectively.
Minimum urinary loss was observed on 50 g/day fat feeding period.
Phospholipids: Urinary losses phospholipids on home diet, fat free diet and diets with 25, 50, 75 and 100 g fat load ranged between 270-690, 120-300, 275-770, 225-680, 290-892 and 338-750 mg per 24 h with mean values of 433.10 ± 174.17, 206.65 67.57, 448.75 ± 189.55, 352.50 ± 188.08, 459.75 ± 247.00 and 472.00 ± 168.49 mg per 24 h, respectively.
Minimum urinary loss was observed on 50 g/day fat feeding period.
Free fatty acids: Urinary losses triglycerides on home diet, fat free diet and diets with 25, 50, 75 and 100 g fat load ranged between 87.17-256, 43.58-213, 187-269, 141-187, 178-128 and 144-269 mg per 24 h with mean values of 161.45 ± 72.62, 97.43 ± 67.93, 224 ± 32.56, 167.68 ± 98.58, 192.10 ± 16.11 and 210.76 ± 49.23 mg per 24 h, respectively.
Minimum urinary loss was observed on 50 g/day fat feeding period.
2. Serum lipid profiles
Triglycerides: Serum triglyceride levels on home diet, fat free diet and diets with 25 and 100 g/day fat load ranged between 34-156, 22-66, 26-166 and 48-134 mg% with mean values of 93.60 ± 51.29, 39.60 ± 18.40, 74.80 ± 56.08 and 80.00 ± 33.15 mg%, respectively.
Rise in serum level was observed on 100 g/day feeding period when compared to 25 g/day.
Cholesterols: Serum cholesterol levels on home diet, fat free diet and diets with 25 and 100 g/day fat load ranged between 180-280, 140-200, 130-300 and 180-300 mg% with mean values of 222.00 ± 26.07, 166.00 ± 26.07, 222.00 ± 66.86 and 226.00 ± 50.79 mg%, respectively.
Rise in serum level was observed on 100 g/day feeding period when compared to 25 g/day.
Phospholipids: Serum phospholipids levels on home diet, fat free diet and diets with 25 and 100 g/day fat load ranged between 62.50-112, 44-69, 75-256 and 75-169 mg% with mean values of 92.50 ± 20.44, 57.50 ± 11.18, 120.00 ± 36.01 and 110.00 ± 37.73 mg%, respectively.
Rise in serum level was observed on 100 g/day feeding period when compared to 25 g/day.
Free fatty acids: Serum free fatty acids levels on home diet, fat free diet and diets with 25 and 100 g/day fat load ranged between 7.68-15.61, 5.38-12.80, 6.14-20.73 and 11.52-39.17 mg% with mean values of 13.92 ± 4.53, 11.62 ± 3.83, 12.64 ± 6.09 and 20.63 ± 10.95 mg%, respectively.
Rise in serum level was observed on 100 g/day feeding period when compared to 25 g/day.
Quality of dietary fats and lipiduria
1. Urinary Losses
Triglycerides: Urinary losses of triglycerides in mustard oil fed group on home diet, fat free diet and diets with 50 g fat per day for 7 days ranged between 1598-3006, 1404-2000 and 1463-4347 mg per 24 h with mean values of 2260.00 ± 667.51, 1685.00 ± 225.64 and 2296.80 ± 1182.42 mg per 24 h, respectively.
The same in ghee fed group between 1404-5076, 1500-3738 and 1537-4660 mg per 24 h with mean values of 2436.80 ± 1514.09, 2137.20 ± 1012.42 and 3650.40 ± 1261.54 mg per 24 h, respectively.
The triglycerides loss was higher in ghee-fed group
Cholesterols: Urinary losses of cholesterols in mustard oil fed group on home diet, fat free diet and diets with 50 g fat per day for 7 days ranged between 72-273, 57-168 and 75-437 mg per 24 h with mean values of 167.60 ± 85.13, 111.00 ± 50.19 and 210.00±131.60 mg per 24 h, respectively.
The same in ghee fed group between 144-570, 105-352 and 189-714 mg per 24 h with mean values of 310.20 ± 170.88, 202.60 ± 97.55 and 418.40 ± 198.29 mg per 24 h, respectively.
The urinary loss was higher in ghee-fed group
Phospholipids: Urinary losses of phospholipids in mustard oil fed group on home diet, fat free diet and diets with 50 g fat per day for 7 days ranged between 100-241, 88-142 and 120-294 mg per 24 h with mean values of 164.00 ± 58.49, 102.30 ± 22.49 and 234.50 ± 68.95 mg per 24 h, respectively.
The same in ghee fed group between 107.50-427.50, 58-325 and 203-578 mg per 24 h with mean values of 326.50 ± 141.21. 209.00 ± 177.32 and 492.50 ± 162.53 mg per 24 h, respectively.
The urinary loss was higher in ghee-fed group
Free fatty acids: Urinary losses of free fatty acids in mustard oil fed group on home diet, fat free diet and diets with 50 g fat per day for 7 days ranged between 38-238, 21-159 and 36-262 mg per 24 h with mean values of 147.69 ± 91.79, 98.87 ± 57.16 and 117.43 ± 87.88 mg per 24 h, respectively.
The same in ghee fed group between 103-667, 97-408 and 123-876 mg per 24 h with mean values of 357.93 ± 255.03, 214.86 ± 130.59 and 494.85 ± 316.50 mg per 24 h, respectively.
The urinary loss was higher in ghee-fed group
2. Serum lipid profiles
Triglycerides: Serum triglycerides in mustard oil fed group on home diet, fat free diet and diets with 50 g fat per day for 7 days ranged between 66-322, 44-267 and 66-367 mg% with mean values of 226.80 ± 99.61, 186.60 ± 84.70 and 260.00 ± 114.38 mg%, respectively.
The same in ghee-fed group between 44-333, 66-289 and 66-367 mg% with mean values of 211.00 ± 111.59, 160.00 ± 108.40 and 230.80 ± 123.40 mg%, respectively.
The rise in serum triglycerides was more in ghee-fed group.
Cholesterols: Serum cholesterols in mustard oil fed group on home diet, fat free diet and diets with 50 g fat per day for 7 days ranged between 80-120, 60-185 and 110-320 mg% with mean values of 164.00 ± 53.08, 125.00 ± 53.15 and 216 ± 95.55 mg%, respectively.
The same in ghee-fed group between 105-240, 90-160 and 110-300 mg% with mean values of 172.00 ± 53.92, 131.00 ± 26.07 and 234.00 ± 86.19 mg%, respectively.
The rise in serum cholesterol was more in ghee-fed group.
Phospholipids: The serum phospholipids in mustard oil fed group on home diet, fat free diet and diets with 50 g fat per day for 7 days ranged between 88-208, 83-183 and 125-263 mg% with mean values of 146.80 ± 44.58, 127.40 ± 41.70 and 216.80 ± 54.64 mg%, respectively.
The same in ghee fed group between 158-363, 75-225 and 138-375 mg% with mean values of 244.40 ± 84.09, 159.00 ± 63.97 and 281.80 ± 92.70 mg%, respectively.
The rise in serum phospholipids was more in ghee-fed group.
Free fatty acids: Serum free fatty acids in mustard oil fed group on home diet, fat free diet and diets with 50 g fat per day for 7 days ranged between 5.63-17.15, 5.12-14.34 and 8.70-18.43 mg% with mean values of 8.55 ± 4.87, 7.07 ± 4.07 and 11.31 ± 4.15 mg%, respectively.
The same in ghee fed group between 7.16-15.10, 5.63-12.80 and 9.98-19.97 mg% with mean values of 11.93 ± 3.05, 9.01 ± 3.12 and 14.69 ± 3.98 mg%, respectively.
The rise in serum free fatty acids levels was more in ghee-fed group.
DISCUSSION
Recent lymphangiographic studies, especially from Far East Asian countries, have revealed the underlying lymphangiectasia resulting from chronic lymphatic obstruction due to filariasis and often demonstrated the site of leakage of chyle into the urinary passage.[1112] Contributions have also come in context to the management.[8] Yet hardly half a dozen articles are available where this entity has been studied as a clinical syndrome due to loss of an important body fluid, the chyle. Chyle is constituted in the cells of small intestine as a net result of the products of absorption of dietary fats and some endogenous constituents.[13] Basically, the chylomicron is a lipid-protein complex and constituted into the systemic venous circulation through intestinal lymph trunk, cisterna chyli and thoracic duct which joins the left jugular vein in the neck.
Majority of the authors writing on chyluria have just indicated a qualitative method of demonstrating chyle in the urine.[14] Bloomstran and Ahren[13] did report their solitary chyluric patient, used as a model to perform C[14] tagged oleic and palmitic acid recovering them in the urine. They observed that the triglycerides account for 90%, phospholipids 1-9% and nonesterified fatty aoids for 1-7% radioactivity. Cahill (1965), reporting his experience on five chylurics, mainly observed massive proteinuria and urinary excretion of lipids but not found much alteration in serum lipids. Chyluric hypolipidemia is an established state.
It is common experience of physicians that the chyluria is minimized by restricting the fat intake. There are no scientific data in the literature to approve or disapprove the above observation. Our study design, used two common types of dietary fats, ghee and mustard oil. It was clear that while fat restriction significantly diminished the urinary losses of triglycerides, phospholipids, cholesterols and free fatty acids as compared to the home diet in both the short-term as well as the long-term studies, massive lipiduria followed even by administering 25 g of fats in the diet. When the amount of the dietary fats was increased, there were paradoxes. The urinary lipids loss diminished with 50 g of fat consumed per day. When this was increased from 50 g of to 75 and 100 g/day, though there was rise in urinary loss of lipids, it was not in proportion to the rise in the diet. This paradox is an enigma.
We tried to adjudge the effect of the quality of dietary fats on the degree of lipiduria and also the resultant serum lipid profiles by using mustard oil and ghee, the two commonly used cooking fats in North India. It is obvious that urinary losses are affected by the quality of the fat consumed. The state of fat restriction can diminish lipiduria in both with mustard oil and ghee. Comparing the effect of the cooking media at the end of the fat-load, ghee was, beyond doubt, a bigger culprit in inducing maximum loss in the urine as compared to the mustard oil. While comparing the effect of these cooking fats on serum lipid profiles, the rise was lesser in mustard oil as compared to ghee. This means that, in terms of improvement of the lipid profiles, ghee is better dietary fat to use, even though it promotes urinary lipidura.
CONCLUSION
From our study, it is evident that fat restriction can diminish urinary losses of fatty acid, triglyceride, cholesterol and phospholipid with their concomitant fall in serum levels. Initial fat load of 25 g/day increases urinary lipiduria significantly as compared to fat free state. Lipiduria is minimum with 50 g/day fat consumption and the degree of lipiduria rises with progressive fat load of 75 and 100 g/day but not proportionately to the rise in daily dietary fat consumption. Despite above, serum lipid profile improves with higher amount of dietary fat consumption. Degree of urinary lipiduria is higher with ghee as compared to mustard oil but serum lipid profile showing beneficial effect of ghee over mustard oil.
