World J Urol (2005) 23: 324–329
DOI 10.1007/s00345-005-0028-0
T O P I C P A PE R
Diana J. Zimmermann Æ Albrecht Hesse
Gerd E. von Unruh
Influence of a high-oxalate diet on intestinal oxalate absorption
Received: 16 September 2005 / Accepted: 4 October 2005 / Published online: 5 November 2005

Springer-Verlag 2005
Abstract Hyperoxaluria is a major risk factor for renal
stones. In most cases, it is sustained by increased dietary
loads. In healthy individuals with a normal Western diet,
the majority of urinary oxalate is usually derived from
endogenous metabolism. However, up to 50% may be
derived from the diet. We were interested in the effect of
a high-oxalate diet on oxalate absorption, not merely on
the frequently studied increased oxalate excretion. In
study I, 25 healthy volunteers were tested with the
[13C2]oxalate absorption test once while following a low-
oxalate (63 mg) and once while following a high-oxalate
(600 mg) diet for 2 days each. In study II, four volun-
teers repeated study I, and afterwards continued with a
high-oxalate diet (600 mg oxalate/day) for 6 weeks. In
the last week, the [13C2]oxalate absorption test was re-
peated. After 4 weeks of individual normal diet, the
oxalate absorption test with a high-oxalate diet was
performed again. The results of study I show that the
mean [13C2]oxalate absorption under low-oxalate diet
was 7.9±4.0%. In the presence of oxalate-rich food, the
percent absorption for the soluble labelled oxalate al-
most doubled (13.7±6.3%). The results of study II show
that the mean [13C2]oxalate absorption of the four vol-
unteers under low-oxalate diet was 7.3±1.4%. The
absorption increased to 14.7±5.2% under 600 mg
oxalate. After 6 weeks under a high-oxalate diet, the
D. J. Zimmermann Æ A. Hesse
Division of Experimental Urology, Department of Urology,
University of Bonn, Sigmund-Freud-Str 25,
Bonn, 53105 Germany
D. J. Zimmermann (&)
Diabetes Research Institute, Koelner Platz 1,
80804 Munich, Germany
E-mail: zimmermann@lrz.uni-muenchen.de
Tel.: +49-89-30793110
Fax: +49-89-3081733
G. E. von Unruh
Department of Internal Medicine I, University of Bonn,
Sigmund-Freud-Str 25, Bonn, 53105 Germany
[13C2]oxalate absorption was significantly decreased
(8.2±1.7%). After the wash-out phase, the absorption
was again high (14.1±2.2%) under the 600 mg oxalate
challenge.
Keywords High-oxalate diet Æ Low-oxalate diet Æ
Oxalate absorption Æ Oxalobacter formigenes
Introduction
Hyperoxaluria is a major risk factor for calcium oxalate
urolithiasis, a disease typically occurring in affluent
societies. Except for the rare condition of primary hy-
peroxaluria, hyperoxaluria appears to be sustained by
an increased dietary load. In normal individuals, the
majority of urinary oxalate is derived from endogenous
metabolism, while 10–20% is generally assumed to be
derived from oral ingestion. However, in 2001, Holmes
et al. [11] presented evidence that dietary oxalate may
contribute up to 50% of the oxalate excreted in urine.
Liebman and Costa [15] reported similar results. Thus,
dietary oxalate may play a more significant role in cal-
cium oxalate stone formation than what was previously
thought. Oxalate is present in large quantities in food of
vegetable origin, cereal grains and some roots. Foodstuff
that contain high levels of oxalate include spinach,
rhubarb, beetroot, Swiss chard, carambola, black tea,
cocoa powder and some nuts [9, 10]. The mean oxalate
intake under a Western diet is approximately 100–
150 mg/day [12]. However, urban diets of the upper in-
come group in India were reported to contain 600 mg
oxalate per day and seasonal rural diets as much as
2,000 mg [17]. Unfortunately, knowledge of the extent
of gastrointestinal absorption of oxalate, especially the
absorption from high-oxalate diets, is still limited. Apart
from the amount and chemical form of the oxalate in
the ingested foodstuff, the amount of free oxalate in the
gastrointestinal tract, or physiological parameters of
the individual, such as intestinal pH and transit time,

oxalate absorption also depends on the amount of
divalent cations, such as calcium and magnesium,
simultaneously present in the chyme. These ca-
tions—derived from ingested foodstuffs, liquids and
digestive secretions—are able to bind oxalate in the gut
and decrease oxalate absorption [2, 21, 22].
This study was performed in order to compare and
quantify the effect of a short (2 days) low-oxalate diet and
a 2-day typical dietary oxalate load (oxalate intake from
spinach) on intestinal oxalate absorption and urinary
oxalate excretion. In a pilot study, the effect of a long-
term (6 week) high-oxalate diet was also investigated.
Methods
Subjects
Twenty-five healthy, non-hospitalised volunteers (13
men, 12 women) participated in study I. The mean age
and mean BMI of the subjects were 29±8.8 years (range
21–62 years) and 22±2.5 kg/m2 (range 17–27 kg/m2),
respectively. Four of these subjects (two women: vol-
unteers 1 and 3; and two men: volunteers 2 and 4)
volunteered for study II also. Mean age and mean BMI
of the four subjects were 37±17 years (range 26–62
years) and 22±1.8 kg/m2 (range 20–24 kg/m2),
respectively.
Inclusion criteria were: (1) no history of renal stone
formation, (2) no gastrointestinal or renal disease, (3)
negative kidney ultrasound, (4) oxalate excretion of
<0.500 mmol/day in a 24 h urine prior to the study. In
this urine, pH, nitrite, leukocytes, protein, glucose,
ketone, urobilinogen, bilirubin and blood were tested
with urinary test strips. No medication was allowed in
the week prior to and during the study. At the begin-
ning of the study, the stool samples of the volunteers
had been tested for the presence of Oxalobacter for-
migenes.
The study protocol was reviewed and approved by
the ethical committee of the Faculty of Medicine of the
University of Bonn. After oral and written information,
the volunteers signed a declaration of consent in order to
participate in the tests.
Study I: The volunteers were tested with the
[13C2]oxalate absorption test once while following a
standardised low-oxalate diet (63 mg = 0.7 mmol oxa-
late/day). After 1 week with unrestricted diet, a second
oxalate absorption test with 600 mg = 6.8 mmol oxa-
late/day was performed.
Study II (pilot study): Four healthy volunteers,
participants of study I, were again tested with the high-
oxalate test of study I and then followed with a high-
oxalate diet (600 mg oxalate/day) for a period of 6
weeks. A self-selected diet without high-oxalate food-
stuffs was fortified with rhubarb juice containing
approximately 500 mg oxalate, taken at lunchtime. In
the last week, the [13C2]oxalate absorption test with
600 mg oxalate was repeated. After a wash-out phase
325
of 4 weeks, during which the volunteers followed a
normal individual diet, the oxalate absorption test of
the high-oxalate diet was performed again. After the
test, the absence of any crystals in the kidneys was
confirmed again by ultrasound examination.
[13C2]oxalate absorption test
Over a period of 2 days, the volunteers adhered to an
identical standardised diet and their entire urine was
collected. The first day represents the control and dietary
adaptation day. The urine collected under these condi-
tions was used for the calibration curve of the subsequent
analytical determination. During the second day (test
day) oxalate absorption was examined. At 8.00 a.m., on
an empty stomach, the volunteers took a capsule, soluble
in gastric juice, containing 50 mg sodium [13C2]oxalate
containing 33.8 mg = 0.37 mmol [13C2]oxalate. The
recovered quantity of this labelled oxalate in the 24 h
urine (collected in 6 h, 6 h and 12 h portions) shows the
oxalate absorption [19, 20].
Diets followed during the [13C2]oxalate absorption test
The diet of the low-oxalate absorption test is charac-
terised by a total oxalate amount of 63 mg/day and
2,500 kcal, 83 g protein, 350 g carbohydrates, 96 g fat,
800 mg (20 mmol) Ca as described [20]. The diet of the
other oxalate absorption tests was a modified form of
the first one. Only the amount of oxalate differed; the
major food composition remained the same. Spinach, an
oxalate-rich vegetable, was chosen to increase the oxa-
late amount. In Western countries, it is a common
vegetable and the volunteers received it as a normal
150 g portion of cooked leafy spinach (Ca content
190 mg) as part of their lunch. The total amount of
oxalate was increased to 600 mg/day and the amount of
Ca to approximately 1,000 mg/day. The oxalate con-
tents of both diets were measured by HPLC-enzyme-
reactor analysis [9].
Analysis
The analytical procedure for [13C2]oxalate measurement
in urine was as published earlier [19]. Labelled and
unlabelled oxalate were quantified by gas chromatogra-
phy–mass spectrometry. The presence of O. formigenes in
the stool samples of the volunteers of study II was tested
for by means of polymerase chain reaction (PCR)
amplification of genomic DNA using specific primers for
the oxc gene [16]. DNA was extracted using the QIAamp
DNA Mini Kit (Qiagen, Chatsworth, CA, USA).
Statistics
The Statistics Package for the Social Sciences program
(SPSS, Inc., Chicago, IL, USA) for Windows, release
326
35
oxalate absorption (%)
30
25
20
15
10
5 calcium oxalate on the second day of both oxalate
0 absorption tests. The baseline (first oxalate absorption
13
[ C2]oxalate absorption tests
Fig. 1 [13C2]oxalate absorption (%) in the 25 volunteers for the
first (63 mg oxalate diet) and the second (600 mg oxalate diet)
[13C2]oxalate absorption test. The lines with the error bars represent
mean ± SD for the entire group
8.0.0 was used. The results of descriptive statistics are
given as mean ± standard deviation (SD). The signifi-
cance of differences was calculated by the non-para-
metric Wilcoxon test for paired samples; P £ 0.05 was
considered significant.
Results
Study I: The mean [13C2]oxalate absorption of all 25
volunteers under low-oxalate diet was 7.9±4.0% of the
50 mg dose of sodium [13C2]oxalate, range 1.8–18.0%
(women 6.9±3.8%, men 9.0±4.0%). Owing to the
short-term enrichment of diet with oxalate-rich food,
more oxalate (labelled and unlabelled) was absorbed.
The percent absorption for the soluble [13C2]oxalate was
almost twice as high (13.7±6.3%, range 3.4–32.7%).
There was no statistically significant gender difference
for the increased [13C2]oxalate absorption (female vol-
unteers absorbed 12.3±4.5% and male volunteers
15.2±7.7% under high oxalate). With low oxalate, the
mean total (endogenous + unlabelled and labelled
exogenous) oxalate excretion was 0.284±0.092 mmol/
day, range 0.134–0.475 mmol/day. With 600 mg oxa-
late, the mean total oxalate excretion increased to
0.485±0.098 mmol/day, range 0.274–0.730 mmol/day,
an increase of 71%. The mean increase by 0.201 mmol
oxalate in the urine consisted of about 0.022 mmol
[13C2]oxalate and 0.179 mmol unlabelled oxalate corre-
sponding to approximately 3% of the oxalate ingested
with the spinach. Although men excreted more oxalate
than did women, there was no statistically significant
gender difference for the increased excretion. Female
volunteers excreted 0.199 mmol/day and male volun-
teers an 0.203 mmol/day additional under high oxalate.
Figures 1 and 2 show the individual oxalate absorptions
and the individual oxalate excretions for each subject on
the second day of both oxalate absorption tests. Mean
and SD values are also indicated.
Both figures illustrate the changes in the absorption
tests under low-oxalate diet compared to those under the
high-oxalate diet as well as the high mean increase in
[13C2]oxalate absorption and total oxalate excretion. In
three subjects, soluble oxalate absorption decreased.
However, this decrease is within the intra-individual
standard deviation for repeated identical tests [20].
Table 1 represents the mean values of urinary vol-
ume, oxalate, calcium, magnesium, sodium, potassium,
citrate and the calculated relative supersaturation with
test) urinary volume and the excretion of calcium, so-
dium and potassium did not differ significantly from that
of the second test. However, there was a significant de-
cline in the urinary excretion of magnesium and citrate.
Oxalate excretion increased and as a result of these
changes the APCaOx [18] also increased.
Study II: The mean [13C2]oxalate absorption of the
four volunteers under low-oxalate diet was 7.3±1.4%.
The absorption increased to 14.7±5.2% with 600 mg
oxalate/day on the second of the 2 days. In study I, the
mean absorption of these four volunteers under 600 mg
oxalate/day for 2 days was 14.1±2.2%. Thus, the short-
term effect of the high-oxalate diet was highly repro-
ducible. After 6 weeks under high-oxalate diet, the mean
[13C2]oxalate absorption was found to have significantly
decreased from 14.7±5.2 to 8.2±1.7%. The mean
absorption at the end of 6 weeks of high-oxalate diet had
decreased by 40% relative to the beginning of the high-
oxalate diet. The two female volunteers showed a drastic
increase and decrease; the two male subjects only a
marginal change; none showed an increase in oxalate
absorption at the end of the 6 week high-oxalate diet.
After the wash-out phase, the mean [13C2]oxalate
absorption increased again to 14.1±2.2% under the
2 day 600 mg oxalate intake, further demonstrating the
high reproducibility of the short-term effect of the high-
oxalate diet. This sequence is illustrated in Fig. 3. The
connecting lines allow one to follow the individual
changes more easily. They do not indicate the absorp-
tion during the time without measurements between
0.800
oxalate excretion (mmol / d)
0.700
0.600
0.500
0.400
0.300
0.200
0.100
0.000
13
[ C2]oxalate absorption tests
Fig. 2 Urinary excretion of oxalate [mmol/day] in the 25 volunteers
for the first (63 mg oxalate diet) and the second (600 mg oxalate
diet) [13C2]oxalate absorption test. The lines with the error bars
represent mean ± SD for the entire group
 327

Table 1 Urinary parameters and APCaOx (mean ± SD) of the 25 urine [11]. However, no study investigating the effect of a
volunteers of study I on the second day of both oxalate absorption
tests
high-oxalate diet on the oxalate absorption in the gut
has been performed to date. The essential finding of
First oxalate Second oxalate P study I is that consumption of oxalate-rich food (here:
absorption test absorption test spinach) for 2 days drastically increased the percent
(63 mg oxalate/day) (600 mg oxalate/day)
oxalate absorption for soluble oxalate as early as on the
Volume 2.441±0.336 2.288±0.507 n.s. second day. As shown in Figs. 1 and 2, on the second
(l/day) day of the applied 2 day oxalate-rich diet, absorption of
Oxalate 0.284±0.092 0.485±0.098 <0.05 soluble [13C2]oxalate was increased by approximately
(mmol/day) 73% and excretion of total oxalate in urine by approx-
Calcium 3.99±1.89 3.71±1.71 n.s.
(mmol/day)
imately 71%. Apart from these hard experimental data,
Magnesium 5.52±1.66 4.71±1.38 <0.05 several important parameters that are required to fully
(mmol/day) understand the fate of oxalate in humans could not be
Sodium 172±41 190±52 n.s. measured. These parameters can only be estimated.
(mmol/day) Known important missing parameters include the
Potassium 60±18 64±12 n.s.
(mmol/day) endogenous synthesis of oxalate, the pH profile of the
Citrate 3.731±1.402 3.101±1.149 <0.05 gastrointestinal tract and the residence time of the diet/
(mmol/day) chyme in the different pH-compartments, as well as the
Creatinine 11.79±4.23 12.80±3.68 <0.05 amount of calcium excreted into the gastrointestinal
(mmol/day)
APCaOx 0.43±0.23 0.86±0.64 <0.05 tract by digestive secretions. For the interpretation of
the data we made reasonable assumptions and used
published information.
tests. The two subjects who tested positive for O. for- About 75–80% of the labelled oxalate that was ab-
migenes, one man and one woman, are indicated by a sorbed was found in the urine collected in the 6 h after
plus sign. ingestion; this excretion pattern was the same as found
With low oxalate, the oxalate excretion of the four previously in 120 healthy volunteers [20]. As this labelled
volunteers was 0.283±0.091 mmol/day, range 0.193– oxalate was not only absorbed but also excreted in the
0.387 mmol/day. With 600 mg oxalate, the mean oxalate first 6 h after ingestion, the spinach eaten 6 h after the
excretion increased to 0.418±0.093 mmol/day, range labelled oxalate should not have caused the increased
0.330–0.539 mmol/day. After 6 weeks under high oxalate absorption. We propose the following explanation for
conditions, the oxalate excretion was 0.456± the effect of the first spinach meal on the absorption of
0.131 mmol/day, range 0.300–0.613 mmol/day. After the soluble oxalate. The high oxalate absorption was caused
wash-out phase and repeat challenge with the high-oxa- by a reduced amount of readily available calcium and
late diet, the mean oxalate excretion was 0.459± magnesium in the gut. The [13C2]oxalate from the so-
0.083 mmol/day, range 0.378–0.544 mmol/day (Fig. 4). dium oxalate-filled capsules of the labelled test dose was
dissolved fully after 20 min. Some of the oxalate from
the spinach was certainly also dissolved in the gastric
Discussion juice, whereas some of it was slowly liberated in the
intestinal tract while the spinach cell walls were digested.
Oxalate intake has an influence on the pathogenesis of Calcium in the daily digestive secretions—an amount
urolithiasis. It is generally known that a high-oxalate comparable to the daily urinary excretion of calcium
intake leads to an increase in oxalate excretion in the [5]—will be secreted over the entire day. Primarily, this

25 0,7
volunteer 1 +
[ C2 ]oxalate absorption (%)

oxalate excretion (mmol / d)

volunteer 2
volunteer 3 0,6
20 volunteer 4 +
0,5
+
15 0,4 +
+
+
10 0,3
0,2
5 volunteer 1 +
0,1 volunteer 2
13

volunteer 3
0 volunteer 4 +
standard test 1. week
0
6. week 10. week standard test 1. week 6. week 10. week
with low oxalate with low oxalate
high oxalate diet wash out phase high oxalate diet wash out phase

Fig. 3 [13C2]oxalate absorption (%) in the volunteers of study II; Fig. 4 Oxalate excretion (mmol/day) in the volunteers of study II;
+ Oxalobacter formigenes positive volunteers; 1 and 3 were + Oxalobacter formigenes positive volunteers; 1 and 3 were
females, volunteers 2 and 4 were males females, volunteers 2 and 4 were males
328
secreted calcium will complex the liberated plant oxalate
directly in the gut. The oxalate load of the first day of
the test complexes free calcium and magnesium ions in
the gut even on the second day. Therefore, on the second
day, there are less unbound calcium and magnesium ions
in the chyme and a higher amount of ingested soluble
oxalate is absorbed. The data only prove that more
[13C2]oxalate from the readily soluble labelled sodium
oxalate was absorbed on the day after the first spinach
meal. Whether more dietary oxalate was also absorbed
cannot be determined from the present data.
To determine the amount of absorbed dietary oxalate
in experiments without labelled oxalate from the excreted
urinary oxalate, the exact endogenous oxalate synthesis
must be known. Methods for the exact measurement of
the endogenous oxalate synthesis under normal diet have
not been reported. The best approximations are the
method of ‘oxalate free diet’ and fasting [8, 11]. Both
methods would give the ‘true’ endogenous oxalate syn-
thesis if no dietary components were metabolised to
oxalate in humans. However, this assumption is wrong.
The alternative approach involves the calculation of the
endogenous synthesis by subtracting the absorbed oxa-
late from the excreted oxalate. Liebman and Chai [14]
derived a formula to calculate the endogenous oxalate
production from the result of a sodium oxalate load test
under a diet very low in oxalate. They assumed identical
percentage absorptions for ingested dietary oxalate and
sodium oxalate. In reality, the bioavailability of dietary
oxalate is lesser (roughly between one-third and two-
thirds) than the bioavailability of sodium oxalate [3]. The
error will be small if a low-oxalate diet is ingested.
Multiplication of the amount of ingested dietary oxalate
by the measured percent absorption of sodium oxalate
yields an upper limit of the amount of exogenous oxalate
in the 24 h urine. On each of our test days, exogenous
oxalate consisted of the exactly measured labelled oxa-
late and absorbed dietary oxalate. Using Liebmans for-
mula, a mean endogenous oxalate production of [0.284-
0.02923-(0.716·0.079)]=0.198 mmol/day or 17.5 mg/
day can be calculated for the 25 volunteers of study I for
the low-oxalate diet. If we made the same calculation,
assuming for dietary oxalate a relative bioavailability of
50% of the bioavailability of sodium oxalate, the mean
endogenous oxalate synthesis would be 0.226 mmol/day
or 19.9 mg/day.
Assuming constant mean endogenous synthesis of
0.226 mmol/day also under the high-oxalate diet,
0.259 mmol oxalate was of exogenous origin. Of the
exogenous oxalate, 0.05 mmol was [13C2]oxalate,
0.209 mmol was from the dietary oxalate. This calcula-
tion indicates that 3% of the oxalate in the spinach was
absorbed. This amount is within the range of published
data of bioavailability of oxalate from spinach [4].
However, bioavailability of oxalate strongly depends on
the other dietary components as demonstrated by Hesse:
oxalate absorption from spinach with cream was 80%
less than from leafy spinach [6].
The short-term increase of oxalate absorption is ex-
tremely important for understanding the occurrence of
diet-induced intermittent hyperoxaluria, since oxalate
absorption under a short-term oxalate-rich diet may be
much higher than expected. The findings from our study
are consistent with results of Holmes et al. [11].
Increasing the dietary oxalate from 50 to 250 mg per day
for several days resulted in a 35% increase of the mean
oxalate excretion of 12 healthy volunteers. In our study,
the increase of ingested oxalate from 63 to 600 mg raised
the excretion of soluble oxalate by 71%.
Following our findings in the short-term (2 day)
study, we were curious as to whether the high oxalate
absorption and excretion persisted under a long-term
high-oxalate diet. Consequently, we performed a pilot
study with four healthy volunteers from study I and
tested the influence of a short-term as well as a long-term
high-oxalate diet on the intestinal oxalate absorption
and urinary oxalate excretion. Simultaneously, the
repeatability of the short-term effect was assessed and
confirmed by the results.
The mean oxalate absorption of these four volunteers
on the second day of the high-oxalate diet was exactly of
the same order of magnitude as that of their first short-
term study results (14.1 and 14.7%, respectively).
However, after 6 weeks under a high-oxalate intake, the
absorption of soluble oxalate was 40% lower than at the
start of the high-oxalate diet. In the two male volunteers,
the reduction was minimal; in the two female volunteers,
however, it was extreme. The results of this pilot study
with only four subjects allow no definitive conclusions,
especially as study I showed no gender differences,
confirming earlier results [20]. However, they point to
previously unrecognised effects indicating the need for
extended studies.
At present, we can only speculate about the reasons
for this decrease of oxalate absorption under a high-
oxalate diet. One plausible explanation would be the
growth of the oxalate degrading bacterial population in
the gut. We tested faecal samples of the volunteers of
study II for the presence of O. formigenes, the most
prominent microorganism capable of oxalate degrada-
tion [1]. Two volunteers were O. formigenes positive, two
were negative. As can be clearly observed in Fig. 3,
presence of O. formigenes cannot be the only explana-
tion. However, as can be seen from Fig. 4, the two
volunteers who tested positive for O. formigenes always
excreted less oxalate than the two volunteers who tested
negative. We did not test for other microbes known to
degrade oxalate [13]. Another explanation would be an
adaptive increase of the calcium excretion into the
intestinal fluid driven by the high-oxalate content of the
chyme. Whatever the reason for the reduction of the
oxalate absorption under long-term high-oxalate diet,
this effect is important for people regularly ingesting an
oxalate-rich diet, such as vegetarians. This protective
adaptation was absent after 4 weeks of a normal mixed
diet.

The finding that on the second day of a high-oxalate
diet the absorption of the soluble [13C2]oxalate had in-
creased drastically offers an explanation for the puzzling
observation that only one-third of the recurrent idio-
pathic stone formers have been classified as oxalate
hyperabsorbers [7]. If a small stone exists, a few days of
high-oxalate diet may be sufficient to support slow
growth of the calcium oxalate urolith even in ‘low oxa-
late absorbers’, as indicated by the increase of the
APCaOx-index (Table 1).
Conclusion
A short-term oxalate-rich diet increases the percentage
of intestinal soluble oxalate absorption. Subjects with
high endogenous synthesis will experience hyperoxalu-
ria. Under a long-term oxalate-rich diet, there exists an
as-yet unexplained adaptation reducing, though not
eliminating, an increase in the percentage of the intesti-
nal oxalate absorption. As a high-oxalate load in urine
plays a central role in calcium oxalate stone growth,
these results stress the necessity to eliminate oxalate-rich
food from the diet of calcium oxalate stone formers.
Acknowledgements The study was supported in part by a grant of
Deutsche Forschungsgemeinschaft (UN91/3). Skilful technical
assistance by B. Bär and M. Klöckner is gratefully acknowledged.
Dr. S. Voss measured the oxalate content of the diets and food-
stuffs and M.E. Schmidt, MD performed the ultrasound examin-
ations.
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