I decided to try something new.
How about walking tours?
This is just that. I have organized a nice stroll through the site for just one topic: Kidney stones themselves. Not how to form them, or remove them, or prevent them, but just about them – their natures, their names, how they are put together, how we know what they are.
You can start with me and sightsee, stop for a while, come back, abandon the tour as uninteresting. I mean it as a way of seeing a topic with a guide who knows something about the big rambling posts you find on this site, and how they can be read so as to get a coherent picture of things.
Are you ready? Do you have your picnic basket and water bottle?
Here is a very good place to start. The post is like one of those simple chapels you encounter in the countryside – few elaborations, purposeful. It means to place the crystals at the center of things, and make clear that prevention is not a myth but something attainable and worth struggling to achieve. It includes a great trial – of water, one of importance and widely accepted by scientists everywhere. When you get to the end, simply click on the return and you will be back here.
What you just read simply spoke about crystals. Here are their names, some of the chemical structures that make them, and an introduction to the arcane and difficult business of crystals. This is a large article, and if you are more than simply curious in general you will probably focus on ‘your’ stone, or wonder which one you have. On reading it over as I prepared this tour, I thought it was too lightly referenced, and mean to add more.
When you send a stone out to a laboratory to find out what crystals make it up you expect to get the answer: What crystals are in it, and the relative proportions of crystals when more than one is present. That answer may be true or not – just so. The technique is scientific, but science bounded by economic constraints so that answers are good but not as good as possible. Given enough time and money per stone one can know everything, exactly. But at the marketplace price, one gets reasonable enough answers most of the time. I am not so sure everyone will like this article because of its message: Be aware; analyse as many stones as possible to be sure you know what you are trying to prevent.
As if at a fair, or flea market, this discussion and the one preceding it seem alike even if different. One tells us about safety in numbers given an imperfect world, the other tells us that we are changing all the time, and our stones, too, so yesterday may no longer be. This is a place to ponder. Of course it is true. Why should we expect otherwise? But even I, who wrote the article, falter after a few stones have gone by. I should not. No one should. If the crystals you make are changing, treatments may need to change.
Since we are in Ireland, along the coast, I guess lunch can be anywhere on the grass. Here perhaps.
We have been touring the foundations of stone disease, some of its oldest parts. Any doctor who cares for patients with this disease will have known all about what we saw. Patients who form stones will want to know precisely what they are made of and how that fact was ascertained. There is a lot of science left to be done in this seemingly well studied realm.
This afternoon, we are going to look at something much less understood, and seemingly very important. What is it that glues the crystals together? Does the glue matter?
We will also study citrate as a molecule that specifically inhibits crystals from forming and growing.
The article was written for scientists but frankly anyone can read it.
The message is science in evolution.
Right now we are all in the dark. It is as though we have come upon a trove of writings in an unknown language. We do not know what is being said, and have no clue as to the purposes of what we see.
Stones are filled with proteins, perhaps many by random association. We think these proteins, which are present in urine, stabilize crystals, perhaps promote their formation or inhibit their growth, and possibly glue them together to make stones of clinical magnitude.
A link comes off of this article to a working paper I wrote about more scientific papers in this area. It is not polished, but it has the stuff.
Unlike the many and mysterious proteins in stones, citrate is a small molecule we measure in every kidney stone urine study, a molecule with well known abilities to reduce the rate of crystal growth and prevent stones. The article, like the protein article, is demanding but essential if one wants to understand how this simple molecule can be so important as it is. We will visit citrate again, over and over, but here it is in the context of the stones themselves.
Certainly it would be a terrible tour company that offered nothing by way of an exposition after supper. This article considers the problem of the stone crystals in a larger scientific context, and explores what science does and how it attempts to discover in the special province of Medicine. It is part of the series on ‘Site Logic’.
Physicians encounter stones in patients, and always have done so, but they themselves, as physicians, cannot determine what the stones contain, their crystals, their proteins. Scientists do that. The roles differ even in the uncommon situation where a physician is also a practicing scientist. How, then, so medicine and science work together? I say it is marriage – a true commons – and within it is a middle ground across which materials, ideas, and discoveries flow. The common kidney stone offers a perfect example.
Fred Coe, your tour guide.