CASES

CASES

IMG_2303Like much of medicine, kidney stone disease is organized around a set of phenotypes, idiopathic calcium oxalate stone formers for example. A useful if medieval Platonic idealization, when looked at closely these phenotypes invariably disintegrate into what one might call medical atomism – the tyranny of the individual case.

When asked for an example of an idiopathic calcium oxalate stone former I never can find exactly the ‘perfect’ case but rather someone who fits well enough but with – how shall I put this? – rough edges, stray facts that do not fit the mold.

What this really means is obvious. Every physician practices ‘personalized medicine’ and, like most medieval intellectual conceptions, phenotypes have value more as metaphor than as a guide to the day’s work.

What it also means in that every patient is a node in the matrix of pathophysiology, clinical manifestations, and treatment complexities that make up this field, being a place in which all together give rise to the one single manifestation – crystal formation – which defines our work.

So I did not bring these cases, suitably disguised, from my precious museum but simply from recent outpatient sessions, as I find in almost every patient more or less a unique set of oddments that serve very well as special instances of general formulations – the reason cases are so important – concerning clinical evaluation, the technical business of pathophysiology, and the elaborate compromises of therapeutics. Every case is an ‘everyman’, and ‘everywoman’. You just have to look close and each one is a universe.

Ages are deliberately vague, dates for labs are presented from 0, the first one, upward in days or weeks or more. Occupations are similar but not the same as the real one – because people deserve privacy. Lab data, stone composition, rates of formation, treatments, and outcomes are rigorously exact.

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Medullary sponge kidney (MSK) is more spoken about than witnessed, and more witnessed than accurately diagnosed. This patient adds to the 12 we have described in our publication, and adds also in having a very long and evolving history with one of us (FLC). We write for a general audience yet hope to include a level of detail that satisfies physicians and scientists. Here, we may fail of clarity to the one audience or of a sufficiency to the other because the disease is complex. But withal, the evolution of diagnosis and care for this person so educates and the surgical anatomy and histopathology so instructs we have chosen to share the experience. What is it we are sharing? MSK is a Unique Disease MSK is remarkably specific in … Continued

This is a first for the site, and perhaps it should have been a feature long ago. After all the generalizations and reviews there is something wonderful about a single instance that contains all the elements of a topic in the kind of instructive detail we can get only in life itself. Pat – who has permitted me to use his name and data – forms calcium stones and has idiopathic hypercalciuria and a job that makes hydration a problem. For treatment I wanted to use low sodium diet to lower his urine calcium excretion and if possible avoid thiazide diuretics just because of his job which is outside and in summertime poses serious heat loads. MIchelle, his wife, created a reliable low sodium diet for him as proven by multiple follow up tests and that reduction of sodium lowered urine sodium and stone risk, as one might expect. I asked her to share her experience in doing this, and she responded with this wonderful article. It helps that she is a professional writer! I am indebted to Michelle and Pat for their story, and I hope you like it. 

CLINICAL FINDINGS A man in his fifties formed his first stone in the early 2000’s and his last 6 months ago. There was a single passage event a year or two after the first stone at which time he was given hydrochlorothiazide 25 mg daily. A right SWL procedure was performed 1.5 years ago because of a stone attack, and  potassium citrate 10 mEq twice daily was added in treatment. A right sided URS procedure was performed 8 months later but was not completed because of bleeding. A right URS 6 months ago is said to have left his right kidney stone free, but some stones were seen on the left. I did not have images to review when I saw him. He believes that all of … Continued

CASE 1: A Stone Former. As you will see, this is a person with considerable numbers of stone attacks who has certainly produced large stones in the past, but he posed major problems in deciding if stones were active and is therefore a perfect place to start. His many laboratory abnormalities are just wonderful for thinking about stone pathophysiology.