Kidney_stone

HOW MUCH IS ENOUGH: DO WE ANALYSE EVERY KIDNEY STONE?

CoeTie4There is no doubt about what I say to patients: “Bring me all the analyses that have been performed on your kidney stones. Bring in any stones you have tucked in a dresser drawer and we will get them analysed.” But what do I say to me, and what do I do as time goes on and more stones form or are passed? Do I analyse all of them? Do you?

The problem of keeping track

Whenever I get a new patient, the stone analyses are at the top of my mind. How can I do anything rational about prevention if I don’t know what the stone crystals are? If there are no analyses at the first visit, like you I do everything I can to track them down; and, I usually succeed. But as time goes on with a patient, and more stones come along – many of them old ones, I hope – there is a tendency to let them go. After all, there were two calcium oxalate stones documented 2 years ago, I say to myself; do I really need to send more of them off in order to prove the obvious, or to meet some standard of perfection?

The problem is, at least in the patients I have studied, things change, and not always for the better.

Evidence for stone conversion

You probably already know that calcium phosphate stones, brushite especially, are much more trouble than routine calcium oxalate stones. What I suspected, and have had an occasion to document Nephrology Dialysis Transplantation Volume 24, Issue 1Pp. 130-136. is that conversion from calcium oxalate to calcium phosphate stone formation is not so rare among our patients with sequential stone analyses during treatment. Out of 4767 patients, we found 445 who had two or more stone analyses, lacked any systemic disease as a cause of stones, had well preserved kidney function, and formed calcium stones without any admixed uric acid, struvite, or cystine: were, in short, idiopathic calcium stone formers with at least two stone analyses.

I would have thought, incidentally, this being a stone research center, we would have had many more stone analyses for this most common kind of patient, but we did not. If it were not for our research, and if we were not maintaining such complete research records as we do, I would never have known we did not have more.

The details of what we found

Of the 445, 62 had a first stone >50% calcium oxalate by analysis and a last stone at least 20% higher in calcium phosphate content. These were the patients who converted from calcium oxalate to calcium phosphate stone formers. As controls we selected from the 445 181 patients who met rather stringent criteria: First stone >90% calcium oxalate and increase of stone calcium phosphate was <20%. In actual fact, the median stone calcium phosphate percentage of those who converted were 12% at the start and 75% at the end, whereas those who did not convert began with a median calcium phosphate percentage of 2% and ended up at about the same. Given only the most rigorously selected patients, 62/(62+181) or 25.5% converted.

In an altogether unrelated study of VA hospital stone analyses, Mandel et al found that successive recurrences of stone had increasing calcium phosphate percentages. They specifically echo our idea, actually antedate our presentation of that idea in print, that stone analyses should be continuous because conversion is not at all uncommon.

Why is increase of stone calcium phosphate important?

I have already pointed out that calcium phosphate stones are more serious a problem than calcium oxalate stones: they are larger on average, often more numerous, and involve the kidney epithelial cells. Brushite stones are very hard and do not fragment well with shock wave therapy. So conversion is not a good clinical outcome.

An altogether different problem is that treatment may not be the same for idiopathic calcium phosphate and calcium oxalate patients. We treat idiopathic calcium stone formers like you do: fluids, reduced diet oxalate, reduced diet sodium, thiazide diuretic agents to lower urine calcium when it is high, and potassium citrate, and use these modalities in various combinations depending on the situation. All of these treatments are reasonable, and the two drugs each have some RCT support.

But potassium citrate has never been tried in calcium phosphate stone formers per se. Some calcium phosphate stone formers no doubt have been in the three RCT for potassium citrate, but we do not know which ones they were, and whether perhaps they did poorly with the drug – had more stones, or perhaps stone growth.

There are reasons to believe calcium stone formation might increase or decrease. Potassium citrate can raise urine citrate and thereby reduce calcium phosphate formation. This is true because citrate binds calcium in a soluble complex leaving less to combine with phosphate, and also because citrate can inhibit the formation and growth of calcium phosphate crystals. But citrate is an alkali and can raise urine pH, and therefore raise urine calcium phosphate supersaturation. So we do not know if it is a good or bad treatment for patients producing calcium phosphate stones. Lacking a trial the matter is moot and wisdom dictates caution.

There are other kinds of stone conversion

It is not just increasing stone phosphate content that has taken me by surprise. Although I have not written a paper about them, I have patients who started as idiopathic calcium oxalate stone formers and began making mixed calcium oxalate – uric acid stones over time. They needed treatment to raise their urine pH. Some had become diabetic; some became obese; some just got old and lost some kidney function. But how many patients have done this I do not know. Occasionally struvite begins forming in calcium stone formers. Eventually the infection becomes obvious: stones become large and gnarled; the urine is obviously infected. But perhaps a more timely analysis would have hastened diagnosis.

What I have begun to do

My message to myself, which I am sharing with you, is that stone analyses are really important over time, and being not too expensive (I have no financial relationships with this vendor, it just so happened to offer me a convenient web site for a reference) is probably worthwhile for most stones that are removed from patients or passed.

I am changing my ways. I send every stone for analysis. I suppose some money will be wasted, but maybe in the long run a lot more will be saved. Even a single extra stone attack can be very expensive.

Should we do research about this topic?

At first thought research would seem practical, and likely to help me decide if my new way is right – or wrong. But the matter is both mundane and not so easily transformed into an experiment. To do what Mandel did, analyse successive stones and determine phosphate content is to do what has already been done. What we did has also been done except for the specific search for new uric acid or struvite appearing over time.

This leads me, at least, to say no. We have a decent clue as to what happens to patients, and the belaboring of the matter may not be worthwhile. Others may say I am wrong in this, and even wrong to do too many stone analyses.

Fred Coe MD

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12 Responses to “HOW MUCH IS ENOUGH: DO WE ANALYSE EVERY KIDNEY STONE?”

  1. muhammad iqbal

    Dear sir,
    it was in the year 1996 when i felt severe pain in the flank area; i visited a surgeon and he advised me using antibiotics. since that time, i have been the victim of stones once in two-year time. Now the doctors say, collect the stones and get them analysed; but the problem is the stones are too minute and i am not able to collect that. some of my tests are as follows; (a) uric acid 5.7 (b) PTH 35 (c) calcium 10.00 (d) calcium and (e) the urine tests often show as normal. the ultrasound results says, concretions. Sir, what would you suggest in order to avoid this havoc.

    Reply
    • Fredric Coe, MD

      Hi Muhammad, Even if minute the crystals can be caught and analysed. If you urinate through a coffee filter paper in a plastic cone the particles may be caught. No matter how small an analysis can be made. The blood values are normal. Until you know what the crystals are it is hard to use the urine values because the supersaturation of your urine with respect to those crystals you form is too high but right now you do not know the crystals. If you assume they are calcium based crystals try to lower the calcium oxalate and calcium phosphate supersaturations to one half of their present values. Ways to do that are in these articles on calcium and oxalate. Regards, Fred Coe

      Reply
  2. Michelle Groleu

    A million thanks to you for sharing this information. For two years I told my primary that I thought something was wrong with my kidneys and I thought perhaps kidney stones might be contributing. No advice was given in any way so I assumed there was no harm. Now I realize that all this time I was passing multiple kidney stones. It is extremely difficult to find competent medical people. A urologist instructed me to go to a vegan diet which I did and several weeks later I called to find out lab resuts and I was told the stones had been “calcium”. No elaboration on what type of calcium stone and clearly the vegan diet had greatly increased any urine oxalate levels. I now pass many stones a day. I look forward to finally meeting with a nephrologist in a couple more weeks. Thanks to your articles I will be informed and understand what is being said.

    I can not thank you enough for posting these extremely informative essays. You are helping countless people and I know you will never receive adequate thanks.

    Reply
  3. Chad R

    Dr. Coe, I would greatly appreciate it if you could contact me. I could really use some help. Thank you

    Respectfully,
    Chad R

    Reply
  4. RAKESH YELLAMELLI

    Sir,Thank for sharing valuable research work.
    I had stones since 2002 now I am 34.Never they hurt me too much even though come out through urine.I had picked up the stones for analysis,but no doctor interested in.recently a stone size 10x6mm blocked in my upper part of the ureter below 6 cm to the pelve…and had successfully come out with out much pain.Sir,I humbly request you to kindly analysis the reason for continuos formation of stones and suggest changes in my life style. Give me the address where shall I send the reports and stones
    Thanking
    RAKESH YELLAMELLI INDIA

    Reply
    • Fredric Coe, MD

      Hi Rakesh, Right now I am unable to provide personal health care for patients who do not come to the university of chicago – my employer. We are trying to begin telemedicine which would enable such but for the moment it is not available. All I can offer is the kind of general advice that is already on the site. It is very important to analyse these stones, and I am sure a laboratory is available to do this – it is the first step to prevention. Regards, Fred Coe

      Reply
  5. April Suzuki

    Hi…I have had kisney stones ans my analysis report back to me. My brushite number is 9.04 and I have other areas that are concerning also. If I send you my report and can you please help me to prevent as much as I can…I am pregnant ans not wanting to ezperoence these again let alone while Im pregnant.

    Reply
    • Fredric Coe, MD

      Hi April, I guess you mean the percent brushite in your stone is 9% but I cannot be sure. If you wish, I can surely help you interpret your reports. Please call my secretary at 773 702 1475 to arrange sending. Fred Coe

      Reply
  6. sandhya

    I need a suggestion for my disease from you how I get that from you. Shall I send my report

    Reply

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