At the end of it all, the science, the medical visits, the surgeries, what we really want is to prevent new stones. That is the main goal. Modern surgery is a blessing for those with stones. But no surgery is far better than even the most skilled and effective surgery.
Prevention of stones is orderly and occurs only over time.
Here is how to do it.
This article is designed to go with my other one which tells how to organize your medical visits so as to achieve these steps.
What is the Science of the Five Steps?
Supersaturation drives crystal formation and growth – this is a physical law that must always apply.
Supersaturation measurements are widely available from commercial vendors.
Because people who are actively forming stones are forming crystals their supersaturations are too high – crystals are forming – with respect to those crystals.
Lower the relevant supersaturations and you must lower formation and growth of those crystals in their stones.
With respect to the most common stones, calcium oxalate and calcium phosphate, and uric acid, supersaturation in urine depends mainly on volume, calcium, oxalate, citrate, and pH. You can lower supersaturation by altering any or all of these in a given person and so far as crystals are concerned the effects are much the same.
1. Know the Stone Crystals
Stones are made of crystals: No crystals no stones. Prevention is prevention of crystals.
Analyze Stones
The proper way to know the crystals is analysis of stones and their fragments. Stone analysis is not expensive. If imperfect, it is the best we have, so use the service liberally. Stone crystals can change, and therefore prevention can need to change direction. There is no reason to discard a stone without analysis just because we think we know the answer.
Uric acid stones are remarkably easy to treat by raising urine pH and require little more discussion.
Cystine stones arise from hereditary kidney transport disorders and require special management.
Struvite stones arise from infection and require special combined surgical medical management.
Drug stones, ammonium acid urate stones, and rare stones – eg. 2,8 dihydroxyadenine stones require special management.
The vast proportion of kidney stones are calcium oxalate and calcium phosphates and uric acid, and this article refers mainly to them.
Guess if You Have To
Red or orange stones probably contain uric acid. Likewise, stones that do not show up on simple abdominal flat plate x rays are probably uric acid. These are easy to prevent, and recurrences are unnecessary.
Allow me to elaborate on this. Pure uric acid stones are almost all due to an excessively acid urine pH, and will stop if you raise that pH. Potassium citrate tablets, 10 mEq size, 2 twice daily is almost always enough. Sometimes it takes 2 tabs 3 times a day. Crystal light lemonade has in one liter about the same amount of alkali as two of the tablets. I could say that there is little excuse for another uric acid stone.
If stones contain uric acid and other crystals, those other crystals need to be dealt with on their own. They may not respond to higher urine pH, and could be worsened.
Yellow stones are probably cystine, and due to cystinuria, a complex disease with its own special treatments. Because almost all kidney stone panels include a cystine screening test, cystinuria is almost never missed. A positive test, however, can reflect cystine trait and the stones can be something else. So it is the negative test that is fully informative.
Small black stones are probably calcium oxalate, and large very homogeneous hard stones are probably brushite. But one cannot be sure.
Big stones that fill up the interior of the kidney are usually cystine, struvite – from infection, or calcium phosphates from alkaline urine and hypercalciuria.
But guessing is not a good way to achieve prevention. Find out whenever possible what crystals you are trying to prevent. Any stone fragment can be analysed. Never pass up an chance to be sure.
2. Obtain Proper Blood and 24 Hour Urine Measurements
I prefer two 24 hour urine kidney stone risk panels as a minimum along with at least one set of fasting blood measurements.
Screen for Systemic Diseases
Here is a table of systemic causes any physician can follow using the blood and 24 hour urine testing. This is not something a patient can do anything about except see that it is accomplished.
The bowel diseases that cause enteric hyperoxaluria – small bowel resection, malabsorption, are usually obvious, as are ileostomy and bariatric surgery.
Medullary sponge kidney and nephrocalcinosis are complicating features physicians need to deal with. Medullary sponge kidneys actually form tiny micro crystals in their dilated ducts. Whether these grow to become clinically important is not clear.
Nephrocalcinosis simply means many crystals are present on x ray images. During ureteroscopy these crystal deposits can be sorted out into real stones and plugs within the terminal ducts of the kidneys. Pain without obstruction is widely described in both of these conditions which complicates management.
Measure Urine Supersaturations of the Stone Crystals
Standard 24 hour urine kidney stone risk panels give supersaturations along with the urine chemistries that control those supersaturations. These are the keys to prevention. Supersaturations control crystallization and can be measured reliably in people. If crystals are being formed the supersaturation is too high and we need to lower it.
Read Your 24 Hour Urine Reports
Your physician will take care of you but a prepared and educated patient can make that care vastly more effective and reliable.
You can understand your 24 hour urine tests and follow along with your physician during your visits and when treatment has been introduced and your urine chemistries change as a result. The details of interest are different for calcium stones and uric acid stones, so I have put them in two separate articles. Do not be put off by all the numbers. Follow the articles with your test panel in hand and you will find things are not so difficult.
Stone prevention is long term and involves changes in diet and behavior and, often, medication use. If you can read your own report you will have a first hand sense of why your treatments are good for prevention and whether your treatments have achieved what they were designed to achieve.
3. Lower By Half the Supersaturations for the Crystals in Stones
There is no one way to reduce supersaturations. Every patient will have a characteristic pattern of abnormalities and supersaturation can be lowered by changing any number of those abnormalities present. Below is my general strategy, but it may not apply to you. If your urine volume is already very high, for example, to raise it would be silly. So consider my ‘strategy’ a general set of rules, easily modified to fit the individual situation.
Raise Urine Volume as High as is Practical
Above 2.5 liters daily is ideal. The site is very rich in advice for fluid treatments. How to drink more. How to get variety. How to avoid low flow periods. Being without cost or risk, fluids are always my first choice.
Reverse Urine Abnormalities Raising Supersaturations for the Crystals in Stones
Identify the factors in the 24 hour urine beside volume that are raising supersaturations for the crystals in stones, and act so as to reverse them toward normal. Common ones are high urine calcium, high urine oxalate from diet, low urine citrate, and low urine pH – for uric acid stones. High pH is a risk factor for calcium phosphate stones but one cannot lower urine pH under most circumstances.
Bang For the Buck
A vulgar phrase, if you think about it. Here are the relative risks of becoming a stone former in the three cohorts of nurses (red) and physicians (males, blue) Dr. Gary Curhan followed. You might say relative to what. For each risk factor it is different: Calcium – less than 100 mg/day; Oxalate – less than 20 mg/day; Citrate – less than 300 mg/day; Volume, less than 1 liter.
The average relative risk is at the end of the crosshatched bars. The ends of the solid bars are the 95th percentiles. When the solid bars are above one risk is certainly present, so you can see the safe ranges for calcium, oxalate, citrate, and volume. Because the plots all have the same risk ranges you can compare these four risk factors. Calcium has the widest effect range. Oxalate is next and increases risk at even 25 mg/day. Citrate causes risk only when below 400 mg/day, and volumes above 2 – 2.24 liters lower all three cohorts into a low risk range.
Although urine volume confers relative risk equivalent to high urine calcium and oxalate only when below 1.25 liters daily (see graph at left), one always wants to raise it as much as is possible because such treatment is without risk or cost. Above 2.25 liters daily is ideal. The site is very rich in advice for fluid treatments. How to drink more. How to get variety. How to avoid low flow periods.
Obtain New 24 Hour Urines to be Sure Supersaturations Have Fallen
There is no point to changing diets or medications without proper follow up to determine if what was done had the desired effects. Six weeks is a good time for the first follow up measurement. Continue measurements until the supersaturation goals have been achieved.
4. Obtain more 24 Hour Urines if New Stones Continue
Crystals follow physical laws and supersaturation is what drives them to form and grow. Continued stones with reduced supersaturations means either supersaturations need to be lower, the 24 hour samples are not being taken on representative days, or the days themselves have periods of low urine flow or other breaks in treatment.
Crystals do not sleep nor do they make mistakes. Any chances they get, they use.
Physicians are trained to ferret out the details of a patient’s history that matter here. It is my main clinical expertise.
Patients are not trained but they are the ones sitting up close at the 50 yard line. So they know more than anyone else. They just may not know what is important for stone prevention.
5. Follow Up Every Year Thereafter Even If Free of New Stones
OH, you might say, those urine measurements cost money.
They do, hundreds of dollars for each one.
The merest surgery can cost near to or even above ten thousand dollars when you consider the total of medical, operating room, anesthesia, and pre and postoperative imaging costs, and the inevitable emergency room visits that provoke the surgery in the first place. This is not to mention lost time from work.
And, did I speak about pain, misery, infections?
It it time for blunt talk. Lab measurements are the compass and altimeter. Flying blind is silly.
A Good Way to Get All This Done
You cannot do the five steps alone, your physician is crucial. He or she cannot do them either; you are crucial. In case you missed it, here is my view on how a patient and physician can best partner for stone prevention.
That’s It
This site is far from complete but it already has a lot of what one needs to carry out these five critical steps. Do them and new stones will cease altogether or at least greatly reduce in frequency. If it does not work, one or more of the steps need correcting. After nearly 45 years preventing stones, I have become bold enough to say this, and mean it.
Good Luck, Fred Coe
I have finally found a urologist that has taken an interest in resolving my stone problem. Last 15-20 yrs have been unbelievable and expensive. Your website and many people on facebook have given me insight into the changes to makeand follow I need. In Jan I have a f/u appt from last April laser to rt kidney and have had very few passable stones since. Have had stones bil but rt has been worse along with rt multiple inf that never cleared up until after this surgery. So am curious to see if more stone formations…prior to appt am scheduled for 24 hr urine, ultra sound and xray…thank you for your web site and the awesome work you are doing….Will keep following.
Hi Jeannie, You are doing the right thing to figure out if there are new stones forming. If there are, then you need more prevention oriented changes to lower supersaturations. Exactly. Fred Coe
Thank you for the informative article. What role does Hyperparathyriodism play?
Hello Curious, hyperparathyroidism is an endocrine disease that causes stones and bone disease, and it almost always curable with surgery. I have not written much about it on the site but there is something here in the article on hypercalciuria. It is on the list of diseases that physicians need to look for in calcium stone formers. Regards, Fred Coe
Dr Coe
You state that the process in the kidneys is the formation of crystals and supersaturation drives the formation
and growth of the stones/crystals. My particular interest is in uric stones.
Uric acid supersaturation can form stones in the kidney/s, or in the blood uric acid crystals, causing gout.
The process in the kidney/s is supersaturation not necessarily causing crystals but rather deposition stones.
Please comment. Thanks.
Hi Richard, and thanks for the question. Uric acid stones are aggregates of uric acid crystals – no crystals no stones. Sometimes the crystals do not clump together to make stones and patients pass uric acid gravel which is orange because the crystals adsorb a urine pigment (uricine – a hemoglobin breakdown product). Often the crystals do clump and form stones. The molecule that makes these crystals and stones is uric acid on which both proton binding sites are bound to protons. This makes both sites less negative and offers water molecules less to hold on to. The rest of the uric acid molecule is very hydrophobic – no charge sites – so water cannot hold it in solution. The solubility of fully protonated uric acid is about 95 mg/liter. Given perhaps 600 – 700 mg of total uric acid a day in urine, and perhaps 2 liters of urine this would make a supersaturation of 300/95 to 350/95, which is very high. The second proton binding site is 1/2 occupied at a urine pH of 5.35, so at a pH of 6 it is fully charged and available for water – the solubility of the monohydrogen urate salts of sodium, potassium, and ammonium (available positive charge partners in urine) is very high, and these salts almost never cause stones. In blood the pH is 7.4 so the relevant salt is sodium monohydrogen urate, which is just at saturation when blood total uric acid is around 8 – 10. This crystal form is what makes for gout – a different crystal from the urine. So, everything is always the same – supersaturation, crystals, and trouble. In joints we get crystals and they cause inflammation. Regards, Fred Coe
Hello Dr. Coe,
Just by chance I came across your article about uric acid kidney stones and it really caught my attention as I have been searching high and low and have yet (until now) to find a decent explanation. I do have a question. I was diagnosed with MSK (left kidney only) about 40 years ago. Up until last year, I never had any obvious symptoms. In January of 2015 I had my first ever episode of kidney stones. Pain was minor and I passed a 2mm stone (confirmed as 100% uric acid) along with many small sand-like stones. To make this story short, ever since then about every two to three weeks, I will pass sand-like stones for a day then not again for several weeks. Nothing larger so far thankfully. I have been seeing a nephrologist and urologist. I have adjusted my diet, been drinking more water mixed with lemon juice in hopes that this would stop. Can you offer any insight as to what caused this to start up suddenly after 40 years? Thank you!
Hi Steve, Your stone was 100% uric acid, and that is prevented completely by raising urine pH with suitable alkali. These kinds of stones are due to an acid urine pH that can come up later in life. Get proper 24 hour urine testing which will show the problem and treat it as noted in the article. The sand and stones will stop. Get the gravel analyzed to be sure it is all uric acid. regards, Fred Coe
2yrs ago I found out I had a very large stone, larger than 2cm called a staghorn calculi, the stone is 60% COMonohydrate, 30% Calcium phosphate, 10% CODihydrate. After 2 lithotripsy surgery’s it is almost gone. I drink 1.5 gallons of water a day is there anything else that helps. I have read the diet the doctor gave me and I don’t eat extreme amounts of any of the food that was on the chart.
Hi David, There is a lot more that should be done. What did your blood and your 24 hour urine tests show? Surely there are some abnormalities, and these need to all be treated. The high fluids are a good think. I presume the diet lists concern oxalate. What about urine calcium, urine citrate? Was your urine volume much lower in the past? Did you eat differently? Were your 24 hour urines – if collected – collected during a period approximating your stone forming life?? Many things can help, but everything begins with what is there as a cause in the first place. Regards, Fred Coe
Please help. My ultrasound reports as below.
Findings: Bilateral non-obstructive renal calculi are domenstrated. The largest on the right is a the uppoer pole measuring 1.8cm. The largest on the left is at the mid to lower pole measuring 1.2cm. No hydronephrosis.
Impression: bilateral non-obstructiverenal calculi.
Can someone please explain this report to me, as my family doctor in Vancouver, BC, Canada, could not say much about it to me and just told me that it is very common in Asians. What does No hydronephrosis means? Is there any way to cure the present condition of my kidney stones? What should I do it? I just met my doctor today. He said there is not treatment or medication for this. I would appreciate your help.
Regards,
Albert
Hi Albert, it sounds as if you have multiple stones in your two kidneys, several of which are rather large. I do not agree that nothing should be done. If the present stones are not obstructing, nor causing significant pain, infection, or bleeding there is no surgical urgency. But why are they forming? Prevention of more stones is an urgent matter as being Asian is not a reason to make stones – there is something causing these and that something needs to be identified and remedied. You should attempt to get your physicians to find out the cause and offer appropriate prevention services. It is not true that there is no treatment for stone prevention – Regards, Fred Coe
Dr. Coe,
Why don’t urologists prescribe pyridoxine more often in hyperoxaluria? Doesnt the data show a benefit in patients with idiopathic disease as well as primary type 1 hyperoxaluria?
Best
R
Hi Ryan, No it has not been shown to be effective. Regards, Fred
Dr. Coe,
Thanks for the fast reply. Not trying to be argumentative, but I’m just curious. Is the data for b6 and urinary oxalate just not very robust? This was the only thing I was able to find: http://medind.nic.in/iaf/t05/i2/iaft05i2p166.pdf
Best
R
Hi Ryan, you are anything but a problem – thanks for writing. The data are more or less negative apart from forms of primary hyperoxaluria. Regards Fred Coe
Hello Dr. Coe,
I am so encouraged by your website, and impressed that you take the time to answer comments and provide such valuable information. I am a 57 year old female, and have been dealing with stones for over 30 years. Years ago I was prescribed loads of antibiotics because I would present with UTI symptoms and no infection, but they treated anyway. I now feel that was due to stones. Most of my care has been crisis management. Over the years, I have passed stones, had one dealt with with lipotripsy, and have had two uretoroscopies, the last one in Dec. 2014. It took doctors almost a year to figure out that the problem I was having was a stone because the xray and ultrasound didn’t pick up the 9 mm stone due to its position related to the pubic bone. It seems that my stone issue has really reved up since about 2005. Since the last stone removal (2014) I have had off and on symptoms of stones – some kidney pain, pelvic pain, urinary issues, blood in urine, etc. My urologist is so busy that I don’t usually get into see him until I am in crisis and need tests. He has done a 24 hr. urine test (2009) but never really followed through on prevention except to tell me that I may have hypercalciuria and to drink water. I had a CT scan in 2013 and he said I may have MSK. I did consult with a urologist at UCLA (March 2015) and he was not convinced of the MSK. He did a 24 hr. and also stated hypercalciuria and recommended water and the DASH diet, with possible Thiazide in the future. He did a Vitamin D, 1, 25-Dihydroxy test and my result was 87 which was out of standard range. Suggested I see a nephrologist (he gave me a name) but that it wasn’t urgent. I have not done that as of yet. My 24 hr. urine (the dates are 5/3 and 5/4 so it was a 48 hour, the measures are for 2 days) in 2009 (Litholink) showed Ca24 of 286 day 1 and 254 day 2 with Ox24 being 34 day 1 and 27 day 2. My volume was low day 2 (1.38) but ok day 1 (2.28). Other out of range numbers – SSCaOx 5.52 day 1 and 8.42 day 2, SSCaP 2.25 day 1 and 2.71 day 2, pH 7.097 day 1 and 6.493 day 2, and UA24 .740 day 1 and ok on day 2 at 0.554. Since then, I had another doctor do a 24 hr. through Quest Lab on 4/14/14 that stated ‘no metobalic abnormalties’, and the doctor reported that my numbers were perfect. The following is the results for the latest Litholink 24 hr. through UCLA urologist mentioned above (date- 4/17/15):
Vol24 – 3.15, SSCaOx – 4.47, Ca24 – 188, Ox24 – 41, Cit24 – 873, SSCaP – .47, pH – 6.076, SSUA – 0.35, UA24 0.598.
Currently, I was in the ER last Thursday night for abdominal pain and was told that I had a gallstone blocking a duct. I was sent to a surgeon on Friday to discuss gallbladder surgery. On Sunday, I started having significant stone symptoms which has continued to be present. I see my GP on Friday for a consult on the gall bladder. I also take a blood pressure med (for about 15 years) (Toprol-xl, 25 mg.), and have had body pain issues (about 15 years) which seem to be arthritis, I assume, due to observing my hands becoming a little disfigured over the last several years (blood tests have never shown anything). My daughter has had a stone, and my older sister has had several (not for many years) and was told she has parathyroid issues but has done nothing about it. I had an older brother that died of Bright’s disease at 2.5 months old.
I am sorry this is so lengthy, but I am looking for any insight you may be willing to give. I am a bit discouraged, and do not know where to go from here. If you have any recommendations of physicians that may follow your treatment protocol in the southern California area I would highly appreciate the referral. You can contact me at the email provided. Thank you for your time.
You are welcome to publish my comment. I meant that you could email if you have a referral. Thanks
Sorry…forgot to mention stones are calcium oxalate
Dear Carla, I understand you have had calcium oxalate stones and presumably have multiple stones in your kidneys – otherwise your physicians would not consider MSK. I cannot tell if you are having recurrent stones or pain and bleeding without actual stones. You have stones formers in a daughter and older sister. Your urine studies 5/3 and 5/4 2009 show a high urine calcium 286 and 254 mg/day, oxalate 34 and 27 mg/day, and volumes of 1.36 and 2.28 liter/day. A new set of measurements 4/17/15 showed a calcium of 158, oxalate 24, citrate of 873, and low supersaturations. You also have high blood pressure and a recent gall bladder stone. You do indeed have hypercalciuria and with your past 1,25D test at 87 and I presume a normal blood calcium and PTH value it is idiopathic hypercalciuria. This latter is strongly familial and inherited. Assuring a normal blood calcium and PTH is very essential as is ruling out any systemic cause of hypercalciuria. I do not know your treatments at this time, but I suspect this: The urine volumes were perhaps not exactly representative of your overall real life and can be lower during your usual work or other activities. I say this because with your current modest calcium and oxalate losses, and high citrate excretions and low SS for CaOx and CaP you should not make any crystals or stones. I would be sure that my urine volume was over 2.5 liters a day every day, and steady over the day. If you are having pain because of passage of prior stones, which is also possible, perhaps your kidneys could be cleared via flexible digital endoscopy. But I would not do this until I was confident I could keep the urine volume high and steady as I just mentioned. The high 1,25 D level is not uncommon in idiopathic hypercalciuria, by the way and is not a problem in itself. The urologist at UCLA sounds like the best bet, and I would discuss your clinical stone/pain issues with him/her and benefits of clearing prior stones. Warm Regards, Fred Coe
Thank you for your quick and thorough reply. Much apprciated. I will continue to pursue medical care with UCLA. I read the article you wrote about treatment protocol with the proper follow-up, etc. I do wish doctors would follow this. It really makes sense. I may print it out and give it to my doctor! I do have stones in my kidneys currently. Last time I went to my local urologist (not UCLA dr.) that’s what prompted him to to say the best he could do was to see me when I have my next stone issue. No real preventive care. That’s what lead me to seek help at UCLA. I will bring your recommendations to my next appt. Thank you. Again, your site and your insight are much appreciated. 🙂
I do have one other question. My regular vitamin D levels seem to hover between 28 – 35. My primary care doctor is always pushing me to take D3 with K2. He says that this should not increase stone formation. I have researched this on the internet but have not found much. Do you have any thoughts on taking Vitamin D and its effect on stone formation? Thank you.
Also, is hypercaciuria related to gallstones?
Not that I know of. Regards, Fred Coe
Hi Carla, Idiopathic hypercalciuria tends to increase 1,25 D production and this can deplete 25D which is the liver storage form of the vitamin. Serum D values in the range of 30 – 40 are adequate. Regards, Fred Coe
I’ve never experienced kidney stones until two years ago. My sister used to get them frequently. I was 66 at the time. I had two 3mm nonobstructing stones in the lower pole of the left kidney. I had Ureteroscopy two times. The first procedure failed as my uterers were two narrow, so I wore a stent for several months. The second procedure removed the stones and I obtained some relief but three months later two more stones were found, also in the left kidney.
I have low Vitamin D levels which are being treated and raised alkaline phosphate but a complete bone scan was normal. The same thing happened about ten years ago, had the bone scan and the ALP returned to normal. I also had a DEXA scan which was normal. All other blood tests were normal as well as kidney tests.
The only difference this time is I have Osteopenia and degenerative damage in the spine at L4,L5. I am getting a physical therapy evaluation soon. I also have Fibromyalgia which flares with the flank pain. However, there is a difference in the pain in the lower back which is very very minimal with no problems with mobility and the flank pain.
I just had the 24 hour urine tests and got the online results. It looks normal but I’m not a medical professional. I see the urologist next week.
Any comments are appreciated as I’m not sure what should happen next. I’m thinking of getting a second opinion. It’s not so much that I don’t like my urologist but maybe another pair of eyes might be helpful.
One more question. Can you have secondary hyperparathyroidism from low vitamin D and still form stones? My calcium levels are normal.
Apologies for the length of this post.
Thanks.
ga
Dear Georgeanne, I am guessing you have idiopathic hypercalciuria and have indeed had episodes of low vitamin D. Check the urine calcium. Is it above 200 mg/day or above 140 mg/gm creatinine? Osteopenia could be postmenopausal in origin but IH also causes it. Given the stones I doubt that your 24 hour urines are normal so much as they are possibly deceptive. What are your stones made of? Some were removed by URS so you must know. Write back with more information. Regards, Fred Coe
Thank you for the timely response.
I believe the stones were calcium bit need to check with my urologist. My urine calcium was 211.
Are you talking about creatinine blood test as I can’t find it on the 24 hour urine test. Is it called something else? My blood creatinine is 8.3. I should mention that in the two years of having this, I have lost 25 pounds without trying. I have always been very thin and small boned but when put on several medications such as SSRIs as well as clonazapan for RLS and other sleep issues, I gained weight. The flank pain if severe enough makes me nauseous and overall a reduced appetite. I also have IBS but have had that for years.
Again thanks. This site is incredible!
Georgeanne
Hi Georgeanne, your urine calcium is a bit high, enough to increase stone risk – follow the link. Your serum creatinine is 0.83, I am sure, which is normal. On the 24 hour urine report look for ‘Cr24’ if you cannot find the word creatinine. No 24 hour urine is any good without a creatinine value to estimate the quality of the collection. I am pretty sure you have idiopathic hypercalciuria and possibly some worsening of bone quality because of it. Diet should be high calcium for your bones and as low a sodium intake as possible. In some cases, when stones are active, thiazide type diuretics are used, but in your case diet has not been tried as yet. We have an excellent article on low sodium diet. Regards, Fred Coe
If I have idiopathic hypercalciuria as well as the raised ALP but not Pagets, should my two daughters be tested for this? My older daughter is forty and younger daughter 35. My sister used to get stones but think it’s been several years.
I think at this point I need a second opinion. I talked to the nurse at my urologists today as it turns out my appointment is week after next not this week.. My urologist is saying my 24 hour urine test is normal but in his defense that may have been his interpretation just glancing at the test since since he also had appoinments which understandably are his priority for the day. There is nothing about creatinine on the test which was sent to Mayo Clinic so this surprises me. Is this usual?
Should I see someone in your or a similar clinic or an endocrinologist who specializes in bone metabolic disorders (?). I live in Champaign about two plus hours from Chicago.
In the meantime, I am very uncomfortable and there’s increased pressure in my left flank. I have never passed any of my stones and don’t think I am now as I am more uncomfortable than in pain.
I think my diet is okay but need to double check your reference. I rarely salt food but do know there are other sources, no red meat and avoid processed foods. I think my calcium intake is high normal but maybe need more?
I know there are limitations as to what you can advise without actually seeing a patient and don’t expect you to answer all of my questions but listed quite a few and will let you choose.
Thank you for your time.
Kind regards.
Georgeanne
Almost forgot. Several years ago my sodium levels were extremely low and would fall to 125 as well as several hospitalizations. It may have been induced by Trileptal as when the doctor took me off of it the levels have since been normal.
I suspect you had the syndrome of inappropriate ADH secretion from that drug. Fred Coe
Hi Georgeanne, I think you do have idiopathic hypercalciuria – normal ranges have altered in the past few years. If you do indeed have this your daughters have about a 50% chance of having it too. Likewise your sister who formed stones. As for your personal care, I will email you as that would be inappropriate on a public site. Regards, Fred Coe
When I take Potassium Citrate I get crippling muscle cramps, most often in my abdominal muscles. Anything I can do to counteract these? I get really sick of Crystal Light !
Hi Barb, I can imagine that drink – or any one drink – can pall after a while. The muscle cramps from potassium citrate is something I have heard about from a few other people. Is it related to the dose? After all a liter of the beverage is 20 mEq of potassium citrate, about that of 2 pills. Regards, Fred Coe
I was taking 2 pills BID-TID depending on my urine pH. The cramps were debilitating. Nothing helped except stopping the Potassium Citrate. Oh well, I enjoy this site. I’m happy I have a local physician who follows up with me and does not just treat me rely on crisis management.
Dear Barb, If alkaline beverages are not too horrible and stones are not forming, I guess you have a reasonable compromise. Regards, Fred Coe
Hello Dr. Coe, I have have read your articles on types of stones and on prevention. I would very much like to prevent any further stones. I did ask my urologist how I can prevent stones and his reply was that I have great questions to which there are not good answers. I have had 3 bout prior bouts of Kidney stones/pyelonephritis/urosepsis in 1992, 2007 and 2014, and now have multiple stones, largest being 1.1cm in the same kidney. The type of stone previously was Carbonate apatite Dahllite. I am overweight 33 BMI, pre-diabetic, and have multiple spinal congenital abnormalities, kiippel-feil syndrome, chronic back pain, IBD, chronic diarrhea and incontinence of stool, and recurrent UTI’s. Is it reasonable to think the recurrent UTI’s are the reason I develop kidney stones? Also, what could you suggest I do to prevent the kidney stones? Currently I keep myself hydrated and of course personal hygiene is critical. A Feb. 6, 2016 urine culture showed 50,000 to 75,000 cfu/ml
Mixed urogenital flora, and urinalysis showed urine leukocytes 3+, blood small,WBC 120, RBC 19. I was put on a 5 day course of antibiotics but am still symptomatic with (R) flank pain. I last had a 24hr urine in 2014 after hospitalization for urosepsis and lithotripsy with results as follows: Citrate, 24-hr Urine 240 mg/24hrs
Citric Acid,24hr UA 183 mg/g creat
TOTAL VOLUME 2750
Urine Timed Creatinine 1.31 g/(24.h)
I would be most appreciative for any advice on why I get recurrent problems and how to prevent the recurrent UTI’s and kidney infections/stone. Thank you!
Dear Mari, You are indeed complex, and given that I do not know the details of your urological situation I hesitate to say too much. Calcium carbonate stones are not specifically caused by infection – infection stones are made of struvite – magnesium ammonium phosphate – although it is possible that the struvite component was missed in the analysis. Matters are so complex here all I can offer to do is speak with your personal physicians, if they wish. It would not be an official consultation, but there would be no charge. Our site is complex but not sufficient for you. Regards, Fred Coe
Gosh, I am so thankful for the information you provide. I have been spitting out calcium oxylate stones from both kidneys since 1989. I’d have an attack about every two years since then. Finally, in 2007 I was put on the Urocit-K which slowed things down until now. Both kidneys have multiple stones , most of which are small but each one has either a 6.1 or 5.8 stone. I’m am working with a new Urologist now as I have changed states. He has me seeing a Nephrologist very soon. I am likely headed for some sort of procedure. My question to you is what can be done to lessen the terrible discomfort with the stent? I know hydration is a biggie but most of the time I feel that the stent is as painful as the stone! It makes me clench my teeth it can be so bad. Any suggestions? Thank you for your input!
Hi Gayle, Although it may sound like heresy, perhaps given all your stent troubles your urologist might try to do without a stent. Ask if that is possible. Regards, Fred Coe
Hello Dr. Coe,
First, I am extremely grateful for your site and commitment to patient education. I had a stone 6 years ago. I had another last April, resolved by lithotripsy; an another in the kidney also resolved by lithotripsy in July. I was hit again this month (March), had lithotripsy, and then a horrifying blockage immediately after that procedure, resulting in a stent being placed for 10 days and removed today. My question has to do with prevention. I’ve been obsessively reading your website trying to get a handle on the info. Here are my basic lab results from last July (from litholink):
SUMMARIES OF LAB REPORT 8/19/2015
STONE RISK FACTORS
Volume: 2.08 liters (normal or desired: 2.5 l)
SS CaOx: 5.96 (6-10) LOW!
Ox 24: 30 mg/d (20-40) NORMAL!
Cit 24: 894 mg/d (>450) NORMAL to HIGH!
Ca 24: 414 mg/d (normal or desired: <250)
UU 24: 1.072 g/d (normal or desired: <.800)
SS Uric Acid: 2.88 (normal 0-1.0)
24 hr Urine pH: 5.330 (normal or desired: 6)
DIETARY FACTORS
Na 24: 185 mmol/d (50-150)
K 24: 121 mmol/d (20-100)
Mg 24: 147 mg/d (30-120)
Sul 24 92 meq/d (20-80)
UUN 24 21.96 g/d (6-17) (Urine Urea Nitrogen)
PCR 1.6 g/kg/d (.8-1.4) (Protein Catabolic Rate)
NORMALIZED VALUES
Cr 24: 3032 mg/d
Cr 24/kg 31.1mg/kg/d (18-24)
Ca 24/kg 4.2 mg/kg/d (<4)
Ca 24/Cr 24 136 mg/d (<140)
STONE ANALYSIS
20% Calcium oxalate monohydrate
80% Uric acid
I should mention that for about three years I've been adhering to a low processed carb, high protein/fat diet that has been very effective maintaining a significant weight loss, and the reintroduction of much more exercise into my life. I recognize the probable link of lots of protein to uric acid stones.
My doctor goes along with the notion that I want to have frequent 24 hr Urine tests to monitor concentrations, and to be very methodical in adding meds, so as not have multiple variables at work in my 24 hr urine results. Fair enough. But today he wants to starts me on 12.5 mg of hydrochlorothiazide to try to wrestle down the very high urine calcium level. He said once we have that under control, we can move onto the uric acid stones component. I guess after my very long-winded set up here is the question of why when my stones are apparently 80% uric acid stones we wouldn't deal with that first? His response to that question was that with that outrageously high Ca concentration, we need to deal with that first. He said something about the high Ca concentration of promoting the tiny crystal formation which may initiate the overall stone forming environment. He suggested that if I wanted to work on the uric acid stone component, I could have a couple lemons worth of juice each day and check the pH of my urine (I have strips). One final question that he didn't really answer is if my CaOx concentration is low, as is my oxalate, then how I am forming CaOx stones anyway?
Thank you kindly.
Hi Eric, Since your urine pH is low, your uric acid SS is very high at 2.88 and your stone is mainly uric acid I would treat that part of your condition. You will need about 40 mEq of potassium citrate – 2 liters of crystal light lemonade or 4 10 mEq potassium citrate pills daily. I think your 24 hour urine is over-collected given 31 mg of creatinine per Kg of body weight or else you are a body builder with almost no body fat, so the total urine calcium per day may be overestimated. I do not know why you formed the calcium oxalate portion of the stone, but for the moment I would focus on the uric acid. Regards, Fred Coe
Hi Dr. Cole,
I have MSK in my right kidney and two large uric stones over 9mm in that same kidney. I have seen blood in my urine now for over a month and they did a Urine/bladder cytology because my urine cells were abnormal. The bladder is fine but the urine was abnormal. They put me on potassium citrate crystals 3,300 mg daily to dissolve these stones. My question is can that much potassium citate actually dissolve uric stones that large? Is there danger taking that much well I feel kind a sick to my stomach. Do I need to worry about the abnormal urine test? Do you feel that I should see a kidney specialist ?besides the urologist? Thank you for all your help!
Hi Gina, Uric acid stones can dissolve if the urine pH is increased to at least 6. Certainly high pH will prevent more. The dose of potassium citrate needed is determined by measurement. I presume your urine pH was low so you could produce uric acid in the first place. So now you have to measure again on the drug and see if it is high enough. The amount you are taking is modest. Higher doses are often needed. YOur physician can assure safety in knowing your kidney function and making appropriate blood measurements. One issue is how you know the stones are uric acid. Be sure your urine pH was really low before treatment as a kind of support for the idea. Perhaps you have some stone analyses? Regards, Fred Coe
My kidney stones started because of parathryoid cancer. Post op I started to feel better than the cancer returned. Unusual, yes. I had another surgery and am on Natpara because of hypocalcemia. I’m still plagued with kidney stones after 18 months. I’ve altered my diet to help minimize oxalate, but am still in daily misery. If there any explanation as to why even with low serum calcium for 18 months I still have stones? I’ve been on high doses or calcium supplements which I’m now titrating down with the Natpara. Should I finally see some relief? Thank you.
Hi Lisa, Did you mean cancer or adenoma? Either way it seems you have hypoparathyroidism and are being treated with parathyroid hormone. I imagine the problem is with your urine and you need 24 hour urine testing to figure our your 24 hour urine calcium losses. Perhaps they are very high. Oxalate is not likely to be the big issue here. High doses of calcium in the presence of inadequate PTH treatment could result in massively high urine calcium and stones. Let us know, Regards, Fred Coe
Hello Dr. Coe,
You mention lemonade as helpful. I have been mixing a couple tablespoons of pure lemon juice with a tablespoon of water and drinking this at least once a day….up to three times a day. Will this help prevent the formation of calcium oxalate stones or of stones in general?
Thanks for taking the time to let us know.
Hi Mike, The approach in the article is more comprehensive than this – if you followed it did you have a low urine citrate? If so perhaps the lemon juice is a good idea but it would hardly be enough. Followup urine testing would let you know. If you did not have a low citrate, but perhaps a high urine calcium or oxalate it would be possibly irrelevant. Likewise your stone type is important – was it calcium oxalate, calcium phosphate, both? Regards, Fred Coe
Im suffering now for aweek with a 3 mm kidney stone ive been drinking loads of water taking all the tablets the hosp has gave me im still in pain what else can i do
Hi E mair – Sorry if I have the name wrong! If your stone is not passing all this time, perhaps your physician would like to remove it. Also be sure it is not obstructing the kidney. Sounds like the limits are being reached. Pain pills go only so far. Regards, Fred Coe
Great site . . . just found it and will be reading up. I’ve had 2 episodes with stones. The first in 2002 when I was suddenly floored by pain. A trip to the ER determined it was a stone and I passed it a couple days later. Took it to my Dr and he kind of shrugged his shoulders and said, “yep . . . well, drink more water.” Not knowing any better, I went on my way. My last one came in 2008 and I knew exactly what it was. This time I got wise and saw my dad’s urologist . . . they gave me the strainer and when I caught it, they analyzed it. Calcium oxalate. They also did blood work and the 24 hour collection. With that, they gave me the information on going low oxalate and recommended increasing water and citrate consumption–and also recommended having a little milk or cheese with anything higher in oxalate that I ate.
So far, so good. Hopefully I can avoid another for awhile . . . although it sounds like I am prone to getting them and it’s more a matter of trying to mitigate the risk & frequency? Anyway . . . I can’t stress enough how important it is to get the analysis done when you have one. If I had known enough to ask the right questions after the first stone, I possibly could have avoided the second or made it take longer to happen. At the time I had the second, I was on a ketogenic diet and eating a huge amount of almonds (cocoa roast, no less), peanut butter and spinach–along with chocolate flavored protein powder for weight lifting. Yeah . . . not good . . about the worst thing I could have been doing I later discovered.
Thanks so much for providing such great info to folks like me.
Hi Tom, Thanks for the comment, and that you like the site. Even though there were reasons and you are stone free, consider checking things out according to a plan – so nothing is passed by. Here is a plan. Regards, Fred Coe
This is good information. I am about to see a new urologist in a few weeks. After having suffered with multiple bouts of stones over the last several years, I am no closer to an answer. The last one was just six months ago and I mentioned to the doctor at my follow up that my mother had kidney issues (and needed one removed) and maybe this was something passed on. He just shrugged and said he didn’t know and sent me on my way. I’ve NEVER had a physician actually try to figure out why I’m getting so many stones much less do a 24 hour test, they just remove them, give me the oxalate list, and send me home. I need answers!
Hi Regina, I am happy you like the article. I always advise people try to follow the steps. Here is a broader overview which was meant as an addendum. And here is my newest – and so long! article that covers all the trials and treatments for calcium stone prevention. Regards, Fred Coe
I passed at least 1 stone Thursday night after sweating in the hot Texas sun all afternoon on Wednesday. I am 64 and had my first stone in my 30’s and have never gone to a doctor about it–but I started running a fevor and felt trauma over my whole body so called my doctor and got an antibiotic -still not up and around yet but will be insisting now to get my urine checked. Thank you! Lots of Google questions brought me to this site.
Hi Margo, Perhaps you have an infection from the obstruction from the stone. I am sure your physicians will treat that successfully. You should indeed figure out the cause. The plan you are reading is my favorite.
Regards, Fred Coe
Forgot to mention I am a nurse and as such am able to test my urine Ph, is there an ideal or not.
Thanks again julia
Hi Dr Coe
I have been having recurrent kidney stones and my first one in 2012 was treated with a lithotripsy with the resulting lab results:
color- brown
composition- SPRCS
ca oxalate dehydrate- 05
ca oxalate monohydr- 35
calcium phosphate- 60
I have had 2 more lithotripsy procedures since then about 2 years ago. Recently my blood pressure has been high 150/110 and I am on 2 B\P meds that are not effective. Could stone formation be causing my problem as my Dr states I may need stents. Is there something I can do to help this situation out? Thank you
Hi Cindy, You are forming predominantly calcium phosphate stones. The usual cause is high urine calcium and pH – too alkaline; treatment is usually as for all idiopathic calcium stone formers – no systemic disease identified. The marked hypertension may be a separate matter, and surely you should be treated. The very low sodium diet that is effective in lowering urine calcium will help to lower blood pressure. If you need stents, is that because of obstruction? If so, that is certainly a very serious matter; I cannot comment having no real information about this in you. Regards, Fred Coe
Thank you for your response. Had follow up MD appointment and no occlusions in arteries to kidneys. However there is again a 9mm stone in my left kidney and no obstructions. So I am looking at your links to try to get this resolved. I never add salt to my foods but probably get too much from processed foods I suspect. Greatful for your knowledge thanks cc
Cindy, I am also an idiopathic calcium stone former. If you can go see Dr. Coe, I would highly recommend it. It is worth the flight (if that’s necessary). I had some very large stones and dozens of small ones, and with Dr. Coe’s help, I have been stone free for the last year. Also, find a VERY GOOD urologist that is really knowledgeable about stones. It made a huge difference for me. Lithotripsy caused me nothing but more problems.
I enjoyed the Information here! I was diagnosed with MSK in 2000 during my pregnancy with my oldest daughter. I passed several stones that apparently had an easier time coming out with the dilated ureters from pregnancy. I have had several stents, lithotripsy, and scopes over the years with on and off problems. In 2010, I gave birth to my youngest daughter and had a hard time because of kidney issues. I had several stones that got caught, tore my right ureter, and they ended up delivering me 6 weeks early because of the issues. She was healthy but I have had issues ever since with hematuria and renal colic. I ALWAYS have hematuria. My nephrologist has me on HCTZ and drinking lots of water, low sodium diet, but my urine never clears up. I often have contraction like pains in my right kidney, and I am worried it will never get better. Any further thoughts? I just did the 24 hour urine which I do often, calcium oxolate stones is what they always are. A recent CT without contrast said I didn’t have any obstructing stones visible at the moment. I appreciate the information. This disease is a painful one for sure.
Hi Jolene, I am not clear about your situation. Is it that the stones you pass or produce have been analysed and are calcium oxalate or are you saying the 24 hour urines suggest they are calcium oxalate. I will assume the former – stones have been analysed and are calcium oxalate. Since you read the five steps article, what was indeed found in the urine? Here is an article to help you understand your own results – see where you fit. That you continue to have pain and unclear urine suggests crystals are forming and things have not been fully treated so far. Regards, Fred Coe
having been a patient from 1993 and have not had a recurrence/stone growth enlargement according to cat scan while in hospital (unrelated medical issue 2012) and paying attention to salt/sodium intake,now but saw no mention here of the genetic issue for those carrying both mthfr gene variants 677/1298 (compound heterozygous diagnoosed 2013) and how the detox pathways/elimination are affected severely not to mention other body systems affected. understand doc Ben Lynch is an expert in this specific biochemistry………but would like to know about a genetic component re stones, excess calcium, etc….
Hi, I do not know of any relationship between this well known folate pathway mutation and kidney stones. High urine calcium is familial, but the genes are not yet determined. Regards, Fred Coe
I have a nightmare life going on here! So hoping that you can lead me in the right direction. In a year and a half I have had four surgeries for kidney stones in both kidneys. 10/5/15, 3/23/16, 6/23/16 and 2/16/17. The urologist identified the stones as brushite. I also had a nephrolithotomy with the 3/23/16 surgery and one stone measured 23 cm and one two days ago was 11 cm. Each surgery the urologist says he breaks up and removes as many as he can but that I have over 100 stones affecting both kidneys. I have learned not to go to the ER as they can only tell me to up my pain medication and see my urologist. On my last visit to the ER I was given Toradol. That was a life saver but I have only had to resort to that twice. About four months ago I saw a nephrologist but was disappointed in that he also only offered crisis management. He did tell me to up my water intake and cut down on oxalates and phosphorus. Funny in a way because I do know exactly what I take in as I have had a feeding tube in place due to the effects of chemo and radiation for right tonsil cancer. I have been on a strictly limited liquid formula diet for two years. I had a 24 hour urine collection test done on 8/11/16 That showed my urine volume was extremely low at 0.94 and I needed to consume more water which I have done through the feeding tube. Hyporoxaluria is circled on the report. Having just had surgery two days ago I am once again dealing with the painful stents. I have an appointment with the urologist to have the stents removed in three weeks. I also have an appointment with the nephrologist at the end of the month. Both doctors are from another country and extremely hard to understand. I think I could get the gist of what they say but neither one is forthcoming with any suggestions as to what I could/need to do. Please let me know what your thoughts are as to the direction I should take. I fear my body can’t take much more of this !
Hi Jo, Your stones are calcium phosphate, so the high oxalate is not material. THe low volume is crucial and needs correction. You cannot lower urine phosphate significantly unless it is artificially high from your tube feeds. I suggest you review your 24 hour urine lab findings – here is some help – and get advice from the tube feed experts about changes. Brushite stones are hard, grow rapidly and do need very aggressive prevention, as you have guessed. Regards, Fred Coe
I am so confused ! After having the surgery on Feb. 16, 2017 And having stents placed in both kidneys by the urologist I saw the nephrologist on Feb. 28th. He was stumped by my telling him my stones were Brushite. He said he had not seen a case in many years that were identified as Brushite. He said he would study Brushite and get back to me. Mind you he had my medical history in front of him including the 24 hour urine collection results. He of course stressed the importance of increasing the water intake through the G-tube which I have done. But, that I had no diet restrictions. Four days later I had a KUB x-Ray done prior to seeing the urologist on March 8th. The urologist made the decision to leave the stents in place until March 14th but to schedule yet another surgery soon. This time a nephrolithotomy as an inpatient again. Today I received a follow up call from the nephrologist saying the term Brushite is just an old term not used anymore and that I have calcium sulfate stones. (Verses your term calcium phosphate). He said I should go back on the diet of restricted oxalates, phosphorus and now uric acid also. As I am still tube feeding I have cut the amount of 2Cal formula in half and replaced it with low oxalates and phosphorus liquids. I am going right now to your suggestion of studying my lab results hoping for direction on all of this. I am desperately trying to figure out what to do to limit the surgeries as I am in pretty poor health dealing with the aftermath of chemo and radiation and certainly did not bounce back from the last surgery on Feb. 16th. I am now down to 82 pounds vs 138 pre chemo and radiation. I am only 4ft 9 inches tall so not a complete skeleton but close. I am fighting as hard as I can to get calories and hydration through the tube each day. In trying to study each label the confusion is great as it seems each different classification has different steps to follow to minimize the formations. So, I feel as though I am flying blind here and don’t know which way to turn. I so value your opinion as to what I should do to improve my situation. I sincerely thank you.
Hi Jo, Brushite stones are not rare, but they do pose special problems being hard to break. If your physician indeed meant to say that brushite – the name of calcium monohydrogen phosphate – is no longer used, then he is not correct. If your stones are indeed calcium sulfate they are rare and I have no experience with such. Such a sulfate stone would have no relationship to diet oxalate or phosphate or uric acid. A brief search of PubMed for calcium sulfate and stones yielded no publications. Brushite stones usually arise from high urine calcium and urine pH, so treatment aims to raise volume and lower calcium losses. Given your serious medical issues and the strange kind of stone, consultation with an expert in stone disease – at a university preferably – would seem urgent. Regards, Fred Coe
Hi, I have had uric acid stones and just moved into a house with very hard water. Do you have a recommendation about water softeners?
Hi Jenny, Nothing could matter less. Uric acid stones are due to unduly acid urine and cured permanently with enough alkali to raise the urine alkalinity. I am sure your physician already this and you will not need to have another stone. Regards, Fred Coe
my 92 year old mother has a 13 m kidney stone and has been taking potassium citrate for the past month . she is scheduled for a laser procedure on march 28th. she has been cleared for the procedure by a cardiologist. is there any other options for eliminating this size stone, thanks, pat
Hi Pat, Surgical decisions are very much in the hands of the surgeon. Ureteroscopy with laser disruption is ideal. I know of no better way. Regards, Fred Coe
Hello Dr. Coe,
This has been a truly helpful site for me ever since last year when I realized that I am a stone-former.
A bit about myself: I am 36-year old South-asian male, 5 feet 6 inches and 70 kilogrammes. From where I am, we luckily get just three months of winter and the rest of the time it is extremely hot. The last few years, our summer months suffered with temperatures at 42 degrees celsius.
I have always had nearly 2.5 to 3 litres of water. But over the past six years, I have noticed that my urine colour becomes yellow if I do not pee within a matter of three to four hours. Earlier, I could hold on to my pee for five to six hours and the colour was usually the same: colourless.
After some summer nights, my urine even became honey yellow.
So, I had been to several doctors, who gave me urinalysis and other tests. They came out normal and they asked me to quit worrying.
I often noticed little black specks in my urine. Very small like pepper grains. I had tried to ascertain whether these were blood clots. But fortunately, they usually flipped or swept away intact when I dropped water on them. I was then around 74 kilogrammes.
Cut to last year in March, I had a bout of hematuria. I was extremely scared. But after having a litre of water, the urine went back to normal colour of light yellow during the next bathroom break.
I went to the doctor. He gave me a bunch of tests. Everything came back normal.
I began to walk and dropped around 6 kilogrammes within the next four months. But again in April, a month after the first episode, I had gross hematuria again: this time for three days.
The doctors took this seriously now. Gave me KUB Ultrasound, Xrays, phase contrast microscopy and other things. Everything came normal. They did not find any stones. and the phase contrast found that the blood was from the Lower urinary tract.
I used to feel like something was pressing down on my left testicle. It was so bad that I could not even sleep at night.
I was more or less certain that I have bladder cancer. But three urologists and a nephrologist assured me that I dont, based on the USG, Xrays and other test findings.
The RBC in my urine continued over the next one and a half months but it gradually decreased. It went from RBC ‘numerous’ to ‘0-1’ during repeated urinalysis over intervals of a week or so.Finally it stopped around July. It was there from the beginning of May till July.
Then around July, I began to feel pain near my abdomen. Like a steel button was being pressed from the inside. I went to the doctors. They gave me sleeping pills. I did not take them.
Finally around the first week of August, around morning, I passed a more than 3 mm stone with really sharp edges. I read your posts and wanted to have the stone analyzed. My urologists did not feel the need of it.
I still often felt some pain for the next few weeks. I went back to ask whether there could be more stones. I also passed a flat oval shaped black thing that was intact and did not seem like a blood clot. Told the uros. They told me that this is probably another stone element and dismissed me.
Having gone through all these problems, I am now trying to deal with the stone problems by myself. I have stopped having green spinach, chocolates, coffee, black tea and additional sugar and salt with my food and drink (I regularly used to take a pinch of salt with my rice during lunch and dinner).
I am regularly walking around 3 to 4 kilometres now.
I would have actually come to you if you were anywhere near my country. Since I cannot, I hope you wont mind me ask the following questions:
1) I am currently drinking 3.5 to 4 litres of water per day. Can I have mint flavoured green tea as a part of this? Will this help in preventing stones?
2) Should I decrease the amount of chicken and beef that I have with my meals?
3) Is oat better for kidney stone prevention over rice as staple food with curry and vegetables?
I still often spot one or two black specks in my urine. Help from you will be greatly appreciated.
Thanks in advance.
Hi Wade, It sounds as if you have passed stones. They need to be analysed. The blood is from stones or even crystals. Here is a proper evaluation plan. I am sure your physicians will want to pursue it with you – they should. Treatment without evaluation is not efficient and often fails. Regards, Fred Coe
Thanks a lot, Dr. Coe.
Hi Dr. Coe,
I have been struggling with kidney stones since September 2016 I have passed one 5mm stone and had a Right ureteroscopy with laser lithiotripsy on 3/10/17. My stones have been analyzed twice here are the results: Calculi composed primarily of:
80% calcium oxalate monohydrate, and
20% calcium phosphate (hydroxy- and carbonate- apatite).
INTERPRETIVE INFORMATION: Calculi (Stone) analysis
Calculi are the products of physiological processes that yield
crystalline compounds in a matrix of biological compounds and
blood. Matrix components are not reported. The clinically
significant crystalline components identified in calculi specimens
are reported. Gross description may not be consistent with
composition determined by FTIR analysis.
the stone from November 18 2016 results are : Calculi composed primarily of
calcium phosphate (hydroxy- and carbonate- apatite).
INTERPRETIVE INFORMATION: Calculi (Stone) analysis
Calculi are the products of physiological processes that yield
crystalline compounds in a matrix of biological compounds and
blood. Matrix components are not reported. The clinically
significant crystalline components identified in calculi specimens
are reported. Gross description may not be consistent with
composition determined by FTIR analysis.
Performed by ARUP Laboratories,
I still have two stones in my left kidney and 6 in my right. I am becoming very frustrated. My urologist is telling me that all I can really do is decrease animal protein and sodium and increase fruit and veggies. I have to believe there is more that can be done to prevent any more stones form forming. I hope you can help.
Hi Melissa, You form stones composed of calcium oxalate and calcium phosphate, and you are reading the Five Steps article. What you need to do is finish all of the steps. You know the stone composition. Your physician needs to exclude systemic diseases – there is a chart in the article for him/her. You need 24 hour urine testing and then directed treatment. I would suggest you just follow the outline you are reading. Regards, Fred Coe
I appreciate your response. Thank you!
Hello,
I recently had a scan as part of a general check up,, and was told that I have one kidney stone, 7mm. From what I have read about the formation of kidney stones, I believe that it possibly developed because until a few months ago I was a keen coffee drinker and also used to eat a lot of cheese. I have changed my diet over the past two months, eating many more alkaline foods. I am due to have another scan in a week’s time to see what is happening with the stone. The doctor has simply suggested that I should drink more, but I already drink about 2 -3 liters each day (water or herbal teas). Do you know if there is anything else that I can safely do in the hope of dissolving the stone or should I wait until I have had the scan and discussed the results with the doctor? I am not in any pain, and it seems that my blood & urine results have all come back normal. Thank you for your help, kind regards, Joanna
Hi Joanna, Coffee is not a risk factor for stones, nor is cheese. One stone treated with water will result in 12% recurrence in five years, if urine volume – not fluid intake – is 2.6 liters/day. Take a look. I doubt your lab tests are entirely normal. Here are criteria to check out. Finally here is a plan for evaluation to be sure you have had all you need. Regards, Fred Coe
Hello Dr Coe. I have been been having problems with calcium oxalate kidney stones for the past eleven years. It was established I had hypercalciuria and then three years ago it was discovered I suffered from Hyperparathyriodism. I had surgery (removal of three of the parathyroids) to correct the problem just over two years ago. My blood calcium levels have returned to normal but I am still creating stones. My urologist is not particularly interested as to why I am continuing to create stones his only advice was to keep hydrated. I am trying my best to research how to manage my condition and how to minimise / prevent the creation of the stones. Recent scans have confirmed that new stones are forming which puts beyond question that the correction of the hyperparathyroidism has not resolved the issue of the stones. What approach do I need to take to at least try and find why this is continuing. Many thanks in advance for any pointers you can give me in trying to steer my doctors in to at least attempting to determine what is now happening.
Hi Adele, I imagine you still have hypercalciuria. Here is my article on primary hyperparathyroidism that speaks about this common matter. Get your 24 hour urine measured – I bet it will be high, and get treated exactly like an idiopathic calcium stone former. Regards, Fred Coe
Hello I am hoping you can help me with your expertise knowledge but not for myself but for my companion fur baby, female dog. She was diagnosed with a stone in her ureter measuring 6mm then on second ultrasound it measured 10mm. She has a bacterial infection unidentified at the moment, and passed mucous and blood clots in her urine for 2 days. This has now cleared. Her alkaline phosphatase in her blood test was high. Measuring 220 U/L which is outside the normal range (1-120). Anion gap was also high 29mmol/l just slightly over normal range (15-25). I am wondering if with this information we could know what kind of stone she has so I can adjust her diet. We are giving her lots of fluids, and she is taking Prazosin. Calcium was normal 2.53mmol/l (2-2.8 is normal). Thank you.
Hi Ness, Veterinary medicine is complex, specialized, and far out of my league. The animals – apart from humans – are off limits because I just don’t know enough to be helpful. You need the right professional here, and I gather you have one. The kind of stone cannot be deduced from what you have provided, and the use of stone analysis in dogs lies outside my range of professional knowledge. Sorry, Fred
Hello Dr. Coe,
Thank you for the article. I had bladder stones removed in March. The stones consist of 15% calcium oxalate dihydrate, 70% calcium oxalate monohydrate, 15% carbonate apatite, stone weights 0.287g. The length is about 2mm. My kidney shows no stones.
The subsequent 24-hour urine tests (w/o creatinine) shows:
oxalic acid: 76 mg/24 h ref: 3.6-38
magnesium: 72 mg/24 h ref: 28-180
calcium: 117 mg/ 24 h ref: 55-300
uric acid: 632 mg/24 h ref: 120-820
total voume: 2296 mL
24-hour urine tests (w/o creatinine) shows:
citric acid: 647 mg/24 h ref: 100-1300
citric acid: 357 mg/g creat ref: 60-660
vreatinine: 1.81 g/24 h 0.63-2.5
total volume: 1915 mL
I used to eat high oxalate food a lot, such as yam, almonds, pecans, berries…
Now I changed my diets to lower oxalate intake.
Since I have no kidney stones, are there any other tests I should take to identify the cause of my bladder stones? Any other measures shall I take to prevent it?
Thank you so much for your time and help!
Hi Bob, Your stones are mainly calcium oxalate monohydrate and your urine oxalate is quite high. The usual cause is low calcium diet with high diet oxalate. I presume the bladder stones reflect some outflow abnormality that prolongs urine dwell time, such as benign prostatic enlargement. Perhaps your physicians might want to do another 24 hour urine with a more comprehensive panel that included creatinine and calcium and oxalate and citrate etc all in one place. Likewise, ask them if high calcium reduced oxalate reduced sodium diet, that is ideal for kidney stones might be good here. Also, consider the importance of urinary drainage. Regards, Fred Coe
Hi Dr. Coe.
Thank you so much for your prompt reply.
(1) What do you by “24 hour urine with a more comprehensive panel that included creatinine and calcium and oxalate and citrate etc all in one place.”
Do you recommend a urine supersaturation test?
(2) Some popular magazine claims that urinary excretion of calcium in diet peaks in 4 – 5 hours after a meal. Therefore, in order to avoid forming calcium stones, bedtime should be at least 4 – 5 hours after dinner. Does the claim have scientific basis?
Thank you again.
Hi Bob, Commercial vendors provide complete 24 hour urine profiles for kidney stone prevention that include supersaturations. Use them, not fragments. All of these rely on our published work. Here is some use of it in this site. Timing of sleep etc is all nonsense based on conjecture. Shun the lot and stick to free university based sites – mine is one of many. Regards, Fred Coe
Hi Dr. Coe,
I had my second 24-hour urine test after limiting high-oxalate diet and increasing calcium intake as you suggested. The test was conducted on 9/23/2017. The first 24-hour urine test was conducted on 5/8/2017.
I had an ultrasound test on 9/7/17. My bladder appears normal with bilateral ureteral jets and no bladder wall thickening, diverticulum or calculus. No echogenic stones. My bladder roughly measures 4.6×5.6×3.9 cm with 53 cubic cm volume. There is central prostate calcifications.
For your reference, I had bladder stones removed in March. The stones consist of 15% calcium oxalate dihydrate, 70% calcium oxalate monohydrate, 15% carbonate apatite, stone weights 0.287g. It’s about 2cm in length. My kidney shows no stones.
The following results from the two tests are w/o creatinine (results from the 2nd test are indicated in the parenthesis):
oxalic acid: 76 (71.8) mg/24h vol: 2296 (1815) mL ref: 3.6-38
magnesium: 72 (103) mg/24h vol: 2296 (1815) mL ref: 28-180
calcium: 117 (205) mg/24h vol: 2296 (1815) mL ref: 55-300
uric acid: 632 (630) mg/24 h vol: 1915 (2332) mL ref: 120-820
The following results from the two tests are with creatinine (results from the 2nd test are indicated in the parenthesis):
citric acid: 647(550) mg/24h vol: 1915 (2332) mL ref: 100-1300
citric acid: 357(344) mg/g creat vol: 1915 (2332) mL ref: 60-660
creatinine: 1.81(1.6) g/24h vol: 1915 (2332) mL ref: 0.63-2.5
The second test also includes a blood test that were not covered in the first test:
PSA, total 0.9 ng/mL ref: =60
eGFR Non-African American 104 mL/min/1.73m2 ref: >=60
Glucose 106 mg/dL ref: 65-99 (fasting)
(Note: I don’t remember if I fasted before the blood test.)
Phosphate (as Phosphorus) 3.9 mg/dL ref: 2.5-4.5
Potassium 4.1 mmol/L ref: 3.5-5.3
Sodium 141 mmol/L ref: 135-146
Urea Nitrogen 20 mg/dL ref: 7-25
Thank you so much
Hi, I do not think you have enough diet calcium, or perhaps it is not timed with the main meals. I see no urine sodium but that must be below 2000 mg. Might I be correct? Please be sure your physician is aware of my suggestions and approves as he/she is responsible for your care. Regards, Fred Coe
Hi, Dr. Coe.
Unfortunately urine sodium level was not measured in either test. My urine calcium level increases from 117 to 205 mg (ref: 55-300) after I took more calcium-rich diet. My blood calcium is 9.6 mg/dL (ref: 8.6-10.3) in the second test. Shall I take even more diet calcium?
I have been keep communicating with my physician about it.
Thank you again!
Hi Bob, these urine calcium levels are normal, and pose no stone risk. The full diet of 1000 mg calcium sounds fine for you especially with low sodium. Check with your physician. Regards, Fred Coe
Corrections: In the previous post, the length of my bladder stone should be 2 cm, not 2 mm.
I posted my case of bladder stones here and asked for advice yesterday. But my post has been deleted without explanation.
-Bob
Hi Bob, Sorry for the delay. Your question is indeed here and my best answer to it for now. Regards, Fred
Hello… I have a double collective system on my left kidney. there are two tubes from my kidney that join together just above the bladder, forming a Y. About 10 years ago I had kidney stones, but could not pass them because they got stuck at the join. I had to have them surgically removed. It was horrible, My urologist put a tube into my back, to my kidney, and I had a bag on it. He needed to create a pathway to the kidney for the surgery. I wore that thing for 2 weeks. He went in and broke up the stones and removed them. Now, about 10 years later I just learned that I have another stone in the same kidney. The stones were calcium oxylate. I am 67 yo and devastated by the news. I can’t take going through that again. Please tell me there are less invasive procedures now. I can’t pass stones because of my double collective system. I am terrified. And does eating nuts really cause kidney stones?
Hi Deborah, I understand your worries. The article is a great plan for evaluation and prevention. As for the surgery I would think a modern flexible ureteroscope should navigate the join with a bit of guile. I gather the join is just above the bladder, but that seems odd; perhaps you mean just below the renal pelvis. In any event, instruments have improved massively since your prior procedure and I am hopeful your surgeon will not have to do so much this time. But prevention is orderly – follow the article. Best, Fred Coe
Dear dr coe, i have read about using chanca piedra for dissolving stones .. do you know anything about this .. ?? thankyou..
Hi Jay, I do. No article as yet, but my reading is that the stuff is nothing at all. Just a way to get some money in exchange for claims. I know I need to write a well referenced article about it and delay out of boredom. There is no science to it that I found thus far. Regards, Fred Coe
There may be minimal scientific study in the US, but apparently there are many, many people in other countries who have used it for generations, with success. They don’t take Phyllanthus because of the result of scientific research, but because of the collective experience of their ancestors. To me, that is very weighty. I was prescribed Phyllanthus by my ND – it’s fairly inexpensive, and in the short time I’ve taken it, I’ve had a few resident stones released (this was after several ER visits, regular visits to a Urologist, several courses of Tamsulosin, CT scans, etc.). Another such item is drinking tea from corn silk. A close Egyptian acquaintance of mine has first hand testimony of generational use and success with using this to help pass and then prevent stones. We’re so advanced in medicine in this country, but we’re often unwilling to learn from the extensive history and experience of other countries that are much older than ours. Is it because of disinterest, money, pride? At any rate, I very much appreciate the ongoing studies on oxalates available on the internet, as well as the information you’ve posted in this thorough article, which I came across in my search. My urologist recommended I manage my oxalate intake, after a recent laser lithotripsy procedure, and it’s been quite an education!
Hi Ross, I will take on the Phyllanthus story when I can. I have read the 12 or 13 PubMed articles about it. As for your own stones, long term prevention of stones is part of a larger story. Stones identify people at risk for bone disease, high blood pressure, and kidney disease, as other articles on this site point out. Proper prevention considers all of these together using what data we have. Regards, Fred Coe
Thank you for replying with such care. As I work through the articles, I’m coming to appreciate the wealth of information on this site. You all have put a lot of effort into covering the subject holistically and thoroughly and at the same time making it readable and practical. Again, thank you.
Hello Dr. Coe. I’m not sure why there is no push for research on Phyllanthus Niuri (Chanca Piedra) given anecdoctal results and use in south america for so many years. I would urge you to look at a few studies, limited as they are, that indicate at least some preventative function and help with clearing stones after ESWL treatment. I have provided links to four studies/articles below.
http://onlinelibrary.wiley.com/doi/10.1046/j.1464-410X.2002.02794.x/full
https://www.researchgate.net/publication/6895645_Can_Phyllanthus_niruri_Affect_the_Efficacy_of_Extracorporeal_Shock_Wave_Lithotripsy_for_Renal_Stones_A_Randomized_Prospective_Long-Term_Study
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1677-55382010000600002
https://link.springer.com/article/10.1007%2Fs00240-004-0432-8?LI=true
I’d like to know what you think after reviewing these articles.
Hi Brian, The reason is that the data do not support a role. I already reviewed the trial – it was negative; subgroup analysis – decided on after the trial showed a p value < 0.05 but that kind of fishing for a p value is nonsense. Here are all 13 entries for this topic in PubMed. None but your trial has any clinical interest. Some are in vitro some in rats etc. The hype on the web is all about selling stuff. But you have aroused my sense of fair play. I will do an article on this stuff – not right now but I will do it. And I will review as I always d0: Data first, nothing second. Thanks for bringing it up – again. Best, Fred
Hello Dr. Coe,
I understand the confidence level was only sufficiently high enough to be significant for the subgroup, but don’t you think that could be fleshed out more with a larger sample size? The entire group, both treatment, and control was 150 patients, wouldn’t a larger group, say 500-1000 patients, potentially provide a result with much greater statistical significance (if the hypothesis is correct)?
Correct me if I’m wrong, but the only other post ESWL treatments to help promote stone-free rates is a prescription for tamsulosin, which has a number of side effects, or the placement of a ureteral stent, which has been shown to sometimes have lower stone free rates and has a number of complications/pain associated with it?
In the studies done so far, there don’t seem to be any major side effects of Phyllanthus niruri (except for possibly mild hypotensive effects) and is incredibly cheap (15 or so dollars for 90 500mg capsules). What harm is there in trying to see if it would be effective or to encourage an additional, more rigorous study of its effects?
Hi Brian, In fact two potassium citrate trials were done showing reduced new stones etc, and worked reasonably well with adequate significances. As for another and larger trial of the Phyllanthus, someone would have to pay for it. The makers even less so given no monetary value. I must say the evidence in the 13 or 14 papers I have seen is not very compelling. But if money came along I am sure physicians could organize a trial. NIH is not likely to do it except through their alternative medicine program. I am not against any possibilities, just aware of the vast trouble and cost of trials, and the rather meager data thus far. Best, Fred
Yes, I did see all of the evidence behind citrate and I found your article on it to be very helpful. I am also using citrate in my diet to help prevent future stones. I know you mentioned crystal light as a cost effective alternative to potassium citrate, but another one that I’m trying is True Lemon, a more natural product that is simply crystalized lemon in powdered form. On their conversion chart, 4 teaspons of powder = 1/2 cup of lemon juice, which I think is a sufficient amount (although I’m sure it depends for each patient). If you buy the value pack of 6, 10.6 oz shaker’s, (each of which should last about 20 days), then you would have a four month supply for 107.95. Even better, if you apply the 50% coupon code I used, LETSTRYTRUE5017, the total for a 4 month supply is on 53.97, with free shipping.
https://www.truelemonstore.com/product-p/81-1030.htm
Hi Brian, The amount of citrate – the ionized form of the citric acid /citrate couple depends on the pH of the final solution. Citric acid is useless for your purposes. SO Isuggest getting a 24 hour urine in followup to be sure your urine citrate has risen to above the risk threshold. I presume citrate was low to begin with and that is your main problem. In case you have any questions about the range of testing here is a good summary. Regards, Fred Coe
Dear Dr. Coe,
I am having recurrent kidney stones and have had for 2 years now. My history of stones started over 20 years ago. I would get one per year, then every 6 months, to quarterly, to monthly, now daily. I have had uric acid stones and calcium stones analyzed. My most recent 24 hour urine showed high levels of the following: Calcium 255, oxalate 76, Sodium 217, Phosphorus 1,576, Creatinine 2,391. My Citrate is 2908 and Ph is 6.1. Total volume 2.64 . Suspected problem is Hypercalciuric and hyperoxaluric Nephrolothiasis. I pass one stone over several days or more, then have a few hours of relief, and get another stone . The stones are small but painful. I currently take Potassium citrate 1080mg 6/day, Chlorthalid 50mg one/day, allopurinol 300mg one/day. I am on a low oxalate diet and have lowered my sodium and protein intake and try to consume 5/6 servings of fruits and vegetables daily . I drink over 2 liters of water per day, and might have a lemonade if not drinking water. My quality of life is lacking as I am in pain 99% of the time. I saw an endocrinologist and was told that it was not my parathyroid. The nephrologist I am currently seeing advised me to find someone who specializes in recurrent stones as she has treated me according to protocol and the treatment is not working. Do you have any suggestions?
Hi, You do not mention the calcium stone type, but probably it is oxalate. I suspect you have a low calcium intake and therefore a high urine oxalate. You have lowered your diet sodium but it is still immense – 217 mEq/day. I would suggest you lower urine diet sodium to below 2000 mg daily; that will permit a higher diet calcium intake – from foods. Time the high calcium foods with your main meals, which should lower urine urine oxalate and reduce stones. With less sodium the dose of chlorthalidone can be reduced to 25 mg/day. The allopurinol is not likely to be effective. Please do not do any of these things on your own; bring this note to the attention of your physician and see if he/she believes it is of help. Regards, Fred Coe
I just had my yearly physical with my primary doctor. He told me there was blood in my urine sample. We talked about kidney stones and he led me to your site. He told me I have a rather large kidney stone and that could be the cause of the blood in my urine. I am nervous now and want answers. I already see a urologist but he’s not very clear or thorough with his explanations. I am having an x-ray done next week to see where the stones are. With that being said, I want to prepare myself for my next discussion with my urologist after my xray. What questions need to be asked to get clear knowledge of what is going on in regards to my kidney stones? I read up on your suggestion for 24 hour urine samples. Should I request this test to be done?
Thank you,
One nervous patient
Hi Patrick, Good question. Here is an article on how to prepare for your visit. With regard to the surgery, that is very particular to the size and location of the stone. With respect to prevention, 24 hour testing is crucial. The article you have is my best on the subject. Regards, Fred Coe
Hi Dr. Coe. Have you heard of this new oxalate reducing enzyme? They are trying to sell it as a food additive to the food industry and to individuals as a home remedy. It seemed legit enough to me that I bought an introductory supply and have started using it. I’d appreciate hearing your thoughts on the claim of scientific merit behind it. Thanks!
Hi Bromley, First, are you sure high urine oxalate is causing your stones? Next, have you done the simple things – a proper diet. If both are yes and urine oxalate remains high, it may be intestinal malabsorption or even primary hyperoxaluria. So even if it worked – no trials, no reason to believe it does work – why use it? As such, I see nothing but money – yours – going somewhere with no reliable benefit to you. If you do use it, check 24 hour urines before and during and ask if urine oxalate fell. Regards, Fred Coe
Oxalate reducing enzyme website:
https://www.nephure.com/nephure-enzyme
No entries in PubMed – no data, no trial, no nothing. Just junk marketing until the data come out if they ever do. Fred Coe
I am a 33 yr old female. I had an ultrasound after suffering chronic UTIs and it revealed I have kidney stones. CT scan confirmed I have 3 stones in one kidney and one in the other kidney, all measuring approx 3 mm. 24-hr urine testing revealed the following abnormalities: very high urine oxalate-114, citrate -491, pH 6.9, uric acid 1.07. The rest was in normal range: SS CaOx 5.5, calcium 85, SS CaP 0.61, SS uric acid .12. My blood work came back normal. My urologist explained the kidney stones are occurring due to my history of Crohns disease. It is strange to me since I have never had any GI surgeries, my Crohns is in remission, and the CT scan showed no current inflammation in the intestines. The only medications I am taking are 400 mg+ Calcium Magnesium Citrate and probiotics daily. He advised I consider undergoing shockwave lithotripsy and add B vitamins and potassium citrate and avoid high oxalate foods. He wanted me to also start allopurinol which I have not yet started. My blood uric acid levels are normal. What do you suggest in this case? I am in no discomfort from the kidney stones at this time and would prefer to pass them naturally. Is that advisable? Also, is high dose K citrate advisable given my situation? How about the allopurinol? Is it possible for me to lower my oxalate level to normal range with diet changes alone? My primary concern with all this is the potential for kidney damage.
Hi Rachel, given the extreme high level of urine oxalate, I am sure your physicians are concerned about primary hyperoxaluria. I would remove all sources of high urine oxalate and raise diet calcium intake to about 1000 mg from foods or if needed supplements taken with main meals and measure again. If this high level persists, you will benefit from evaluation at a major kidney stone diagnostic center. If the level falls, you will have an approach to treatment. Usually high urine oxalate from Crohns is after bowel resection as you correctly have surmised. I do notice the very high urine uric acid suggesting a very high intake of animal or plant DNA/RNA – protein sources have lots of cell nuclei – and that also can raise urine oxalate but not usually to these levels. The correct answer here is very important. Regards, Fred Coe
Thank you Dr Coe for your response and for your wonderful website. I feel like my urologist is either not aware or just not concerned about the potential concerns of my high urine oxalate and uric acid levels. He has not even mentioned primary/secondary hyperoxaluria. I am seriously concerned and I have radically changed my diet in response. I would very much like to get to the bottom of WHY my levels are so out of the normal range but I don’t know where to go. Would you advise I seek out a different urologist? Or is this something that I need to go to a pathologist? Geneticist? Nephrologist? And lastly, would you advise I take potassium citrate given my numbers?
Hi Rachel, The high urine oxalate needs to be understood and your own physician is the natural first source. If he/she cannot figure it out, perhaps a referral to a convenient nephrologist would help. More cumbersome but likelier to resolve matters, is there a university medical school nearby? Usually they have people who can deal with this level of complexity. Obviously high calcium and low oxalate diet with retesting is workable, and perhaps the urine oxalate will fall. But I am far away and high urine oxalate levels are worrisome so someone there needs to take care of this. Regards, Fred Coe
Dr Coe, I have a 30 year history of stone formation. Presented at age 20, then not again until age 31 when Lithotripsy was performed and now in the past 2 years I’ve had surgery to remove 19 bilateral stones up to 4 mm……18 months later (today) I have 18 NEW stones bilaterally even with sodium restrictions of 1200 mg/day and 66-120 oz lemon water as day in that time frame.
At this point I am looking for an expert level referal in the Phoenix AZ area (possibly Mayo AZ Kidney Center).
Any Suggestions? Thank you, Joe.
Hi Joe, I do have suggestions. Anyone with 18 new stones is in trouble and things are confused. Sort things out and prevention is practical – especially with lots of stones. The article has five steps, you do not mention the kinds of stones, or your 24 hour urine results. Somehow stones are being promoted and you need to know what they are and what is in the urine. This is always productive of prevention. Always. Regards, Fred Coe
Hello, Dr. Poe, and thank you for your time.
Is lithotripsy not reliable for Calcium Oxalate stones? I had an ER visit 5 years ago for a kidney stone; had ‘several stones’ in my left kidney. F/U with Urology for a 24 hr urine, nothing else. I have had ~ 2 episodes of pain/year since that time (always relieved with hydration) until 4 months ago, when I had 3 episodes in Oct, unrelieved with hydration, but 1 Vicodin relieved pain each time. Finally in Jan this year, I had another ED visit. 4 days later passed a 5mm black stone; F/U with Urology last week : he stated I had several stones in the Left, largest being 15 mm, and would need percutaneous nephrostolithotomy, Neph tube x1 week. Right kidney has multiple stones, largest being ~ 7mm. For that side he would do outpatient Ureteroscopy with stent x1 week. He gave me an oxalate food list, and did a 24 hour urine, which I do not have the results of at this time. He stated Lithotripsy doesn’t work well. ? I am a bit overwhelmed at the thought of TWO surgeries in the near future. Do the stones have to be removed? Only because of their large size? Any thoughts would be helpful. Thank you. I am 64 years old, semi-retired RN. No other health issues, except Glaucoma.
Hi Cindy, SWL works fine for such stones but has a special place – usually one stone and not too big. Ureteroscopy is replacing shock wave because it can assure a stone free kidney. If you have multiple stones your physician is doing the right thing. Prevention is crucial and the article you are commenting from is a good one. Try to follow it and see if it does not take you where you need to go. As for need for removal, it depends on size and other specific factors to the individual. Regards, Fred Coe
Is there a way to diagnose what type of kidney stones i have with labs? None showed up on ct, contrast ct, or ultrasound. Epithilial sloughing and trace sand in cytoscope of bladder and severe pain with 8 day hospital stay is only indication that i might “possibly” have stones. One year later have same pain. Is there a specific test to daignose stones if they dont show up on ct and ultrasound?
Hi Chita, the ‘sand’ may be crystals, and they can be analysed to determine the crystal form and thereby guide treatment. Crystals can cause pain and bleeding but escape notice otherwise. When you have a pain attack strain your urine through a filter for some days and you may collect some of the crystals for analysis – done in routine commercial labs. Regards, Fred Coe
Hello Dr. Coe,
Thank you so much for your wonderful articles and for sharing your knowledge. I’ve had a non-obstructing kidney stone for a couple of years with no significant change. At my last visit to my urologist my ultrasound showed that my lower pole kidney stone has increased in size to .8mm (and possibly another one right behind it). My urologist has a “wait and see” philosophy since I’m not in pain. My concern is that the stone will just keep growing in size making it more difficult to come out. My question is: Should a lower pole .8mm stone be removed if it’s not causing pain? If so, can a ureterscope reach a lower pole stone? I was basically told to drink a lot of water and come back again next year… no 24 hour urine test was suggested and very little additional info was offered. Thanks again for all you do to provide reliable information!
Hi Susan, Yes, modern scopes can get to the stone and remove it. Whether to do it or not is so personal. If it worries you, have it out. If it is causing no obstruction, infection, pain or bleeding removal is elective – meaning at your leisure or to your desire. For prevention, begin at the first stone, otherwise is silly. Regards, Fred Coe
Hello Dr. Coe,
I recently passed my 2nd stone, (“several” 1-2 mm left in right kidney), composition:
6MM, 98% Calcium Oxalate Monohydrate, 2% Protein
My first was,
4MM, 96% Calcium Ox, 2% Protein, 1% ea Calcium Phospate Carbonate/Hydroxyl
My 24 hr urine comparison revealed,
Improved:
Urine volume up from 1.71 to 2.54
CaOx down from 7.42 to 4.99
Urine Sodium down 171 to 105
Calcium/Creatine 211 to 207
Not good:
PH up from 6.0 to 6.1
Urine Calcium up 244 to 284
Protein .9 to 1.4
Phosphorus .826 to 1.085
Sulfate 30 to 55
Nitrogen 7.32 to 12.69
Calcium/kg 3.7 to 4.3
During this 24 hr analysis, I tried to keep it somewhat real and did not realize the sodium in “reduced sodium” soy sauce (2400 per 1/4 c.) so that was out of ordinary, will not use again!
I didn’t record foods in 1st 24 hr to compare.
Sodium 3,000 overall
Protein about 69 (high also)
Calcium only 69% of 1200 goal (low)
Thiazide recommended but doing another analysis in 3 months first. I really don’t want to take medication. Could this be off due to sodium, protein, calcium above? Surprisingly my sodium was within range(?)
Suggestions? Thank you so much in advance!
My apologies if this is a repeat, I’m having trouble submitting
Hi Lisa, I think this really is a duplicate. Regards, Fred Coe
Hello, Dr. Coe. Thank you so much for your impressive assistance with kidney stone prevention. I had my first stone diagnosed June 2017 due to severe pain, nausea, etc. In ER, I had a CT scan which identified a stone of 3 mm that had left the kidney and several stones in the right kidney. I passed the stone w/o knowing and didn’t catch it (no instructions were given about straining urine). A new CT in Sept. of 2017 confirmed that I had passed the stone but as in the previous scan, that I have an additional stone of 5.4mm and two smaller ones. I have had no pain or discomfort since the ER visit a year ago. My questions are: 1) if I don’t know the type of stone I had passed, could the 24h urine test be useful to show details about current stones? 2) I haven’t seen a nephrologist yet ( just a urologist). Is there anything that can be done with 5.4 mm and smaller stones if no symptoms are present? I’m of course interested in preventing futures ones but am wondering if I should do anything at this point. 3) I read a lot of information from your website but I wonder if I missed this: does climate affect kidney stone production? I’ve lived in FL for 4 yrs now and have no family history of kidney stones. But here in FL, I encountered many women like me in their 30s and 40s who had multiple stones. I wonder if climate is the culprit. Thank you much for your time and advice!!!
Hi Ligia, Yes indeed, prevention of more matters and you should do it. The article you wrote in on is one of my best on a way to proceed, even if you do not know the stone type. As for Florida and stones, I have failed to write about it but hotter climates do promote stones. So be sure and add extra water to whatever else your tests point to for prevention. Regards, Fred Coe
my doctor this time wants to put in a stint during the shockwave treatment, then take it out weeks later,is this neccasary,the last doctor didnt do it
i have had stones taken out 4 times in 6 years and followed all doctor recommendations,my mother and grandfather had same problem and had part of some gland taken out in there jaw -neck area ,and never got another stone,should i check into this ,what would it be called
Hi John, This is in reply to both of your comments. Stents are a surgical decision and often the exact particulars of a given stone dictate their use, so that your physician wants to use it and a prior one did not is probably a reflection of differing conditions. As for the gland, you are referring to primary hyperparathyroidism, and since it is in several relatives be sure you are evaluated for it. Regards, Fred Coe