My Question
Tell me what you want next on this site; that is my question.
I have been writing this site – with the able help of my co-authors – since July 2014, and have reached what I might call a kind of plateau. Much of what I came to say about the most common kinds of kidney stone patients is said. Because the main work is done for the moment I have come with my question to you.
The readership of the site has grown from 50 people in the first month to a present running average of 55,000 – 65,000 people monthly, depending on the season, and many of the visitors read quite a bit each. People find the site valuable, and I am happy for that.
But, what next? I can guess, I can plan, and I can write.
I can also ask.
You might question why I chose Wedding Dance Outdoors by Pieter Bruegel the Elder. The picture is wonderful, so my reasons may not matter all that much.
Up Till 2017
Because I set out to create a definitive site, not a mere collection of opinions, I built a three layer cake.
Primary articles rest on peer reviewed literature and have links in them – some say too many, some say not enough – to scientific papers on PubMed. Secondary articles elaborate on and explain the primary ones in less technical detail. They link back to the primary articles rather than to PubMed. Public articles are for patients and their families. They show how science gives us useful ways to prevent stones. They have fewer links, and those are mainly to secondary articles.
Since 2017 to now – July 2018
Since I first wrote this article I created the Kidney Stone guide Book, and new topic listings for the whole site. Some of what people asked for I have done. Here is the table of all of it. Done means just that. Part means I know I need some components. Some means I have examples and can add more.
I’d love to read about possible tips for people, like myself, who do not tolerate diuretics like chlorthalidone or HCTZ.
Also, alternative suggestions for those of us experiencing the pain of stones but for whom it’s not realistic to go to the ER each time because of the cost and their demand for a new CT scan as “proof” every time. Home healthcare? Taking Flomax all the time? If I went to the ER each time I had a stone, I’d practically live there.
Thanks Dr. Coe!
-Becky
I’d love to read about possible tips for people, like myself, who do not tolerate diuretics like chlorthalidone or HCTZ.
Also, alternative suggestions for those of us experiencing the pain of stones but for whom it’s not realistic to go to the ER each time because of the cost and their demand for a new CT scan as “proof” every time. Home healthcare? Taking Flomax all the time? If I went to the ER each time I had a stone, I’d practically live there.
Thanks Dr. Coe!
-Becky
Hi Fredric
I would like to see an article that clarifies the difference between MSK and stone disease symptoms, possible connections with both, if any as many of our members also suffer from many of the coexisting symptoms, hypercalciuria, hyperoxaluria, calcium oxalate stones, calcium phosphate duct plugging (in the past belived to be part of MSK) and nephrocalcinosis
Unfortunately there still seems to be a lot of confusion in our MSK support group, where most members have been diagnosed with MSK and claim that kidney stone prevention diets don’t work for MSK patients who may be unaware that many of the symptoms are also part of stone disease which according to your Kidney Stone Diet articles based on research, experience in treatment, can also be treated through diet (combined with high water intake and stone prevention meds).
Thank you for all your hard work and dedication!
A low oxylate diet when combined with a heart healthy and diabetic diet leaves the patient with fairly narrow choices and makes dining out ( in restaurants or as a guest in a home ) less than enjoyable. It may be mundane but it is at mealtime that most stone formers confront their condition. Perhaps your readers would appreciate a section focusing on navigating this “narrow channel” since by middle age many of us are dealing with multiple health issues and not just stone formation.
Dr. Coe,
Many thanks to you and your colleagues for launching this site and for your contributions to stone disease. As a physician specializing in the metabolic profiling and prevention of stones, I find the articles engaging and educational (and to the latter, I very much appreciate your efforts to link your writing to the fine arts).
In terms of future articles, I would like to see more clinical vignettes with the relevant urine, blood, and imaging diagnostics with special attention to the physiologic interplay of the presented chemistries in addition to your approach to management.
Thanks…and Happy Holidays!
Interested in Kidney Stone research and innovations in treatment.
Also interested in Kidney Stone Clinical Trials and locations.
Also interested in Kidney Stone Home Healthcare Tests and Treatments.
Merry Christmas and a Prosperous New Year from Ron and Ella Quinn
I would love help with a diet for Calcium Phosphate stones. Is there a low phosphate diet?
Much thanks for all your wonderful info!!
With MSK and non-moving stones, some of us have pain in the flank or side, under the rib cage. Most doctors do not believe we should be having pain unless the stones are moving, which causes us to suffer and have a decreased quality of life. Also what pain management treatment or protocols could benefit us. Thanks.
I have a similar question as Cecile. I have had one stone attack but initially they said the pain was not from the 7-8mm stone that they see on catscan in the mid to upper pole of my kidney. Because there was no blockage. I since get sporadic renal colic pain that is helped with Advil. I have consulted FIVE urologists. One says leave it alone – until it starts to travel. 3 others said the would TRY ESWL but no guarantee it will work and no guarantee that it won’t cause smaller fragments to clog a ureter. And then my most recent consult said he would not even bother with ESWL. I already know my urethra needed dilation for cystoscopy so likely fragments could get jammed in my ureter. He said based on the fact that i have pain off and on it should be treated. Also the catscan says it is probably in an upper pole infundibulum – so he feels he can best get it with Ureteroscopy and Laser Lithotripsy. Because I am young (reasonably – lol, 50 years old) and very healthy the general anesthesia is worth the risk. He did say he might not be able to get in to the ureter, so i might need a stent for 2 weeks and then he’d go back in and laser, but he won’t know that until he gets in there. Tough decision but I just don’t want to worry about future attack of the pain or if stone travels.
Hi Dr Coe. Thanks so much for taking the time to research on and write informative and helpful articles for those of us who need them! I would like to learn more about bone health – how kidney disease plays a role and how hypertension, vitamin D and calcium are linked. Your articles have helped me educate myself a lot since I have been diagnosed with MSK in January, 2015. There really is a paucity of information and I really appreciate the fact you have put yourself out there to help us all. Look forward to your next submission! Happy holidays to you and yours….A. Schell
Fred,
your site is a wonderful resource. I only signed on a few months ago, and I have to admit I haven’t caught up with all the articles yet, so these ideas may be well covered already. I’m an FNP–a newbie–sole provider at a small rural clinic, with no nearby specialists. So basic clinically oriented articles are always welcome.
In particular, anything explaining kidney stone manifestations in Urinary Analysis results would be good.
Also, thinking of the stones and bones rhyme, anything related to severe osteoporosis, (or osteoporosis headed towards severe) would also be good.
I’m also seeing lots of poorly controlled elderly diabetics with CKD, so anything pertaining to their treatment, diagnosis would be good.
Also, I’m very interested in Vitamin D deficiency, of which I’m seeing a lot of in the north of NV.
And let’s see: anything on nutrition. I see many people with no insurance, or with ferocious co-pays that might as well be no insurance, when my pts can’t pay them. So any conditions that can be improved by diet rather than pills or supplements is always good.
And again, I imagine you’ve done much of this already. I need to carve out more time to read your excellent work.
BTW, do you have ECHO up in our part of the world? We have monthly video consults here chaired by experts. Not sure if we have one on kidney issues, but we sure should.
thanks and best,
Peg Nicholson
It seems that more and more health conditions relate back to the health of one’s gut. I would like to see an article discussing the influence of a healthy or unhealthy gut microbiome on stone disease. Assuming that a connection exists between gut health and stone formation, healing the gut and/or targeted supplementation with specific nutrients or probiotics might be another weapon in the arsenal against stone disease.
I am a patient. Why no follow up visits appts? Is seeing you again and testing not important? How do you know I am doing well? How do you manage your patients for follow up, test, treatment?
Thanks
New to your site. I’m 71 with stones starting around age 35. Many family members have had oxalate stones. One of several other health issues for me is bariatric surgery.
Updated information is not available via my HMO. I donated LOW OXALATE COOKBOOKs to their patient education center a decade ago to bring them into this century as their oxalate info was dated. The books were created for Vulva pain sufferers. (SOLD BY AMAZON) t. A researcher tested all the oxalate values listed in the front of the books. The scientists has been retesting values for prepared high oxalate foods since the research had only been on raw foods. This group seems to be deminishing but their information was once the best I could find.
I can do email and go to a website and not much else. I’m overwhelmed on most sites. I don’t know where to start or a path to follow. I do know this site is where I want to get my info. I would like to see a guide on this site. Something like categories.
for Meds for stones, supplements, a few foods to avoid etc. I’d like to know if it makes a difference if I eat protien or chocolate a little through out the day or in one sitting.
I had stones removed recently so production hasn’t stopped with age. I need easy to follow information. Food ideas that require a few ingredients and very little of my limited energy. Thanks for asking for input.
This site has been the most helpful I have ever come across in helping me understand kidney stones, thank you so much. I would like some articles on kidney stones and bone health, having experienced a vertebral fracture (without a traumatic event) and having no osteoporosis, cause unknown. I would love to be able to take preventative measures to improve my bone health going forwards, and to understand the connection between kidney stones and bone health. Video format for information generally would be great, but I also appreciate the articles of all kinds.
Do water pills really help prevent stones?
Dr Coe,
I am immensely grateful for your site and your generous good work. You are rare in that you obviously have a deep love for research and gleaning the practical from it AND communicating with people/patients about approaches to applying what we know now to day to day disease management. My brief history of stones is having one 8 years ago, with no stone capture, no real analysis of underlying conditions….classic urgent care situation. And then having 3 stones requiring lithotripsy in a period of a year and half. Finally via your articles and being super aggressive with my urologist and then nephrologist, have gotten on a path of lifestyle change (superhydration and low Na diet) and medication that seems to be fixing my high pH urine and proneness to supersaturations.
Part of my ongoing questions have to do with the balance between the ideal dietary guidelines to prevent stone formation and a perhaps not so strict set guidelines that go along with drug interventions. Put another way, my uncle a retired physician, said to me in the midst of my most rapid stone formation, something like, “you should be able to get the right drugs to prevent stones without any change of diet”. That seems over-stated. I have chosen to take hydrochlorothiazide and K-Citrate AND push fluids hard, AND not add salt to food, and reach for low Na or no Na products where possible (for example no salt corn chips). But obviously, low sodium in particular is a constant battle. I recently discovered that even super simple, healthy so called “artisanal” bread can easily have 200-400mg of Na per slice. Yikes! When I’m trying to stay at roughly 1500-200 per day, and having two slices of toast and scrambled eggs for breakfast and I’m potentially halfway to my total before leaving the house! But I guess what I’m trying to understand is if I’m taking the drugs, maybe I’m being crazy about so closely watching inherent Na content in foods (as opposed to settling with just not adding salt out of a shaker). To be honest, food and weight control have been a constant battle in my life for a few decades. So this is particularly thorny struggle. Again, thank you very much for your wonderful work in research and patient education.
Eric Rounds, Santa Fe, New Mexico
Correction to my post, I am taking chlorthalidone, not hydrochlorothiazide.
Dr. Coe
Thanks for all the analytical writing that you do regarding stone development and prevention. I now have more knowledge about kidney stones than half the doctors I have seen over the years. Since I have read all of your articles I will keep my suggestion / request short and to the point. I would like to see an article that discusses the relationship between malabsorption issues and their influences on stone development and how malabsorption issues may complicate prevention. The hot malabsorption issues currently are celiac disease and bariatric surgery; however I would be most interested in ileostomies as that reflects my personal situation. Thanks.
Jeff
What beverages are recommended besides water to achieve high fluid intake? What if you also can’t tolerate artificial sweeteners or lactose? Are there any beverages that can increase your chances of stones?
What is the recommended low stone producing diet for eating at restaurants?
Hello Fred and thank you for the remarquable ressources provided in this site.
I have a blog on kidney stone, and I’ve learn a lot from you and still do. By the way, it’s a french blog colique-neprhetique.fr
So, I have some simple questions that lead me to some theories if you can help with:
– Why do some form kidney stone and others don’t even if they eat and drink the same thing. To form a kidney stone it has to be an exagerate reaction not just a simple genetic disposition. So I’m wondering if there’s other things that can make a big difference.
– Another question, is what is changing with age, why I am forming kidney sontes at 31 and not at 15 when I was working out and playing football without drinking any liquid for hours. What have changed in my body. What can I do to change it back?
– I’ve read that the camel can produce a very saturated urine and even with that don’t have kidney stone, how is that possible? I wonder what inhibitors he got, probably not all citrate. It will be interesting if we know what are all the inhibitors to see if the kidney stone makers lack them and why are they lacking them. Maybe we focus a lot on citrate because we lack information about the rest of the inhibitors. It’s never that easy in the human body.
– I’ve read someone talking about gut microbiome, and that’s a nice start. Studies pointed out the fact that some bacterial gut transform oxalate into other thing. They also have a defensive role against leaky gut.
– Leaky gut is another interesting principle for kidney stone to study as it may facilitate the passing of different indesirable things to the blood and then to the urine.
next comment…
– Other thing about leaky gut is that it will provoke inflammation in the body by allowing macro-molecules in the body. Is there a clear relation between inflammation or auto-immune illness and kidney stone. My theory is that there’s some molecules pro-inflammatory that will be pro-kidney stone also and other molecule anti-inflammatory that can naturally inhibit them. I’ve seen a paper that discuss the relation between inflammation and kidney stone in one of your article. And another article discuss the protein and other molecules in the urine who can be pro KS or inhibit them. So the idea that I’d like to back up with science is : if we have an inflammation in the body or an auto-immune illness who come from an inflammation from a leaky gut like when a person is lactose intolerent or gluten intolerent or just eat junk food with chimicals that are pro-inflammatory, this inflammation and the resulting molecules are pro kidney stones. Whereas a body without any inflammation will have enough inhibitors to inhibit kidney stones even with little liquid.
My goal is to find what clicks, what are the fundamental causes of kidney stone in order to get out of the “drink a lot of liquid and take a diet for the rest of your life”. I don’t like the idea of a kidney stone former as a illness. I think that it doesn’t exist, but it’s a consequences of other various things and I’m trying to look for the global ones like inflammation and auto-immune illness, bad gut microbiome, acidosis and of course bad diet as an unbalanced diet who form unbalanced urine.
If you can comment these ideas it would help me in my research a lot, and hopefully your readers too.
Thank you,
Stéphane Holistique
PS : Why recommand to take less oxalate to prevent calcium oxalate even in people without hyperoxaluria? Same question about purine for uric acid stone without Hyperuricosuria. It must be other things, lack of inhibitors maybe?
Thank you,
Stéphane Holistique
First of all I would like to thank you Dr. Fred Coe for all of the times and effort and love that you have already put into this site. It is a remarkable site and appreciated by so many. I don’t want much for the future of this site except for all you can keep giving, all your knowledge all your patience and information that I know was found though many years of research and data and late nights. If I wanted anything for myself from here it would be more info on the exact differences of tubual pluggings and msk. Also, everything that you know about brushite stones to have come to the conclusion they are nasty. You are one in a million and we here in my group all appreciate all what you are doing for kidney stone knowledge. Thank you from the bottom of my stoney kidneys and of course my heart.
If you had kidney reflux (grade 1) as a child, would that scar/damage your kidney? Would it cause constant kidney pain as an adult? I have the symptoms of MSK without the actual sponge kidneys.
Hi Meghan, Reflux can lead to scarring as well as high blood pressure and loss of kidney function. Pain would be more likely if scarred regions became infected. Another possibility is obstruction has developed or reflux remains. Your urologist has probably looked into all this already. Warm regards, Fred Coe
Hi Dr. Coe!
My question is this. I have been diagnose with MEN1 and before I was prescribed Natpara I was taking 8000 mg/day of supplemental calcium approved by my endocrinologist after parathyroid cancer x 2. There were some hiccups during my initial Natpara treatment and I was on far more than the 1200 mg/day I’m now taking. I’ve had a 24 hour Litholink test done and my urologist says my risk factors for more stone formation are minimal. I’m still suffering from symptoms daily, though. It’s miserable. Any idea how long it will take to clear my renal system from them? THANK YOU!
Hi Lisa, I take this as two entries. One is that we need some articles on the site about primary hyperparathyroidism and its related diseases. The other is about you. I believe what you are describing is this: You have a diagnosis of parathyroid cancer for which your parathyroid glands have been removed and you are therefore hypoparathyroid. For this you were taking 8,000 mg/day of calcium and then put on parathyroid hormone and presently 1,200 mg of calcium. You have symptoms I presume are from low blood calcium. The drug is supposed to be used in a combination: serum 25D is in the normal range; active vitamin D may be used to minimize the dose of PTH; calcium supplements are adjusted to maintain serum calcium. If you have symptoms you need more calcium supplement, and this is reasonable as your urine calcium is – I gather – not high. I would bring the urine data to the endocrinologist who is actually treating you, as he/she is the one who needs to navigate between blood and urine calcium. I take it what you mean by clear your renal system is somehow get rid of stones. They will not dissolve, so if they pass the goal is to not form more – thence the concerns about your urine calcium. Your care is really complex, and I am sorry for so long a note. Long as it is it is not complete because your physicians have access to the real data and I am simply inferring. Regards, Fred Coe
Hi Dr. Coe,
First, warm congratulations and thanks are in order! This is a tremendous milestone and a great gift to all who suffer from kidney stones and to the doctors that treat us! I started reading in 2015, and assumed the site must have been around for many years because of its breadth.
Thank you for asking for input. I have found the videos to be well chosen and they really helped to crystalize the concepts in my mind (no pun intended.) That said, I’m an analytical reader at heart and gravitate toward you primary articles. I have a number of ideas for articles of various types. Some would likely require new research.
1 – How to diagnose the sub-types of IH (absorptive, renal leak, etc.) using supersaturation tests, blood work, bone density, or etc.
I see many scattered dots in your graphs that deviate far from the averages, and my hypothesis is that some of this might be explained by different subtypes. Various treatments also seem to work better for some than others (e.g. me). My thought is that knowing more about the root cause of one’s IH could improve outcomes.
2 – Significance of not just what we eat and how much we hydrate, but when.
Calcium coincident with oxalate containing foods is a key example. This seems like an area ripe for research. Fortunately many patients can be stone free without worrying about this level of detail, but others are harder cases, and it may help many when traveling. We have already discussed eating a day’s protein in one large meal vs. more spread out. I am also very interested in how supersaturations rise and fall over the hours following a meal. Graphs would be wonderful. Some foods seem to cause a quick spike. And you have taught me that others, such as salt, have an effect averaged over several days. (I’ve been investigating using test strips to collect such data, but it has been challenging to get accurate and repeatable readings with the resolution I would like.)
3 – How our body acts, and how supersaturations and stone risk vary day vs. night.
4 – Effective strategies – thinking outside the box – to avoid kidney stones during travel. Consider airport/airline food, limitations on hydration (e.g. due to limited rest facilities), unfamiliar food overseas, and limited availability of nutrition information. It’s a zoo.
5 – Significance of, and how to interpret blood work, such as renal panels to track progress of treatments.
6 – Continue your excellent work on interpreting supersaturation reports and explain the rest of the parameters, such as UUN 24. Also more on high creatinine, and on factors that can skew PCR.
7 – Research new inhibitors which could be injested to add to the well-known benefits of citrate.
8 – As already suggested, perhaps a dedicated article highlighting the relationship to bone disease. Perhaps explain when DXA scans are appropriate.
9 – As already suggested, more on phosphate stones and dietary considerations.
10 – Risks, benefits, tradeoffs of ureteroscopy vs. ESWL and other topics and suggestions related to passing of stones.
11 – How to make the best use of imaging, and tradeoffs of each. False positives, false negatives, minimizing radiation exposure risk, etc.
E.g. I find ultrasound has often greatly exaggerated stone size. And have a friend that had ureteroscopy without a CT scan first to confirm other imaging, only to find that there weren’t actually any stones. Also whether doing CT scans both with and without contrast make any sense, given the amount of radiation, if it is clear that pH is far too high to support uric acid stones.
12 – Research on ways to reduce urine pH when needed for CaP stone formers without requiring the unwanted an unhealthy release of calcium from the bones to stave off metabolic acidosis.
13 – Comparison of various potassium supplements, including side effects such as stomach irritation. Citrate vs. Chloride vs. Gluconate, etc.
My pharmacist said KCl seems to be the worst, and I don’t seem to be able to tolerate even ER tablets. Also get the word out on the importance of the serum potassium level on Cit 24 and the SSs.
While we’re talking about the upcoming year…given your appreciation for beauty, you might enjoy taking a well-earned vacation here: http://kidneystones.uchicago.edu/treatment-of-idiopathic-calcium-stones/. I’ve had the privilege of standing in that spot. Glacier NP is beautiful. And if possible, continue to the Canadian Rockies for gems like Morrain Lake-my personal favorite. Do go in the summer, however. Winters are long and some roads may be closed for three seasons.
Thank you again, and best regards, Al
Thanks, Al. No, the site began just 2.5 years ago, and it has indeed taken up a lot of time. Very worthwhile, and I think lots of people use it to their advantage. I will add your comments to my table – linked to the article, and try to answer to them over time. I would like to go to the parks again, and perhaps I will. Warm regards, Fred
Hi Dr. Coe,
I have been re-reading many of your articles this year and really appreciate all the work you have been doing to update and to add new content. I found FLUID PRESCRIPTION FOR KIDNEY STONES of particular interest and help with my questions above!
Thanks again! – Al
Hello again, About the kind of articles. I like primary article more because I like to understand all in detail. But the secondary are nice, to have the whole picture, and in case the primary was too complex.
Thanks for your extraordinary work and dedication to help others.
Stephane Holistique
Thank you, Stephane, Regards, Fred
Dr. Coe,
Thank you so much for your informative and easy to understand articles. I would like to know if there is any literature out there linking kidney stones to Cushings Syndrome. Also, my son Morgan who is in his second year of medical school would like to know if there is an established link between Cushings Syndrome and kidney stones, what is the biochemistry/disease process behind the link?
Are there any links between thyroid disease and kidney stones?
Thank you again for being so engaged with your patients.
Sincerely,
Midge Gilmour
Hi Midge, Cushings can cause stones because it can cause hypercalciuria. In a lifetime I have seen it only rarely. You have probably surmised that my site has yet to contend with the systemic diseases. It is the next phase, easier in a way but detailed. As for thyroid disease, hyperthyroidism is a cause because of hypercalciuria. I will add these to my list. Warm regards, Fred
Dr Fred,
your library length of information on this site is wonderfully educational. Not only has a link to the site stayed in my email inbox but I keep coming back to read 😂. Glad to read about citrate benefits. I’m on fresh lemon juice…
I wonder if it is possible to add your knowledge of how bladder diverticulum can harbour multiple crystals,stones/size increase over time and how antibiotics can fail to clear a bladder infection that is being seeded by interlayered stones/multi bacteria in bladder diverticulum.
Hi Andy, Thanks for the comment. Crystal formation and persistent infection in a stagnant chamber like a diverticulum – many would say it long dwell time itself permits urine to dissipate its supersaturation in crystal formation and bacterial infection of crystals that hampers antibiotic clearance. I have not written on this and need to. Whether the theory of mere stasis suffices – that is moot. Regards, Fred Coe
Dear sir fred,
Im following up on my question of jan 1st 2017 for two reasons.
1)im not sure if you had time to follow up on your reply.
2) last week was rather unpleasant with bladder outlet blockage infection etc. In awaiting midstream urine culture results and had a surprising but relieving allclear ultrasound on april 28th 2017(just gone). Analysis was comfortable bladder filled at 250ml and my known,and unfixable on nhs uk -diverticulum -was 100ml.
Emergency trimethoprim antibiotics have cleared my urine odour and clouding pretty quickly which was left too long. (Original reason was incomplete voiding cycle with high leukocytes but no infection so it was left.
In thinking diverticulum is far too high a rjsk factor to leave unfixed but whatever lol. Ther3fore it seems im again.incredibly lucky not to have retained stones. Stagnant pocket is still a wonder to me.
Hi Andy, I re-read by response and it still seems reasonable. You clearly have incomplete bladder drainage with a stagnant pool of urine in a diverticulum and with infection. I would think you need something to assure more normal drainage, and also removal of the diverticulum. Even in UK. Regards, Fred Coe
Thanks sir fred and thanks for maintaining your very helpful site.
Hello, Dr. Coe.
Do you have any articles regarding matrix stones? I haven’t been able to find anything real specific around what the exact cause is, side effects, etc.
Sincerely,
C Routh
Hi Christine, I am sorry to say I do not have anything on matrix stones. Are you sure no crystals occur in your stones? Be sure, because if any do the answer is to prevent them. Regards, Fred Coe
I love your style of writing and data sequencing, Dr. Coe. Today was the first time I found and read any of your articles.
Serum uric acid reaches saturation and precipates. The precipitate collects in various joints causing symptoms for gout.
Serum uric acid is removed/filtered by the kidneys and sent to the bladder for elimination.
Do the kidneys accumulate uric acid in the filtering process, where uric acid might precipate to form or make larger stones?
Do we know if gout leads to kidney stones?
Do stones inhibit uric acid filtration, raising serum concentration so gout occurs?
Do the kidneys distinguish and prioritize candidates for filtration?
What impact does bile (and gall stones) have on uric acid processes?
I would also like to know how the endocannabinoid system influences our filtration systems.
I REALLY appreciate this opportunity you’ve given us. I have a million more questions!
Kind Regards,
Kristina
Hi Kristina, Thanks for the compliment and that you enjoy the site. It is serum sodium urate that crystallizes in joints; blood pH is too high – 7 – to permit uric acid itself. Filtration of urate has no crystallization risk, and in the tubule fluid sodium, potassium and ammonium hydrogen urates do not supersaturate enough to cause crystals; but in the terminal parts of the nephrons pH can fall and uric acid itself crystallizes. There are subtleties. WHen serum urate levels become high enough – not sure about the level – tubules could plug with urate salts – so called ‘urate’ nephropathy as distinguished from uric acid nephropathy which is uric acid crystallizing in the terminal parts of the nephrons and in the final urine. Doubt exists about whether urate nephropathy occurs and how often. As for filtration, urate is alone in blood – uric acid is not present above trace amounts because of the pH. The endogenous endocannabinoids may indeed affect renal filtration because exogenous compounds do. Anandamide at least in rate, reduces filtration by dilating both the afferent and efferent arterioles. Likewise there is evidence for cannabinoid receptors in cultured renal proximal tubule cells and when occupied they signal changes in tubule cell tubule cell sodium handling that itself can control filtration via tubulo-glomerular feedback. I hope this gives at least some sense of what these compounds may be doing. I do not discuss them on this site as they have no obvious relationship to kidney stones. Best, Fred
Dear Dr. Coe,
Thank you for your tremendous dedication to this site and providing such a precious resource.
I feel I am right smack in the middle of a ping pong match regarding good/bad food choices for kidney stones which I have, to my displeasure 3, (calcium oxalate) – though they be wee ones. One site says “eat strawberries” the other sternly cautions- “To be avoided” and so for spinach, avocado, beans, seeds, and on and on. I am confused!!!
I have become a committed water imbiber but have yet to wade through the Big Food Choice puddle.
Your help would be greatly appreciated.
Thank you.
Vida
Hi Veda, I found three versions of this comment and kept this one as being the longest and most complete. That you have calcium oxalate stones does not mean you need to do anything about diet oxalate. What matters is the abnormalities in your urine that are causing stones. Here is a good overall treatment article that includes the issue of diet oxalate and all of the other measures that make up a proper program. Water and diet oxalate are just parts. Regards, Fred Coe
Dear Dr. Coe,
Please accept my apology for my tardy reply.
Thank you very much for your reply. I have already started to read the article and will return to it many times as it is a very detailed and important resource.
I will bring it to the attention of my physician to start monitoring the urine for abnormalities so as to hopefully detect what may be contributing factors to the kidney stones.
I did say I was a converted imbiber but must say now that I went from 0 to 8 cups of water and that was truly too abundant an intake. So I have tapered down to 3-4 cups of water daily which I am absorbing without any tumultuous consequences.
Thank you again.
Vida
Dear Dr. Coe,
Thank you for your research in this area!
What are your thoughts on children with autism without kidney stones with high oxalic acid in their urine contributing to behavior changes? These children often have food sensitivities to dairy, so it seems like supplementation may be easier? Adults with high oxalates will also experience “oxalate dumping” periodically with painful muscles and sometimes with symptoms of interstitial cystitis. For these two populations, would your recommendation be similar – Ca supplementation with higher oxalate meals and lower sodium? What could be done to reduce oxalates in the tissues (not in the urine) that may be causing pain? Would you also recommend supplementation with magnesium citrate and Vitamin K2 (menaquinone) along with regular calcium supplementation along with B6, or would that interfere with the binding of calcium to oxalates.
https://www.greatplainslaboratory.com/articles-1/2015/11/13/oxalates-control-is-a-major-new-factor-in-autism-therapy
Thank you!
Susan
Hi Susan, I know of no real data to support the theory you mention. I do know of sites that promote oxalate management for various conditions beside stones and do not believe they have adequate evidence to support their claims. Oxalate dumping seems an unlikely idea, and I doubt it exists. I do believe the theories being promoted also promote sales of things and there is little reason to believe those things will help your child. Sorry to be negative, but science is science. Regards, Fred Coe
Thank you Dr Coe
l want to know the name of the food additive that creates oxalate stones. l am avoiding all processed/packaged factory foods. l have ca ox stones and am a member of Jills group
Janet Longford.jaylow1952@gmail.com
Hi Janet, I do not remember mentioning a food additive that causes calcium oxalate stones. I know of none right off. Jill might know. Otherwise, perhaps none exist. Regards, Fred Coe
I’m a 79 year old woman that has had stones most of my life.The first one recorded was in 1963. It should be noted that one of my kidneys has two ureters that join together before entering the bladder.
In 2007, I began taking Urocit K and the juice of a lemon each day. My diet changed a bit (a little less protein) and things improved. The stones were reduced to gravel. I did develop osteopenia but with the help of Vitamin D3, I eventually got over it. Some time after that I don’t remember the exact date I began taking the time release Urocit K and there was further improvement.
I had always been over weight so my GP encouraged me to to try a vegetarian diet with an emphasis on eating no processed food. Along with eating vegetables and fruit I do eat a small amount of seeds and nuts, eggs everyday and 2 ounces of salmon four times a week. Since I started this routine some other medications have been reduced or stopped altogether. Of course all this time I continued the juice of a lemon each day and the Urocit K.
Over the years I began to have incontinence and began losing my short term memory. Of course I stopped taking medication for incontinence and sought help from a physical therapist. The incontinence improved somewhat but I was not responding like I should. Quite by accident I realized that the lemon juice was causing bladder irritation which was the cause of the leakage.
For now I have stopped the lemon juice knowing that may not be a good idea. My question, Is the lemon juice essential or is the Urocit K enough? If I should continue with the lemon juice is there some way to help with the acidity?
My regular urologist is no longer taking Medicare so I’m in the process of trying to find a new urologist that knows and follows your thinking about caring for kidney stones. I would appreciate your comment.
Thank you,
Evelyn Ann
Hi Evelyn Ann, I think the lemon juice can be dropped if it irritates your bladder. As for a new urologist, if you say where you live I could try to find someone. Regards, Fred Coe
Thank you for your replied. I live in Longmont, Colorado and the towns close to me are Ft. Collins, Loveland, Lafayette, Louisville and Boulder.
I got my stone report. It was made up of calcium oxalate dihydrate 30%, calcium oxalate monohydrate 35%, carbonate apatite stone 35%.
I know calcium oxalate are common, but I was not aware there were two types, and I can’t find much info on carbonate apatite. What does the combination mean? Should I change my diet as one would for a calcium oxalate stone?
Totally confused,
Tim
Hi Timothy, The two types of calcium oxalate are not of concern to most physicians or any patients. The apatite is calcium phosphate, and that means you are not simply a common calcium oxalate stone former. Here is an article about the calcium phosphate stones. In fact you are a hybrid, mainly calcium oxalate but tending to the phosphate variety. What that means is that stone prevention needs to be pursued with more vigor than usual. Regards, Fred Coe
I thought your article was going to be “how to reduce high blood pressure for kidney stone formers”. I read through a lot of stuff (meant for a medical student preparing for his exam), but I couldn’t find anything about hypertension. Maybe you can highlight the site?
Hi Fred, The article indeed covers all current dietary, lifestyle, and medication responses to blood pressure, and gives rather specific details. It is, of course, meant as informational for long term management, and not for acute issues such as you describe in your other posting. Regards, Fred Coe
I am hoping you can clear this up for us sufferers. I am reading on fairview.org the following: New research shows that eating calcium-rich and oxalate-rich foods together lowers your risk of stones by binding the minerals in the stomach and intestines before they can reach the kidneys.
I am very confused, I thought a low-oxylate diet was important?
Hi Patricia, I suspect fairview has been reading my site. The effects of diet calcium on urine oxalate are very well known. Here is a good article on the topic. In fact the correct approach is high diet calcium + low diet sodium, the latter prevents urine calcium from rising excessively + moderation of diet oxalate to avoid the highest oxalate foods to keep an average of about 200 mg/day or less. All this is part of the kidney stone diet – which is identical to the ideal US diet. Regards, Fred Coe
Hello and thanks for all the information! Since I discovered that I am a stone former, I visit your site often. Have you some information about moringa, a plant used in Africa and India as a super food? Various web sites tell me that its oxalate level might be at approximately 25-35 mg, or about one twentieth of what spinach has. Additionally, some state that moringa’s oxalate is “non-soluble”. What does that mean?
Hi Roger, If you are a stone former, pursue prevention as best you can based on what science we have to date. Here is a good place to begin reading. My life is filled with claims for super foods, stone breakers, etc: None have any science at all. Justs hype. For you the best approach is serum and 24 hour urine testing, stone analysis, to know what has caused your stones, and reversal of those abnormalities. As for soluble and non soluble oxalate I presume that means if the oxalate is bound to calcium it will be less well absorbed. Regards, Fred Coe
Dear Dr Coe
I have either read or heard that uric acid stones may become cores/triggers for Ca stones to form on like calcium oxalate stones forming on CaP stones. You showed a study of allopurinol inhibiting Ca stone formation (you also mentioned for unknown reasons). Yet at the early program in this years ASN, I think someone mentioned that uric acid stones and Ca stones have no relation. Can you comment on that? I may have misheard (I know I should have asked at the site but this question popped up in my head later).
Hi Hiroo, I mentioned the Allopurinol trial for calcium oxalate stones in my lecture, and that uric acid might promote calcium oxalate crystallization, and that after some decades not Charles Pak, nor Rosemary Ryall, nor I could prove it, so the drug has a trial – very good one – and no mechanism. This is why you could hear two opinions, both true, and seeming to contradict each other. They do not: the trial says yes, the mechanism is not known. SO most of us do not use the drug. Best, Fred
How do I find a doctor who will help me prevent stones rather than treat them after the fact? Is there an organization I can call? What are some questions to ask? I don’t want to insult anyone but I want someone interested in prevention and who will allow me to do the urine test.
Hi Rene, If you have never had a stone, the best idea is to follow the US recommended diet – it closely follows the kidney stone diet that we use in stone prevention but is intended to maintain the health of the US population. If you have no stones, I would not personally advise spending time and money on 24 hour urine testing. But if you do want such testing, and are willing to pay for it yourself – no stones, no insurance company will pay – I am sure your personal physician will order for you. Regards, Fred Coe
Thanks, Dr. Coe. I have had a stone and feel another coming on now. I’ll do as you suggest and ask my doctor. It’ll be a lot more cost effective than paying for lithotripsy for break up the 3 mm stone from 2016.
My 74-year-old brother has had kidney stones on 3 occasions since 1970. Five months ago an ultrasound showed that he has 2 non-obstructing calcifications, one of which, he was told, would need “help” when it starts moving. My question is, do we have to wait until he is in excruciating pain to get this taken care of, or are kidney stones ever removed before they cause pain. Thank you.
I have taken probiotics in the past and when I read about Oxalobacter Formigenes metabolizing oxalates I looked for more information and found a study that is underway: Oxalobacter Formigenes Colonization and Urinary Oxalate Excretion: https://clinicaltrials.gov/ct2/show/NCT03752684
Is this anywhere near being ready to be a therapy or is there any other option to get a little microbial help on the oxalate front?
Hi Bud, a good idea and a big flop in reality. The oxalobacter need oxalate to eat, so mostly they die when you take them. No benefits in the trials. Forget about it. Regards, Fred Coe
Hi Dr. Coe, Just curious about a few things related to kidneys and how problems in the kidneys might manifest symptoms. Can kidney problems ever manifest themselves in the urinary tract (for example burning after urinating) or the prostate when there are no pains coming from the kidneys themselves? Can kidney problems cause prostate problems or are these organs connected in any way? I realize these questions may be too complicated to answer on this forum, but I am not a doctor so I do not know if a simple answer exists for these questions. Thank you.
Hi John, I presume this is in the absence of stones, because stones can affect the kidneys and bladder giving urinary symptoms. Sans stones, the prostate and kidneys are separate except that gradual obstruction of urine outflow from prostate enlargement can eventuate in kidney damage if left unchecked. Given your symptoms I would suspect the problem lies in the prostate and the kidneys are not a cause nor a victim. Regards, Fred Coe
Wondering about TheralLith XR Taking 4 pills daily with 2 pills containing Vitamin B67.5mg,magnesium …50% magnesiam citrate,…50% magnesiam oxide and finally potassium citrate 90 mg. Is this a good supplement to take as it is relatively expensive.
Hi Kathleen, I looked up the stuff in this product. It contains 3 – 4 mEq of potassium citrate, and some magnesium and B6. The amount of potassium citrate is about 1/3 of one normal 10 mEq pill, and one needs at least 2 – 4 of those normal pills to have any effect, even presuming citrate is appropriate for your stones. As for the magnesium, you can buy it cheaply OTC in 200 mg tablets. Vitamin b6 is in routine vitamin pills. No data support any of the constituents except potassium citrate, and the amount in the product is too low to matter. So it is hype and nonsense unless very inexpensive – so cheap you could use 3 twice a day to match two daily actual potassium citrate tablets. I see no value in it at all. Regards, Fred Coe
Here are some medical facts about my wife. I will ask a few specific questions below. We hope to benefit from your knowledge and experience:
She is 70, weight 112 lbs, 5’5” in good health taking no medication. In August of 2018 she was found to have her first known kidney stone ever. Testing was done to clarify why she had blood in her urine and a staghorn kidney stone approximately 3cm x 2.5cm was found in the right kidney, close to the junction where the ureter leaves the kidney (without blockage) in the right renal pelvis. She reports having had a kidney infection about 45 years ago after childbirth that required multiple antibiotics and then sulfa. She also reports a fairly typical history of occasional UTI in the years since, with one infection requiring sulfa that she thinks may have also involved the kidney. She had the percutaneous surgical procedure using Swiss Lithocast ultrasound on 9/5/2018, leaving approximately 25% of the volume of the stone. The remnant in her kidney is 1.9 cm x 1.1 cm. Test of removed stone particles found the stone to be Carbonate Apatite (Dahllite) 100%. She continues to have trace blood in her urine fairly regularly, with it sometimes showing no blood (based on home testing with a strip). The urologist is hesitant to try a different surgical procedure given the size of the remaining stone—neither lithotripsy nor ureteroscopy. My wife has no pain, and it fact, never had pain since the stone was well-lodged before and still appears well-lodged on xray after surgery. Instead, he did a 24 hour urine on 11/12/2018 which found Urine Volume to be 2.55 liters per day, SSCaOx to be 4.33, urine calcium to be 347 mg/day, urine oxalate to be 18mg per day, urine citrate to be 899 mg/day, SSCaP was 1.48, urine Ph was 6.249, SS Uric Acid to be 0.23, and urine uric acid to be 0.458. All of her blood test results are normal including parathyroid. The Urologist is starting her today on 25mg per day of Chlorthalidone, but my wife is going to cut the pills in half and will start on 12.5mg per day.
Here is the gist of my question, and I must apologize for being a psychologist. It would seem the operative theory is that my wife has historically had no dietary or genetic risk for the most common types of kidney stones, but did acquire over time one fairly large stone that is known to be due to infection. I have read that high carbonate content in Apatite is consistent with the mineral being formed during infection. The only diagnostic test that the urologist has focused on is the relatively high level of urine calcium. But, high urine calcium does not cause infection. Nor is she at particular risk for Calcium Oxalate stones, Calcium Phosphate, or Uric Acid stones. So, why is she on Chlorthalidone? If anything, it would look like my wife has a high urine volume, would not be prone to supersaturation, and has never had a kidney stone other than the one that was arguably due to infection. Is there any risk that these calcium ions in the urine will bind with her current stone and make it grow? It has been a long time since I took organic chemistry, but I see no logic to support that. The stone should have full valence, probably has no further infection after substantial reduction in volume and lots of Cipro from the surgery, and Chlorthalidone given to a woman with normal blood pressure has no clear rationale and will likely have some negative side effects. It may have a benefit of increasing her blood calcium as I understand this. What am I missing? Perhaps she should get a KUB every year or two and if there is no growth and no new stone, we should try to forget about it? What is your suggestion? My wife already urinates more than anyone I know (since she drinks more water than anyone I know), so she is anxious about the new medicine. Thank you for your help.
Hi Michael, The high urine calcium is from idiopathic hypercalciuria and a very common cause of calcium stones. Ddahlite is a form of calcium phosphate and is not from infection at all, but quite often found in people with hypercalciuria. People with hypercalciuria are prone to pain attacks from crystal formation, and these can be like urinary infections and often misdiagnosed, so some of her earlier history may reflect this mechanism. Infection stones are magnesium ammonium phosphate, sometimes with included calcium carbonate; the urine pH is usually a lot higher than your wife’s because of the ammonia production. It is true that labs sometimes misclassify stone types, so perhaps your physician should make sure, but infection stone does not seem relevant here. Chlorthalidone will lower urine calcium, but is best used with low sodium diet – below 2000 mg daily – so it is more effective. Low sodium diet alone works in some people, and you might want to see how low her urine calcium can be brought with it. Of course, I am not her physician, and only S/He is really responsible here. Regards, Fred Coe
Thank you for your 2/24/2019 reply which informed us that Calcium Apatite (Dahllite) is a type of Calcium Phosphate stone and is not related to infection. In another section of your website you note that Calcium Phosphate stones only form in alkaline urine above 6.3. Since her 24 hour urine had a Ph of 6.24, this would seem to be a worthwhile intervention–just to lower her Ph a bit. One approach is to modify her diet (eat less of her common foods that have high alkaline tendencies and eat more of foods she likes that acidify urine) using The Acid Alkaline Food Guide (Brown & Trivieri). Another approach might be for her to regularly ingest cranberry extract, red wine vinegar and/or Vitamin C. I have purchased a decent Ph meter and I suppose the empirical approach (see what reduces her uring Ph) would make sense. Does this approach make sense to you? She has only had the one staghorn stone ever. She has never had a Calcium Oxylate stone. Apparently some people think Vitamin C can precipitate Calcium Oxylate stones and others do not. What is your view? Would it be worthwhile to lower her Ph down to 5.8 or so? She still does not like being on the diuretic and is actually drinking less water as a result. This “law of off-setting behavior” coupled with the negative side effects of the diuretic suggest to me she should get off the diuretic and go with the more obvious approach of acidifying her urine. We will talk with her urologist at the next appointment, but would like to hear your views. Thank you so much.
Hi Michael, I would not favor change in urine pH – I like the theory but prefer more established methods. Take a look here at how to evaluate for causes of stones, and pursue prevention. Regards, Fred Coe
Hi Dr. Coe, long time kidney stone sufferer, had 9 stones removed in november and my doctor put me on chlorthalidone last month and not to bother with the low oxylate diet. I have flank pain but 3 remaining stones should not be the cause according to the doctor. The Rx is giving me painful side effects, spoke with the nurse but no call back. Can you give me the truth about the diet? I’d like to discontinue the pills to see if the pain subsides but i am not getting answers at all. Thank you.
Hi Patricia, Perhaps the stones were calcium phosphate, in which case oxalate is irrelevant. Perhaps your 24 hour urine showed normal levels of oxalate, so likewise for the diet. In general low oxalate diet is not a major value unless urine oxalate is above 25 mg/d and even then urine volume, or calcium (CTD lowers it) may so overweigh oxalate as to make it of minor importance. Here is my best on progressive treatment – diet then meds. See if it helps clarify matters to you. Regards, Fred Coe
My husband has been diagnosed both in the past and presently with kidney stones that are made main,y from uric acid (His father not surprisingly had Gout). My husband ignored his diet and continued to consume large amounts of red meat, any meat, shellfish and more. He eats huge amounts of blue cheese and parmigiana cheese too.
I need a detailed list of exactly what foods he can and cannot have. Recipes would also be good but I am not sure whether he can have any dairy, eggs, nuts etc.
Thank you so much. I am willing to go on a vegetarian diet as well as it will only benefit me.
Hi Francine,
You are best off taking the course to learn how to meal plan and incorporating the diet overall. It is involved and will need time and attention. It sounds like your husband is eating too much sodium and animal protein. I am sorry he has not yet changed his diet as his stone reoccurrence will only increase if he keeps this up. You do not have to go on a veggie diet, nor does he. He just needs to learn to keep his portion size under control. Read this article on The Kidney Stone Prevention Course that I teach and many have benefited from.https://kidneystones.uchicago.edu/online-education-course-lessens-stone-risk/
JIll
i was a parent of your’s in the mid 90’s. I enjoyed the program and found you to be one of the most renowned Dr’s in this area. Unfortunately due to personal circumstances, i was unable to continue. The stones have not gone away and have had multiple procedures since then. I have had recent blood work and 2 urine analysis performed. I am am also seeing a dietitian for this and other issuers. i am to be on a low sodium, low oxalate diet and high calcium diet recommended by my internist and the urologist. Does your video address simply “what to eat and what not to eat?” Coming from Italian heritage and Mediterranean foods as well, this is a DRAMATIC change in life style and OVERWHELMING trying to incorporate it as you state in your articles. This is the battle i believe many of us face and discourages us in trying to sick to a diet. Through consultation or for a fee, can a simple list of foods be prepared “yes, can eat”, “no can”t eat”, “yes, can eat in moderation” with recommended amounts? Would this be in the video? I am familiar obviously what is going on with me and am looking to simplify.
Hi Salvatore, It is not practical to make such a list. But here is the kidney stone diet, and it is identical to the ideal US diet. So actually anyone in the US is advised to eat this way and can using standard food. Jill Harris has inexpensive online courses and classes and probably is your best bet for help. Regards, Fred Coe
I have two questions:
1. Is there a comprehensive list of foods with information on calcium, salt, and oxliates either on this website or elsewhere?
2. In a reply Dr. Coe states that there is no truth in the connection between drinking lemon juice (unsweetened) and stones, yet Jill Harris has info on the benefit of drinking lemonaide to raise urine citrate levels which reduces stone formation risk. This seems to be a contradiction. Can you please clarify. Thank you, Jack Luskin
Hi Jack, Jill and I are partners, so I am sorry if we appear to have lost touch with each other. It is that if one wants to increase urine citrate – the only value of lemons – we have better ways of doing it. Lemons have a low enough pH that the amount of citrate vs citric acid is not ideal- too much acid form vs the citrate or alkaline form. Lemonades, like Crystal Light, have a higher pH than lemon juice and a lot of citrate. So Jill and I favor lemonades of certain kinds, and we neither promote squeezing lemons. As for high calcium low sodium foods, Jill and I did our best here. Regards, Fred Coe