ART OF STONE PREVENTION

CoeTie4

A particular manner

Here and there physician friends have asked me about how I practice. But however much I have written about kidney stones, nowhere before have I told about how I practice because I feared my style might seem too odd. But it is not if you consider how narrowly I have chosen to focus.

My clinical life is based on several facts. One is that doctors send me their patients and expect that I will prevent recurrent stones. That is all they want from me. This means that I can depend on other physicians to do everything else, focus on the pathogenesis of kidney stones in a particular patient and fashion for that patient a program of prevention which will disrupt that pathogenesis and reduce or possibly abolish their illness.

In the title of this post, I say ‘art’ because physicians are makers. We make a treatment plan for every patient that will result, in this case, in less stones. In the making of such plans, I use only a few remedies, which most of you know about, but I probably use them a bit differently from most.

Time

Although I have seen about 6,000 stone patients, I still take a very long time with each one. New patients require an hour or more, and it might surprise you to know that many return visits can take as long or longer. Such lavishness would be unreasonable in the broad world of medicine, only in a world like mine, subsidized by a tolerant university and the willingness of our culture to support a few odd sojourners like me can someone lavish so much time on one task.

The time is partly to get the history right. Stones arise through a compound of inheritance, habit, accident, and chance, and no two patients are exactly alike in how they became stone formers. Although I have not written any proof of it, no two have the very same treatment programs if you consider not just superficial aspects of diet and drugs but the details of life and work and habit that need to be altered. It is in those details, in the thick of the brambles, I usually find the real reasons for stones and, having found them, fashion my treatment plan around them. This patient did some odd thing, that one something else, for a while or for a lifetime, and will not tell me right away. Some do not know what caused their stones. Some know very well but will not tell unless I stumble on it. That is where the variety hides, and where I spend a lot of time.

The rest of the long time I take is used in explaining and in finding ways to change things, for I must bring about a change in life. It sounds easy if you have not tried it, but most of you know it is not easy. Patients will always acquiesce on the moment, and then do as they desire. I must somehow change their desires or fail. And these desires are about important matters: How they work, how they eat, how they entertain themselves, how they strive to remain healthy. I know that much of general medicine concerns itself with healthy habits, but my work is not like that. It is not general, but so particular as to reach into the detailed reality of the lives as lived, and it is there one meets with beliefs and resistances, and desires, and habits.

What crystals know

Of course it is not behavior that makes crystals from, it is urine chemistry. I use the standard 24 hour urine to gauge the immediate forces that control crystallization and use my clinical history to understand what aspects of life have affected those forces and which of them might be alterable. Everyone does this, I simply do it with unusual focus as it is all I do.

Consider this patient.

A woman of 42 began forming stones at 32, not an unusual age. Her latest stone was in the past year, and in between the first and last she had 4 other episodes. For her stones she has had 3 SWL procedures, and one ureteroscopic removal. An early stone report showed calcium oxalate dihydrate with 15% hydroxyapatite. A more recent stone analysis reported 45% calcium oxalate dihydrate, 5% brushite, and the rest hydroxyapatite. A recent CT showed bilateral universal papillary and perhaps medullary calcifications varying from 1 to 5 mm. A brief trial of hydrochlorothiazide some years prior had resulted in hypotension and the drug was stopped within 3 months. She had been advised to maintain a high fluid intake, which she said was her habit.

Her mother, who had herself developed premenopausal osteoporosis, urged calcium supplements on her which she used from her early twenties. She became a nurse, and in her mid twenties specialized in orthopedic surgical work. She married and had two children at ages 33 and 35, which interrupted but did not stop her nursing career that continued through a combination of day care and willing grandparents. When stones began she stopped the calcium supplements, and went on a low calcium diet. Her husband is a skilled pipe fitter with steady work in a foundry.

As I do in all cases, I obtain the blood and urine laboratory results I will need in advance of the visit so they are available without needing yet another visit. So when I had finished with the initial  history, I had the labs ready. Her blood chemistries were normal – in particular she was normocalcemic. Her 24 hour urine studies – I do three, not two as is more common – showed mild hypercalciuria, mild hyperoxaluria, a volume of above 2 liters, a pH of 6.5 on average, and only modest supersaturations with respect to both calcium oxalate and calcium phosphate. Urine sodium excretion averaged 175 mEq/day. Her urine calcium excretion varied with her urine sodium excretion in an obvious manner, as I commonly find. I made her a little graph to illustrate the point.

What life does

Of course, this is a patient with sodium dependent, genetic – idiopathic – hypercalciuria which may have been worsened by maternal advice and lessened by low calcium diet. As expected, she had modest osteopenia – I ordered a DEXA scan as any of you would do. The natural initial treatment would be low sodium, high calcium diet since thiazide had already proven troublesome and her calcium excretion was sodium dependent. But her work made me suspicious: how did she achieve her ample urine volumes being a surgical nurse? One of her three collections was on the weekend but I had insisted that two be during working days and the volumes at work and on the weekend matched reasonably well.

The answer, which took some time to get to, is that she drank after her long cases – one or two cases a day – and in the early evenings. The high sodium was from everywhere. Her husband and she were so busy that ‘food’ was ‘take out’ most of the week, and she, being in a hospital much of her day, snacked, as nurses do, on pretzels, chips, and peanuts. Willing as they were, the grandparents could not cook for them to any great extent, and, in fact, had high sodium food habits of their own. So, how can I treat her in a way that will work? How will she achieve constant high fluids, much reduced diet sodium, and much increased diet calcium?

What I did

This is a sophisticated nurse. She knew her fluid intake was variable to an extreme because of surgery and suspected the low extremes were promoting her stones. But she did not tell me. I had to ‘find out’ by going through her meals and what she drank with each, her work schedule, the nature of her cases, and even her snacks before the obviousness of the fluid problem led her to tell me she certainly knew daily intermittent dehydration was a problem.

She knew surgery was causing a dehydration problem, but she was the larger wage earner of the pair, so less surgery was not an option and she did not want it to come up with me. As for her diet, she did not know that high sodium intake would raise her urine calcium, or that combined with a low calcium diet would reduce bone mineral balance; but she did know the family ate badly. This latter she did not tell me until I had asked after all her meals; she knew there was no time to cook or shop properly but given the work she and her husband did what could be done about it?

Of course, making a way for her was not easy. It was all about the nearly impossible realities of two busy people. I did find ways, and her followup urines showed more calcium than at the beginning – higher calcium diet, somewhat less sodium, less oxalate – the low calcium diet and peanut snacks had raised her urine oxalate, and the same volumes. So on average her supersaturations were not better. But she assured me that the urine volumes were steadier throughout the working days. Over time she pushed the sodium down, the volumes up, and saturations fell more. Because of her many stones, and that she had converted from calcium oxalate to brushite and apatite, I added a very low dose of a long acting (23 hour 1/2 life) thiazide – chlorthalidone, 12.5 mg every other day – and achieved a reasonable result.

How, you might ask, did I get her sodium intake down and her urine flow up steadily yet she remain an operating room nurse? I talked to her about how she and her husband worked out their schedules and realized there was no time in the week for anything like cooking. So, I recommended they shop and do batch cooking on the weekends, freeze meals in proper sized containers, and use them for lunches and suppers. As for her water, I worked out her rotating in and out of scrub with several colleagues, which permitted fluids. She has been free of new stones for several years.

The manuscript score is said – on the web – to be an original by Bach. Perhaps a few of you who play classical keyboard music will have recognized the opening of the first fugue in d minor from ‘Art of Fugue’, his vast unfinished masterpiece. Bach is an immortal genius, and we are common folk, but the principle holds. He was a maker, as we are. Perhaps so much greater a maker that the comparison seems ridiculous, but I disagree. We make treatments out of the materials at hand and with what skills we can achieve. If we believe, as does the spiritus mundi of the West, that even one individual life is priceless, then what we do is, in its way, considerable under heaven. And, I might say, worth even my extravagances of time in the doing of it.

When I work

I see patients only one half day a week, because as a professor I do research which takes a lot of time and for which research grants provide support. Likewise, the writing of books, chapters, reviews, and papers takes up a lot of life. My meager clinical life is not odd for a university research profession; many I know do what I do. It is in fact the very smallness of the actual clinical time which permits me to be so specialized, and to have leisure to review what has happened to the patients I have seen so that past mistakes need not be repeated for a lifetime. My Google page is public; if you follow the link, and look, many of my papers have described what I have seen, and in the making of them I have made and remade the way I work with patients.

How I get paid

The only way that works is to bill by time. I keep track of how long I spend, and the university bills for that time. The documentation of the medical record for various levels of care is a distraction to me, and utterly unfit to what I do. What good is a stock review of systems, as an example, to someone who is after extreme details concerning the whole health and behavior of a patient? The basic assumption of my practice is that other doctors provide the broad range of care and have sent their patient to me for one special thing. I tell all patients about my specificity and the need to have proper primary care; to my knowledge they all do.

How I report

The computer formatted record is useless to me. I need to produce a consultant’s report, and do it in a way patients like and I find very effective. I use a blank report form in the EMR and share the screen with the patient by turning it at an angle where we both can see it. I tell patients we will write the record together and to correct any errors as we go along. I use up about a full single spaced page and when they leave patients get the report to take with them. We mail it out with all labs alter on to the physicians, and the patient. Incidentally, I have sent all my patients their entire record since I began in 1969, and have never encountered a single problem in doing it.

Something for later on

I haven’t told you everything. Nor can I. But I can bring some cases, as time goes on, and hope they show what I cannot tell. You might offer some, too. I am happy to have guests post a case. Let me know.

Bach was a teacher, incidentally. He wrote the 48 preludes and fugues partly for his gifted children to learn from. I believe the violin and cello suites, French and English suites, even the Musical Offering – though presumably made for Frederick II of Prussia – were also by way of education, perhaps his own. As for Art of Fugue why write 17 fugues in d minor on one theme if not by way of illustration; they make their way through every kind of fugal technique, and culminate in an unfinished fugue of such complexity no one has ever been able to fashion a reasonable ending for it.

Fredric L Coe MD

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33 Responses to “ART OF STONE PREVENTION”

  1. Arno Lowi

    hello Dr. Coe, I sure wish I had discovered you 40 years ago. 60 year old male here, with first passing of kidney stone at age 26, and 6 since then. Also first recorded hypertension about the exact same time. A couple of times the stones were clearly related to eating spinach and swiss chard and beet greens, because I did not know at the time that those foods are very high in oxalate, and they were my favorite foods one summer in my 30s. I continue to form stones, depite adhering to a low oxalate diet, adequate H20, and daily dosing with K Citrate. I take Verapamil, Losartan, and Flomax. I am going to ask a simple question. I have three siblings, and none of them have ever had a kidney stone, neither do any of them have hypertension. Another difference between me and my siblings is I have Ehlers Danlos Syndrome, which affects many aspects of my life, notably chronically dislocating joints with pulled tendons and ligaments, orthostatic hypotension with hundreds of dangerous instances of syncope, and aortic arch enlargement on echo. The question is: is the kidney stone forming possibly related to connective tissue issues in the kidney? Second question, if I may have a second one, is do you have any recommendations for my regimen. Thank you.

    Reply
  2. Sarah

    Thank you for all the information you provide on here! I enjoy reading everything. I wanted to let you know how I got rid of 4 kidney stones in 2 months as confirmed by ct scan with contrast and ultrasound. In Dec I had an emergency ultrasound for pain radiating from my ovary (it was discovered I had a ruptured cyst) but coincidentally the tech saw 4 stones (3 in left kidney and 1 in right) all around 4-6mm on average on ultrasound. Needless to say I was dismayed as my last kidney stone was 5 years ago and it was 1cm which was surgically removed and a temporary stent put in my ureter. I have been taking daily 300mg of magnesium citrate for years and if I had colicky pain I started Chancra piedra right away and the pain resolved. With my new finding a I did a google search on anything new coming out in the urology field concerning kidney stones and came upon new promising research on hydroxycitrate. I looked and looked but only could find one product that was hydroxycitrate (I did not want a garcinia Cambodia product for weight loss). My ultrasound was Dec 8, after this time I started drinking much more fluid during the day and started hydroxycitrate on Jan 5, I took 500-750mg daily until Feb 28 (1.5 months) and stopped. Yestrday March 8 I had an abdominal CT with contrast as my urologist wanted to see how large the stones were and what the next plan was. I am happy to say I received results today and no renal calculi was noted at all. All I can attribute this to is the hydroxycitrate. Even my urologist was stunned that all of them are completely gone with no trace and asked to see the product I was taking. Just wanted to share this somewhere and say that maybe, just maybe this might be a new way to help stone formers. The product I was taking was hydroxycitrate by Solgar.

    Reply
    • Fredric Coe, MD

      Hi Sarah, hydroxycitrate is a readily available commercial weight loss product that can affect crystals. I have remained silent about it pending some trial evidence. But a CT with contrast worries me- one cannot see stones through contrast. Be sure views were taken before contrast was given else they may be there, still. Regards, Fred Coe

      Reply
  3. Michael Egan

    Hi Dr. Coe,

    I’m a 45 year old male and have just had my second lithotripsy procedure – two years in a row!

    Given my recent history and the latest CT scan showing another stone developing in the the kidney now, it is pretty clear I’m a “stone grower.”

    I’m looking for any recommendations for doctors or facilities with kidney stone experts who can help me reverse my stone growing.

    I was considering traveling to the Cleveland Clinic or Columbia’s Kidney Stone Center, but I’m wondering if there are any experts you recommend who are closer to my residence in charlotte, NC?

    Thanks in advance for any help/suggestions.

    Regards,
    Mike

    Reply
    • Fredric Coe, MD

      Hi Michael, You mention two excellent centers. If you have to fly, you can also come to us – we never say so in this site, by choice – but do help many who fly here. I am not familiar with stone prevention in Charlotte. Regards, Fred Coe

      Reply
  4. Julie D.

    Dr. Coe, I am curious if you feel I might be a good patient for you. I am now 36 and started passing stones at age 20 (spent almost half my life with kidney stones). I’ve had 5 or 6 lithotripsies (losing count now) and felt that these only exacerbated my stone formation since the fragments always dropped to the base of my kidneys and didn’t pass. Some of the CT scans I’ve had the radiologists actually stop counting the stones and stated so in the report because there were so many. I have them in both kidneys. I just passed another stone yesterday and was anxious because I haven’t been to the urologist in a while so I have no idea on the current size of my stones. I tend to just pass the stones on my own at home because I figure there isn’t much point going to a hospital since I suspect the only thing they’d be able to do is confirm stone size and help manage the pain. I now only have a lithotripsy if a stone is too large to pass. My mom and sister both have a history of a few kidney stones, but nothing even close to the number I have.

    I suspect that food allergies may be a contributor to my stone formation. I suspect that I retain fluids when I’m exposed to a food allergen and that decreases the fluid available for urine. When I was pregnant, I gained 50 pounds the first time and 30 pounds the second time. Within a week of birth, I had lost almost all of the weight gained during pregnancy because it was water weight. I didn’t discover my food allergies until after my second pregnancy at around age 30. When I first discovered my food allergies, I lost 60 pounds in about a year. I’ve suffered from these food allergies for most of my life without realizing it. One of my major difficulties is that I really cannot avoid all of my food allergens. One is corn and it is literally in everything so my only hope with this one is to keep the level low enough that I don’t have bad reactions.

    Since trying to avoid my allergens, I had much reduced frequency of passing stones. However, I’ve been busy professionally and have reverted back to a bad diet of eating out too much. I am convinced this is why I started passing stones again. I also had to gain weight because after losing 60 pounds I was underweight. So I resorted to eating some things that I shouldn’t to avoid being skin and bones. Now I am overweight and need to lose weight again. I feel like the doctors I’ve seen in the past just use the same old formula they’ve always tried and hope it works. It sounds like you are different and different is very welcome at this point. If you have the ability to work with me remotely or help me locate a colleague in Texas with a similar focus on stone prevention and finding the root of the stone formation cause, then that would be ideal since I am not sure if travel would be possible (would depend upon required frequency). Thank you in advance for any thoughts you may care to share. Regards, Julie

    Reply
    • Fredric Coe, MD

      Hi Julie, Indeed at UT southwestern, Dallas, I know three outstanding kidney stone experts. Dr Peggy Pearl, Dr Orson Moe, and Dr Sakhaee. All three are famous for their work, and good friends of mine. Surely one or another will resolve your problems and prevent more stones. I would pick one, let them know I sent you, and perhaps choose which of the three will be most efficient for you. Let me know, Regards, Fred Coe

      Reply

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