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.
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
Return to Walking Tour on Supersaturation
78 Responses to “ART OF STONE PREVENTION”
Dear Dr. Coe:
I have been diagnosed with a bladder infection of Morganella Morganii 100,000 CFU/ml. This type of bladder infection is typically associated with catheters and bladder stones. The urologist did not do any tests for bladder stones and I clearly am not catheterized. She said that bladder stones generally don’t occur in women because our ureters are short and large diameter. My symptoms are frequent urination of small volumes and on infrequent occasions some dull aches in my lower abdomen which I interpret to be emanating from my bladder. I am post menopausal and have a BMI of 25.
Alb/Cr Ratio, Random 8 mcg/mg Cr (0 – 29 mcg/mg Cr)
U Albumin Conc, Random 7.2 mg/L
U Creatinine 87 mg/dl
My eGFR has ranged from 59 to 70 mL/min/1.73 m² over the last 5 years
Here is a little history – I started a ketogenic diet when diagnosed with diabetes almost 5 years ago. Although diagnosed as Type 2 initially, it was later determined to be Latent Autoimmune Diabetes of Adults (LADA), Type 1. My diabetes is well controlled my HbA1c was 5.6 at last testing. The ketogenic diet was able to allow me to avoid starting insulin for 4 years, but I was consuming foods that were high in oxalates (particularly almonds, almond milk, and almond flour, as well as spinach). About 1-1/2 years ago I developed bladder pain that sometimes was bad enough to keep me awake at night. After researching on the internet I came to the conclusion that it might have been caused by high oxalates, so I cut way down on high oxalate containing foods. The bladder pain essentially went away, but I was left with the symptoms of more frequent urination of small volumes which the urologist attributed to being older (65) and incomplete emptying of my bladder. So my question is this: might I be an unusual case of a women with bladder stones and that the stones are potentially creating a welcoming environment for the Morganella bacteria and also making complete emptying of my bladder difficult? I have not been treated for the bladder infection, as the antibiotic offered had nasty side effects, so I declined to take it. The urologist did not think having the infection was a concern. None of my doctors have been concerned with my somewhat low eGFR, but it makes me wonder if it could be related to the oxalates. I have read research on hydroxycitrates (before seeing the post on your website) and recently started taking some to see if it would make any difference. Would you recommend pursuing any additional testing based on my history?
Fredric L Coe, MD
Hi Betty, I would think a CT of the bladder area would disclose any stones. I would ask my urologist why your bladder does not empty completely given that the female urethra is indeed short. A (very) brief review of M Morganii on PubMed yielded many hits. Here is a recent review. The organism has urease so it can transform urea into ammonia and promote struvite infection stones. This is why it is very important to look for stones in your bladder – or perhaps crystals. It is a pathogen and highly resistant to antibiotics, and increasing in prevalence world wide. I am concerned that if it is producing crystals using urease it can persist in your bladder, cause your symptoms by irritating the bladder lining, and possibly reach into the kidneys. I would start with ways to look for crystals. Antibiotics are not very effective given its remarkable resistance elements. I wonder how it got there – in you. On PubMed you will find a lot of articles like this one. Regards, Fred Coe
Honorable Dr. Coe,
After going through numerous doctors/urologists/nephrologists, i am stuck in the position of having little to no hope of prevention of these recurrent stones. At one point, I had passed 6 in a month with the biggest being 1.4 cm.
I have the returned results of supersaturation profiles as well as serum results but as a layman, these are little or no use to me without the expertise. Having received the results, my doctor’s just prescribe the regular – “drink lemon water route”. As I know how beneficial the lemon water can be in prevention of my oxalate and phosphate oxalate stones I have continuously utilized these guidelines as well as the guidelines of increased calcium/limited sodium to no avail. It seems hopeless. I am constantly at a point of having a stone in my ureter at any given time. I have gone through numerous doctors who offer no help in prevention or cause but of course opt for treatment of current stones via surgery (understandably so). The follow up is scarce or lacking even after pushing.
As background, I am not an overweight individual at 6’0, weighing 180 lbs, living a semi sedentary life at an office job.
My supersaturation profiles come up normal with the below heavy discrepancies:
Citric acid : 15 mg/24 hr
Urine sulfate : 32 mEq/24hr
Calcium Oxalate ratio : 6.41
Brushite Ratio : 4.21
Monosodium urate : 6.49
I know a lot of these are a “hodge-podge” of ingredients and the perfect storm for stone formation.
Please note – ph levels of urine always indicate the 7-7.5 range.
My blood levels at this point come up with high creatinine content at ~1.68 range.
Blood urea nitrogen also comes up as ~24 mg/dL
A recent test of pth function came up as the pth intact value of 98.9 pg/mL.
My first stone attack was 2015-2016 and I am a 27 yo make.
I take escitalporam oxalate 7.5 mg – and I see in the very rare side effects is stone formation but have been told numerous times this is not the cause.
I do not know what to do and need true expertise in the field.
Thank you kindly doctor.
Fredric L Coe, MD
Hi Paul, You do not mention what your many stones are made of. I suspect they are hydroxyapatite given the shocking urine pH of 7-7.5. You have reduced kidney functions (creatinine in serum 1.68) and the high PTH of 98 could be from that or from primary hyperparathyroidism – you do not mention your serum calcium level as being high; is it? The high urine pH and almost negligible urine citrate suggest a form of renal tubular acidosis. I have also seen this in phosphate stone formers whose blood levels of total CO2 are normal. The drug is not a stone risk despite the menacing name – a search of PubMed shows no cases of the drug causing renal tubular acidosis. I think you need a very skilled stone expert to figure out what is wrong. If you tell me where you live I could try to identify someone near enough. Regards, Fred Coe
Your website is by far the most informative I have found and I thank you in advance for any insight you may have. I am 62 have passed a 7mm stone in 2006 and another 4mm in 2018. (calcium oxalate) I currently have 3 stones in each kidney- I have no pain, no abscess etc. I follow up yearly and each time they find 1-3 stones but this is the first time that 2 stones measure over 4mm. I have faithfully taken B6 and magnesium and drink at least 2.5 L fluids daily. But in hindsight, I see that I eat way too many green leafy vegetables, nuts, and dark chocolate and possibly not enough calcium (either 1/2 cup of milk or 1 container yoghurt and a bit of cheese every day). Do I have to schedule a shock wave lithotripsy per my doctor’s recommendation or can I wait and make some drastic changes in my diet and possibly reduce the stones?
Fredric L Coe, MD
Hi Sandra, You have calcium oxalate stones that are ongoing, and you do not know why. I would strongly suggest testing 24 hour urine and blood to find out and focus treatment on what is the cause of your stones. Changing diet without knowledge can be futile. Regards, Fred Coe
Dear Dr. Fred
Back with a doubt. I did analysis to my vit D and although i go and walk in the sun during summer months and eat a varied diet, now in the winter months, my endocrinologist told me to take vit D, one pill a month. She told me it is only maintenance, not treatment. Is it OK? She told me it wont increase my risk of stones. Thanks
Fredric L Coe, MD
Hi Maria, Routine vitamin D supplements do not raise kidney stone risk. Regards, Fred Coe
Dr. Coe, I appreciate the information you share with us! So far, I have never passed a kidney stone, but I have heard stories from an aunt. I have had quite a lot of joint pain, and that pain moves around a lot including to my back. Sometimes it is just a stiff neck, other times it is pain in my achilles tendon, pain in my knee, or pain in my back. I suspect some of the pain has been in my kidneys. While I work I try to find time to drink water and coffee. It is difficult to find the time. In the past, I ate green vegetables daily including spinach, asparagus, or broccoli. That has been stopped, because of the oxalates. In the past, I occasionally took calcium supplements, but I’ve noticed the calcium supplements and vitamin D have been associated with my increased pain. Now I think you would suggest that we consume dairy products, and maybe you would suggest they be combined with the cocoa or coffee we crave. I snack on salted peanuts, and maybe I should stop. I have tried potassium citrate, and I noticed it relieved my back pain. Simultaneously, it seems to change the dull joint pain into intermittent stinging in random spots under my skin. Maybe you can shed some light on what I am experiencing. And is it likely that my joint pain is related to calcium oxalate? https://www.nutritionist-resource.org.uk/memberarticles/oxalates-a-possible-cause-of-pain-and-illness
Fredric L Coe, MD
Hi Richard, Since you do not have known stones, much of what we write here does not apply to you. Oxalate is a rather modest offender in people with normal kidneys and not likely to cause systemic pain despite the occasional hype in the press. I would strongly suggest leaving well enough alone and not doing serious changes in diet or taking supplements without your physician’s help. If you are concerned about stones, ultra low dose CT scanning poses minimal radiation risk and can settle the matter. Regards, Fred Coe
Can you recommend a surgeon in San Francisco who can help me with my stones. I am in so much pain. I am a 53yr old male and my last urologist Dr Kahn had retired and I desperately need a great recommendation as I have extreme pain on my right side from new stones
Dr. Marshall Stoller is a prominent doc in your area at UCSF
I had a RNY surgery in 2000. There is no history of stones in my family. I had one small stone in the upper folds of my right kidney which was removed in 2015. I have had small ones in the left that have passed on their own. This past Sept had a large ugly CaOX stone that was stuck in the top of my right ureter removed. There was no urine coming out of the right side noted in surgery. The Xrays and CT showed the stone but didn’t mention it was in the ureter just on the bottom of the kidney. I had no real symptoms and planned to get it done in November. Luckily circumstances of losing insurance happened and I had the surgery in Sept. My right kidney is much thinner than my left which looks normal. I do not know how long no urine was able to pass on the right side. My GFR was normal until 5 years ago and began going down.(I am 62) The last values were 38, now 42. Naturopaths have given me Kidney Korrect to try, I do a monthly IV to get more fluids and B vitamins. I am thinking to ask to switch from Lisinopril (been on for 10 years) to one with a diuretic if it helps with the stones. My fluid intake is low. I putout 1-1.2L/day and I have to push to get that. For fourty years I was a lab tech and not allowed to drink at work except during my 30 min lunch on an 8-12 hr shift. I’ve lost my natural ability to be thirsty. My diet has been chocolate and ice tea with very little water, supplemented with hi protein food because of the RNY. Between the RNY and the stones, many of the foods to eat conflict. My 24hr urine oxalate is extremely hi and citrate low. I’ve dropped the ice tea, still drink a cup of hot tea in the AM), drink some herbal teas, and trying to cut down on the chocolate. I’m trying to drink more as I am now retired and can drink freely for once, I am taking CitriCal twice a day. I had a sample of UriCit-KCit but the 15mg size is way too big for me to swallow so we are trying diet, more water and Citircal first. I will try now to follow a low oxalate diet and drink more water. AM I destined to have kidney failure at some point and continue to have stones? When the stent came out after 2 weeks there were visible crystals on the end of the stent.
Fredric L Coe
Dear Lorri, You have a very serious problem. Some function is lost on the right from obstruction and overall kidney function is reduced a low and urine oxalate is very high. Your risks are partly from more stones, which can be improved with fluids and reduced diet oxalate, and with increased diet calcium to lower oxalate absorption. But crystals can form inside the kidneys and cause progressive renal failure. I would discuss this latter with your physicians, and consider the possibility of reversion to a gastric sleeve. The Roux en Y procedure drives your high urine oxalate, and it is hard to reduce it. Be sure and discuss this matter with your physicians sooner than later. Regards, Fred Coe
Thank you Dr. Coe
Will b sharing your presentation with my Endocrinologist, Dr. Wayne Enron.
He has offered to help, where others have failed. Please tell me that there is DNA testing that can solve the kidney stone mystery, or fat malabsorption research that can unlock the mystery of bile salts.
Suzanne Plesha from Pennsylvania
P.S. Do you work with a colleague named Rita McGill? She was my kidney doctor in PA
Fredric L Coe
Hi Suzanne, DNA has not been of much help so far. Fat malabsorption is a factor in people which small bowel malabsorption, from bowel resection, obesity surgery, or inflammatory bowel disease or pancreatic insufficiency. Rita and I do work together, and she is a wonderful colleague. Regards, Fred Coe
Thank you Dr. Coe,
for your prompt reply.
I see my Endocrinologist tomorrow, Dec. 3, I will be sharing your reply.
Hello Dr. Coe,
I am a 53 yr. old male, had 4 stones that required medical attention since i was 32. The last stone was in Aug. 2018 that was on the right side that 5.7mm that blocked the kidney and required Lithotrypsy and stent placement. The one in 2010 was on the left side and it was 6.4mm caused hydronephrosis and pylonephritis, required surgical intervention.
The stones were mixed.
The most current 24hr collection test showed: high SSCAOX, as well as Urine Oxalate, the PH 6.118, with moderate uric acid at 0.875.
What would you recommend, is there a specialist in NY to see?
Fredric L Coe
Hi Yuri, Dr David Goldfarb practices in NY at NYU and is an expert in these matters. He will want to know what the stone was a mix of. I can recommend him highly. Regards, Fred Coe
On July 1, 2019 I had a 5 mm. stone that had been lodged in the proximal portion of my ureter since, at least, May 1, 2018, move down to the distal portion of my ureter. Other than the pain felt on July 1 during its’ movement and the occult blood produced for a few days coincident with that movement, I have had no further symptoms of pain or occult blood. My Urologist order a KUB x-ray which showed the stone in the distal portion of the ureter on July 24th. Is there any reason to have this constantly x-rayed every few weeks and/or the stone removed by ureterscopy IF IT IS PRODUCING NO SYMPTOMS, whatsoever? Thank you, very much, for any advice, on this matter….of which I am in disagreement with my Urologist on what I see is an excessive prescription of testing on his part.
Fredric L Coe
Hi Kurt, Here is the problem. It is precisely this kind of stone that can silently obstruct your kidney and cause irreparable damage, so in this case no amount of surveillance is too much – low risk, but of catastrophic outcome. If I were she/he I would be doing ultrasounds or flat plates and worrying about kidney loss. Likewise, after a while I would want the stone out altogether, and URS would be a first choice. Here is a rare case where an outsider with no real knowledge of your medical details can still weigh in – your physician is right and he/she is protecting you. Do it. Regards, Fred Coe