Like much of medicine, kidney stone disease is organized around a set of phenotypes, idiopathic calcium oxalate stone formers for example. A useful if medieval Platonic idealization, when looked at closely these phenotypes invariably disintegrate into what one might call medical atomism – the tyranny of the individual case.
When asked for an example of an idiopathic calcium oxalate stone former I never can find exactly the ‘perfect’ case but rather someone who fits well enough but with – how shall I put this? – rough edges, stray facts that do not fit the mold.
What this really means is obvious. Every physician practices ‘personalized medicine’ and, like most medieval intellectual conceptions, phenotypes have value more as metaphor than as a guide to the day’s work.
What it also means in that every patient is a node in the matrix of pathophysiology, clinical manifestations, and treatment complexities that make up this field, being a place in which all together give rise to the one single manifestation – crystal formation – which defines our work.
So I did not bring these cases, suitably disguised, from my precious museum but simply from recent outpatient sessions, as I find in almost every patient more or less a unique set of oddments that serve very well as special instances of general formulations – the reason cases are so important – concerning clinical evaluation, the technical business of pathophysiology, and the elaborate compromises of therapeutics. Every case is an ‘everyman’, and ‘everywoman’. You just have to look close and each one is a universe.
Ages are deliberately vague, dates for labs are presented from 0, the first one, upward in days or weeks or more. Occupations are similar but not the same as the real one – because people deserve privacy. Lab data, stone composition, rates of formation, treatments, and outcomes are rigorously exact.
Case 1: A Stone Former
As you will see, this is a person with considerable numbers of stone attacks who has certainly produced large stones in the past, but he posed major problems in deciding if stones were active and is therefore a perfect place to start. His many laboratory abnormalities are just wonderful for thinking about stone pathophysiology.
Case 3: A Success Story
This is a first for the site, and perhaps it should have been a feature long ago. After all the generalizations and reviews there is something wonderful about a single instance that contains all the elements of a topic in the kind of instructive detail we can get only in life itself. Pat – who has permitted me to use his name and data – forms calcium stones and has idiopathic hypercalciuria and a job that makes hydration a problem.
Case 5: Severe Hyperoxaluria
Severe hyperoxaluria – always worrisome, never something to dismiss or even wait a long time thinking about. The Vegetable Seller’ by Flemish painter Joachim Beuckelaer (c.1534-1574) seems a perfect image for this exercise in vegetable excess. He was never very famous but influential concerning food and kitchen scenes. Jill Harris (pictured right) co-authored this article with me. Kidney Stone History This 47 year old woman had her first manifest stone 12 years before I first met her.
Case 2: A Calcium Oxalate Stone Former
CLINICAL FINDINGS: A man in his fifties formed his first stone in the early 2000’s and his last 6 months ago. There was a single passage event a year or two after the first stone at which time he was given hydrochlorothiazide 25 mg daily.
Case 4: Medullary Sponge Kidney
Medullary sponge kidney (MSK) is more spoken about than witnessed, and more witnessed than accurately diagnosed. This patient adds to the 12 we have described in our publication, and adds also in having a very long and evolving history with one of us (FLC). We write for a general audience yet hope to include a level of detail that satisfies physicians and scientists. Here, we may fail of clarity to the one audience or of a sufficiency to the other because the disease is complex.
Case 6: Bariatric Surgery and Kidney Injury
Bariatric surgeries can injure kidneys by raising urine oxalate excretion. This latter causes kidney stones, and raises risk of acute and chronic oxalate nephropathy. Overall, their benefits far outweigh these risks, especially when patients and physicians take proper precautions.But risk lurks as if in shadows, and waits on accident. The patient here inadvertently raised her risk of injury. Like all instances this one is just that: Opportunity to inspect the details of an undesired outcome so as to reduce the chance it will happen to others.