How to Lower Blood Pressure in Kidney Stone Patients

Unfortunately producing stones means higher risk of hypertension and kidney disease. But most of the diet changes and even first line medications for stone prevention also lower blood pressure. Here is how that works.

The featured painting, Vincent Van Gogh, The Starry Night. 1889. Oil on canvas hangs in The Museum of Modern Art, New York. Somehow, to me, the whorles of color bring blood pressure to mind. Some say the yellow halos about objects came from digitalis excess, from his physician.

My Sources

From time to time, quantitative scholars produce ‘guidelines’ about diagnosis and treatment of disease. Recently, a band of such have compiled results from the large literature on blood pressure treatment and given us this new compendium. For those with a taste for ‘primary’ sources’, here is the full version. I plodded through this turgid swamp, this winding endless bog, and gathered for you the wildflowers one commonly finds in such places. Here they are: the nuggets of gold left in the pan.

Blood pressure

There Are So Many in a Day

The heart is powerful and quick. Every left ventricle contraction stretches and distends our blood vessel walls with the blood pumped into them. They relax for a moment on the diastolic, between beats, while the left ventricle refills from the lungs through the left atrium. Given 70 beats a minute, and 1,440 minutes in a day, each day brings 100,940 separate systolic pressure peaks and diastolic troughs to bear on our arteries.

Pressure Itself Causes Disease

Evidence from masses of trials would have it that it is these pressures themselves that directly cause stroke, heart failure, and presumably heart attacks. Other factors interact with pressure to worsen the damage elevated pressure can cause. Diabetes and chronic kidney disease, certainly. Age and being male also enhance risk from high pressure. There are more, less compelling factors as well, like blood lipids. But the one thing we can most easily change is the pressure itself.

What Raises Pressure?

Your genes certainly play a role. Next come factors you can control like obesity and high sodium intake. Other things that seem to foster high pressure are a sedentary life style and inadequate potassium from fruits and veggies. Likewise for smoking and excessive alcohol intake. All of these factors are what we alter when we want to lower blood pressure and are not yet at the point of adding medications.

We Need Multiple Measurements

We are diagnosing and treating numbers – systolic peaks and diastolic troughs. But think about the miserable sample we have – a few beats measured with a cuff by your physician, or a few more measured by you at home. From this meager glimpse, a few frames out of a movie that runs all day and night all your life long, we need to judge and plan.

What can we do?

A single measurement by a physician or nurse can be very accurate, but poorly represent the average of all those heartbeats. One can wear an ambulatory blood pressure monitor that makes frequent measurements, but present models are clumsy. Repeated filling of the cuff every 10 or 15 minutes is tolerable for perhaps a day or so.

Home Blood Pressure

This leaves home blood pressure monitoring. The guidelines recommend it, and I long have asked my patients to do it if high blood pressure seems a problem. Common sense favors them – a cheap way to get a lot of measurements. Experts find they predict cardiovascular outcomes better than office pressures from physicians. Commercial, cheap digital devices reduce measurement to pushing a button.

But there are some things to watch.

Machines

Buy a good machine. Use arm cuff models. Shun wrist monitors as potentially inaccurate.

Cuffs

The cuffs are specific to either the left or right arm. You cannot switch a left arm cuff to the right arm or the opposite. So buy the side you want. The cuff needs to go around your upper arm with a good length to spare and be wide enough to cover the upper arm. So if you are large, or overweight, or a muscle builder, get a large cuff. They come in sizes. If you are thin, or not too muscular, or just small, you want a cuff that fits, so choose for you. Some cuffs, notably those from the preferred manufacturers listed below, can accommodate a standard to large arm, but be sure the one you buy will fit you.

Which Machines are Good?

Although 195 pages long, the guidelines fail to give us the names and model numbers of reliable instruments.

But Consumers Reports (CR), usually a very reliable source, has rated them. Only four of the 14 arm cuff units they studied in their lab, showed excellent accuracy.

Their top unit was Omron10 Series BP786N. However, as good as it seemed in their laboratory 3 of 10 recent reviews found it inaccurate. Most criticised its bluetooth connectivity. Next was Rite – Aid BP3AR1-4DRITE. For it 13/18 reviews were scathing – inaccurate mostly. The third, A&D Medical UA767F had only 3 reviews, two of which complained about faulty construction. Accuracy did not come up, but so few! The fourth, ReliOn, from Walmart had 5/9 reviewers complain of inaccuracy. The unit is made by Omron, incidentally.

Why Are So Many Users Dissatisfied About Accuracy?

How can CR find uniform accuracy and users not?

CR buys units at retail outlets.

Here is their measurement protocol: ‘Accuracy is based on how the model’s readings compared with those taken on a mercury sphygmomanometer used by two trained testers.’

The users had comparisons made at their physician’s offices. Possibly, the users encountered less able comparisons in those offices than those made in the CR labs – ie, the physician office testing is problematic. Possibly, units vary. Possibly, cuff placement makes a big difference, but in a physician office this is presumably supervised by a nurse. Possibly, most users are happy, comparisons at physician offices are fine, and they do not bother to write in.

Bottom Line

Possibly this, possible that: what do we do? Bring the machine to your physician, get it checked. Take note of how CR did it (just above) and see if the nurse will duplicate those tests – 2 comparisons, i.e. four measurements.

Procedure of Measurement

No, it is not just ‘put on the cuff, push the button, done.’

When

Mornings before taking any medications and/or evening before supper. Never after a meal. Likewise, never until at least 30 minutes after smoking, caffeine, or exercise.

Experts say to sit quietly at rest for at least 5 minutes before the measurement. Frankly, that is a long time. I don’t see nurses taking that much time in physician offices. Probably a nice long contenting rest gives better – more stable – results. But if we ask too much, we may end up quitting.

I say 2 minutes or so is reasonable.

At the beginning, for the first few weeks, measure in the morning and in the evening before supper to see if there is a big difference. If there is, then make all your measurements at the higher time. If not, then pick the one most convenient and stick to it.

Technique

Sit in a straight chair – no slumping.

Put your feet flat on the ground and uncross your legs – pooling of blood below the knees is not ideal.

Put on the cuff as the instructions show – there is usually an arrow to align it with your elbow. It should be snug.

Support your lower arm on a desk or table. It – your forearm – will be below your heart, but your upper arm – from the elbow to the shoulder – will be more or less along the course of your heart.

Let a few minutes go by as you think about something nice.

Push the button.

I think two readings are ideal, about a minute apart. The system memory will record them.

Get Trained and Checked

If you are neither a physician or nurse, here is a time to use your physician’s office in a cost effective and unquestionably valuable way. Schedule a time, bring in your machine, and let a nurse show you how to use it. She can check your reading of you against her own reading with your machine – they must match. Likewise, she can check her measurement of you with your machine against her measurement of you with her machine – usually more expensive and accurate than yours.

Although CR used classical mercury manometers, the automatic machines your doctor has in the office are usually a lot more expensive and more accurate than anything you would buy, and good enough to check your machine against.

Records

All this fuss – let’s keep the numbers straight. Personally I like a spreadsheet – free from so many sources now. I put the systolic, diastolic, and pulse rate in three columns, and the dates on the rows. If you make morning and evening measurements, use six columns, 3 for each time. But some paper will do if you have no spreadsheet, or the will to make one.

Should we record the first and second measurement as two rows for a single date, or average them to one row? I like the latter. Average: add the two together and divide by 2. Your phone calculator will do it just fine.

Name The numbers

You have made your measurements. Now, what do they mean? Who has ‘hypertension’? Who needs treatment for it?

BP Categories

Their Names

Below 120 and below 80: Normal. This is the far left bars on the chart. Red are diastolic blue systolic ranges. I set the lower end of the normal ranges rather arbitrarily. The keys are the tops of the bars.

120-129, and below 80: Elevated. The red bar does not reach 80, the blue bar is above the 120 line.

130 to 139 OR 80-89: Stage 1 hypertension. I labeled as stage 1 (D) when it is the diastolic pressure that makes the diagnosis, and stage 1 (S) when it is the systolic value.

Above 140 OR above 90: Stage 2 hypertension. Likewise I labeled the bars for whether the diastolic (D) or systolic (S) value made the cut.

When both systolic and diastolic values create the stage 1 or 2 hypertension, treatment is the same. But perhaps one should worry more and act with dispatch.

All of these blood pressure names refer to the average of two or more measurements made on two or more occasions.

At the Borders 

What about 120 and 80? Elevated, of course. The systolic pressure is above the threshold.

But this is a game of razor edges! No one can tell blood pressure to one mmHg. One can best say that around these border values one makes a kind of judgement. How else to proceed?

Power of Numbers

If you really do measure a lot of blood pressures at home you can get an increasingly accurate average of your pressure, and that kind of average probably reflects well your ‘true’ average – the average of all 100,000 heartbeats a day over many weeks or months.

Special Problems

In a well ordered world, blood pressure grade is more or less the same using office blood pressure and home blood pressure measurements. For example, if values indicate high blood pressure in both settings one refers to the condition as ‘sustained’ hypertension. On the other hand, when normal in both settings one says simply ‘normal’

White Coat Hypertension

But what do we say when measurements in physician offices exceed those made at home?

Personally I detest wearing a white coat. They never fit well and make me look faint and ghostly. Because they are so ugly, I wear real clothes, almost never color white. But historically, and even now, some doctors show up in their white cotton and poorly tailored coat – like garments, and apparently raise blood pressure either because they are doctors or because patients detest their coats as much as I do.

When office blood pressures are consistently above home blood pressures by more than 20 mmHg systolic or more than 10 mmHg diastolic, one considers this diagnosis. It matters because, in trials, white coat hypertension fails to predict increased all cause mortality, so adding medications or advancing medication levels would be futile, simply add side effects and complexity without benefit. One uses the home pressures as the guide. Sometimes, when matters are unclear, daytime ambulatory monitors help clear things up.

Masked Hypertension

Here things are opposite. In the office, no hypertension. At home, hypertension. Unlike the white coat variety, this ‘masked’ hypertension predicts a risk of cardiovascular and all cause mortality twice as high as when blood pressures are normal. So your home pressures can be critical. Likewise, here, ambulatory measurements for a day or two can help.

Secondary Hypertension

Most hypertension is genetic – primary. But here and there diseases raise blood pressure and we treat those diseases as a primary aim. This is completely analogous to the distinction between idiopathic kidneys stones and stones arising from systemic diseases, but diseases that cause hypertension are a much lower fraction of the hypertensive population.

I shall not review screening for and documenting secondary causes of high blood pressure. It is a deep area of clinical medicine, and not one in which I publish as a professional clinical researcher. Whereas for stone diseases I am such, and correspondingly bold in reducing medical details to a public medium, here I demur, but out of courtesy not fear. For I could do well as a summarizer of the blood pressure causes, perhaps better than some who represent themselves as blood pressure experts. But should I not leave to them their own demesne without my footprints on the lawn?

The Importance of Physicians and Good Measurements

It is for your physician to screen and document, as I said.

There is more. If you are on treatment, or not, and if you have increased risk factors for cardiovascular disease or not, physicians can elaborate on my simple explanations in regard to risk and urgency of treatment. One needs to rely on their physician and use what I say as background.

The physician who is treating you for stone prevention is an excellent one to do all this. Stone prevention uses multiple office visits, and time efficiency benefits from stone physicians also seeing to blood pressure.

But obviously, home blood pressures really matter. So do what I said. Get trained, and check your machine.

Likewise, make lots of measurements. They are free. You cannot tell me that life permits no five minutes a day before supper to measure and record. No risk, no cost. Pure benefit.

Risk Factors

Risk of cardiovascular death, heart attack, or stroke is higher in people with at least two of these vs. those with only one. Risk factors help set the threshold for use of medication in lowering blood pressure.

Relatively Fixed and Fixed Risk Factors

Fixed

Family history of cardiovascular disease. Increasing age. Male sex – biological maleness. What can you do about these?

Relatively Fixed

Chronic kidney disease (CKD). Obstructive sleep apnea. Low socioeconomic conditions of life. I know the second and third are always potentially remediable, but the guidelines I am parsing for you say otherwise. Frankly, for sleep apnea the best message is that if you suspect it is present get a sleep study and fix it. As for the last of the three, I am far beyond my expertise.

Fixing May Not Help

Psychosocial stress

Modifiable Risk Factors

Smoking; diabetes; lipid abnormalities; obesity and overweight; too much alcohol; physical inactivity or low fitness; poor diet. All of these are remediable and should be remediated. Why not? Stop smoking. Get your blood glucose as well controlled as possible. Diet, and exercise properly. Easy to say? Sure. Crucial? Sure.

Special for Kidney Stone Patients

Having crystals in your kidneys, and being prone to repeated obstruction from stones, virtually all stone formers might best consider themselves as having CKD even if glomerular filtration is not reduced. Stone formers are at increased risk for both high blood pressure and overt kidney disease. So when you do your addition of risk factors, add 1 up front because you form stones.

That means your go into the higher risk bracket with only one other. If you are male, or older, too bad. You are already in a high risk category.

This is a powerful argument for all stone formers to attack every modifiable risk factor with zeal and impudence. Why tolerate any of them if exercise, a good diet, and restraint can eliminate risk factors you do not need? And, as for blood pressure, insist on the best possible outcome.

Goals

Lesser Goals Are Recommended

By the way, have I mentioned what are the blood pressure goals?

According to official doctrine of the Guidelines: Below 130 mmHg systolic pressure and below 80.

But, in the most recent SPRINT trial, below 120/80 mmHg as a goal gave better cardiovascular outcomes.

So why the higher official goal from the Guidelines, this massive pool of experts. One reason is a higher incidence of a serious side effects: Acute kidney injury 4.1 vs. 2.5% total over the entire 5 year trial.

But against this, put the real message: Heart attack or acute coronary syndrome, or heart failure or death from cardiovascular event – 2.25 vs. 2.9 events per year. 

This little snippet from the trial shows the lower hazard for death – any cause, with more intensive treatment aimed at below 120 and below 80 mmHg.

What, then, is the other reason, since the acute kidney injury cannot suffice? It is that the lower goals have not been tested per se in their own trial, using ‘hard’ endpoints such as death.

The Bugaboo of Evidence Based Medicine as Practiced

Here, is why I have trouble with the ‘evidence based medicine’ school of thought. This is quoted, in context, from page 169 of the big swamp: ‘The combination of epidemiological data showing a graded relationship between BP and outcomes, particularly above a BP of 120/80 mm Hg, and the results of the SPRINT trial showing benefit of more comprehensive treatment to a target BP of <120/80 mm Hg, suggests that a lifelong BP below that level will substantially lower CVD and CKD incidence. This is especially the case for younger individuals, those with DM, and those with high lifetime CVD risk based on the presence of multiple risk factors, including high BP. If hard, cardiovascular outcome clinical trials remain the sole driver of evidence-based guidelines, then determining the full benefit of earlier intervention may not be possible because of the cost and length of time needed for intervention.’

Need Conservative Mean Lesser Benefit?

What, indeed, is this mass of words telling us? They suspect, in all their wisdom and pride of knowledge, that below 120/80 is better but cannot say it lacking ‘…hard, cardiovascular outcome clinical trials…’. They cannot say it and so revert to higher – almost certainly less beneficial – blood pressure goals.

Why not revert to the lower ones that seem better?

While we wait for more trials that may never prove practical, what keeps these experts from supporting lower blood pressure goals? Obviously from their own words, they lack the evidence. But they also lack evidence in the other direction. No evidence says 130/80 is better than below 120/80.

My Own Uneducated View

Being no devotee of ‘evidence based medicine’ as presently practiced, I simply propose we ignore their niggling preposterous suggestion, and always go for below 120 and below 80. If our patients experience lightheadedness, we know to back off. We know to move slowly toward our goal. And we know that it makes no sense to offer the lesser quality outcomes from a higher goal blood pressure, waiting for some long off trial to ‘prove’ it is lesser, while our patients lose the benefits of an obvious better choice – obvious to these experts who nevertheless cannot say so until they have ‘hard’ evidence.

Remember, that ‘hard’ evidence must be more cardiovascular events in the over 120/80 group than in the under 120/80 group. Is this an ethical stance?

Physicians Are Not Simple

There is also judgment. If someone has kidney disease, is old or frail, or has cardiovascular disease, we know cautions exist. Patients know, and so do their physicians. Treatment needs monitoring, labs as well as blood pressure measurements. The guideline authors cannot admit that physicians – and patients, too – have not only agency but wit, and thought. As much as I have published reams of numbers lifelong, and performed my own abstruse calculations, I never once have believed they are medical practice – merely its shadow.

Non Drug Treatments

We have our goals: Below 120 and below 80, if possible.

The Kidney Stone Diet

Sodium, Potassium, Sugars, Protein

Low in sodium, high in potassium anions from veggies and fruits, low in refined sugars, moderate in protein – it is ideal for blood pressure reduction. That is one reason why the US task force on diet recommends more or less the very same for all Americans. Unlike the rather vague diet plan in the long and involved guidelines, the stone diet goals are crisp and spare. You can use them with confidence for blood pressure and stones together.

We have become accustomed to low diet sodium advice. High diet potassium is of equal importance. Here is a remarkable review of the topic my partner Dr Elaine Worcester pointed out to me. Physicians who are reading this article surely will want to read the reference. Some patients, too.

Here are predicted blood pressure changes (reductions) from the guidelines:

Sodium <1500 mg/d or 1000 mg/d below your present value – 5 to 6 mmHg systolic and 2 -3 diastolic.

Increase of potassium intake to 100 mEq/day, 4,000 mg/day: 4 to 5 mmHg systolic and 2 mmHg diastolic.

The whole ensemble of low sodium, high potassium, embedded in a DASH type diet: 11 mmHg systolic, 3 mmHg diastolic. This is about what one gets from adding the sodium and potassium reductions together.

Fats

The guidelines continue the low fat recommendation and I am in no position to argue. But given the main effect of refined sugar to raise triglycerides and other noxious lipids, and the long saga of sugar money corrupting science via a deflection of blame onto food lipids, I may sing in the low fat choir but in a soft and muted voice, mouthing the words, impatient for the song to end.

Dash and Me

Dash diet is a kind of veggie, fruit and nut, grain and milk, spare protein and meat variety of the stone diet. I do not favor all the nuts, as being gratuitous oxalate for stone formers. Likewise, the diet has been brutally commercialized with people making money off of innumerable Dash books. That repels me so, I cannot recommend their products.

The US Diet Website

Free, colorful, and filled with diet advice, I much prefer it. I have made more than clear how the kidney stone diet and the US diet guidelines say almost the same things. Only regulation of diet oxalate below 200 mg/d, a matter irrelevant to blood pressure control, differs.

Weight Loss

The kidney stone diet when properly exercised will reduce excess calories. Because it matches the US diet guidelines, and they offer elaborate portion guides, adherence to the stone diet should permit gradual weight control. But high blood pressure adds a significant special meaning.

Lowering weight to the ideal can get you a reduction of 5 mmHg systolic and 2 to 3 mmHg diastolic. This should add to the changes from diet.

Exercise

If you get 90 to 150 minutes a week of aerobic exercise at 65 to 75% of your maximum heart rate (every gym posts these) you get 5 to 8 mmHg systolic and 2 to 4 diastolic. Alternatively, you can do dynamic resistance exercise at 50 to 80% of your maximum for 90 minutes/week. This will get you 4 mmHg systolic and 2 diastolic. Isometric resistance exercises in 3 sessions a week over 10 weeks involving hand gripping to 30 to 40% of maximum gets you 5 mmHg systolic and 4 mmHg diastolic, respectively.

Put together, about 1.5 hours a week of exercises get you about 4 – 5 mmHg systolic and 2 – 4 mmHg diastolic. This should add to diet and weight loss.

Alcohol

No more than 2 drinks a day for men, one for women. A drink means 14 gm of alcohol, or 12 ounces of regular beer, 5 ounces of wine, or 1.5 ounce of distilled spirits. No actual values shown for BP change.

Summary from Diet and Exercise – So called Lifestyle Changes

Diet sodium less than 1,500 mg/d or 1,000 mg below usual – 5 to 6 mmHg systolic and 2 -3 diastolic

Diet potassium 100 mEq/day, 4,000 mg/day – 4 to 5 mmHg systolic and 2 mmHg diastolic

Dash (kidney stone) diet – 11 systolic but only 3 diastolic; so the systolic parts add more independently than diastolic.

Weight Loss – 5 mmHg systolic and 2 to 3 mmHg diastolic

Exercise – 4 – 5 mmHg systolic and 2 – 4 mmHg diastolic

Put these together and even though they may not add up independently we are talking about as much as 11 + 5 + 4 = 20 mmHg systolic from sodium, potassium, weight loss, and exercise alone. This is massive, and without any risk or side effects apart from loss of fun, and facing the gym.

Medications

If you cannot do the diet, the workout, the weight loss, or do them but find you need more, it is meds. But the meds are the same as we use for kidney stone prevention. How fortunate is that?

Staging

People with really high blood pressures, above 160 systolic and/or above 100 mmHg diastolic need medication without delay. Otherwise, why not do all four lifestyle changes, and see where you are?

Depending on BP Levels and Risk Factors

Normal Blood Pressure

Normal blood pressure is not treated with medications even if you have risk factors – like being male, or older, for example. This is true if that pressure was that way or became that way with diet, exercise, weight loss, and reduced alcohol.

Because you are a stone former – who else is reading this blog? – you want the kidney stone diet even with a normal blood pressure, of course. This may well lower your blood pressure within the normal range. If so, that is fine.

Elevated Blood Pressure

Elevated blood pressure is treated without meds, by diet, weight loss, exercise and reduced alcohol. The diet would be needed for the stones. The exercise, weight loss, and exercise are extra, necessary for blood pressure.

Stage 1 Hypertension

Because all stone formers can be considered as having a form of kidney disease, it is safe to say every stone former has at least one risk factor. That means even one more prompts use of meds on top of the weight loss, diet, exercise, low alcohol complex.

Given mere age or maleness will do, the guys sort of lose. Likewise anyone with diabetes or a family history of cardiovascular disease. Naturally, anyone with established cardiovascular disease will be on treatment, or get treated.

Stage 2 Hypertension

More or less, everyone in this class needs medications.

Prefered Medications

Thiazide Type Diuretics

Here is a kind of good news. These are the first of the primary agents, and the ones that are known to have saved the most lives and the most morbidities. And, of them, my favorite – chlorthalidone – is most prefered: long half life and best trial evidence. The doses we use for lowering urine calcium, 12.5 to 25 mg daily are exactly those for blood pressure control. Thiazide like drugs are proven in three trials to reduce new stone formation.

For those who want an alternative, indapamide 1.25 to 2.5 mg is ideal, being long acting. Hydrochlorothiazide 25 – 50 mg daily is also usable.

One uses these agents on top of the kidney stone diet and, for blood pressure, on top of exercise, weight loss, and reduced alcohol. The low sodium of the diet permits a greater effect of the drug on blood pressure and urine calcium lowering, and reduced potassium wasting.

Potassium Citrate

Citrate is very valuable in stone prevention, and often the first choice medication. For those with hypertension who need potassium citrate for their stone prevention, I always wait and see if the extra potassium lowers their blood pressures enough to obviate other medications. A standard dose is 40 – 60 mEq daily, but if combined with the kidney stone diet this will amount to 140 to 160 mEq/d of potassium.

Most stone formers, although they have CKD risk and often some kidney damage, have no limit on renal potassium elimination. By contrast to the situation with more severe forms of CKD, one rarely has concerns about potassium use. Even so, if eGFR is reduced I always check a serum potassium after one week of potassium treatments.

If thiazide lowers serum potassium, potassium citrate is an ideal replacement. In fact, I often begin both potassium citrate and chlorthalidone together to avoid a fall in urine citrate from mild potassium depletion.

ACE or ARB

Angiotensin converting enzyme inhibitors (ACE) or angiotensin receptor blocking agents (ARB) are preferred as either a primary first drug or a second drug to use when thiazide is insufficient. For me, ARB is preferable, as ACE can cause coughing in not a few patients. Unlike thiazide that has a main role in stone prevention, these drugs are entirely separate.

Three Drugs or More

If potassium and thiazide and ACE/ARB fail to reach goal blood pressures, we are in a different universe, and I do not want to extend this article into it. Nephrologists regularly treat with multiple agents, and I am one of them. But the issues are more complex and this article already long enough. Interestingly, given stone prevention uses the diet and potassium citrate, I wonder how many patients who really use the diet and also exercise and lose weight will really need three drugs or more.

Sum It Up

Stone formers are more apt than others to become hypertensive. Likewise, they are at risk for kidney disease. This means that blood pressure levels are critical in any kidney stone prevention program. Any hint of even borderline measurements prompts me to get home blood pressures, in profusion, and do what I have written here.

My treatment goals using diet, weight loss, exercise, and moderation of alcohol, are below 120 and below 80 mmHg.

It is very easy to combine stone prevention and hypertension treatment. One diet suffices for both. One of the main stone prevention drugs – chlorthalidone – is an ideal first line treatment for high blood pressure when a drug is needed. Another, potassium citrate, has a potential to lower blood pressure and may be sufficient, with the kidney stone diet and exercise and weight loss, to achieve goal pressures.

Being more prone to kidney disease and hypertension, stone formers are best off always aiming at lean body weight, exercise, moderation of alcohol, and the kidney stone diet. Stone prevention should aim at all of this for all patients.

Kidney stones can portend hypertension, CKD, and bone disease. All of us have to treat our patients, not just their stones. Always, and in the least burdensome manner possible. All patients with stones should expect this from their physicians.

64 Responses to “How to Lower Blood Pressure in Kidney Stone Patients”

  1. Beth

    So pleased I came across your website. I am 65 years old with a duplex kidney, and have had kidney stones on and off for 7 years. Drinking the juice of freshly squeezed lemons 2-4/day reduced the size, until now. I stopped drinking the lemon juice for a few years, and now at present I have a stone 20 mm long and 5 mm wide. That was a very big surprise. I have never had excruciating pain so I didn’t worry much about it, until now. I have developed high blood pressure 170-150/90-80 quite suddenly. I also have increased my fluids to 4 quarts/day. My eGRF and electrolyes are normal. My doctor has never known me to be hypertensive and feels that I am just too stressed about the surgery I must have to eliminate the stone. He has put me on Tamsulosin and told me to relax. Other than this problem I am in excellent health with normal weight, liver function and my dietary intake is full of fresh good food with no processed items.
    Do you think that drinking excessive fluids can raise my BP that significantly or is it the stone which has become a problem now? I do have slight hydro nephrosis.
    Thank you so much.
    Beth

    Reply
    • Fredric L Coe, MD

      Hi Beth, Do you have uric acid stones? It sounds like it. If so, potassium citrate is a lot better way to prevent growth and new stones than lemon juice. Your blood pressure is high and perhaps from stress or something else. I would be concerned enough to suggest you do home blood pressures – as in the article you have posted on. Fluids will not raise blood pressure. Perhaps your physicians might want to be sure about your kidney function and possible obstruction from the stone. In any event if pressures are high much of the time they may wish to take steps to reduce it. Regards, Fred Coe

      Reply
  2. Sara

    Hi,
    I found this article interesting and relevant to me.
    I am a 36 year old female, this is my story:
    Always in good health, I never had any health or medical issues until February 2018 when I woke up suddenly in extreme pain on lower left side. Long story short I had an 8mm stone obstructing my left ureter. I had a ureteroscopy, stone was completely removed intact and I had a stent put in which was removed 10 days later.
    In July that year I had a CT scan which showed up multiple small stones in both kidneys but my urologist at the time said it was nothing to worry about so just left it.
    I had no further issues until July 2019 when I was 5 months pregnant with our 4th child and had a sudden extremely painful attack in my left kidney. I had an ultrasound which vaguely showed a largish stone in my left kidney but not much could be done due to the pregnancy so I suffered through weeks of pain until it eventually subsided. I gave birth to our son in November and eveything seeed fine until 2 weeks postpartum I experienced some frightening symptoms and went straight to my GP who tested my blood pressure which was roughly 177/102. (Throughout 4 pregnancies my bp was always completely normal, Inhad never had any high bp problems.) She tested several more times and it was similarly high. She prescribed labetalol and told me to monitor my bp with a machine at home that I had borrowed.
    Again, long story short I ended up in hospital twice for 3 days each time in the following month with very high bp and feeling awful. Was put on enalapril by physician which I am still taking (11 months later.)
    Numerous tests haven’t showed up any other health problems however a recent CT scan showed a large stone in left kidney and multiple smaller stones in both.
    My bp had been stable for months and I was slowly coming off the enalapril but bp has suddenly spiked again 4 days ago. I am fine during the day but bp is in 140s/90s in the afternoon/evenings and I feel terrible.
    Do you think this sudden spike is kidney stone related?

    Reply
    • Fredric L Coe, MD

      Hi Sara, You are describing a really complex problem and I am far away and cannot dare to say much. In general post partum high blood pressure can be renal in origin, but if your stone is partly obstructing that can raise blood pressure, too. You should have a nephrologist and she/he work with your urologist to decipher what is causing this problem. I am not evasive, but concerned that I lack the information to be of real help and could be a source of confusion. If your physicians are themselves in favor, perhaps you and they might wish an outside consultant to help. Regards, Fred Coe

      Reply
  3. Babak

    Dear Dr. Coe,

    I had my first episode of kidney stones in 2005. The next one was in late 2015. But since 2019, I’ve had three episodes (that I’ve felt the pain of).

    Particularly alarming is my elevated BP—especially my diastolic pressure, which is truculently above 85, and shoots up to the high 90s often. My systolic is often in the 130s, but with meditation, deep breathing, and exercise I can get it down to the 120s, and even 1-teens. After aerobic exercise, both my numbers drop. My systolic drops by a whopping 30 points often (from the 140s to 11x, and diastolic by about 10 points. And they stay that lowered for several hours after exercise.

    No matter how far I’ve searched, I haven’t been able to find peer-reviewed journal articles (or even regular WWW articles) discussing the connection between diastolic pressure and kidney stones.

    A more recent symptom is tinnitus.

    I lowered my sugar intake long ago. But my cholesterol has been elevated (in the 240s as of a year ago). I’ll make a serious effort to change the remaining suboptimal aspects of my diet as well, based on some of the recommendations on your page on the kidney-stone diet.

    My father used to suffer from gout, but never had kidney stones.

    I wonder if you have any insight on how to attack the diastolic pressure, and whether you know of any connections between tinnitus and kidney stones, BP, cholesterol.

    Medicine is not my expertise, but I *am* able to parse through journal articles and make sense of them, in case that helps you point in me the right direction.

    Many thanks,

    Babak.

    Reply
    • Fredric L Coe, MD

      Hi Babak, I suspect you are on the younger side during which diastolic pressure rises in proportion or even out of proportion to systolic pressure. In general with age the systolic pressure is high the diastolic low. But either one is hypertension and treated in the same ways. The article walks through the non drug and drug approaches and I endorse them all. Aerobic exercise, loss of visceral fat as much as possible, low sodium diet – 65 mEq – 1500 mg/d is ideal, and the 24 hour urines for stone prevention show the sodium. If all of these do not bring both pressures into a decent range (shown in the article) then one adds meds. One choice is a long acting thiazide type drug like chlorthalidone 12.5 to 25 mg/d. Another is an A2 receptor blocker like losartan 25 mg/d. Central to everything is daily home BP before eating, I suggest before supper is usually convenient – put the results into a spread sheet so you can track the trends. Of course get a personal physician who will be responsible for your care. Hypertension with stones is odd only because both share many common treatments, both use 24 hour urines to advantage, and stones promote high blood pressure. Regards, Fred Coe

      Reply
      • Babak

        Dear Dr. Coe,

        I thought I had submitted an acknowledgment reply to you, but I must have done something wrong in posting it, because I don’t see it.

        Thank you very much for your quick and thorough reply.

        I wish I were as young as you guessed; I’m a male and in my early 50s.

        I’ll heed your advice and implement the lifestyle changes and use some of the diagnostic tools you suggested. And I’ll read the other pages on your site more carefully to get more details and assemble a more thorough picture.

        Many thanks for the generosity of your time and knowledge..

        Regards,

        Babak.

        Reply
  4. Matthew

    I am 44 male and in decent shape. I have produced oxcelate stones since I was 19. I roughly pass 4-5 a year. Worst year was over 100. I have been diagnosed with hypertension since age 25 and have been on meds since. My currents doctor states that kidney stones wont raise my blood pressure. I have been having bouts of increased BP and it has directly correlated to fighting a stone before it drops into my bladder. Currently I am feeling the discomfort of another stone and my BP spikes at different times of the day. Any suggestions on treatment?

    Reply
  5. Hardeep Singh

    I had kidney stone in 2009 (and then 2009, 2012, 2020 now) when I faced pain, went to hospital, did ultrasound which confirm there is stone (sometime not) and they told me to increase water to pass which I reckon did work. One reason I don’t understand why they keep coming back (maybe I don’t keep with precautions). But bad thing I got high BP during this and start BP medicine in 2019. I asked doctor whats the reason for High BP and they never mentioned Kidney stone ever once. I hope I can improve this condition and maybe can reduce some of my BP or BP medicine intake. Thanks for this article doctor. Much appreciated

    Reply
  6. dewanna wheeler

    I was diagnosed by a nephrologist with Gitelman’s disease approximately 3 years ago. Multiple trips to ER with low potassium while already receiving potassium chloride 20meq daily. I am currently 50 years of age. Until age 30 blood pressure ran 90 /60. With birth of my first child and pre-eclampsia blood pressure was never that low again. Now I have severe hypertension. I am taking diltiazem 360 LA and Bystolic 20 mg daily. Blood pressure still not controlled. So as a last resort I was placed on valsartan 80 mg qd . I have had kidney stones for 35 years. I went 14 years without needing one to be treated. Then last summer I had one which was a size 8. After being on valsartan and gabapentin for less than a week I have formed a confirmed size 6 stone. I crave salt all the time and my legs are swollen most of the time. In referencing articles it does not say why ARB’s and Ace Inhibitors are to be avoided. I tried clonidine patch, but after being on it for 7 days it decreased sodium levels. any suggestions.

    Reply
    • Fredric L Coe

      Hi dewanna, I gather that your diagnosis was 3 years ago, but presume low potassium and magnesium and blood pressure were always present. It would seem that your episode of preeclampsia has overlaid the electrolyte disorder with kidney disease causing high blood pressure. Given stones for 35 years is very confusing in that Gitelman’s much lowers urine calcium so stone formation would be very unlikely. Given the confusing findings, can you clarify if your potassium wasting was present all or much of your life or a recent matter perhaps after your preeclampsia. Just on the surface, you do not seem to have Gitelman’s syndrome but perhaps some other problem. Regards, Fred Coe

      Reply
  7. peter

    HBP 199/90, how can I lower?
    age 86 stress test ok

    HBP 199/98
    stress test and ct to check earth ok
    kidney gfr 59
    createene 1.3
    1 kidney stone
    age 86
    how can I lower the BP
    THANK YOU

    Reply
    • Fredric L Coe

      Hi Peter, This is very high blood pressure. Given a creatinine of 1.3 I would think your eGFR might be even lower than you note. At your age and with this level of pressure you must have a nephrologist take care of you. As well, you need that now, because the pressure is high enough for worry. Management is complex for you, and needs highly trained physician help. Please do this right away. Regards, Fred Coe

      Reply
  8. Rafael

    Thanks for the great article! My husband has kidney stones and recently started hypertension treatment. He is currently on Chlorthalidone and amlodipine, and he also takes potassium citrate for the stones. The BP has improved but the diastolic pressure is still in the mid 80s to low 90s. We know that telmisartan and other similar drugs are an alternative if his pressure does not improve further (besides him losing weight and exercising more, which is something he struggles with). However, we also read that Telmisartan can increase the potassium levels even further when given together with potassium citrate. Is this something that causes trouble in practice or just a theoretical interaction?

    Reply
    • Fredric L Coe

      Hi Rafael, Given chlorthalidone causes renal potassium wasting I imagine a sartan will be safe. Of course his physician needs to be in charge and make appropriate followup measurements of serum potassium. I do agree exercise and weight loss are far better than any meds, and should be used as fully as possible, and I am sure his physician will agree. Regards, Fred Coe

      Reply
  9. Sathya from India

    Thanks Fredric,
    I have ureteral obstruction at lilac level on right side of kidney and I feel pain too nowdays. Suggest me some natural ways to dissolve my stones.
    Which is the best way to remove stones either medications or surgery? Do I need to take BP medicine for my lifetime if it is due to sodium intolerance?
    Regards
    Sathya

    Reply
  10. Sathya from India

    Hi Fredric,
    First of all, thanks a lot for such a nice article. It is very useful to me. My doctor diagnosed me with severe hypertension around 170/110mm of Hg a year ago. Since then I am taking medicine a Telma-H 40mg in the morning. He diagnosed with small kidney stone 2mm and mild hydroneuphrosis problem. I am on DASH diet now. Now the size of stone becomes 4mm recently with pain. Is my hypertension due to stones? Is it possible to reverse my BP to normal without meds after removing stones? Eagerly waiting for your suggestion.
    Regards
    Sathya

    Reply

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