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.
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.
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.
Buy a good machine. Use arm cuff models. Shun wrist monitors as potentially inaccurate.
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.
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.’
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.
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.
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?
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.
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.
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.
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 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
Family history of cardiovascular disease. Increasing age. Male sex – biological maleness. What can you do about these?
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
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.
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.
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.
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.
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.
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.
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.
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.
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?
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.
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.
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.