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.
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.
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.
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.
97 Responses to “How to Lower Blood Pressure in Kidney Stone Patients”
Having low blood pressure and stones in kidney and back pain very much And having tensions and what is solution required to solve this problem
Fredric L Coe, MD
Hi Manojj, Having a low blood pressure is usually a good thing unless your physicians have found something worrisome in your particular case. Pain and stones are never good, and prevention is workable. Here is my best effort at an introduction. Regards, Fred Coe
Dearest Dr. Coe,
I was a patient of yours referred by Dr. Joseph Nuzzarello (Wheaton, IL) about 20 years ago with cystine stones. I subsequently have had surgeries, have passed several and currently have 3 stones in my right kidney. My major problem right now is high blood pressure. I have been on captopril 75mm 2x a day but I am stalling at high 140s/90s with high spikes as well. I am 58 years old and hope there is a “blood pressure cocktail” that I can refer my primary doctor to research. Also, should my blood pressure be brought up/treated by my urologist or remain with my primary care physician? I have to thank you for truly saving my life all those years ago. Meeting you and consulting with you gave me and my little family a new lease on life. You are my hero! Thank you! Lisa
Fredric L Coe, MD
Dear Lisa, The captopril is a dual purpose blood pressure medication that can bind cystine but is itself not ideal for blood pressure. Your blood pressure is best treated by a nephrologist because with cystinuria there is always some risk of loss of kidney function. Likewise, it sounds like management of your cystinuria has been less than ideal and should be bettered. This, too, is done by nephrologists with an interest in stone disease. If your personal physicians desire it, you might benefit from consultation at a center – as you did when I saw you years ago. With telehealth that can be remote. Regards, Fred
I have kidney stones because my body is not absorbing calcium so it’s going into my urine and forming stones. My doc put me on 3 different types of thiazide meds and potassium. With or without potassium, I experience horrible heart palpitations all day. It feels like I’m having a panic attack, so I cannot take those meds. My blood pressure is good, so I think the meds are negatively impacting my BP and causing intolerable side effects.
You mentioned ACE or ARB. Are there any other options?
Fredric L Coe, MD
Hi Tim, The thiazide are to lower urine calcium. This article helps explain the best approach to lowering urine calcium in idiopathic hypercalciuria – which I presume you have. The ACE and ARB drugs are to lower blood pressure which is for you irrelevant as you say your BP is normal. Regards, Fred Coe
Hello Fred. Could I ask does Kidney stones cause High Boood Pressure?
My husband jss always had kidney stones and the past 6 months his blood pressure has been sky high . Before it would go up but then go down. Now it’s continually high. He has been put on blood pressure Meds today. Will this help his stones at all ?
Fredric L Coe, MD
Hi Lisa, Indeed stone formers have increased risk for high blood pressure. The linked article is ideal for him as it points to the value of home BP and also presents current approaches to treatment, both drugs and diet + lifestyle. Regards, Fred Coe
Dr. Coe, thank you for such a informative, understandable article. My husband has had cystine stones since childhood and has always had slightly above normal BP, but recently (likely due to COVID lockdowns and a distinct decrease in physical activity) his blood pressure has risen. Do you have any specific advice for someone with cystine stones?
Fredric L Coe, MD
Hi Kim, Cystinuria is a serious stone problem as you know, and needs very expert medical treatment. Higher BP and even reduced kidney function are common. BP treatment is the same as in all patients, just as outlined in the article you are writing on. But prevention of cystine stones is very difficult, drugs are available and not easy to use. Regards, Fred Coe
Hi Dr. Coe,
I need advice as to which type Dr. should be managing my care, or a RD? I aready have high BP, under control with 80mg Valsartan. I had my first and pray my only stone, last month. ER/hospital and then treated with lithotripsy. They took a CT scan in the hospital, then xrays. I passed what was left of the stone which the urologist tells me was 100% calcium oxalte. How do I know if I will get another one? They did not do a post lithotripsy CT, only x-ray. I did the 24 urine test–Dr. told me my citrate is low and prescribed 500 mg calcium and postassium citrate. They tested my blood, not parathyroid disease (don’t even know what this means). He told me no vitamin C and to eat a low oxalate diet. I have had foot surgery (couple months before the surpise stone) and am pretty sedentary right now, with the other foot to follow as soon as the first one heals (long story, it’s going slowly). I don’t know what to do–cannot really exercise, am struggling to adopt the low oxalate diet because I don’t have enough information–I asked about combining milk with (spinach) for example and Dr. laughed at me and said that wasn’t how it worked. I also take levothryoxine every morning which I absolutely need to function, and directions say no calcium for four hours after taking, so I am struggling. Any advice? I am trying to eat healthy, cut sugar, alcohol, salt etc. I am pretty sure I did this to myself by drinking 6 cups of tea a day for 30 years, along with a rather bad chocolate addiction. So I am trying to change those habits as well, so far so good, but it is hard. Should I go to a dietician? I can’t stand my urologist–not going back to him.
Fredric L Coe, MD
Hi KLE, postoperative simple x ray is common. Usually there are fragments left behind after lithotripsy, many of which will pass over some weeks. So a CT at one month or so is a reasonable idea. Low citrate is common among women with CaOx stones so the K citrate is a reasonable idea. The extra calcium is to reduce urine oxalate – if you take it with meals that contain oxalate that effects will be most beneficial: calcium in the GI tract reduces oxalate absorption. Hyperparathyroidism is diagnosed from blood and urine testing. The main criterion is high serum calcium which I presume you do not have. As for putting milk into spinach it is not a silly idea, but you are better off without that particular vegetable. Here is our low oxalate diet paper. Here is something much better – a proper diet for stone prevention. As for physicians, perhaps a nephrologist might be better suited to stone prevention. Also, given telemedicine is not chic you can get consultation from anywhere. Regards, Fred Coe
Thank you for your advice, I appreciate it. I’ve ordered a cookbook online for low oxalate eating, and am integrating the calcium and potassium citrate into my day. Onward and upward!
Hello I would love some advice about my situation.
History: Kidney stones 22+ years ago found to be from prenatal vitamins (calcium) during summer (dehydration). Uncontrolled hypertension on and off since 24+ years (since first pregnancy). 3 years ago heart attack NSTEMI. 1 year ago diagnosed Hyperaldosteronism. Was switched from Triemetrene HCTZ to Epleranone (I also take Statin, Aspirin, Carvedilol, Amlodipine).
Epleranone causes extreme thirst for me and I am constantly drinking fluids and wake up 3-4 times per night for bathroom. Also feelings of dehydration such as dull headache. After starting Epleranone I gained 10 pounds within 3 months (saw nutrionist after Heart Attack my diet is very good more mediterranean style very low salt). Although I have elevated Aldosterone (maxed at 30), my Renin is extremely low which makes my PRA exteremly high. My doctor had me increase Epleranone to 3/day to try to push up the Renin. Within a month I had kidney stones which i thought was a coincidence (I had recently had a salt loading test and thought maybe that caused it.) When my Renin was still too low he raised my Epleranone to 4/day. I got kidney stones again within 1 week. When I reported this to my doctor’s office I was informed that “Epleranone does not cause kidney stones”. Perhaps not, but something did and it was too much of a coincidence for me (meanwhile even at maximum dose my Renin just barely made into normal range and the PRA still flagged extremely high. I went down to 2/day Epleranone and feel better. Finally saw Urologost (6 months after event) who scheduled me for a CT scan.
Should I get the scan now, or go back to 4/day Epleranone (which doctor wants) for a few weeks and then get the scan? I fear the scan now will show nothing but I hate to put myself though that again.
What can I/doctor do to raise Renin? Even when my Aldosterone was medicated well within normnal range, the PRA was still sky high due to the Renin.
I see a Cardiologist, Endocrinologist and now Urologist. Do I need a Kidney specialist? I thought the Urologist would help me with the Renin problem.
Note: HA is pretty rare and my Engocrinologist has only seen this 3 times in practice including me. I am willing to drive further but do not know how to find someone with extensive experience.
Fredric L Coe, MD
Hi Melissa, I presume you have bilateral primary hyperaldosteronisn – not surgically curable – and thence must rely on drugs. Failure of EPH to raise renin has been reported, and a newer agent worked, so perhaps this will be of use to your physicians. In a trial setting EPH caused little symptoms vs. amlodipine, and I suspect your weight gain may be from the latter agent. Specifically thirst and weight gain are not reported from EHP. As your physicians have not treated many primary hyperaldosteronism patients they may need to do a web search on PubMed to become familiar with the nuances of this complex system. In this limited venue I cannot provide a really proper review. Regards, Fred Coe
My current situation is that I have very high blood pressure. Averages 150-160. I did not take it that seriously for years now, and was not getting good medical advice. I was on Lisinopril and Amlodipine, and frankly wondered if they were doing any good because my BP numbers were all over the place, infrequently as low as 140 or the high 130’s and sometimes as high as 170. I never felt I had a problem and my eye doctor said I have no sign of eye problems caused by HBP. I am 5’9″ and weight 235 and I know I am unhealthy because I feel terrible. My life is a disaster, and I want a life back. I am working now to exercise as much as possible, brisk to fast walking 5 times a week for 5 miles, usually takes me about 1hr 45min. After walking I feel great, but when I urinate it comes out brown like strong tea, and for the first time I have noticed solids or sediments in my urine.
Now I have a new medical practitioner and I went off the Amlodipine now for 3 weeks, because of edema … my feet were swollen over time and I did not notice it happened so gradually. Every time I got out for a long walk now I realize I come home and my urine is incredibly dark. I never noticed if I had this problem before, but it is like strong tea. If I drink a lot of water it goes away, but now after those walks I am seeing small solids in my urine for hours after I have walked. I have for a years now had difficulty urinating, frequent urination and very small volumes, 1/4 to 1/2 cup I would estimate. It also interferes with my sleep. I don’t feel I drink enough water, and have started making sure I drink at least 3-4 12 ounce bottles of water each day … but this is very hard for me for some reason. For some reason the seriousness of my health just has not hit me until recently, probably because I have mostly felt healthy, but not any more.
My diet now is mostly plant-based, but I also eat meat, but if animal based it is mostly fish, canned salmon or sardines when I do. I don’t really know how I let this situation get so bad other than a lack of energy or depression, and I am determined now to turn this around – I have to.
The walking I have been doing for about the last month, and the dark urine I just noticed by urinating into a clear plastic cup, so I don’t know how long it has been. I am fearful that I could possibly have bladder cancer, and the more I read the more I scare myself. In addition I have also had difficulty urinating, slow start, slow stream, and stop and starts for so long in my life that I just assumed it was normal. My diet for many years was very full of sugar, but I have almost completely cut that out now.
My immediate goal is to try to figure out how to find out confidently where I am and what my priorities should be, should I be lucky enough not to have a terrible or life-threatening illness. I feel like there are multiple issues and that I will be lucky if all of them are not serious. The more I read the more my mind spirals. Previously my doctors told me my issue was being over-weight and that if I lost weight my blood pressure would probably go down, but I have lost 10 pounds now and my BP is going up, I have also gone off the Amlodipine and the doctor is considering a different medication. My anxiety level is high, and it is hard to maintain a positive outlook as my medical insurance is not very good. I guess I am wondering if anything I am saying either raises red flags, or is something that can tell you what I should do and check off and in what order? What can or should I do? Can you please help me with some advice? I read a lot of good information above, thank you.
Sorry, I forgot to mention I did have a calcium kidney stone once about 20 years ago after an hours long bicycle ride in the hot sun. Never had a recurrence of that, but I am not sure what those solids are in my dark urine after my long walks lately … which is what brought me here.
Fredric L Coe, MD
Hi BPK, Have the material analyzed, that will help clarify matters. Fred
Fredric L Coe, MD
Hi BPK, You should collect some of the sediment and have it analyzed. It may be crystals. A good way is to urinate through a coffee filter held in a funnel, let it dry and ask your physician to have it analyzed by a kidney stone lab. Your physician can look at your urine and see if it is blood. As for blood pressure, you do not mention any attempts to lower diet sodium – a very beneficial aid to make drugs more effective. Regards, Fred Coe
Beth in Dubai
Hi Dr. Coe,
First, I really enjoyed reading your article – never thought I would get a chuckle out of something about blood pressure and kidney stones. I was just wondering if having two stones within the span of a year is normal (more or less). I had one stone that passed during a visit to the ER (I think it was 4-5mm) and then a year later had to have a 1 cm stone removed via laser lithotripsy. I’ve also recently been diagnosed with high blood pressure (3 months after the second stone). Is it typically the case to be hit kind of back-to-back? Thank you!
Fredric L Coe, MD
Hi Beth, the lithotripsy is suspicious for causing BP to rise, and no – I am not surprised. I would do all the things in the article to lower BP and be sure and measure it at home – I think daily measurements are ideal because boredom sets in and anxiety dies out so you get a clear measurement. Regards, Fred Coe
Hello Dr. Coe,
I appreciate this blog very much and have been following it for quite some
time after history of 3 calcium oxalate stones over the last 10years – I am 40 now, and have been do following all the dietary recommendations. After my last stone (in 2019) I seem to have developed elevated BP. I’m have ‘white coat’ but monitor at home (although also have very marked anxiety at home during measurements) – my measurements are usually around 110-115/83-86. I guess this is stage 1 hypertension, even though systolic is pretty low.
Would you treat this BP with medications?
I exercise regularly (several miles running/walking per day + yoga and sodium <1500). Trying to keep sugar to a minimum + potassium through food (although it’s hard to get enough potassium on a low oxalate diet). Have been doing lifestyle interventions for 2 years now, and no change to the BP.
My doctor does not think my BP necessitates medication yet.
I forgot to mention that ultrasound found one 2mm stone in right kidney in lower pole. It’s just been left there and they said no treatment was needed unless it became symptomatic.
Could this be a contributor to the isolated diastolic? What tends to cause isolated diastolic in active, Middle Aged women of regular weight, non-smoker? My GP does not think I need a referral to cardiology or nephrology at this time.
Being in this gray area gives me a tremendous amount of anxiety and stress, especially after 2017 guidelines updates. I am wondering if I should more actively push for meds, or just try and relax without checking so frequently (hoping less anxiety might bring diastolic down), generally.
Thank you kindly!!
Fredric L Coe, MD
Hi Lien, I answered below before seeing this. Daily measurements allay measurement anxiety – every day at some fixed time, never after eating or exercise. Elevated diastolic is expected in young middle age, so the elevation is not ideal – if it is really there. Fred
Fredric L Coe, MD
Hi Lien, Be sure about the sodium intake by checking 24 hour urine excretion – 1500 mg daily is hard to achieve. As for measurement anxiety, the best cure is measurement every day – after a while physiology begins to dissociate from psychology and you will get a true reading. The slight diastolic elevation is not ideal, so attend to the 24 hour urine sodium and of course any extra abdominal fat. Eventually, one’s physician has to decide. Regards, Fred Coe
I am a 67 year old woman with a 20+ year history of hypertension. For most of those years I had significant “white coat” spikes of BP in medical settings, but it has now progressed to having spikes anytime there is great stress or anxiety. My spikes can go as high as 200/100 with pulse sometimes over well over 100. This is a huge source of stress and worry for me, as anytime I go to a doctor or have a medical procedure, I have these huge spikes, which causes everyone great concern. This past year I have now developed palpitations (PAC’s), and a recent echo showed mild thickening in the left ventricle. I have been on Amlodipine 10mg and Losartan 50 mg (2x day), plus 10mg Rosuvastatin for a number of years. My BP is well controlled at home (consistent home monitoring), but still spiking very high during anxiety or stress. I recently started seeing a hypertension specialist and he just changed my meds to Amlodipine-Olmesartan 5-40, and lowered my statin to 5mg. I started these new meds yesterday. I developed my first kidney stone in 2019 and my second in late 2020. I had never had a kidney stone before that. I read that this new medication, Amlodipine-Olmesartan can reduce urine output, which is concerning for me now that I am at risk for more kidney stones. My doctors have never discussed with me the correlation between hypertension and kidney stones, but I am concerned that hypertension meds are, in part, causing my kidney stones. Are there BP meds that do not increase risk of kidney stones?
Also any advice on which doctor is best to oversee and treat hypertension? I have a PCP, cardiologist and hypertension specialist (internal medicine with a hypertension specialty – only deals with hypertension). All three sometimes give differing advice, or make med changes the other hasn’t, etc. I would also like to see a nephrologist for kidneys, but I understand they also deal with blood pressure. How does a patient know who to really listen too when there are so many doctors, each with their own specialty? Help!
Fredric L Coe, MD
Hi Deb, Very complex, and for this reason my comments are just that – I do not know all the facts about you. In general, the sartans work a lot better with either very reduced diet sodium or with a thiazide type diuretic. This is because either measure makes blood pressure dependent on angiotensin – which the olmesartan blocks. This might be a reason your BP is not easily controlled. Your drugs should not cause stones, but if they are uric acid stones I would not be surprised as urine becomes acidic with prolonged high blood pressure. Given your reactions to stress your physicians might want to consider a low dose of a beta blocker, but with the thickening of your heart muscle that approach is complex. You are right, your situation is very complicated, and one can only hope that one of your physicians takes the lead and gets your pressure controlled. Regards, Fred Coe