Personalized kidney stone prevention perfectly exemplifies the goals and aspirations of this modern age of precision medicine. Nowhere more than here is treatment specific to a given patient. Computer – like and driven by exacting physical laws, stone crystals respond to forces we can quantify in homely but surprisingly informative 24 hour urine collections. Crystal specific, patient specific treatments not only reduce stone formation. I have observed that patients easily distinguish this treatment from vague nostrums or imagined remedies thrown out to them by friends or busy and distracted practitioners. I believe such understanding promotes long term use, although I have no trial to prove it. The featured image shows salt harvesting from evaporation ponds. Saltwater evaporates in sunlight, overloads with sodium chloride … Continued
Why This Guide Book?
This is a big site and getting bigger. People can browse the articles, but nothing connects them except the long table of contents that runs down the left side of the pages and, of course, hyperlinks.
This lack of connection led me to the idea of a book for the site.
As a way to fulfil that idea I have made and remade this book through many forms by now. Some of you have, perhaps, encountered earlier versions appearing and disappearing like ghosts.
Gradually, I settled on the idea of a guide book. Here and there, in the past, I have written like a guide. My walking tours of supersaturation, for example. But this is more ambitious. I am after synthesis and cohesion because I believe they will make it easier for patients to follow the story and achieve stone prevention.
Perhaps I am wrong, but we will not find out without trying.
Like any book this one has an introduction – just below. It introduces important ideas you will need through your use of this guidebook and this site.
Lucas Cranach the Elder (1475 – 1553) painted the Judgement of Paris between 1512 and 1514. The painting hangs in the Metropolitan Museum of Art. Do Athena, Hera, and Aphrodite foresee Agamemnon dead, the burning towers, Hector at the gates of Ileum? Surely Paris, of his fateful judgment, knew nothing. And these violent, shape changing deities, why would they draw two civilizations into the fire?
The Common Pathway
Only kidneys can make kidney stones and kidney calcifications. Their specialized anatomical locales and cell surfaces offer unique lodgement places that supersaturations can fill and coat with crystals. Their power to convert metabolic energy into supersaturations drives stone formation, and we prevent kidney stones mainly by signalling kidneys to supersaturate less. Sometimes, as in calcified calyceal cysts, perhaps medullary sponge kidney, and certainly correctable urinary tract abnormalities we help prevent stone formation with surgery.
I call the combination of the supersaturating power and peculiar anatomy and cell biology of kidneys the common path. Practically speaking, we regularly alter supersaturation and only rarely prevent stones through corrective surgery.
Kidney Stone Phenotypes
Kidneys Produce but Do Not Control the Final Pathway
Although the work kidneys do on their tubule fluid creates supersaturation as a form of energy, controllers of that work lie outside kidneys for the most part. These controllers include fluids, diet, habits, gene variation, perhaps, and certainly many systemic and kidney diseases. It is true that none can produce stones except through the common pathway but also true that without their pathological drive kidneys need not tend to form crystals.
Phenotypes Concern the Controllers of the Final Pathway
From this it is obvious that not the common pathway but the myriads of drivers create specific kinds of stone formers. If we extend this reasoning just a tiny bit further, the idea of ‘kinds of stone formers’ generalizes to the idea of phenotypes. For example, stone formers with no systemic or kidney disease at all must be a group as distinct from patients with a disease like primary hyperparathyroidism. By extension, patients with each systemic disease would form a unique ‘phenotype’ – a group of patients who share important traits in common that can guide diagnosis and treatment.
Even within the large group that has no systemic diseases, so called idiopathic stone formers, some produce calcium stones, some uric acid stones, some struvite stones, and each of these would be distinct and therefore a phenotype.
Treatments Aim at the Controllers
Phenotypes are crucial to medical practice because in general we treat the drivers of the final pathway – the individual traits that make up the phenotype, and observe the result by measuring the effects of such treatment on supersaturations – the part of the final pathway we can affect through treatment. The special anatomy of kidneys in which crystallizations form are part of the final pathway but because we cannot readily alter them except via surgery they represent a special case.
Many kidney stone diseases cause bone disease. Although we may not always focus on bone we should. Unlike stones, I cannot specify a common pathway to bone disease but rather suggest it usually arises from the drivers of the common pathway. Therefore bone disease varies with the stone phenotype.
How To Use This Site
The Myth of ‘Just Drink More’
If I believed the myth I would do something other than write this site. Chapter one illustrates the failure of the myth for even people who have formed only one stone. Once aware of the need for personalized and precise phenotype driven treatment patients and their physicians can focus on attaining that goal and shun mere empirics and especially trendy and untested remedies.
I wrote this guide book to help achieve that kind of treatment. Out of the complexity of the site it offers a reasonable path to follow.
The Common Pathway
Everyone needs to understand the common pathway. Whatever peculiarities give rise to stones they can act only through it. We gauge the efficacy of all treatments directed against those particularities by changes in the common pathway. Given its importance I devoted the second chapter to it. You might think the third chapter on what to do might precede this one on the common pathway. But being so central no one can proceed effectively without some knowledge of it.
Nothing more misdirects and baffles prevention than confusion. And confusion comes naturally in so common and seemingly mundane a disease as kidney stones. Everyone seems to know a remedy and the more ‘natural’ the better. But in fact, kidney stones arise like all diseases from complicated origins, many reasonably benign and tractable and some perfectly dangerous. As in all diseases educated patients fare better, so it is here. Thence this site. Being against confusion, chapter three is an opener of the way.
Prevention Proceeds From Phenotype
I introduce phenotypes here, in chapter four. I name them all, and point to resources you need in order to identify which one applies.
Chapter five concerns a single phenotype, one so common some confuse it with the universe of stone disease. It is not, and such thinking causes errors. Idiopathic stone formers, those sans any named systemic disease as a cause of stones, clump into their own distinctive sub – phenotypes all of which lie within the larger idiopathic stone former phenotype – as in those beautiful Chinese puzzle boxes that open to show yet another within.
Apex Articles Link Downward
Articles on one subject like supersaturation overlap by intention. But I arranged them broadly in hierarchies so that one or two stand at the apex of the topic and link downward. Not always, of course, because the site grew like a garden more than a building. Yet often enough that if you knew them the apex ones would guide your reading. The chapters in this book link to those at the apex. I am gradually rewriting articles to strengthen this construct.
A Preferred Order of Reading
LIke any book this one works best in the order I wrote it. For patients I strongly advise reading that way.
This Book is in Preparation – Many chapters remain a promise
How kidney stones form surely offers clues to how to prevent them. But they hide those clues very well. We cannot watch them form, as in a movie. It would take too long and we have no cameras inside kidneys. Stones form hidden from sight and all we have is the final results. So, we need hypotheses about how they form. Where Kidney Stones Grow With that in mind, and to begin with, what exactly do we know? One thing we know for certain: clinically significant calcium oxalate kidney stones grow in human kidneys attached to ‘plaque’ – deposits of calcium phosphate embedded within kidney tissue. Another: Calcium phosphate deposits plug the terminal ends of kidney tubules. On the open ends … Continued
Among the thousands of comments on this site, this one theme rings out. Patients Are Confused Many patients just have no idea about what to do. They suffer from confusion. They have stones, one or many. Surgeries occur, or not. CT scans show this number of stones, or that number. Physicians may say contradictory things, or things that seem contradictory. And all the while new stones may form, more pain attacks may come, and lay to waste life otherwise spent in pursuit of work and family happiness. As a way out, people seek remedies, on the web, from friends, from physicians, of course, and often they do not work. Or, they do work but seem not to. The painting, Taking the Census, by Francis William … Continued
Phenotype is a medical term physicians use to identify groups of patients who share diagnoses and treatments in common. Although every kidney stone former has unique traits that need attention, they can be grouped into phenotypes for which certain general treatment approaches have been tried and found valuable. Within those general approaches refined treatment answers to those unique details particular to a given patient. Your Name When successful, the process of this chapter grants you a name. That name sums up where you fit in as a type of patient. Because patients within a given type have in common causes of stones, treatments and trials, and long term outlooks – so called prognoses you want to know where you fit in. That name is the name … Continued
You have idiopathic calcium stones. That means much of this site applies to you and your disorder. But the many articles read without a guide or sequence can confuse. You would be best off reading here, and following links as they come up. Of course you are free to browse as you like, but if you want a guide, I am here. Pieter Brueghel II (The Younger) A Village Fair (Village festival in Honour of Saint Hubert and Saint Anthony) 1564/1638 (Mackelvie Trust Collection, Auckland Art Gallery Toi o Tāmaki, purchased 1961) shows a crowd, which is appropriate for this most common kind of stone former. Begin Here You should not use this chapter unless you have come to it by the right … Continued
I often hear physicians say, ‘Of course, a lot of my patients had only one stone, so I just tell them to drink a lot of water.’ I don’t criticise them for saying it or doing it. They follow standard practice. The defects lie in those of us who study the data and fail to make ourselves useful by making ourselves clear. Let me be clear, then. Ideally, prevention should start before the first stone. The Image, Jan Steen, Couple in a Bedroom, 1665-1675 seems to convey the idea of ‘Why Wait’. Water is Great Water as a treatment is spectacular. It undoes the very process of renal water conservation that creates supersaturation. And let’s be clear. Supersaturation is the beginning … Continued
In my very long and complicated article I detailed primary hyperparathyroidism (PHPT) like a good scientist should. With all my heart I tried to make it plain enough for people in general to get a sense of how things work, but looking back on it, I doubt many will. Anyway, this book structure makes a place for summary and synthesis. Is this PHPT lite? Not really. It is PHPT practical, devoid of all but assets material to evaluation and treatment. Even so, in those areas I go into perhaps greater depth than in the parent article. The two articles complement each other as best I can arrange. Alabama Grist Mill Dam by Beverly Hammond catches the sense of how PTH works on … Continued
Uric acid stones, to me, means not just pure uric acid stones but any uric acid in stones. If this seems fey, let me explain. Uric acid is a peculiar kind of crystal. Low urine pH causes them and treatment that raise urine pH prevent them altogether. Whether they form combined with calcium stones or pure, treatment is the same. Why then scruple over percentages? If I find uric acid in any stone, I look at urine pH with a yellow eye. Should it be low I treat it surely and on the moment so at least that crystal be banished forever. The Profligate Punished by Neglect, Edward Penny 1774 catches the common motif of diet excess, obesity, diabetes, and … Continued