My Question
Tell me what you want next on this site; that is my question.
I have been writing this site – with the able help of my co-authors – since July 2014, and have reached what I might call a kind of plateau. Much of what I came to say about the most common kinds of kidney stone patients is said. Because the main work is done for the moment I have come with my question to you.
The readership of the site has grown from 50 people in the first month to a present running average of 55,000 – 65,000 people monthly, depending on the season, and many of the visitors read quite a bit each. People find the site valuable, and I am happy for that.
But, what next? I can guess, I can plan, and I can write.
I can also ask.
You might question why I chose Wedding Dance Outdoors by Pieter Bruegel the Elder. The picture is wonderful, so my reasons may not matter all that much.
Up Till 2017
Because I set out to create a definitive site, not a mere collection of opinions, I built a three layer cake.
Primary articles rest on peer reviewed literature and have links in them – some say too many, some say not enough – to scientific papers on PubMed. Secondary articles elaborate on and explain the primary ones in less technical detail. They link back to the primary articles rather than to PubMed. Public articles are for patients and their families. They show how science gives us useful ways to prevent stones. They have fewer links, and those are mainly to secondary articles.
Since 2017 to now – July 2018
Since I first wrote this article I created the Kidney Stone guide Book, and new topic listings for the whole site. Some of what people asked for I have done. Here is the table of all of it. Done means just that. Part means I know I need some components. Some means I have examples and can add more.
Dr Coe,want to get an opinion on a patients panel, how can I contact you
Hello Dr, my email is flcoe@uchicago.edu. Regards, Fred Coe
Dr Coe. What is a conglomerate of stones
Hi Jill, I guess it means a collection of stones of various sizes, shapes, or compositions. Fred
Hello Dr Coe. I first saw you back in 1994 when I had my first stone 3 more have followed over the years. Calcium oxalate. I’ve been taking KlorCon/EF 25meq twice daily since. Also on tamsulosin .4 mg 1/day Trospium Cl ER/60 mg 1/day. I’ve had yearly KUB X-rays to follow up. Fast forward to Dec of ‘24 I had an ultrasound that showed 1.0 cm on right kidney and 0.8 cm no obstructing stone on the left. No further imaging was recommended. Then a CT was done with the impression that stable scattered calculi was in both kidneys no hydronephrosis. My Dr is recommending lithotripsy because he says that if stone were to become lose it would be too large to pass and I’d be in an emergency room. I was lucky enough to pass the others but as you know it was a horrific event. Just looking for reassurance as I have never had any kind of procedure done and not sure how lithotripsy is done and success rate. Thank you in advance of any recommendations is greatly appreciated
Hi Bill, SOunds like I did not do so well for you and perhaps you needed more treatment than I provided. Or are you saying there are a lot of stable small stones in the kidneys? If by lithotripsy your surgeon means extra corporeal shock wave, and if there are a lot of small stones, it is a complex surgical judgment which I cannot help with. If there is a 1 cm single stone that is another matter. From here, now, I guess I cannot be of much help. But you might want new 24 hour urine testing to see what risk factors are present despite the treatment I began years ago. Best, Fred
I have been told i have silica based stones. I get one about every 10 years and they normally are 9 MM or larger and require lithotrypsie to breakup before they can be passed. How can i prevent them?
Hi Ed, the most likely cause in the US and in an adult is use of silica based antacids. This is the most recent review I could find. Regards, Fred Coe
Hello Dr. Coe. I’ve searched your site but could find no information regarding Chanca Piedra (Phyllanthus niruri). Anecdotal information seems to be encouraging. Is there any research on this? Thank you.
Hi Victor, I have promised myself to write on this and cannot quite get up the energy. It is probably nonsense so far as I can tell, but one really good scientist did some nice work in it. As for dissolving stones, no possibility. For prevention, unlikely, but I need to read the few publications worth reading. Sorry for the delay, Fred Coe
Dr Coe. I have had large uric acid stones. Lithotripsy, laser surgery and surgery thru my back to crush and vacum the stones..
However, once I started Potassium citrate acid crystals powder 2x a day in liquids…I’ve been stone free for almost 2 years…MY DILEMMA…BOTH PHARMACEUTICAL COMPANIES HAVE DISCONTINUED PRODUCING THIS PRODUCT…I TOOK CYTRA-K CRYSTALS 3300/1002 mg.
What can I take as a replacement..I am also hoing to have Bariatric sleeve surgery in a few months…
Thank you in advance for your response and guidance..
Hi Arlene, POtassium citrate 1080 mg tabs are available and work as well as cytra. You must be on it or an equivalent as it prevent uric acid stones perfectly. Uric acid stones are promoted by excess body weight, incidentally, because high BMI leads to low urine pH. With a sleeve and weight loss your urine pH may rise and the stones cease. Regards, Fred Coe
Hi Dr. Coe, after having abdominal pain since August 4th, I went in for a CT scan on August 8, which showed a 5-6mm stone in my right proximal ureter. X-ray on August 14th showed stone still in proximal ureter, but while I experienced frequent pain from August 4th – August 13th, no pain since August 13th. My urologist wants to schedule ureteroscopy, but I was wondering if it would be imprudent to wait 2-4 more weeks to see if the stone passes naturally. Thank you and my best regards.
Hi JC, I presume your urologist has decided that your proximal ureteral stone is not destined to pass – it is at the critical size – and poses a risk for obstruction. Lack of pain means nothing, as obstruction can painlessly destroy a kidney. So, I sense your urologist is right to want to remove the thing. Of course I am far away and without any details here so this is mere commentary. Regards, Fred Coe
Hi Dr. Coe,
I am a 53 year old Make that has been having kidney stones since I was 33 yrs old. Had 4 cases where medical intervention was needed. The most recent was 8/2018 on the right side what was 6.5mm and I need Laser Lithotrypsy when it was stuck.
in 2010 I had a 5.7 on the left side that was stuck, developed hydronphrosis on top of it all.
The stones are a mix, mostly on the Uric acid side.
Last 24 hr collection test showed:
SSCaOx – 10.37
Urin Calsioum -191
Urin Oxalate – 54
PH – 6.118
Uric Acid – 0.875
Was hoping you can suggest something.
Thank you.
Yuri
Hi Yuri, Your labs show a urine pH too high for uric acid stones, but a SS for CaOx perfectly compatible with calcium oxalate stones. Are you sure you know what the stones are? Your oxalate is very high, calcium borderline, and perhaps this reflects a low calcium cite. Surely urine volume is too low given the high SS CaOx, as calcium is not high enough for that. My suggestions are in this article, and this one, too. I think that a methodical evaluation and treatment follow through should be enough. Regards, Fred Coe
Thank you Dr. Coe for your fast reply.
the last 24hr test was done 3 months after the last 4x3x5 stone was broken down in 2018 in the right proximal ureter. I was given potassium cytrate, and I started drinking water with high PH. Increased the intake after this test, but still not at 3 liters given the lifestyle.
After the last procedure to remove the stone, I asked if the sample was collected and I was told no.
I am hoping you might be able to recommend someone in the NY area to be able to help if needed. I am trying not to lead to surgery every time I have a stone. The stones in every case were detected over a week prior to getting blockage. The process of lets wait and see if it will pass is not working.
Id there a way to break down the stone before it gets stock.
Thank you again,
Yuri
Hi Yuri, Dr David Goldfarb at NYU would be my choice – he is very skilled in stone prevention. Please feel free to use my name by way of introduction. Regards, Fred Coe
Thank you for the referral Dr. Coe.
One other thing that I remember is the first stones were dark in color dark grey I would say.
For my info what is the normal calcium level, and what is the normal calcium intake?
Yuri
Hi Yuri, serum ca 8.9-10.1 in our lab – lab dependent; urine calcium stone risk begins at 200 mg/d. Regards, Fred Coe
Dr COE, I am sitting in a Lithtripsy center where my wife is having her 22nd lithotripsy. She had gone 5 years since last one but we ended up in emergency room last weekend and scan detected a 4 mm and 8 mm stones. I assume 22 of these things is not normal. Do you have any suggestions on what she should do?
Hi Edward, I do indeed. She has had a remarkable number of stones and needs to change course. Firstly, she needs serum and 24 hour urine testing to determine cause of stones, and of course stone analyses so she knows what the crystals are. Then, why so many SWL procedures? One possibility is that one or more large stone fragmented and fragments are causing more and more procedures. I would discuss this with her surgeon. Ureteroscopy is probably better by now as stone removal can be more complete, but this is for her surgeon to determine. A second surgical opinion is not unreasonable after 22 SWL treatments, and I would ask her surgeon to help arrange that. Regards, Fred Coe
I have a long history of kidney stones. My most recent stone was analyzed at 10% calcium oxalate/ 80% calcium monohydrogen phosphate dihydrate (brushite), and 10% calcium phosphate. I have had this same composition for the previous stone I passed as well. I have yet to be able to prevent stone formation. With this stone makeup, what are your thoughts on why I’m getting them and how to avoid getting them? Thanks
Hi Sylvie,
Bread can still be eaten on a low oxalate diet. This is an article I wrote that has proven to help many patients (https://kidneystonediet.com/good-oxalate-list/). Make sure you get a urine collection done so that you can see what treatment plan will work best for you.
Best, Jill
Hello Dr. Coe,
I have Medullary Sponge Kidneys and have kidney stones. The stones come and go and vary in size. I now have bad hypertension which they are possibly contributing to the fact that it was found that I have renal artery stenosis. I also have high PTH but normal calcium & have previously had low phosphorus. My question is, do you know if the renal artery stenosis is related to the Medullary Sponge Kidneys? I cannot find any correlation & am concerned as to why I developed renal artery stenosis. Also wondering why I am suddenly having possible parathyroid issues. I do know that parathyroid issues tend to go along with kidney disease but it is odd to me that it all went crazy at once. Any input greatly appreciated. Thanks so much.
Hi Kimberly, MSK is not associated with renal artery stenosis, so you have two diseases. MSK is often diagnosed from CT scans, and mostly those diagnoses are incorrect. High serum PTH with normal fasting serum calcium is not primary hyperparathyroidism, a cause of stones, but usually from low calcium diet, vitamin D deficiency, or reduced kidney function. So called ‘secondary’ hyperparathyroidism. It is not surgically treated, but points to other diseases – listed – that are treated. The causes of your stones need to be determined by 24 hour urine and serum testing, as in all stone formers. I am sure your physicians have already done this, or will. The reasons for renal artery stenosis are usually atherosclerosis or fibromuscular hyperplasia, and your physicians have probably already figured out which one. Blood pressure treatment with RAS is highly specialized and usually supervised by experts. Regards, Fred Coe
My family is not predisposed to kidney stone but they are predisposed to osteoporosis. Is calcium citrate the best form of calcium to take as a supplement – in terms of reducing risk of kidney stones? Thank you.
Hi Kristin, if osteoporosis is occuring before menopause or in men, genetic hypercalciuria is a common cause. It is diagnosed by 24 hour urine testing. If it is present low sodium diet is crucial to permit high diet calcium without undue rise in urine calcium and risk of stones. Regards, Fred Coe
When I started to eat a very healthy, vegetarian diet, my kidney function started to slowly decline over the course of 2 years Creatinine level crept up to 2.0. My nephrology was puzzled as I am a healthy 66 years old bike rider. Suddenly, in Nov. 2019, my creatinine spiked to 5.0 and I was in hospital for 3 days. Kidney biopsy shows a lot of oxalate in kidneys, driven by lots of spinach and nuts and oxalate in my supposedly “healthy diet”. Drinking 2.5 liters of water and severely restricting oxatle in foods has brought creatinine back down to 2.1 over 2 months. Any suggestions or comments? I have never had a stone. But did have very high antibiotic use for Lyme 3 years ago. I use the oxalate chart on this site for my diet. Thanks!!!
Hi Dan S, This is a very serious matter. I do not believe a diet of spinach etc can cause oxalate nephropathy without some other cause(s) also in play. Common ones include prior GI weight loss surgery, some form of GI malabsorption, concomitant use of diuretics, laxatives, or high dose NSAIDS, or underlying primary hyperoxaluria of mild degree. I presume your urine oxalate has been measured, but you do not mention the level. If you and your physicians wish I would be pleased to look in more detail, because if mere diet caused a creatinine of 5 and your kidney has oxalate crystals in the tissues one needs to know why so another episode does not occur. I am not at all convinced that mere diet will be enough. Regards, Fred Coe
Dr. Coe,
What are your thoughts on probiotics and fiber impacting oxalate absorption? Do you know of any studies?
Thanks!
Hi Marilyn, the probiotics have been a failure. Given the ideal way to lower oxalate is a normal calcium intake of 1000 to 1,200 mg daily you do not need anything else, and you need the calcium. The food calcium needs to go with the more substantial meals where oxalate is likely to lurk. Regards, Fred Coe
What causes a stone to leave the kidney and try to make an exit? I’m a 65 year-old woman. I presently have a 7mm stone in my ureter, with a stent in place. Stone and stent will be removed in two weeks. My urologist said there are more stones in my kidneys. How do I encourage them to stay in place? Thanks.
Hi Kathryn, Stones in your kidneys will do as they choose. Your surgeon can remove them, but the benefit depends on how many and how much surgery is required. In general stones need not be removed unless they are causing obstruction, pain, serious bleeding, or infection. Of import is what kind of stone, in an older person they may be uric acid, and therefore can be dissolved and absolutely prevented. If calcium, you need to find out what causes them – here is a good starting place. Regards, Fred Coe
What are your thoughts on the influence of oxalobacter formigenes on stone formation? O. Formigenes is sensitive to multiple antibiotics so, is it possible that the effect of antibiotics on gut bacteria plays a role in the development of kidney stones?
Hi Louise, It has been tried and alas dies unless you eat extra oxalate for it. So it is not a usable stone treatment. Regards, Fred Coe
Given the Covid-19 pandemic, I’ve been trying to build up my immune system. However, I wanted to better understand if any supplements promote stone formation and growth. In particular, what are your thoughts on VitD, VitC, Zinc, turmeric, and curcumin intake? Thanks.
Hi Nick, Vitamin D at doses up to 2000 u/d are not in general a concern for health. Vitamin C above the daily minimum required does pose risk of stones – two studies. About zinc, and the two spices I have no knowledge. Regards, Fred Coe
Given the Covid-19 pandemic, I’ve been trying to enhance my immune system. However, I wanted to better understand what (if any) issues may develop with certain supplements. In particular, what are your thoughts on VitD, VitC, Zinc, turmeric, and curcumin.
Hi Nick,
Many of those supplements can increase your oxalate levels. Eating well, hydrating, sleeping well, and managing your stress, will all benefit your immune system. You need to check blood to see if you need Vitamin D, C in doses of 2,000 mg/day converts to oxalate, and turmeric is high in oxalate.
Best, Jill
Newly diagnosed with 8mm in kidney, not sure what kind (how do I find this out) and so my main question is can I dissolve the stone with supplements like:
biotics Super Phosphoric liquid
and Stone Free by Planetary Herbals
or any other means???
I saw what my husband went through a couple weeks ago and am mortified.
Hi Maggie, Your physician can measure its density on CT scan. Low values suggest uric acid – that can dissolve. Higher values calcium stones that cannot be dissolved. Above all find out why you make stones and take steps for prevention – here is a good starting place. Regards, Fred Coe
I am a Physician Assistant in Urology.
I have a 55 y/o M, obese but no other medical issues , granted he doesn’t go see physicians regularly.
We are treating him for bladder outlet obstruction (BOO), uric acid stones.
We are working on his obstruction. His urine pH is 5 despite taking Potassium Citrate 45 mEq TID.
Two questions
1. Am I missing a metabolic issue?
2. what else can I do to increase his urine pH?
Thanks
Hi Les, Given 45 mEq of K Citrate 3 times a day = 135 mEq of alkali – the urine pH at 5 is impressive. I wonder if he takes it or absorbs. Is his urine K appropriate – should be well over 130 mEq/d; is his urine ammonia suppressed – should be < 10% of his urine sulfate. Is his citrate perhaps remarkably high >2000 mg/d? Somewhere in all this is the reason. Let me know. Fred
how much of a oxalate restriction is required in someone on a vegan diet and hx of Uric and Oxalate stones? Would supplementation with calcium or plant based milks with added calcium be helpful to add to meals with higher Ox content?
Hi Jennifer,
Read this:
Best, Jill
Dear Dr Coe,
I came to your site to research kidney stones and was very impressed, and grateful. You know so very very much and wondered if you wouldn’t mind answering my “odd” question please, if it is at all within your interest. Feel free to answer it via my email rather than on your site, if you prefer, as it is off topic. And, of course you can tell me, you are totally disinterested in my question, and I’d fully respect that too!
My question is: do you know what form magnesium is excreted in the urine? Does it form complexes/molecules with citrate, sulphate, phosphate, bicarbonate, etc…
I’ve read that magnesium is lost in the urine at times of stress…and wondered in what form the Mg leaves. Do you know, or know where I can find such information?
PS. I’ve also heard that Mg binds with oxalates, and is anti-inflammatory. Apart from any concerns re. GI irritation, would perhaps Mg citrate be better than K-citrate given so many people are Mg deficient, anyway and need supplements? Sorry if it is a dumb question, too.
Hi Sarah, Urine Mg forms complexes with oxalate, phosphate, sulfate, citrate – all the anions. As for renal Mg handling I do not know about stress per se, the reabsorption is regulated mainly in the thick ascending limb and distal convoluted tubule. As for magnesium citrate it has laxative properties, so may not be absorbed well and could cause GI fluid losses. Mg supplements are usually as the oxide. Regards, Fred
Dear Dr Coe,
In your opinion, does the ketogenic diet increase the risk of kidney stones forming? I say forming, rather than breaking off and becoming symptomatic? thank you for your website.
Hi Sarah, Not much data either way, and it depends on the kind of stones. In principle, uric acid stones might arise from the diet as urine becomes more acidic. If you use the diet and form stones proper 24 hour and blood testing will show what problems there are, and would be prudent. Regards, Fred Coe
? I’ve had kidney stones ( 1 kidney) and wear a illestomy and need to collect a 24 hr. urine to find out what kind of stones is forming? How would I do that?
Hi Darlene,
You urinate into a collection jug. Should have no problem even though you have an ileostomy-
j
My goodness what a wonderful resource. Thank you for all your work and contributions!
I’ve a few things I search for answers to that my benefit your readers. Personally, I’ve a calcium deficiency and form UA stones. I also seem to get headaches from Urocit-K in does as low as mEq 7.5. Oddly I can drink Crystal Light at 2/3 strength (don’t care for the taste of full strength, and I’m drinking 3l day of the stuff, so…) Thus these questions:
1) What should I expect from Calcium Citrate as regards urine PH? I expect a raise in my PH, but limited testing with Citrical Max Plus has shown a lowering. At the same time correlation is not causation, so I’ve taken to the internet for something definitive. Sadly, I’ve found nothing. That answer might be of benefit for many. Would you share your thoughts on this as an attempt to boost my calcium and increase my PH (lower acidity)?
2) I asked my urologist (who is cooperating) to move me down from the 15 mEq bid to 5 mEQ ER bid in the hopes I find my own tolerability level in terms of release concentration (dose) and daily intake (frequency). Obviously I need to move up from 5mEq. However, so far I’ve not found anything speaking to the release duration/window or half life. I may have found reference (link below) that suggests ER’s efficacy is 12 hours, but I’m not sure I interpret correctly. Would you share your advice?
https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=d2c923d5-85c1-4bbb-9f93-556080a5ef87
(section 12.1)
3) Related to the headaches from Urocit-K, I’ve been told by my son (ED doc) that some medicines require an adjustment period to build tolerance (lay person interpretation). He’s suggested I may be able to tolerate 15 mEQ ER bid if I build up to it. He’s no idea if Potasium Citrate might behave in such a way. I’m sure he’ll look for me, but again, your thoughts would benefit not just me, but others too.
4) Finally, towards raising my urine PH to an average PH of 6 – 6.25, I’m considering increasing the alkalinity of the water I drink. The internet, as always, had supporters and doubters. Your site is highly trusted site and your comment on alkaline water would be deeply appreciated, I suspect, by all of us in similar situations.
My sincere thank you again for this website!
Dan
Hi Dan, Uric acid stones arise from low urine pH and raising urine pH above 6 prevents them altogether. You need 24 hour urines to get average urine pH so rely on them. As for alkali, if you do not like potassium citrate use sodium bicarbonate – you can get OTC tablets cheap and use enough to get 20 – 40 mEq of bicarbonate daily,, monitoring 24 hour urine pH. Lacking chloride, the extra sodium rarely raises blood pressure. As for calcium deficiency, I do not understand the term. If your diet is calcium deficient you are free to choose a better one. The amounts of alkali you report will rarely suffice and calcium citrate is not a reliable alkali. Regards, Fred Coe
Hi need your help. I have a kidney stone 1 cm. My urine show few bacteria and white blood cells and a few Squamish cells and some nitrates. I just finished a round of antibiotics and all of the above still present. Dr wants me to take the keflex again for 7 days and get a shot of an antibiotic I have passed soft clots that came back as being dried blood and one culture showed calcium phosphate. They want to do a lithotripsy on Friday and put in a shunt. I’m concerned I’m not so sure this is safe for me if the stone is infected. They think the stone is throwing off the infection which is E Coli. Please let me know what you think. I’ve been faithfully doing Jill’s kidney stone diet. My health is so important to me. Please advise us lithrotripsy safe with infection?
Hi Patty, I gather you have infection with a stone and calcium phosphate crystals were found in a urinalysis. Usually antibiotics are enough to treat E Coli, and your physician seems to be trying to rid you of the infection before doing SWL. It seems about right. The alternative, ureteroscopy, would involve even more instrumentation. Of course I am not a surgeon and am far away, so your personal physician is in a far better position to judge. From what I can tell, she/he is doing what I would expect. Regards, Fred Coe
Hi
What are the chances of someone having multiple (4) kidney stones having chronic kidney failure?
Hi Eric, Just forming stones is associated with loss of kidney function and high blood pressure, and obstruction from stones can damage kidneys. But lots of things can damage kidneys. Nephrologists exist to figure out what has caused chronic kidney failure and how to mitigate its consequences. I most strongly advise consulting with one. Regards, Fred Coe
Dr. Coe,
I have enjoyed your website greatly. Thank you for sharing your knowledge. My questions are as follows:
1.) How often do stone formers form stones in only one kidney, while the other shows no stones and looks perfectly healthy under CT scan?
2.) Can rotation of the kidney on the sagittal axis be a cause for large uric acid stone formation, or is large stone formation generally the cause for rotation?
3.) Does treatment/removal of stones affect rotation of the kidney?
4.) Would treatment for uric acid stone formation in an injured and/or rotated kidney be cause for issues with a healthy kidney that is not forming stones?
I’m sorry for so many questions. You thoroughly covered the topic of uric acid stone formation (thank you), but I didn’t see any information that addressed any of the above questions. Thank you for taking the time to notice my questions. I sincerely hope they aren’t too far off topic.
With thanks and appreciation for the knowledge already given,
TreeSprite
Hi TreeSprite, Not rare to be on one side – but the other can begin making them. Often the side with stones has something odd anatomically. Rotation is an oddness that can promote stones, but uric acid stones are special and need a very acid urine – take a look. Rotation is not altered by stopping stones. Prevention of uric acid stones will not endanger either kidney. Note: Uric acid stones come from overly acid urine and can always be prevented by alkali to raise the urine pH. Best, Fred Coe
Thank you for this website, Dr. Coe. I’ve found it very helpful. I have a few questions:
1) First, a chicken and egg question. Do you know if having a current stone (otherwise causing no problems) can raise blood pressure? Or is it that people with hypertension are more likely to form stones? I’m a little unclear from what you said on the site as to which comes first — the stones or the elevated blood pressure. I ask because since having a (calcium oxylate) stone episode in the spring of 2019, my blood pressure has gone up by about 20 points (systolic, about 5 points diastolic). Previously, I was in a normal range but now am in a concerning one. And this is after I have lost weight, reduced sodium in my diet, and increased the amount of exercise I’m doing. I also wonder whether increasing the volume of water I drink might be a factor. Since my stone incident, I am drinking close to 3 liters of fluid (mostly water) per day.
2) Do you know if there is a relationship between thyroid abnormalities (apart from the parathyroid) and stone formation? In my case, I was diagnosed with a toxic goiter 13 years ago, had radioactive iodine treatment for it, and have been on Synthroid since then. I had my first kidney stone within a month of being diagnosed with the goiter (before the iodine treatment) and then had two more at the same time (one in each kidney) in 2019.
Thank you very much for your help.
Hi Elizabeth, stones and high blood pressure are associated and I doubt blood pressure causes stones. So either stones raise pressure or both arise from some underlying set of abnormalities. Treatment of blood pressure in stone formers is pretty straightforward. Water does no raise BP, for sure. Your spate of hyperthyroidism might have started your stone forming as it raises urine calcium, and perhaps you initiated crystals then that became more visible in 2019. In any event a full evaluation for causes of stones is important for you. Regards, Fred Coe
Thank you for such an informative website, I have found it very helpful. I am curious about drinking water quality and the effect it has on kidney stone formation. Our house water source comes from a well that has hard water. When we moved in 9 months ago there was a lot of scale build up on all of our fixtures because of the hard water. The house was built in 1980. We installed a water softener on January 5th that uses Soft Salt, a few weeks later we also installed a 3 stage filter system under the kitchen sink for our drinking water. I have had issues with oxalate stones for about 15 years. On January 19th I got the results of my 24 urine collection, my calcium levels for the first time were high, at 458 mg. I had been taking a total of 800 mg of calcium citrate spit into 4 doses. My urologist took me off all calcium and referred me to a nephrologist. Because of referral issues it took almost 4 months to get that appointment so after a month I started taking 400 mg of calcium split into two doses. In 2018 I had a bone scan and was diagnosed with mild ostopenia and told to take 1000 to 1200 mg of calcium daily. The nephrologist checked my PTH, along with other labs and they were all in the normal range. I was prescribed 25 mg hydrochlorothiazide in split doses and told to take 800 mg of calcium citrate, which I am taking in split doses with meals. The last 24 urine collection was done in 2018, back then my calcium urine was in the normal range. Do you think the elevated urine calcium was from the well water? Considering that I have osteopenia and I am on hydrochlorothiazide should I adjust my calcium dose? I get some added calcium diet, but probably no enough to get the 1200 mg that was recommended after the bone scan. I stay very hydrated, maybe too hydrated, my last 24 urine collection was 4055 ml and the prior one in 2018 was 2800 ml. A CT scan was done in January and I still have about 5 stones, passed a few stones when comparing the scan to the last kidney x-ray. But I still have one stone that is considered too large to pass that may need to be removed.
Hi Linda L, It is hard to answer you because timing is not given. I gather stones began before your move, but that is a guess. On Jan 19 your urine calcium was reported as 458 and in 2018 your urine calcium was ‘normal’. You have been taking considerable amounts of extra calcium for bone loss, and there is some question about water as a past calcium source. To me the most interesting fact is that a normal urine calcium in 2018 was 450 in 2021. By the time of the collection you had installed filters, so water was no longer an issue. I do not know your age, but perhaps you became monocausal between 2018 and 2021, and are actively losing bone. Alternatively you have developed primary hyperparathyroidism. This latter raises serum calcium, but often slightly – are your serum calcium levels (not on thiazide) below 10? If not, I would be suspicious of PHPT. With so little information, I cannot do more. Regards, Fred Coe
I am 67 years old and went through menopause over 10 years ago. I was tested for hyperparathyroidism at my first visit with my nephrologist this spring, the test showed normal levels in the blood. Based on the 24 hour urine collection and normal hyperparathyroidism test the Dr prescribed 25 mg of hydrochlorothiazide. My serum calcium levels have always been in the normal range. The kidney x-ray from 2018 showed I still had about 8 kidney stones, which was before I was diagnosed with high urine calcium. My first MRI 15 years ago showed a dozen stones between both kidneys. Some of those stones were smaller ones that have passed over the years. The recent MRI indicates a 6mm stones that I have been told will probably require removal because it is too large to pass. The two 24 hour urine collections were done 3 years apart, 2018 & 2021, both had high oxalate 52, and now 61 mg. Oxalate has gone up even though I cut way down on oxalates in my diet. I used to eat a lot of foods high in oxalates, almonds, beans, and high oxalate vegetables. I made a lot of dietary changes in 2018, after a very painful kidney stone passing episode. I am wondering if I should still take the 1000 mg of calcium citrate that was recommend after my bone scan, considering that I have started taking the thiazide? Should I ask the Dr about doing another 24 hour urine collection before my next appointment which is not scheduled until September? Thank you for your time.
Hi Linda, You do not mention your urine calcium. Is it high? Did the thiazide lower it? High urine oxalate can be from the wrong foods – here is our best on that. If you take a calcium supplement, split it into portions and use part with each main meal, as calcium will block oxalate absorption and lower urine oxalate. Thiazide is no reason to stop the calcium supplement. I would get a new 24 hour urine to see if the drug has lowered stone risk. Be sure and analyze any removed stones. Regards, Fred Coe
Dr. Coe,
Would taking Vit C seriously adversely effect using K citrate for Ca stones? Is there a dose which would likely be acceptable?
Thank you
Howard Kaplan, MD
Hi Howard,
Not directly but ascorbate does seem a preferred substrate for hepatic oxalate production. And, best available data say hepatic production is a major part of normal urine oxalate. So I tell my patients to avoid more than the once a day vitamin amounts of ascorbate, unless that is impossible – and I know of few reasons it is. Best, Fred
How do I find a struvite stone specialist? My stone production has moved from single to multiple production and I’ve already gone septic once.
Hi Anne, these stones arise from infection and require a very highly skilled surgical/medical approach. I strongly suggest your physicians consider referral to a university stone center to be sure of the best strategy. Sepsis is a constant risk, and the stones can damage kidneys. Regards, Fred Coe
Dr. Coe,
I was diagnosed with MSK 25 years ago by IVP. Now 50, on potassium citrate, I have stone events every 2-3 years, undergo lithotripsy, and pain always resolved. Now I am faced with chronic flank pain on one side, no obstructions. A recent lithotripsy of a few non obstructing stones and Randall’s plaque didn’t resolve my pain. my urologist noted many calculi in the “meat” of the kidney they didn’t remove. Is removal of these stones possible? I have read of success with laser papillotomy from several research papers. This is my last hope for at least a temporary pain free period of time. What are your thoughts on this procedure? Worth a shot? The thought of pain management as the only solution for excruciating renal pain is incredibly depressing. These tiny stones that aren’t suppose to cause pain are killing me.
Hi Jennifer, I wonder if you have MSK or calcium phosphate stones, or perhaps lots of plaque with many calcium oxalate stones on them? Infection is not present, I presume. We have been finding evidence of inflammation in kidneys with stones, but cannot as yet link it with symptoms. Likewise, small stone pain is a very well known urological issue and surgery or not a vexed question. I cannot offer a real opinion about something so complex from just a sketch, and suggest your physicians might want to seek referral for you at a stone center geographically convenient. That may help decide about the wisdom of surgical intervention. Sorry to be so vague, but better vague than misleading. Regards, Fred Coe
Not sure if i am writing in the right place but i have a question for Dr Coe
Diagnosed with RTA in my early 20’s, now 57. Chronic kidney stones. Previously was taking potassium citrate. Just recently, by a new physician, was told to stop taking potassium citrate because my urine is very basic. Also urine citrate level is low. Currently taking magox and vitamin D. Stones are calicium/ phosphate and a small amount of oxalate. Waiting on 24 hour urine results from litholink.
Confused about diet recommendations i have read. According to what i have read , some of the food/fluid recommendations will actually cause further increase in urine ph. Because my urine ph is already high , i am confused as to what i should be eating/drinking and what i should be avoiding.
Hi Lisa, Very complex. A lot depends on how your urine pH actually behaves. Does it even come down, even without alkali treatment?? As you give alkali citrate and pH both rise. In RTA urine pH is never low (below 6) and often is so high without alkali that one treats with potassium citrate to get citrate into the urine. In more common calcium phosphate stone formers – whose urine citrate is low for the urine pH – one follows the SS for calcium phosphate. Citrate lowers is, it rises with pH and one aims for the lowest SS. Your physician is educated for this and has to figure out the best way. You can get genetic testing for RTA and insurance pays. If you have RTA nothing will lower urine pH and one just treats to raise citrate. Regards, Fred Coe
Thank you for your response My urine PH is ALWAYS high. Never had genetic testing done. I have always thought this was caused by a reaction to a medication I had as a child. I will get genetic testing done. My daughter-in-law was just diagnosed 6 months ago with dRTA – her father had the same. Therefore, I am concerned my granddaughter may have dRTA as well. She is currently 2 years old. This is so shocking to me as it is my understanding that dRTA is very rare. She will need to be tested
Hi Lisa, it is worthwhile to diagnose dRTA as it can alter treatment. REgards, Fred Coe
Hello Dr Coe,
During a go to meeting Jill Harris asked that I ask you these question- . Prefacing question –
Urine calcium being 131 mg/d, urine oxalate 44mg/d, urine citrate 290 mg/d, urine pH 6.348, supsat CaOx 3.6 , urine Oxalate 44, SupSat CaP 0.47, SupSat uric acid 0.16, urine uric acid 0.543 ->
composition first Stone was 30% CaC2O4.H2O & 70% CaC2O4.2H2O — after 1st stone, given 1080 mg K3C6H5O7 ER TID w/ meals -4 months later 2nd stone composition was
80% CaC2O4.H2O & 20% CaC2O4.2H2O . <–Urine calcium 289 mg/d, urine oxalate 28mg/d, urine citrate 795 mg/d, urine pH 7.246, supsat CaOx 2.50 , urine Oxalate 44, SupSat CaP 1.63, SupSat uric acid 0.02, urine uric acid 0.630 .
Q1. stone compare compostion flip flop regarding CaC2O4.H2O & CaC2O4.2H2O ? Q2. Why such a great increase in Urine Ca ?
Q3. With urine pH over 7 seems CaP stone possibilty ?
Q4. Maybe cut back on K3C6H5O7 ER 1080 mg tab.
Q5. Drinking 84 oz- 112 oz daily water Average 100 oz — and 76 yrs of age — seems this would defer kidney stones ? Still also trying to figure why my initally low urine citrate ? I want to thank you for your site which I have read and your email I received…, "STRUCTURE OF SCIENTIFIC RESEARCH" ( by you and your daughter — fantastic perception and presentation ) accompanied with your dedication and sense of humor also. Along with Jill Harris LPN kidney stone prevention — I feel most fortunate & hope you do not mind that I have shared with others, including some doctors. Ed
Hi Ed, The two common forms of calcium oxalate crystals, mono and dihydrate not rarely coexist. The former generally reflects a relative excess of oxalate over calcium, the latter the opposite. Oxalate concentration is much lower than calcium in urine (0.2-0.4 vs 2 – 4 mmol/l). Urine citrate is regulated by acid base balance, and can vary – I notice it went up nicely with K citrate. This usually points to a dietary origin (too few veggies and fruits). Your urine SS values seem rather low, so I am not overly worried about a recurrence. Also, you have Jill on your side – enough for most people, I would say. Regards, Fred Coe
Good afternoon Dr. Coe, I have Mast Cell Activation Syndrome and I have been taking H1 and H2 blockers Claritin and Pepcid, for more than 10 years. I formed a kidney stone 4.5mm 80% Calcium Oxalate Monohydrate and 20% Calcium Oxalate Dihydrate. I am just learning all of the parameters, reading your site, and have begun a relationship with the KSD in recent months. I have done some research that Pepcid can cause kidney stones due to the calcium carbonate. It is one of the things that helps to calm my mast cells, prior to taking this medication, I did not have kidney stones. No family history and this has been one occurrence. If there are no other alternatives, would your best advice be to stop the H2 blocker? Are there any other alternatives? I will do any and every thing not to go through that surgery and pain ever again. Thank you kindly in advance for your advice and wisdom on this matter.
Hi Racquel, Calcium carbonate can cause kidney stones, and if you were taking large amounts it would be a reasonable cause. H2 blockers do not contain calcium carbonate, however, and are not known to cause calcium oxalate stones. If you need the histamine blockers, is there an alternative to the calcium carbonate? Regards, Fred Coe
Hi Dr Koe,
My husband was part of your kidney stone research many years ago. He was taking 2 medications you prescribed that were very helpful. I believe they were chlorthalidone and amiloride. He was stone free on them for 1 1/2 years and was taken off them due to other medical concerns. He continues to have a lot of kidney stones and just had surgery to have 8 of them broken up. I would like his cardiologist and urologist to revisit what was working in the past and see if he can be put back on it but I can not find the records. Is there any way you can help?
Hi Cathy, I believe we have already attended to this. If not, please let my secretary know – 773 702 1474, All the best, Fred Coe
Hello Dr. Coe,
I am a 53 year old female suffering from increased osteoarthritis pain as I age. I had one stone incident 3+ years ago, which has not been repeated thanks to Jill and the Kidney Stone Diet. I am desperately seeking a supplement I can take to help with the pain. I’ve been reading and reading and have seen several studies regarding curcumin. While turmeric seems to be a definite no, curcumin, from what I can see, is not only not a threat in terms of forming stones, but has in fact been shown, in mice, to actually prevent them. I’m curious as to your thoughts on these studies. I gave up all supplements upon discovering I had kidney stones late 2019. Thank you. Pam
Hi Pam, circumin does not increase urine oxalate. Mouse and rat models of kidney stones have so mislead research I shun them and scorn their results. Regards, Fred Coe
A CT showed a 4mm non-obstructing stone. I was scared to try to pass it and asked for a ureteroscopy to retrieve it. Urologist could not find any free floating stone and determined it was in some crevice he couldn’t reach with the flexible scope. As I remember, he told me not to worry about it. 9yrs later, I had an ultrasound which showed what I believe to be the same stone (I still have never passed a stone so it would probably be the same one). It has not grown in size.
My question is if the stone is lodged in some tissue crevices, what is the likelihood it could break free and enter the collection system where it could enter ureter? I’m trying to figure out what to do, as I’m nervous to go on a long flight with this still in me although I’m not in any pain.
Hi David, Low likelihood of passing and one does not go back in after such a stone. Most probably will never bother you. Fred
Thank you for taking the time to answer Dr. Coe. It makes me feel better about the situation. My Urologist is at Elmhurst Hospital and introduced me to your work. Maybe he was a student of yours. I’ve been subscribed to your news letter since the stone was discovered in 2015.
How does a stone wind up in a crevice where it can’t be reached? I couldn’t find any info online about such a case. Is it that uncommon?
feeling relieved,
David
Hi David, Stones mostly form on tissue calcification that themselves form because of how kidneys process stone forming salts. As for your stones, here is my best approach to a proper evaluation to plan for prevention. Regards, Fred Coe
Hello, My stone risk factor is high Ca 24 – 350 (mg/d) Report indicates hypercalciuria and to exclude hypercalcemia, Vit D excess, sarcoidosis, hyperthyroidism and malignant neoplasm from consideration.
Report says to treat with low sodium, calcium at 1000mg/day and low protein and possible thiazide medication. I’m trying to educate myself how to lower it.
I’m a little overwhelmed with all the material and not sure where to start. Can you make a recommendation, possibly with a link? Does a section address this specifically?
Hi Dave, Sounds like you had a Litholink 24 hour urine test. Your physician is supposed to explain the results to you. You have high urine calcium, a very common cause of stones, and treatable. Here is a pretty good introduction. Here is one on how to read lab reports. These should help. Regards, Fred Coe
Dr could you explain why I now have caliectasis in the same kidney that had surgery and hydronephrosis from the stones (they were very large) does this pose a problem with kidney failure at a later date? It seems to be increasing instead of decreasing. the kidney has gone back to its original size but I am left with caliectasis, no stones praise the Lord!! Am I drinking too much water? LOL
my urologist made that inference once but nothing more and my nephrologist just sort of brushed it off, but now it is increasing and I am concerned
thank you so much you are amazing with all this information
Hi Charli, possibly there is internal obstruction from tiny stones or strictures that hampers drainage out of particular calyces. Each calyx complex (they often partner) drains into the larger collecting system via a relatively narrow isthmus. Sometimes radiologists can look for and identify narrowings therein, but not all the time. THis is an issue for your surgeon, who was there and knows what is there. As for water intake, possibly high flows might cause harmless dilation. The worry about dilated calyces is that the dwell time of urine increases and being supersaturated crystals can form – of tiny size but capable of growing if caught up for a while in a slow flowing area. If your urologist is not concerned I would be happy. Your nephrologist is unlikely to have much direct knowledge of this rather arcane matter, though some do. Best, Fred Coe
Dr, I have high urine calcium (292) and high pH (7.6). Parathyroid issues and what not have been ruled out, Doctor says high urine calcium is idiopathic, and says it does not warrant medication. I follow Jill Harris‘s page and KDS diet goals diligently, especially low sodium and little to no added sugar. I drink at least 100 ounces of fluids. I had been finding it very helpful to drink peppermint iced tea with crystal light lemonade added, maybe a three to one ratio (2/3 tea). I’m now learning that I should not be drinking too much crystal light or other beverages that contains citric acid because it can raise urine pH even more. My question is how much is too much? Or should I just never have any at all anymore? I was probably consuming 8 to16 ounces of the lemonade mixed into a 50+ oz pot of peppermint herb tea. The remainder of my fluids is water, 1 cup of decaf coffee, milk, occasional beer, low sugar calcium fortified orange juice… I really love the tea and it helps me get my fluids, so I’m just wondering if there is any amount that is safe. Urine citrate was 740 if that matters. I never caught the stone, so I don’t know what the make up was. It showed up on KUB x-ray, and then in follow up imaging it was gone. So all I know was there was calcium involved! I’m very disheartened at how nonchalant and even unaware my doctors have been about diet, oxalates, and all of the other information and research you have made available. I am 60 yo fit female in otherwise very good health. Thank you!
Hi Perla, You cannot evaluate what the diet is doing to stone risk except from the 24 hour urine values and they are not in your note. So too much /too little is not something I can help with. Perhaps you might want to post the most recent 24 hour urine values? Best, Fred Coe
Sure thing. I track *every* mg of sodium and sugar, rarely go over 1000 on sodium or 10 on sugar. Minimal meat… I don’t know what else I can do, and I don’t know why sodium was still 101 and calcium was even higher than it was in March (270). Had the blood work to rule out PTH. At a loss and just wondering if I can enjoy no sugar lemonade to help with hydration or if that’s off the table due to pH. Thanks!!
Volume 5110
Calc ox saturation 2.3
Calcium 292
Oxalate 32
Citrate 740
Cal phos saturation 1.37
pH 7.626
Uric acid sat 0.01
Uric acid 450
Sodium 101
Potassium 110
Magnesium 144
Phosphorus 882
Ammonium 21
Chloride 95
Sulfate 35
Urea nitrogen 9.16
Prot catabolic rate 1.4
Creatine 1050
Creatine/kg wt 22.1
Calc/kg wt 6.1
Calc/creatine ratio 278
Hi Perla, with your high urine volume stone risk is not so high. It is the high pH that I notice – you eat a lot of protein which would tend to lower pH and do not mention taking alkali but pH is 7.6! Why? You mentioin minimal meat, so perhaps your food is all vegetables? The high pH is perhaps your main problem. Regards, Fred Coe
Why indeed! At 47.63 kg bodyweight, I eat no more than 48 g of meat protein per day, usually less, closer to 25 g. I don’t eat a LOT of plants, but I do try to get five servings of fruits and vegetables per day, not always successfully. Just wondered if I had to cut out all citrate containing products and foods such as the aforementioned lemonade or the true lemon products that I use to flavor peppermint iced tea with a little liquid Stevia sweetener. Would that make any difference in pH levels? Should I cut out my salads and eat more meat? And as far as the urine calcium are you thinking the high urine calcium isn’t as much of a concern as long as I keep the fluid intake up nice and high? I just don’t know what to do and my doctors just shrug.
Hi Perla, I looked and could not find your original question on the post used here. I guess a prior question concerned alkaline urine and you form calcium phosphate stones, but without the reference question I am at a loss to respond here. Fred
I was diagnosed with renal sonogram/KUB at VMG faint calcific densities bilaterally; 6 mm right MP, 8 mm left UP stone. After ureteroscopy surgeon said it appears calcifications are parenchymal and not within the collecting system.
Urine analysis showed Leukocyte Esterase: Small, protein 300, and specific gravity 1.030.
I spend a lot of time in the backcountry and am nervous about one of these stones moving down and becoming obstructed. Is it possible to remove them?
Also I am 61 and have osteopenia. I am supposed to take calcium supplements but not sure what to take as I don’t want to increase chances of kidney stone formation. What are my options?
And what does the protein 300 mean?
Thanks!
Hi Sue, It is either plugging of tubules or plaque.Randall’s PlaqueNeither are stones but rather the base stones form on. Both suggest high urine calcium or very low urine volume, and 24 hour urine testing is reasonable. Best, Fred Coe
I have osteoporosis and my doctor wants me to get a Bisphosphonate injection, but they are not recommended if you get kidney stones. Is it ok for me to get the injection? Or am I at risk of kidney stones?
Hi SUe, I know of no reason bisphosphonates are a special problem in stone formers. Regards, Fred Coe
Hi Dr. Coe, I have been to your office a long time ago. You also see or used to see my Uncle Eli Jack. We both have Nephrocalcinosis and I have medullary sponge kidney. He said he never knew if he did or not. I am an US tech now and I scan myself once a month. I’m very lobulated and they look like fluffy clouds. I drink, at least, 1.5 gallons of water a day. I have been since you did my 3, 24-hr urine back to back and they barely had urine. My question is, how do I slow this down. I still take my chlorthalidone, drink the water and drink powder oxalate stuff, along with potassium chloride and citrate and yet I feel like it grows at an alarming rate. I never get super big stones, they are just a bunch of stuff sitting in the kidney. Thank you! Tami
Hi Tammy, I no longer have access to very old records – things change at large institutions. And I cannot remember any details. Is the renal calcification increasing or just there? If the latter, that is what one expects because the mineral is in the kidney tissue. All I can offer is to see you via telehealth, but perhaps you are stable and not in need of more care. I cannot tell from your note. My best to you and your uncle Eli. Fred
is it possible for kidney stones to dissolve without surgery if there are just two of them 3 millimeters & 5 millimeters in size, given the proper diet away from oxalates? And any particular medicine that would help them dissolve?
Hi Georgine, Anything is possible in medicine, but stones rarely dissolve. Often very small ones pass unnoticed. If you have them, be evaluated as to cause and seek treatment based on what is found. That is a good way to protect yourself. Best, Fred Coe