Here, stones are due to some serious systemic disease. We need to prevent them, but that invariably requires we cope with the disease that causes them.
One could rightly say that uric acid stones fall in this category in that the low urine pH that drives them arises usually from obesity, diabetes, gout, or at least metabolic syndrome. But in all cases treatment devolves into simple increase of urine pH, and one does not cope with the underlying disease.
Likewise for cystinuria. It arises from inherited transport abnormalities in the kidney proximal tubule. Once again, we cannot treat those abnormalities but only the final urine cystine concentration and therefore supersaturation. Even so, renal function tends to fall more in cystinuria than most other forms of stone disease, so I list it here.
Medullary sponge kidney is also hard to be sure about. A developmental renal malformation, it nevertheless has been described in association with other diseases and so is included here, as well.
The lovely painting by Jan Steen (1625-1679) hangs in Apsley House, London.
Systemic Stone Disease
Chapter 12: Distal renal tubular acidosis – Detailed, but also clinically useful
Chapter 7: Primary Hyperparathyroidism – Covers diagnosis and treatment
Primary Hyperparathyroidism – A detailed review including familial disease
Chapter 10: Bariatric surgery and kidney stones – Mechanisms and treatment
Case 6: Bariatric surgery and kidney injury – How to protect against oxalate kidney injury
The diagnostic dilemma of medullary sponge kidney – Stones occur because of abnormal kidney structure
Chapter 9: Cystinuria: An Introduction for Patients
Chapter 11: Ileostomy Kidney Stones – Mechanisms of stones and treatment
Can exocrine pancreatic insufficiency and/or low stomach acid contribute to calcium oxalate stone formation and if so, how? Can taking plant-based (aspergillus) digestive enzymes
Hi Ruth, indeed pancreatic insufficiency can lead to high urine oxalate and stones. If you have that you need 24 hour urine studies to measure oxalate excretion, as it can be rather high and pose risks of stones and kidney damage. Regards, Fred Coe
Thank you. I have an appointment with a nephrologist on Thursday.
How does the low bicarbonate output from the pancreas, that is common with severe EPI, relate to urine pH and stone formation?
Hi Dan, Exocrine pancreatic insufficiency – I am sure this is what you meant by the abbreviation – can cause stones a lot of ways and it also depends on the cause. Malabsorption is not rare, and leads to high urine oxalate excretion and calcium oxalate stones. Cystic fibrosis causes EPI and also renal tubular acidosis and calcium phosphate stones. The reduced bicarbonate secretion would reduce bicarbonate losses from the blood, but I do not think this would alter acid excretion or urine pH enough to cause stones – not a lot of data on this! I guess stone analysis and urine studies are essential in this condition, and I presume you have had them. If not, I strongly urge you do. Regards, Fred Coe
I ran across a correlation between tuberculosis and kidney problems, but can’t find much about it at all. I had tuberculosis as an infant and kidney stones pretty consistently as an adult. Would that disease or the medications fighting the disease have started something way back then that would translate into making kidney stones now? Mine are calcium oxalate.
Hi Jennifer, TB can leave scars that calcify but is not a cause of stone disease. I would pursue a full evaluation to find the cause, and suspect it will be other than your prior TB. Regards, Fred Coe
Would the plant-based digestive enzymes (VeggieGest made from asperguillis niger) that I take for my exocrine pancreatic insufficiency contribute to calcium/oxalate stone formation? I spoke with a company rep that said the enzymes are grown on aspergillus niger, but then purified and made into plant enzymes.
Hi Ruth,
Not sure about this. After the purification process, it might lessen any oxalate that was originally contained. What plant enzymes are being used?
Jill
Dr. Coe,
I’m following your recommendations through Jill Harris’s web site and coaching and have made great strides in reducing my CaOx stone risk.
Every few weeks I treat myself to higher oxalate food. How many days should I wait after an uncharacteristic meal before I do a Litholink collection?
I have a slow bowel, where sometimes I go 3 days between BMs. Does that impact my CaOx risk or affect my Litholink testing?
Thanks for your work!
Bob Bogardus
Carmel, CA
(Resubmitted as I had typed Jill’s last name wrong… Sorry!)
Hi Bob, I would guess about 4 days will be enough that the one meal will be without effect. But, remember, the Litholink will look a lot better than during your treat! Bowel transit has no known relationship to stone disease. Regards, Fred Coe
A year and five months ago I had surgery to remove a nearly one inch kidney stone. My stone compensation is 80% Uric Acid and 20% Calcium Oxalate. I have constant diarrhea and supposedly have Ulcerative Colitis but no medication has worked for me. Plus I have no gallbladder now and I do not follow the normal Colitis symptoms. After the surgery in May 1, 2019, I passed a stone in February 2020 and a CTScan showers two more small stones in the bottom of my kidney. I drink lots of water and try to follow diet recommendations but still are forming these stones. I did better it seemed before I tried the low purine diet. I really need help and my intestinal problem plus the Covid exposure keeps me from seeing a doctor tho I have an appointment this week. I’m getting afraid of the numerous CTScans for fear of cancer. What should I do? Would a registered diatician help? Thanks, I’m really up the creek without a paddle. I also have about five ulcers in my stomach and Cipro given seems to have caused an occasional acid reflux.
Hi Sylvia, You are forming Uric acid stones because of GI alkali losses which lower urine pH. POtassium, or even sodium alkali will prevent uric acid stones, and your physicians can easily provide it. You need 24 hour urine testing to determine you4 24 hour average pH and with treatment to be sure it has risen about 6. Once again, your physicians can easily do this. Water alone will not work and low purine diet is useless as the problem is from too acid a urine, Regards Fred Coe
Recently my stone analysis came back as:
Calcium Oxalate Dihydrate (Weddellite) 20%
Carbonate Apatite (Dahllite) 40%
Ammonium-Magnesium Phosphate Hexahydrate (Struvite) 40%
I do not have any symptoms of a UTI. I am lost.
Hi Briana, POssibly the struvite is a lab mistake – not rare. KIDNEY STONE ANALYSIS: How Bad is It?Possibly you are indeed infected without infection. Urine cultures need to be comprehensive as some urease possessing bacteria are hard to grow. Your 24 hour urine testing will give a clue. Stone forming infections tend to raise urine pH AND ammonia so look and see if the pH is very high (7 or more) and the ammonia also high (more than 40 mmol/d). Regards, Fred Coe
Hello there i had two 1.5cm and 1.3cm stones removed that were removed a month ago via perc tic procedure.
here are my 48 hour urine results, any insight?
Calcium, Urine 248 High mg/24 hr
Citrate, Urine 448 Low mg/24 hr
Calcium Phosphate Saturation 2.30 High
pH, 24 hr, Urine01 6.273 High
Magnesium, Urine01 160 High mg/24 hr 30-120
Creatinine/Kg Body Weight 01 20.4 High mg/24 hr/kg 8.7-20.3
day 2
Calcium Oxalate Saturation01 4.86 Low
Citrate, Urine01 397 Low mg/24 hr >550
Calcium Phosphate Saturation01 2.07 High
pH, 24 hr, Urine01 6.553 High 5.800-6.200
Sodium, Urine01 160 High mmol/24 hr 50-150
Hi Brian, One might guess it is the combine of high urine pH and calcium causing high CaP SS. But stone type is crucial and you do not list urine oxalate so things are so incomplete I would not be at all sure. Here is what a complete evaluation is like, and I suggest you follow it because you had a PERC, meaning large stone burden. If I were to guess the stones are brushite but that is sheer guessing and stone analysis is easy to obtain. Regards, Fred Coe