This may be the most important article – to me – I have written thus far.
It is a plea and argument that stone patients need more from us than prevention of stones, because often enough they harbor significant diseases that associate with stone forming and require their own treatments. We need to treat the patients, not just their stones.
The magnificent Garden of Earthly Delights (Hieronymus Bosch, 1450 – 1516) hangs in the Prado. I chose it here as it contains the whole world, which is to say that every patient is that self same.
Stone Formers Have Other Disease Risks
When you look at the data, kidney stones belong to a manifold of diseases that run together: Bone disease, kidney disease, hypertension, and stones themselves. This is to say that forming stones identifies someone as having a pattern of increased risk, modest risk, certainly, but well worth considering.
Renal and Cardiovascular Risk
For example, in Olmsted County about 1.2% of people eventually came to need dialysis or transplantation, but rates were 2.4% for those with stones. In other words low risk is amplified a bit. On the other hand, over 18 years, about 18% of people developed stage 3 chronic kidney disease (CKD) vs. 25% of stone formers. You might say modest CKD poses little threat to life, but in reality this kind of disease associates with higher rates of cardiovascular disease such as heart attack and stroke.
The same for hypertension. Having even one stone raises risk by about 1.5 times the rate for non stone formers.
While it is tempting to string these together in presumed causal linkages – e.g. stones damage kidneys, which leads to kidney disease and hypertension, etc – one may be better off to accept the simple fact of their association and act accordingly. Science will ultimately sort out what causes what.
Bone Risk
Likewise for bone disease. Whereas vertebral fracture in later life affected about 5% of people in Olmsted County, rates were over 20% in stone formers. I believe idiopathic hypercalciuria and low calcium diet massively contribute to this bone problem, but I am limited to my time and the future may show us more.
So What?
It is a matter of long term risk assessment and reduction. Stones tend to peak at younger ages, CKD, hypertension, and fractures come later in life. Both reduce life’s quality, and even longevity. If the final risk and type of damage is modest, risk mitigation seems equally so. Just a proper diet and – when needed – thiazide and potassium citrate should do wonders for stone reduction and improvement of health in later years. That self same diet acts against obesity, insulin resistance, diabetes, and osteoporosis. That is why the stone diet so much resembles the diet recommended for all Americans.
Systemic Diseases Can Cause Stones
One reason for all these associations may be that stones can arise from established systemic diseases that themselves affect kidneys, or bones, or blood pressure. For example, uric acid stones form because urine is too acidic. But that acid urine often comes from obesity, diabetes, or bowel or kidney disease, or insulin resistance, or metabolic syndrome. That will tend to associate stone forming with hypertension and bone and kidney disease when one looks at population studies. Likewise, cystinuria is an inherited disorder of kidney function, and chronic kidney disease is a common outcome. Renal tubular acidosis and Dent’s disease are other examples. Primary hyperparathyroidism is perhaps the clearest possible instance. It causes calcium stones and bone disease, and high serum calcium can damage kidneys and raise blood pressure.
In each case, disease causes stones and stones can add more injury on top of diseases that have preceded them. No one needs be surprised that hypertension, bone disease, and kidney disease accompany stones under such circumstances.
Idiopathic Calcium Stones Have Added Risks, Too
By contrast, common idiopathic calcium stones seem to arise from a complex interaction between genetics and our particularly bad modern diet so rich in salt and sugar and protein, and low in calcium and veggies. Such an interaction would fit with the familial nature of stones and the success of diet changes in reducing new stone formation. As an added pathway of injury, calcium deposits in the kidneys could raise blood pressure and cause kidney disease, and disorders like idiopathic hypercalciuria promote bone disease.
This scenario posits that increased vulnerability to the bad effects of our modern diet may cause stones, bone disease, raise blood pressure, and by a multitude of pathways lead to kidney disease. In other words having stones is the mark of multiple vulnerabilities to a diet too rich in salt, sugar and protein, and low in potassium. Even though the linkages may be deeper and less apparent than this, stones become an all too obvious sign of what may be a manifold of disorders each of which deserves attention.
Preventing Stones Is Not Enough
Given this reasoning and the facts that have lead to it, proper care of stone patients cannot be stone prevention alone.
Of course we want to prevent stones. They are dangerous, painful, and utterly disruptive to a normal life. But beyond the stones, we want to treat or prevent the diseases they travel with. Because stones single out people with multiple disease risks, we need to treat the whole patient, not just prevent kidney stones.
Evaluate Every Patient
Systemic Causes Can be Hard to Diagnose
When they know about them, physicians are apt to treat systemic diseases effectively. But they may not know for some time.
Consider primary hyperparathyroidism. Mild increase of serum calcium can be lost in the noise and confusion of blood samples not always drawn fasting, not always drawn well, and not always run by highly precise labs. Vitamin D deficiency and even modest reduction of kidney function can mask primary hyperparathyroidism.
Intestinal malabsorption may have few symptoms yet produce hyperoxaluria. Primary hyperoxaluria itself is not evident unless a 24 hour urine has been obtained. If stones are lost, or not analysed, uric acid stones and even cystinuria can be missed – for a while.
The rare genetic diseases – Dent’s disease, renal tubular acidosis as examples, can be colorful and odd looking but mainly we diagnose them from coordinated serum and urine laboratory measurements. The not uncommon and unfortunate tendency to restrict 24 hour urine testing to recurrent stone formers can much delay diagnosis.
Uric acid stone formers are rarely ‘idiopathic’ in that the low urine pH they require is not a normal finding. I already listed the panoply of underlying disorders one usually encounters. Almost never do they lack systemic problems, so almost never is it enough to just prevent more stones.
Likewise for struvite stones that bacteria produce. These infected foreign bodies need special surgical care. Often, struvite forms over calcium stones of idiopathic etiology, so two problems need attention.
Evaluate All First Time Stone Formers
Detect Systemic Diseases
Consequently, no stone former should be let go without a proper evaluation. You simply cannot diagnose systemic diseases without fasting blood and 24 hour urine testing combined with considerable clinical acuity. Of course stone analysis is paramount. How else to discover uric acid or cystine, or dreaded struvite – from infection. Explicitly, even first time stone formers cannot be left untested and told to drink more. That approach that invites mistake.
Improve Treatment Outcomes
Idiopathic calcium stone formers are diagnosed by exclusion. That means no one can be so classified without serum and 24 hour urine studies and stone analysis. Once identified, they are best off with immediate multimodality treatment. The more stones formed, the less effective our treatments. Just high fluids ignores the need for changes in diet calcium and sodium to protect against bone mineral loss, reduction of refined sugar as a hedge against insulin resistance and metabolic syndrome, as examples. It ignores the need to manage against bone and kidney disease, and high blood pressure.
Promote Healthy Diet
How can I best say this? Every first time stone former deserves serum and 24 hour urine testing. Period. Why wait? To neglect systemic disease is sinful. If idiopathic, stone prevention begins simply with a healthy diet that otherwise might have been put off for convenience’s sake, but followed from necessity contributes to a healthier life not only for the patient but the family as well.
Said perhaps more aptly, stone prevention based on a proper diet and medications when needed reduces risk of later life fractures, as well as high blood pressure, chronic kidney disease, and their associated increased risk of cardiovascular diseases such as heart attack and stroke.
Canary in the Mineshaft
Put another way, most patients will have idiopathic calcium stones.They are lucky in having no overt systemic diseases. But just because their idiopathic calcium stones bring patients to physicians for care, the stones cannot be all we attend to.
Bone Disease
‘Every stone clinic is a bone clinic‘ – Professor David Bushinsky.
Find It
Stone formers fracture more commonly than others do. I think idiopathic hypercalciuria and low calcium diets are a main reason why. But whatever the real reasons turns out to be, we want to lower that risk.
Given established idiopathic hypercalciuria, a bone mineral density (BMD) scan seems reasonable, and insurance carriers may pay for it. Multiple studies document reduced bone mineral density in IH. We do not have enough clinical data to advise a bone scan for other idiopathic stone formers, yet. Even so, I favor scans given a history of low calcium diet or of family fracturing. Obviously, we need more data about bone disease in non hypercalciuric calcium stone formers.
Treat It
We obtain a scan and estimate fracture risk. What then?
If fracture risk is modest, high calcium, low sodium diet should be reasonable. You might say it is also proper for IH as a way to prevent stones, and I agree. So in treating the one we help treat the other. Likewise for thiazide: proper to lower urine calcium and reduce new stones, known to improve bone mineral balance and reduce fractures.
I hear you saying, ‘so why measure BMD?’
Sometimes, we will find advanced bone disease at the beginning, and treat it with bone specific medications. If BMD is only modestly reduced we know we need to repeat the scan after some period of diet treatment. Should all be well – stable or improved BMD – we have done well. But if not, further treatment can be offered, such as bone specific medication appropriate to fracture risk.
What we gain is precious time, a baseline to work against, and a bone oriented follow up we might have otherwise not performed.
Hypertension
You might say, every primary care physician looks for hypertension, finds it, and treats it. But that cannot be. The fraction of people with high blood pressure under control from treatment has been estimated at only about 50%.
Because stone formers are at higher risk than normal, we need to be sure about blood pressure. To me, this means not only making a measurement at clinical visits but also looking at what others have found. If values seem suspicious, the cost of home blood pressures is virtually negligible compared to the benefits of early recognition.
Once again, treatment of stones usually involves low sodium intake, high potassium from fruits and veggies, thiazide, and reduction of sugar intake – which will tend toward weight loss and improvement in insulin sensitivity. All of these measures can lower blood pressure and may suffice.
If it does not, we can augment medical treatment ourselves or work with primary care physicians to have it done if pressures remain above ideal despite the kidney stone diet and thiazide. Because we know risk of kidney disease is increased, we may be more vigilant than others.
Kidney Disease
It Happens
I am surprised kidneys fare as well as they do given repeated obstruction from stones, infections, and procedures like shock wave lithotripsy and percutaneous nephrolithotomy. All of these offer possibilities for kidney tissue injury and inflammation. Virtually all stone forming kidneys harbor calcium deposits. Tissue cannot but recognize them and react.
Years of work have established that resilience has its limits. Stone formers do progress to chronic kidney disease and even serious kidney failure at higher rates than normal.
We Can Help
One cannot reduce this complex matter to a few clinical nostrums. Say instead we have the responsibility for wary observance and care to mitigate. I mean by this attention to even slight reductions of eGFR and to stone related events that can damage kidneys. Obvious examples of the latter: contrast agents; dehydration from vomiting when NSAIDS are being used for stone pain; multiple shock wave procedures; painless and therefore missed stone obstruction.
Our basic stone prevention diet – low sodium, moderate protein – helps protect kidneys, as does attention to blood pressure. Likewise for reduced sugar intake that helps stave off obesity, insulin resistance, and diabetes. But stones themselves and the procedures to visualize or remove them can deceive us. The very urgency of a stone attack may divert attention from the need to protect against kidney injury, however inadvertent.
My Message to Patients
Stones are bad enough, but they may signal risk for as bad or worse. Shun monotherapies like ‘lots of water’; low oxalate diet as panacea; lemon juice; or nostrums found on the web. They are often ineffective and do not speak to all that may be wrong.
Demand blood and 24 hour urine testing after even one stone.
Ask about bone disease, blood pressure, kidney function.
Learn and follow the kidney stone diet. It has a good scientific base and matches what all US people are advised to eat anyway. The diet, supplemented with thiazide or potassium citrate when needed, helps protect against bone and kidney disease, and hypertension, as well as more stones.
Offered procedures, ask about kidney protection, risks to kidney function. Know what your kidney function is, and always ask about changes in it, if any.
Know your blood pressure and see it is kept in proper limits.
If your bone mineral density has been low, be sure it is re-measured at intervals, and that you get treatment, if needed, to stabilize it.
My Message to My Fellow Physicians
Stones can be the first sign of systemic diseases. Find them early.
Shun single modality remedies. Because they do not protect against bone or kidney disease, or against hypertension, they are wrong at their core: too narrow for a population at higher than normal risk. Especially first time stone formers, so numerous as they are, deserve a proper initial evaluation for systemic diseases, bone disease, hypertension, and kidney disease.
At minimum, every stone patients should follow the ideal US diet – which is indeed the ideal kidney stone diet. What possible reason can we adduce for acting otherwise?
The hypertension, bone disease, and kidney disease in our stone formers are our responsibility simply because we have ongoing treatment relationships centered around stones. Stone prevention modalities can benefit bone, blood pressure, and, consequently, kidneys. Stone passage and surgical interventions pose risks of kidney injury.
My Message to My Fellow Clinical Investigators
We lack important data concerning bone disease, hypertension, and kidney disease in idiopathic calcium stone formers. These are compelling problems. It is not for me to say what we need, it is for you to think about what we need to practice better, and help as best you can.
My Message to NIH – NIDDK
Shun and discourage thoughtless management of idiopathic stones as if stones were THE problem. Stones are part of a larger problem.
Lots of water, or lemon juice, magic enzymes and bacteria, or obsession over diet oxalate may reduce stone recurrence for a time. But such monovalent remedies are no service to patients who might have more benefitted from a better diet they do not understand and embrace because of distraction and false security.
The ideal stone diet follows the ideal national diet shaped by your peers in government service. We need funds to foster that diet in stone prevention because it also acts against bone disease, hypertension, obesity, and diabetes, crucial issues to stone patients at risk for fractures, hypertension, and kidney disease.
We need research that helps physicians detect and manage bone disease, hypertension, and kidney disease in stone formers in ways that are austere, efficient, comprehensive, and effective. That would be a dignified and thoughtful use of public funds.
Dear Mr Coe,
Neither my english nor my kidneys have improved since my last email.
I’m currently stuck between another kidney surgery and open hart surgery for hypertrophic obstructive cardiomyopathy. I’m in good hands with Dr Heitner and Dr Song OHSU Portland. I just wanted to thank you for all your great articles and website.
I making an effort to follow your advice.
Jacques R Lecomte
Grants Pass OREGON
This is a very good article. My urologist which I have used for 30 or more years knew I had chronic UTIs and treated them. Then at age 29 I passed 3 very large stones on my own; and doctor ordered radiology to see if I had other large stones. I did and was scheduled for lithotripsy. I passed gravel for a solid week. When I returned for postsurgery check, my urologist said to drink 12 glasses of water a day and that I had calcium oxlate. It wasn’t until I kept have infections that were becoming harder and harder to get rid of that my urologist ordered more test and showed that I had spongy kidney disease and that the kidney reflux I was born with and thought was cured after multiple surgeries when I was 2 still existed. He never performed a 24 hour urine, never ordered a blood test. He did thankfully order more radiology tests that let me know my reflux was still present and I had spongy kidney disease. I now have hypertension and ckd. I so wish I had found this information when I passed my first stone.
Hi Debi, be sure your blood pressure is controlled properly and that everything is being done to protect your kidneys. Regards, Fred Coe
What a great article!
Thank you, Linda! Warmest regards, Fred
This is a great article and your right we need more doctors to look at this other conditions. I have had chronic vitamin D deficiency, which I believe has caused my oteopenia, degenerative disc disease and I also have herniated discs. I have Medullary Sponge Kidney disease and I do the drinking of more water add lemon, stopped pop took lots of food out of my diet, limited my intake of so many others. I have lost 26% kidney function over the last year and a half. No one discussed this with me or what caused it. I know these things because I keep an eye on my lab, rad reports, etc. I also have a complex renal cyst measuring over 3.5mm and have significant kidney pain in that kidney. I’m told it’s not from the cyst. As a nurse and patient who knows my body well, I’ve eliminated other possible causes. Yet I get push back from my nephrologist about it and when I ask questions about lab values I get no real answers. I appreciate the information and actually just asked our kidney group how many of us have bone/ joint issues. There were quit a few. Again, great article and information we need more doctors to speak up and do more research.
Hi Holly, All too often bones are neglected. Vitamin D deficiency may possibly be accelerated by idiopathic hypercalciuria – no trial but some data obtained years ago. You really should be sure about adequate calcium intake and reduced sodium, and perhaps you may need specific bone directed meds. The loss of kidney function seems rapid – be sure there are no obstructing stones. Regards, Fred Coe
I have been struggling right along with my daughter Megan who just turned 18 and who was diagnosed with kidney stones/crystals at about 15 years of age and who has been suffering from what I am learning sounds like small stone syndrome. She has passed a couple of very small stones over the years and had started with approximately 9 small stones or crystals and at last US was down to approx. 4-5. She has been thru every workup to try and find a cause for her discomfort and inability to play sports and do the activities she loves due to the pain and discomfort. We have been told many things by many doctors but most feel they should not be causing her the issues they seem to be. She has missed out on many great things in her life due to the discomfort and pain and has been thru many unnecessary tests and procedures. Being a nurse myself, let alone her mother, it has been extremely frustrating and agonizing to not be able to help her or find a cause/cure. I have read about the flex ureteroscopy and mentioned it to docs where I live and none really recommend or understand or offer it. I would be more than willing to fly with my daughter somewhere where they are well known for doing a thorough workup and offering treatment options that may work and give her back her life. Please respond to my email address asap and let me know of any suggestions, recommendations or opportunities you may have to offer. Thank you for your time and attention
Hi Wendy, I will write to you via your email address. Regards, Fred Coe
Hi – I have ckd stage 3, type 2 diabetes, hbp, slightly high cholesterol, have had episodes of gout, several calcium oxalate stones, what can I do to get and stay healthy?
Hi Cindy, your question, though short, is global. The stones are arising from urine abnormalities, and you will need proper testing. Diabetes is best treated with diet and weight loss and meds if necessary, and that is complex medicine. The stage 3 CKD sounds like hypertensive renal disease, but your physician will know if that is correct. Maintaining a normal blood pressure is critical. I guess the only thing I can say from this distance is to pursue a proper stone evaluation and see what your treatment options are. The kidney stone diet, incidentally, is excellent for diabetes and hypertension. Regards, Fred Coe
Does the stone diet apply to stones in the gallbladder and salivary glands also? Are the risk factors the same?
Hi Jenna, No. Gall stones are entirely different. As for salivary stones, they are calcium phosphate but probably unrelated to kidney stones. Regards, Fred Coe
Dear Dr. Coe –
Thank you very much for so much information. My 43 year old husband had his first stone removed via lithotripsy this fall. It was a massive stone, Dr. estimated about 2 cm before the lithotripsy per his scope. Composition is primarily calcium oxalate monohydrate and dihydrate. Based on his latest blood and renal ultrasound, all is unremarkable. Now to try to move him to a more appropriate diet – will be challenging. Even though he already is on meds for hypertension. However, the radiology report mentions a 2.6 m simple cyst on the left kidney. Is this something common or to look into further? He has a nephrologist as his father is currently in CKD Stg. 5 with in-home dialysis 5 days a week for the last 4 years.
Thank you,
A concerned wife
Hi Meghan, He should have a complete evaluation to find the cause. Soon. The cyst is not important if judged benign and lacking crystals in it. Being healthy altogether the kidney stone diet is always a good idea, but may not be enough. Regards, Fred Coe
thank you for all of this info. I am a physican and looking to order the appropriate 24 hr urine testing on a pt. under my care who has a hx of frequent kd stones, she’s had mildly elevated blood calcium levels, however she has extrapulmonary sarcoidosis. before recommending specific diet and treatment I want to analyze her 24 hr urine, but I’m not clear on what I need to order at the lab. Thank you for your help on this
Hi Dr Larivee, If you are in the US the easiest is to use a commercial vendor like Litholink. If not in the US at minimum I would ask for 24 hour urine calcium and creatinine. Given the high serum calcium, your patient could have primary hyperparathyroidism – normal to high PTH high urine calcium, one of the vitamin D excess states – suppressed PTH high urine calcium; benign familial hypercalcemia – normal PTH and low urine calcium. The urine calcium can be interpreted using the creatinine as a collection marker – should be 18 to 22 mg/kg. Also normal urine calcium/gm creatinine is <140. Warm regards, Fred Coe
Hi Dr. Coe,
My brother has recently seen you for advice on his kidney stones and I deal with kidney stones as well. Our dad has a history of them, too. I’m 42 years old and had my first kidney stone about 5 years ago(4-5mm). I had procedure to remove it and then I was put on potassium citrate. This past October, I had my 2nd and 3rd kidney stone. The small 2nd one(that eventually passed on its own) brought me to the ER and the 3rd(8mm) on right side was found on the ct scan in the ER. Shortly after, I had procedure to crush that stone on right side and then have been put back on potassium citrate 2x day. I was told my stone is a carbonate apetite stone but I haven’t found many articles on that type of stone. I am told it is a rare type of stone. As of recently, I have had some slight discomfort on my right side and hoping it is not another stone, especially after just having my procedure 4 months ago. I was trying to think if there was anything new in my diet since my procedure and the only thing really is that I’m now taking vitamin D supplement since I was very low at my physical in November. I’m very curious to know how I can try and prevent these type of stones in the future. The worry alone, if and when I will get another stone, seems to affect my daily life whether it be when traveling for work or being with my children.
Hi Jamee, As you do not give your full name I cannot identify your brother and thence his causes of stones. Carbonate apatite stones are simply a form of the common calcium phosphate stone – the name is fancy and important but not clinically relevant. Prevention and treatment is along the main track – take a look here. If I knew who you were I could tell you perhaps where to look – very commonly causes are genetic. You can email me. Regards, Fred Coe
Dear Dr. Coe,
This comment has 2 purposes: To support your comments and to share freely, knowledge that can help so many.
Thank you for this informative article. All health care practitioners should heed your advice to consider the entire patient. The greatest weakness of modern medicine, is in the design of waiting until disease occurs and then using heroic care to “save” the patient from their own bad habits. There is a better way.
My kidney stone and health solution:
I had a kidney stone every 2 years for a total of 16 stones. I passes all but 3, and was thankful for modern medicine to relieve my pain with those 3 I was unable to pass. I had extensive diagnostic testing which led to the advice to increase water consumption and eliminate oxalates from my diet. This did not work. About 10 years ago I found out that I had high cholesterol. I opted to pass on the statins and write my own diet based upon available research. I adopted a diet of mostly fruits and vegetables, eliminated nearly all animal products, especially animal fats, refined sugar, and dairy products. It has been over 6 years since my last kidney stone. I no longer wake at night to urinate. This points to reduced prostate inflammation. (at 59 years of age) My urine flows free, strong, and is generally much clearer.
Coincidentally, my cholesterol came down over 70 points in 3 weeks on this diet. Triglycerides and blood pressure were reduced as well. I continue to eat healthfully every day with occasional indulgence on holidays only, for the most part. I am now 30 pounds lighter than I was when I started. I lost weight gradually. You will likely recognize the value of this: My C-reactive protein was over 5 when I started, and it now hovers around 0.2. The chronic lower back pain I suffered for many years is now gone.
Since this time I have helped many patients discover the restorative powers of correct eating. Some have struggled to change their diet, yet reaped the benefits of working through it. I have seen some pretty amazing things result from adherence to healthful eating. Relief from rheumatoid and osteoarthritis pain, normalized blood lipids, a return to healthy blood sugar, weight loss, improved vision and clearer thought. Diet is the most important, and most powerful medicine at our disposal. There is virtually no risk in using it to regain health, even while the doctor is treating your disease with medications. Improvement is pretty much automatic. The only downside, if it is one, is that you must continue with this improved diet/lifestyle for long enough to see results. This can vary from a few weeks to a year or more. It has literally changed my health and life for the better. I will never return to my old habits.
A diet more in line with the design of our anatomy and physiology is a powerful approach to health and healing.
After 14 or so painful kidney stones, I had pretty much lost hope for lasting relief. I hope that sharing my experience can help others.
Thanks for spreading your knowledge Dr. Coe.
Dr. David Vitko
Columbiana, OH
Hi Dr Vitko, Thank you for sharing your thoughts and experiences. We all appreciate this. Best, Fred
I concur wholeheartedly with you and Dr. David Vitko, DC.
It was just in the last few months that I discovered that most of the health issues I have been addressing these last 7 years are all symptoms of metabolic syndrome (Syndrome X). Diet and proper supplementation are key components to recovery of the syndrome and the ills I have been experiencing. Only time will tell how successfully I have discouraged the recurrence of stones, but it’s only been the last two months that I have no longer needed thermals, pajamas, and 5 blankets to get warm enough at night to fall asleep. It’s been wonderful. At 71 and diabetic for the last 20 years I do have some continuing issues with my blood sugar and aging itself, but I am in much better health than I was 13 years ago when I started working on my weight and other issues as I became aware of them. Eating properly is at the root of all my progress.
I had one 7mm stone. I was told that metabolic testing was not done on people who just had one stone. I was fussing about vitamin D levels, and the urologist finally said I could do a 24 hour urine test. That’s how I found out I had severe hyperoxaluria.
Hi Brinlea, Oh my, severe hyperoxaluria is an important finding. Be sure about the cause and get it treated. It can be diet, or more. How good that you persevered. Regards, Fred Coe
Dear All
Thank you for sharing your experience which is very helpful.
I am a diabetic patient and has got stone problem in my Kidney. I am 36 years old.
I would like if you could please advise me how I should proceed. From the above, it is clear that a proper diet will be very helpful. Apart from that, is there anything which I should do.
Thanks
Sahir
Hi Sahir, Indeed there is. Begin with a full evaluation for the stones. Here is a good article. Diabetics can develop kidney disease and hypertension at higher rates than common, so kidney function, presence of urine protein, and blood pressure are all important issues. Regards, Fred Coe
I am searching for a low sodium low oxalate diet. I had kidney stone blast and did a 24 hr urine test. Dr. said very important to have low sodium and low oxalate diet. So many lists have conflicting information. Please help me with correct information and the best way to find it. Thanks so much. Jan Tennyson
Hi Jan, The kidney stone diet is what you want. It has a few moving parts that all have to be in place. I can recommend it because of the science and also because it closely resembles the ideal US diet for everyone. Take a look, Regards, Fred Coe
I had had my first kidney stone on 9/27/18. Initially I was told it was 3mm and should be able to pass it on my own because of where it was located. The results from the CT Scan in the ER were as follows:
“There is a 3 mm stone seen within the distal left ureter near the left UVJ. This does result in mild to moderate left-sided hydronephrosis with stranding and inflammatory changes in the perinephric fat of the left kidney.”
Taking Flomax and drinking a minimum of 150 oz of water a day I was unable to pass it on my own. I am a 53 year old female, postmenopausal, 5’6 and weigh about 140 lbs. I had a ureteroscopy on 10/16/18. The stone broke up during surgery, so I did not leave the hospital stone free. Also my doctor lost, misplaced or forgot to send in the fragments they removed during surgery.
I fortunately passed two additional fragments on my own and one as able to be analyzed. It was found to be: “Uric Acid Dihydrate 80%
Calcium Oxalate Monohydrate (Whewellite) 20%”
Current treatment is drinking baking soda to manipulate the ph of my urine. I could not take the Potassium citrate due to a heart condition SVT.
My doctor has done no blood work and no 24hr urine collection. I still have pain in this kidney, so a CT scan with contrast was ordered and completed this past Friday. No results yet.
I have no history of diabetes, heart disease or high blood pressure…yet. My father had all of this in addition to uric acid stones.
I am looking for any suggestions on how to proceed with diet, additional testing or basically any knowledge you can share with me.
I unfortunately have not had a good experience with my urologist and just need further direction.
Thank you in advance!
Hi Denise, Uric acid stones mean an abnormally acid urine. Diabetes, obesity, gout, intestinal disease or functional diarrhea – chronic, or, in your case, perhaps, inheritance from dad. You also formed calcium oxalate crystals. You need the same evaluation as any other stone former. Sodium alkali is alright but the sodium load may raise blood pressure. The 24 hour urine pH is more reliable than spot testing as the stone mass depends on the average. But be clear, my advice is meant to complement your work with your physician who is in fact responsible for your care. If your urologist is not too interested in the details of prevention, perhaps a nephrologist might be added. Regards, Fred Coe
Someone I know seems to have chronic kidney stones. I think it is a great idea to focus on what is causing the kidney stones rather than solely the kidney stone prevention itself. CKD treatment can definitely help to prevent kidney damage and the need for dialysis later in life. It is good to know that major prevention for stones is a proper diet.
Hi Michael, I have put up this comment even though you link to a commercial (Baxter) site. The company is legitimate, after all. We should make clear that most kidney stone patients who have kidney disease have very mild forms of it and rarely require special ‘CKD’ care. Regards, Fred
I have a son who has a rare disorder called pelizaeus-merzbacher disease. He is 19, weighs 50lbs, has always had low bone density, does bone density infusions regularly. Started passing hundreds of gravel like sediment tiny stones in October of 2017. Has had a scope to hopefully retrieve larger ones with no success as they were to small to grab. He had a 24 urine collection, showing not enough fluids but he can not tolerate large amounts of fluids due to size, disease, and GI issues. His stones are calcium oxalate. He is solely g-button fed. His diet is blended from real food. Extremely low oxalate, almost no sodium, and average calcium intake. We’ve worked hard to raise water intake, up to 1200ml in 24 hrs. This is all he can handle. He takes flomax, Hydrochlorathiazide, and during times that stones break away from kidneys, he takes lorazepam and oxycodone for pain. It can take up to three weeks with excruciating pain attacks up to three to four times a day. Before we see a stone. I feel so bad for him! He is non verbal and there are moments, I feel like this is going to end his life… He holds his breath during pain attacks and his heart rate gets up to the 170’s…
On a regular basis his HR is 110’s which has been normal all of his life. His BP is in normal ranges, for his age. Not your average stone former for sure. 🙁
Any advice at all, is welcomed!
Hi Julie, As you know well, this is an intractable disease with no present treatments apart from some stem cell experiments. I imagine his stones are forming from increased CaOx supersaturation and that things might be better if you could get some urine collected for measurement to determine which elements beside low volume are causing the stones. Even if 24 hour urine is impossible, some timed collections would help. The 24 hour urine you got would be helpful – just what did it show?? I would be happy to take a look for you. Regards, Fred Coe
If I remember correctly, it was just low intake/output but I felt the timing of the test was bad. They placed a catheter as we were leaving the hospital, that he had just had a procedure done and had to be npo for 12 hrs prior to the procedure. The stones we have collected are of calcium/oxalate. They feel because he does weight bare at all and a majority of the time he is laying that his bones are releasing the calcium into his blood stream. It’s just horrific to watch my frail little son, have to deal with this kind of pain.
Hi Julie, Perhaps one can get some briefer timed urine samples for analysis to figure out if it is just volume or perhaps what he is fed might be changed to his advantage. Likewise one can look for crystals in the urine as a hint as to what and when events are starting. Obviously all this is to try to reduce the miseries from crystal passage. Regards, Fred
40 year old female. Kidney stone maker since age 14. Had two small stones at age 14 and 15 but it wasn’t until I turned 16 that it was discovered that I had been getting stones all those times. Had some big stones in my late teens and early 20s. Then I went on birth control depo. Didn’t hardly any until I came off of birth control to have a baby and then went back on. Now I randomly “suffer”’from an actual menstrual cycle – which had completely gone away for years. In the last 5 years I have had at least twenty procedures and many many ER trips and missed work due to constant large stones. I am coming up on 6 months of changing to a full vegan diet. Every other bad medical issue (diabetes type 2 – diagnosis 2 years ago, weight, hypertension) I have is getting better rapidly, yet I have had three episodes with stones since early October 2018. Now have two that I am going in for a 3rd procedure (ESWL) this Friday so far in 2019. Oh and I also recently had a cycle pop up out of nowhere. What should I do? I have a great Urologist. We just seem to be doing a lot of damage control and not enough prevention.
Hi Kim, You do not say, but I presume your stones were calcium oxalate and now contain phosphate or brushite – can you say what they are? I believe you have idiopathic hypercalciuria to account for your stones in adolescence, and that it is not fully treated. Here is an ideal place to begin reading about how to get fully evaluated and treated. Regards, Fred Coe
I have a question concerning recommendations on my current stone situation (no previous history of stones, am 48yo male). I have had no symptoms other than microscopic hematuria with occasional gross hematuria. I work out and exercise regularly, and have wondered if the gross hematuria days could be caused by more vigorous aerobic exercise (or tiny pieces of stone passing). I have had a CT scan and blood work. I have a 6mm stone and a 7mm stone in the same kidney. I eat a healthy diet, weight and body mass are good with no smoking/drinking, etc. We are heading on a long trip and the urologist recommended not starting treatment until I return as I could have to deal with pieces of stones or problems afterward that would interfere with the trip. In your experience what would you tell a patient in my situation. I don’t want to have a problem flare up and interfere with the family trip.
Hi Charles, There are several issues here. I do not think undertaking prevention will affect your trip unless the stones are uric acid. Your urologist can tell from their CT density. If they are uric acid and you begin treatment they can dissolve with fragment passage. If they are not uric acid, treatment will not dissolve them, even, but prevent more. Dehydration etc can promote stones, but you would be wise to get a complete evaluation and treatment based on the results. This is my favorite article on standard evaluation and prevention. If your trip is imminent, you certainly can wait for all this, as stones have been forming for a while now – in other words don’t rush and inconvenience yourself. Regards, Fred Coe
can you please tell me some home remedies to treat kidney stone except diet pattern. I am suffering from kidney stone 11 mm size. Left kidney is affected with it. I am taking medicine concerned to ayurveda from following site.
all health clue
Hi rajesh, apart from diet there are no proven remedies to prevent stones. Why would you bother about remedies of unproven worth when a reasonable diet and fluids are simpler and have supporting data? Regards, Fred Coe
Hi Dr. Coe,
Nice essay. I have a few questions for you if you don’t mind: (1) As I understand it, calcium oxalate stones can sometimes be dissolved. Is this also true for struvite stones? (2) Is it possible to have a stone or stones which are a composite of both calcium oxalate and struvite? Do stones containing struvite always present as “staghorn” stones? Thank you.
Regards,
Nelson
Hi Nelson, Calcium oxalate stones are almost never dissolved – I would say never. Struvite stones can dissolve if one inhibits the bacterial urease with hydroxamic acid, but that drug has a lot of side effects. Calcium oxalate and struvite not rarely coexist, and when so usually means pre existing stones have become infected with bacteria that possess urease and can therefore hydrolyse urea to ammonia producing the struvite crystal. The staghorn shape is not rare but also not necessary. Because they can grow almost without limit struvite stones can fill up all available space in the collecting system making the staghorn appearance. Regards, Fred Coe
Hello,
I’m looking for some advice. I thought your article was great. As a chronic Stone former for several years I feel like even with a Nephrologist, a urologist, and a primary care doctor none are treating the problem. Just the symptoms. I’ve had lithotripsy 11 times in a year. I had 2 parathyroids removed last July, and even with increased water intake, lemon water, lower salt intake, etc. Nothing is helping. I was told I would feel like a new person after my parathyroid surgery. Sadly I’m passing stones still. I’ve been in kidney failure twice. My calcium level is still 10.2 at 39 years old after parathyroid removal. Any advice you could give? Thank you!
Hi Troy, I am concerned as your physicians and you are. Too many lithotripsies! I presume your serum calcium was elevated and you had primary hyperparathyroidism, and I presume it is still there given the calcium you record. That two glands were removed and serum calcium is still high – fasting blood, taken before calcium supplements, I hope – suggests a multi gland disease. Be sure, with your physicians, that serum calcium is indeed high, not from some artifacts such as I mentioned and that serum PTH is normal or high with the high serum calcium in the same blood samples. If so you have untreated disease. Cured PHPT can leave hypercalciuria behind, so new 24 hour urine testing may help. But altogether your situation is so complex no outsider can do more than make a few suggestions. Your physicians are entirely responsible and are, I am sure, doing everything they can to fix matters. If they reach a point of uncertainty they can arrange for referral to a center with perhaps more expertise. Regards, Fred Coe
Hello Doctor. I too suffer with chronic kidney stones since I was only 14. I had another stent placed just two weeks ago and I already feel another stone in my right uvj. I can literally tell my doctors exactly where they are now.. are there any permanent treatments to avoid constantly being hospitalized? I’ve heard of semi permanent stents but I’m sure I’d just form stones in and around that also.
Thank you
Hi Ashley, Stones so early in life always have causes and you need 24 hour and serum studies to find those causes and aim prevention at them. Stents and all of their wretchedness are the outcome of failed prevention, and prevention is rather good when done properly. In your case prevention matters more than usual given procedures and early onset. Regards, Fred Coe
Is all the increased calcium in the urine coming from the bones in Idiopathic Hypercalcuria?
Hi Beverly, No. It comes from diet if you are eating a high calcium intake and from bone if you are not. So the ideal is high diet calcium and some other measure to control urine calcium such as reduced diet sodium and/or thiazide. Diet is ideal, as safe and effective. Regards, Fred Coe
Thank you for your devotion to this. I have MSK and suffer from multiple stones. I have had a dual percutaneous procedure two remove two 1 inch stones blocking my left upper lobe. I have also had multiple lithotripsy procedures and many cystotomy treatments Last one being the end of April. I am already filling with stones. 8mm being the largest. I also have many others in both kidneys and a cyst as well.
All 4-24 hour urine come back normal other than elevated protein and blood.
I drink at least 3L of water a day. I also eat well and do not use salt. I do eat some sugar and now I am questioning whether I should also be cutting it out of my diet.
I form 4 types of stones. Often discouraged at the lack of knowledge when I am in a dire situation and need to go to the ER.
Thank you Dr. Coe
Hi Pauline, YOu say you have had 4 types of kidney stones but do not say what they were. Likewise, ‘normal’ values for 24 hour urines are a legal matter, a need to specify a range thought to be characteristic of non patients. But stone risk varies with urine calcium, oxalate, volume, citrate, and supersaturation in a regular manner, so you need to look at your values from a graded risk point of view. As for your diet, it follows your urine risk factors, but in general the ideal kidney stone diet closely resembles the ideal us diet. Check your results and see. Regards, Fred Coe
Good Article. I’m a 50 year old stone producer of about 25 years. Oddly I produce 90% of my stones on the right side. I have cycles of frequency then stretches of no issues. I’ve had too many basket-grab, shock-wave and now my preferred is laser b/c it totally vaporizes the stone. Hate stents b/c for me they are more painful than most stones, I’ve passed up to a 6mm [that one was a challenge]. I frequently pass 2-4mm stones with little issues now most of the time no blood before/during or after…I always have to have a stash of norco’s on hand b/c I never know where/when I’m gonna drop a rock. I’m thankful God gave me the will power to be able to go on/off the pain dope w/o becoming an addict. Though at this point anything less than a 10/325 does nothing for me, I know I’ve got a serious attack when a few in a short time does not curb the pain. If I cant pass in about 2 days I usually go to the ER for IV pain relief and KUB imaging. It usually takes me 2-3 days of weening-off at lower dosages to avoid ‘tweeking’ = sweats, pissy moods, sleep issues. Norco makes my skin itch so I have to take Benedryl which makes me sleepy, I take something b/c it upsets my stomach and also a damn laxative b/c they bind me up.
A lot of us have this problem! We are not alone with frequent stone issues…Keep it in perspective, I used to let it get me down. Stones are my ‘thing’ like it or not and at 50 there are a lot more [worse] issues I could have! Dementia, Diabetes, CANCER of any kind etc, etc.
Hi Nick, zi would think that medical stone prevention is very worthwhile for you, and you may well want to pursue it. So many stones cause pain and also raise risk of eventual kidney injury. Prevention is effective, and probably will save you a lot of trouble. Regards, Fred Coe
Dr. Coe, thank you for all of the very helpful information you make available to us all! Do you have any doctor recommendations in the Washington, DC area (Maryland and Virginia are fine too) for a women with recurrent kidney stones? Many thanks!
Dr Brian Matlaga at Johns Hopkins is brilliant, and I would recommend him without reservation. Regards, Fred Coe
Hi, I was diagnosed with RTA. I always have stones and mainly in my left kidney. Have had several lithotripsy procedures and other “retrieval” procedures. I am concerned that my kidneys will be or already are damaged. Do I request blood work for that? I am on the max dose of potassium citrate. I have hypothyroidism and celiac disease. I am wondering if the stones are the outcome of autoimmune diseases. My mom is just like me and she always has bone spurs in her heels! Thanks!
Hi Stephanie, Here is what I have written about RTA and you might want to see how well you and your mother fit into this pattern. If you really have this, your care is indeed complex and involves blood and 24 hour urine monitoring and concern for reduction of kidney function. Usually one seeks at least consultation with a specialist in the disease as it is rare. It is also often hereditary, so important for your family. Autoimmune diseases can cause RTA, likewise a matter for specialty consultation. Lithotripsy would not be my favorite approach compared to ureteroscopy, and stone removal would be only because of obstruction, infection, bleeding of consequence, or pain; merely removal of stones would not be ideal. Much of the crystals are actually in the kidney tissues. All this is assuming you have RTA, which brings me back to strongly recommending expert advice. Regards, Fred Coe
I have had calcium stones for years over 22 and this one I have now is the worst I have ever experienced. I have not be pleased with the urologist in our area. They just want to jump at the chance to do a surgery on me. My stones never pass its months with no relief ! Any suggestions for that
Hi Tammy, As for the current stone, if the stone is obstructing and will not pass your surgeon is right to remove it. Obstruction is not good for kidneys. Of more import, have you done everything you can to prevent more stones. Take a look and be sure. Regards, Fred Coe
Hi Dr. Coe,
Thank you for the comprehensive website. I wonder if you would like to weigh in on my particular case.
I am 57 years old. Ten years ago, while under treatment for another condition, approximately 20 stones were found in both of my kidneys. I have never passed any and haven’t had any complications from them. I go yearly to a urologist for an ultrasound and a check-up. I did go to a nephrologist about six years ago. My urine collection indicated oxolate stones. He had wanted to put me on a water pill and mentioned that it could induce pre-diabetes. As I am the grandchild of two diabetics with multiple amputations and daughter of a diabetic, I didn’t want to risk this, so I didn’t go back to him and then just put my head in the sand.
Fast forward to late 2019. My internist had suggested a bone density test. It turns out I have osteoporosis with T scores in the -3 range. Some other facts about me: I don’t consider myself postmenopausal as I am still having some high estradiol readings. I am hypothyroid with Hashimotos Thyroiditis. I had achieved Weight Watchers Lifetime in 2015 and had been eating a low sodium and relatively low sugar diet. As I don’t drink coffee, I have at different periods in my life drank bottled ice tea, or Diet Coke or black tea for the caffeine content. Probably averaging about 20 ounces of the soda daily.
I did just join up with the Kidney Stone Diet and look forward to my first conference call tonight. I do have appointments with a new nephrologist and an endocrinologist but aren’t able to be seen in until late March/April timeframes. Many thanks and looking forward to hearing from you.
Hi Sheryl, I suspect you have genetic hypercalciuria as a factor in your stone and bone disease. If so, the kidney stone diet is ideal for you. Jill is an expert in using it, so you signed up at the right place. But with t scores of -3 your physicians may need to offer bone active medication, and if they do I would suggest you follow their advice. Regards, Fred Coe
Hi Dr Coe,
I have hypercalcuria at 320 and sodium at 100. I just had a serum vitamin D test and it was at 32 and a Dexa that showed a normal z score of .3 and t scores ranging from .1 to -.5. My doctor wants to me try to reduce my sodium which I am doing based on your website. Also, he wants me to take a megadose of 50,000 IU of vitamin D2 three times a week for four weeks followed by 5,000 IU vitamin D3 per day for a month to get my vitamin D level up to 50. Is there any chance a megadose of D2 or even a daily 5000 IU level of vitamin D3 will worsen the hypercalcuiria? Is megadose of D2 have a better/worse or same affect as a megadose of D3? Lastly, could a more optimal serum vitamin D level of 50 result in better calcium absorption and reduce urine calcium? I am a bit skiddish of taking this vitamin D without comprehending the implications.
Thanks for being a great patient advocate and sharing your knowledge,
Kendall
Hi Kendall, You appear to have genetic hypercalciuria that is present even with a reasonably low diet sodium. The vitamin D levels are low normal and if your physicians wants to raise them I have no issues. A lower diet sodium may well lower urine calcium, and is desirable. Higher vitamin D levels will not lower urine calcium. You do not mention stones, and your bones seem reasonable, so perhaps you simply have uncomplicated hypercalciuria. Regards, Fred Coe
Thanks Dr Coe,
I do have a history of 5 kidney stones and I am 51 year old female. I was reading about megadoses of vitamin D and their increase of urine calcium of certain individuals via these articles but perhaps these studies are not corroborated? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5872784/ and https://www.endocrinologyadvisor.com/home/topics/general-endocrinology/risk-for-hypercalciuria-with-recommended-dose-of-vitamin-d-supplement/. The doctor thinks a higher vitamin D will help me absorb calcium better. I am not sure if that is a common belief among all physicians so also wanted your opinion on that hypothesis. Unsure increasing serum vitamin D is a great idea given the risk of exacerbating hypercalciuria or whether higher levels help bone density at all.
Thanks,
Kendall
Hi Kendall, I guess the question is what is being treated. Higher doses of 25D, the common pill, can increase calcium absorption and if the vitamin D level in the blood increases by 10% or so massed trial data suggest a positive bone effect. Urine calcium may well rise, and that needs to be considered a competing risk – for stones. To counter that one needs to control diet sodium. The kidney stone diet was put together to permit ample diet calcium, and perhaps that is what you are most seeking. Regards, Fred Coe
Hi Dr Coe
I’m from Canada and I’m 45 yrs old I have had 7 kidney stone removal procedures in the last 5 years both sides and always more then 3 on each side some almost an inch and a half. Why do I get them every 6 months after being removed? They were tested and came back as calcium stones. Any real advice for me. I am so tired of nobody looking into this and going about this as a normal thing
Hi Tracy, Prevention is very important, and here is a good place to start. In Canada, 24 hour urine testing appears scarce and rationed – from comments I have had in the past – but such testing is crucial. Read through how prevention works and see if your physicians can get it done for you. Given so many procedures, cost consciousness alone should motivate everyone. For me, your situation demands prevention. Regards, Fred Coe
I have had several calcium oxalate/phosphate kidney stones causing symptoms of microscopic hematuria with occasional moderate hematuria 2+. I am on thiaziade medication and kidney stone diet. My last removal was a 10mm stone in my lower pole kidney but without obstruction via ureteroscopy and laser lithotripsy and my eGFR went down 20%. Urologist wanted to remove it as he said then I could avoid an emergency surgery later so I did so. The urologist wants to do x-rays annually to check my stone situation. My current thinking is to allow NO procedures ureteroscopy OR ESWL unless there is a blockage despite possible hematuria. Am I off base in my plan? Is there ever a good reason to remove a stone located in the kidney and not causing blockage but maybe a bit of bleeding?
Hi Jordan, The fall in renal function should be brief. If not, be sure no stone remnants still obstruct a kidney. This can be silent. I like the x rays but given the very low radiation from ultra low dose CT I prefer them to routine flat plates – that have poor sensitivity. If a stone is not causing obstruction, pain, bleeding of significance, or infection I have little personal enthusiasm for its removal. Regards, Fred Coe
Dr. Coe – Your website is simply amazing. My mom had four kidney surgeries over the past year (two with Dr. Monga, who unfortunately is no longer at Cleveland Clinic). After each of them, she experienced bad infections and in November 2019 she was in ICU with sepsis. We recently learned she needs yet another surgery. I was in the process of enrolling her in your Kidney Stone Prevention Program, when a bigger issue arose… she works at our local hospital and she just tested positive for Covid yesterday.
My mom has multiple at-risk factors, not the least of which is her kidneys. I read a few studies about how Covid is really bad on the kidneys (for example a May 4 article
in the Journal of the American Society of Nephrology). I was wondering if you had any guidance or suggestions regarding this.
My mom had blood in her urine and a temp
two Sundays ago (May 3, 2020). She assumed it was a UTI and started taking Keflex. I am now concerned that the blood in her urine was actually Covid attacking the kidneys. Her right kidney was only operating at 23-33% before she contracted Covid.
I came home to monitor her. I know what to look out for with regard to her breathing and pulse ox. But here are my question:
(1) What symptoms or signs should I look out for with regard to Covid effecting her kidneys? How can we tell if it is causing AKI or blood clots to form in her kidneys before it’s too late?
(2) I explained to her new doctor my concerns, but she wasn’t very receptive. Should I demand that someone check her kidneys now to make sure everything is fine? If so, what types of tests, imaging, etc. should I even be asking for?
Again, I cannot tell you how helpful you and this website has been with quenching some of my fears in normal times, so I thank you.
Brittany
Hi Brittany, Most likely the blood is from stones. Covid effects are most marked in increase of serum creatinine or increased urine protein excretion, but if she has bleeding from stones the blood will raise urine protein. So for the moment I would rely on serum creatinine as a gauge. If it rises, it could be Covid or possibly obstruction from a stone. I hope this is helpful. Regards, Fred Coe
Does Truvia in granules have oxalate? I know Stevia leaves does.
Thx in advance,
Patricia Sammarelli
Hi Patricia, No it does not. Fred
Hi Dr. Coe,
I was recently told by my Nephrologist that with my Urine Ammonium level at 52 and with my Protein (PCR) being at 0.9 my Urine Ammonium levels should be in the range of the 30’s 40’s, rather than 52. My previous (14) 24hr urine results over the past 5 years have averaged 58. My current PH is 6.9. I was told there is known cause for this condition, he did indicate it may be low potassium, but my blood potassium is 4.3. My current 24 Hr Urine results are as follows.
I do have some concerns and questions that maybe you can help address. What causes a patient to have this condition?
Is this something that I should be concerned about? What are the potential treatments (dietary, life style or medications) to help?
Thank you very much,
Mike Kane
24 Hr Urine Results – 5-29-20
Vol 24 – 4.18, SS CaOx – 2.10, Ca 24 – 213, Ox 24 – 25, Cit 24 – 429, SS Cap – 0.72, pH – 6.933, SS UA – 0.02, UA 24 – 0.273
Dietary Factors
Na24 – 46, K24 – 116, Mg 24- 121, P24 – 0.538, Nh4- 24 – 52, CL 24 – 119, Sul 24 – 30, UUN 9.13, PCR – 0.9
Hi Michael, I am rather thrilled at a nephrologist who pays attention to urine ammonia. Most I encounter do not do this. Your urine ammonia is very high because your urine sulfate – part of the acid load that would drive ammonia production – is only 30, and ammonia is usually 2/3 of the sulfate. Apart from potassium depletion, which you do not have – serum K 4.3 urine K 116 mEq/d – infection with urea hydrolyzing bacteria is possible. The urea is broken down to ammonia, so pH rises and struvite stones can form. That is possible. A more subtle possibility is that you have calcium phosphate stones and over produce ammonia as the reason for a high pH and therefore calcium phosphate stones. The latter is our own work recently published. I would advise culturing the urine for bacteria that possess urease. Some are fastidious and grow only in anaerobic conditions on enriched media. These are best detected by genetic means. Others are vigorous soil bacteria – proteus, pseudomonas, enterobacter, klebsiella. My Guess the you are a calcium phosphate stone former. My respects to your intellectually superior nephrologist. Fred Coe
Hi Dr. Coe, thank you for your response. Some additional stone history, my 1st stones were in 2014, 2015, a few 2-3mm calcium oxalate stones in my left kidney, then two 8mm stones from my left kidney that were logged in my ureter in 2016 those too were calcium oxalate stones removed via lithotripsy. My urine sulfate average in the 14 pervious 24 hour urines is 38. Based upon your response, for a possible infection with urea hydrolyzing bacteria, with your advising to culturing the urine for bacteria that possess urease, is there a test available that I could request from my PCP or my nephrologist to order? Also are there any other assessments or testing that I should consider?
Thank you very much,
Mike Kane
Hi Michael, given your stones are calcium oxalate with little or no admixed calcium phosphate – be sure this is true, often oral reports say calcium oxalate when 1/2 of the stone is calcium phosphate! – check the actual written report – then a urea hydrolyzing bacteria is probable. One orders a urine culture and asks for fastidious urea splitting bacteria. Regards, Fred Coe
Hi Dr. Coe, thank you for your response. Some additional stone history, my 1st stones were in 2014, 2015, a few 2-3mm calcium oxalate stones in my left kidney, then two 8mm stones from my left kidney that were logged in my ureter in 2016 those too were calcium oxalate stones removed via lithotripsy. My urine sulfate average in the 14 previous 24 hour urines is 38. Also my evening urine has had a sulfur type of smell to it. Based upon your response, for a possible infection with urea hydrolyzing bacteria, with your advising to culturing the urine for bacteria that possess urease, is there a test available that I could request from my PCP or my nephrologist to order? Also are there any other assessments or testing that I should consider?
Thank you very much,
Mike Kane
Hi Michael, I believe I answered this below. Fred
Hi Dr. Coe, thank you for your response. Some additional stone history, my 1st stones were in 2014, 2015, a few 2-3mm calcium oxalate stones in my left kidney, then two 8mm stones from my left kidney that were logged in my ureter in 2016 those too were calcium oxalate stones removed via lithotripsy. My urine sulfate average in the 14 previous 24 hour urines is 38. Also my evening urine has had a sulfur type of smell to it. Based upon your response, for a possible infection with urea hydrolyzing bacteria, with your advising to culturing the urine for bacteria that possess urease, is there a test available that I could request from my PCP or my nephrologist to order? Also are there any other assessments or testing that I should consider?
Thank you very much,
Michael Kane
Hi, I think I answered this already. Please let me know if I did not. Fred
Aged 41 now and I got my first stone at age 14. Had sporadic stones through my twenties but after the birth of my daughter in 2013 (Age 35) I have been producing non stop stones, bilaterally. 24 hour urine shows elevated calcium but Doc has me on Thorazide and bananas. Too soon to tell if it’s working but had approximately 9 ER visits and 4 surgeries, including a failed PCNL and an emergency stent removal due to blood clot complications following my umteenth ESWL all in 2019 (The blood clot, stone, stent combo was thee absolute worst pain I have ever experienced in my life).
(A quick recall of 2015-2020 – probably close to 25 procedures and matching ER trips to match…. anywhere from 6 to 12 weeks out of work each year since 2015 on FMLA and many, many dollars spent).
Love my Urology team but I’m wondering if they are missing Hyperoxaluria?! How do I get tested?
All other results always come back normal…. kidney functions, no hyperthyroidism, and plenty of output. I do produce calcium oxalate stones. At this point I’m surprised my kidneys haven’t just totally giving up on me.
Currently have 2 in the left and pieces in the right. Had Cysto yesterday with stent placement … this is following major Spinal surgery on 3/11 as well…. Anterior Corpectomy with Dissection and Fusion (ACDF) which came out of left field and I actually thought it was radiating kidney stone pain my shoulder!!!
Any and all help you can offer for my stone saga would be greatly appreciated!
Thank you!!
Hi Kim, It sounds like a horrible lot of stones and procedures. Treatment of calcium oxalate stones is rather programmatic. Here is a good article on it so you can see if all the steps have been taken. Prevention is crucial for you! Regards, Fred Coe
Hi Dr Cole.
I am a sufferer of Uric acid stone and I am unable to get potassium citrate pills where I am located however I do have access to it in the liquid form was wondering what you think is a good dosage to start at I am currently taking 10 ml 3 times a day but every time I test my urine it seems to only hold in a alkaline state for a short period of time. I also take 300 MG of allupurinol every night
Thank you,
John Paul
Hi John, I believe it is you who has also requested telehealth consultation. Potassium citrate liquid is fine. Usually one wants 20 mEq 2 – 3 times a day and you need to collect the 24 hour urine to get average pH. Ideally, the pills are slow release and last longer. You can spread out the dosing to 10 mEq 4 – 5 times a day and perhaps get better coverage. Regards, Fred Coe
Dr Coe
Could ou comment on the role of vitamin D supplementation and the risk fo stones in various scenarios ie caOxalate formers etc. I realize this is a complex question but, supplementing with Vit has become more popular in light of “suggestion” that covid-19 risk “might” be mitigated by supplementing people with relatively low levels etc. Also were one to consider, would weekly or even monthly dosing of Vit D (any form preferable?) be better for potential stone formation than daily dosing. A lot there , sorry but thanks in advance
Hi Eliot, Ordinary dosing with D supplements – 1000 to 2000 U/d are not known to promote stones. Serum D levels below 50 likewise. I know of no studies comparing daily vs other dosing. Fred
Hello sir,
I am an hbv patient with normal lft. I have been having pain for over 2months on my left side/admonen that radiates to back and also make my left leg tingle.Done several ultrasound,ct scan and colonscopy nothing was found. I was placed on medications for colitis but pain didn’t stop.So I did another ultra sound few days ago because the pain was spreading from the left side to the right abdomen with pinching feeling on my right side close to the armpit and found out that I have bilateral hydronephrosis/mild hydronephrosis.Prior to the scan I had done eucr and urine mcs with the result below
Sodium 138,potassium 3.6,chloride 99,bicarbonate 26,Urea 45,creatinine 0.9. So I went to see an urologist which confirmed that I have kidney stones.i don’t understand why ct and previous scans couldn’t pick it?how can I get the diet plan,please I need your insight and to be sure if its really a kidney stone or calyces as some sonograph people pointed out
Hi Taiwo, Ultrasound is insensitive and also non specific in regards to stones vs. CT scans, so your story is no surprise. You have stones and this article is my best on how to proceed. Regards, Fred Coe
Hi Dr. Coe,
Thank you for all of the great articles. I am finding them very helpful and I do have a few questions, that I am hoping you can help with, or point me in the right direction. Passed by first stone last year (I am 55) – and it was a Carbonate Apatite (Dahllite) 100%. Since then I have passed a few more this year (thankfully very small) and they are same stone type. I do not have any infection or UTI’s. After a 24hr. urine test my Urologist suggested that I see a Nephrologist, which I will be making an appointment with. Are there any specific questions that I should ask? Any specific tests I should ask for? I would like to be as prepared as much as possible. According to my 24hr. results, everything was in the normal range except for my Urine Citrate which was 32, and my PH was 6.482. Volume was 2.13, with Magnesium 54 and Sulfate 43 being on the boarderline. Other than being overweight… my blood pressure, sugar levels, and Cholesterol is good and I only take Synthroid for a slow Thyroid. I did have a slightly high protein level in my blood last year, and the Hematologist suggested that a see a Rheumatolgist,, but with COVID, I put it on the back burner, which I plan on following up on. I want to take care of these kidney stones first. Not sure if that has any effect on kidney stones. Any suggestions you can give me would be extremely helpful. Thank you for your time.
Hi Jeanine, The high urine pH and low citrate go well with your calcium phosphate stones. In fact the citrate is so low as to be eye catching. I do not understand the high blood protein last year, but some immune disorders cause renal tubular acidosis and that could be a real cause for your stone. The most famous of these is Sjogren’s syndrome, but there are many more. Often blood changes (low total CO2 and potassium) are slight at first. Regards, Fred Coe
Hello Dr Coe. I am a 67 year old female patient who experienced my first calcium oxalate stone last May. It was large enough to require a stent and surgical removal. My kidney doctor told me at that time I have many small stones in the making and so adherence to the low oxalate diet was highly recommended. At the time he told me also to discontinue my calcium citrate supplement.
My complications are 2. I also have osteoporosis(diagnosed 2.5 years ago) but have not started any meds because I have had a large amount of dental work done including 2 implants over those 2.5 years. That dental work is now finished. My dexa scans have shown no change in my osteoporosis readings, which are just “over the border” from osteopenia. I attribute that at least partly to my exercising and diet, including the calcium supplement prior to the kidney stone episode. My endocrinologist will most likely want me to start fosamax (he had suggested that 2.5 years ago), but I am also disinclined to do that if I can stabilize with lifestyle, diet and exercise. I have an appointment upcoming.
Complication 2 is high blood pressure. My primary care doc had me start 25 mg losartan about 4 months ago. But I actually feel somewhat strange on it, hard to describe. Constant slight headache, anxious or irritable some times when normally not so. I have also gained some weight, which depresses me as I try very hard to stay healthy slim. The only other med I take is an Estring for post menopausal annoyances and I lead an active, outdoorsy life style in addition to doing weight training. So I am just confused about how to put all of these things together, especially as it pertains to diet and supplements. My biggest fear is having another kidney stone. My second biggest fear is not being able to continue an active lifestyle for fear of fractures. Should I restart calcium? I try to get enough in my diet but sometimes that is difficult. Should I consult a registered dietician? Thanks so much for taking my questions.
Terri
Hi terri, You do not say what was found in your blood and 24 hour urine samples. New onset of calcium oxalate stones in later life is not common, but here is what I can say about it. Losartan is a great drug, and I suspect it is lowering your blood pressure and thereby giving you some odd sensations. Be sure to take home BP and see the results. My guess is that your urine calcium rose, or your urine citrate fell with age, causing your stones, but your labs will tell the story. As for the bones, if you are very active I am not sure that fosamax – or its infusion equivalents – is necessarily a bad idea. Regards, Fred Coe
Dr. Coe:
I am 71 years old. I had prostate cancer 7 years ago and had it successfully treated with laser ablation. All MRIs and PSA tests since then have been good. About the time the prostate cancer was diagnosed I also had a blood clot in my leg and was prescribed 10mg Xarelto.
Last September I took a cross-country flight and, as advised by my Hematologist, took some extra blood thinners for the flight. The day after the flight I had gross hematuria (bright red). That lasted for a few days. An ultrasound showed a 6mm kidney stone. A cystoscopy was clear. An MRI w/contrast of the kidneys showed nothing.
Last week, again after taking extra blood thinners, I noticed hematuria. This time the urine was more brownish than bright red. Another ultrasound found the same kidney stone but this time it measured 4mm. More tests to follow.
What’s the likelihood that the bleeding is caused by the kidney stone? If the kidney stone is the culprit, does it make sense that blood thinners would trigger the bleeding?
Thanks for your insight and time.
Hi Donald, I am betting that the stone caused urine bleeding once the anticoagulant had increased risk of bleeding for any given kind of tissue injury – including a stone. Fred
Good morning,
I am a scientist in hereditary oncology so you can understand my need to investigate when things with my own health do not make sense. I’m a highly active individual and resistance train 4x/week along with regular cardio. I track and weigh my food daily to help support my active lifestyle and goals so I have very comprehensive view of my diet. I developed my first kidney stone at 17 and have had them show up to haunt me consistently every 7 years with the majority being so large I have to undergo surgery for removal. Analysis has always shown calcium oxalate. With my last surgery I was sent to a “stone clinic” where a 24-hr urine collection was done and paired with my stone analysis. The physician I met with after getting results back said I had calcium in my urine and my protein levels were high and that both of these could indicate Im consuming too little or too much calcium in my diet and the same goes for protein. Since Ive tracked food intake for years I said “oh thats great, I know exactly what I consume so if you could give me ranges for what I should target for calcium and protein I’ll adapt my diet around that.” The physician replied “I cannot give you any ranges, Im not a dietician.” Needless to say I never returned to stone clinic for advice on stone prevention.
Additionally, 4 years ago I had routine blood work and my cholesterol (total and LDL) was way above normal ranges. This was treated with a statin and not looked into any further. 2 years later I had a number of hormone labs drawn due to unexpected weight gain and a few other symptoms that did not make sense given my healthy and consistent lifestyle. My PTH came back high (96pg/mL), serum calcium normal, vit D low (28ng/mL) and creatinine normal, I was told to take more vitamin D and retest. I retested 3 months later and my D was normal (32ng/mL) and PTH was normal 56pg/mL. A year later these values were retested with D staying the exact same (32ng/mL) but PTH was back up to just below “high” at 91pg/mL and high creatinine of 1.18mg/dL. I was told all my labs came back normal and fine.
Its been a year an a half since I’ve had any labs other than monitoring high cholesterol to continue honing my statin for the high cholesterol. I just looked back at all of these this week and feel like Im connecting the dots no one else cared to look at because my labs and history of stones/high cholesterol/high PTH were being treated as these individual components by my care providers. At this point Im convinced these are all linked and my healthy lifestyle has probably helped to mask them a bit but these should not have been overlooked. I’m not sure if my consistent increase of body fat over the past 4 years is related, but seeing as these are involved in metabolic pathways I dont think I can rule it out.
I made an appointment with my primary to discuss next week and plan to push for additional labs, however, Im wondering if the outcome will be continued pushing of vitamin D and continued use of the statin. This feels like treating symptoms rather than treating root cause to me. I’d love to hear your perspective.
Hi Courtney, This responds to the above and to the stone analysis of 90% CaP. You may have primary hyperparathyroidism, and to find out you need 2 or 3 fasting am bloods off meds that might affect serum calcium or PTH and in the blood measurements of calcium phosphate PTH 25 vitamin D and 1,25 vitamin D. A new 24 hour urine near to the bloods can help. PHPT can signal with serum values of above 10 mg/dl + serum PTH that is not low, and 25D levels that are adequate. HIgh 1,25D would be helpful because it can drive idiopathic hypercalciuria, and low serum phosphare because it can point to common gene defects NaPi2-c variants that raise urine calcium and 1,25D. I hope this helps you progress matters, regards, Fred