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Kidney Stones: Your Questions Answered

Online Health Chat with Manoj Monga, MD and Carolyn Snyder, MPH, RD, LD

April 20, 2012

Introduction

Cleveland_Clinic_Host: According to the National Kidney and Urologic Diseases Information Clearing House, nearly three million people visit their health care provider, and more than half a million people visit emergency rooms, for kidney stone problems.

Many of these patients also suffer from recurrent or complex kidney stones that are often debilitating to their lives. When this happens, surgical procedures may be an option.

The majority of such kidney stones, depending on their size and location, can be removed with minimally invasive techniques such as shock wave lithotripsy (SWL), ureteroscopy, or percutaneous surgery, which goes through the skin. SWL is a relatively non-invasive procedure that uses targeted shock waves to break stones into tiny pieces that are passed naturally in the urine. A ureteroscopy uses small instruments to grab stones from the ureter.

Cleveland Clinic urologists were among the first in Ohio to use lithotripsy, and more than 3,000 patients have had lithotripsy at Cleveland Clinic. Additionally, the American Urologic Association has designated Cleveland Clinic as a national lithotripsy training center for physicians.

Dr. Manoj Monga joined the Glickman Urological & Kidney Institute in September 2010 and specializes in kidney stone disease, minimally invasive treatments for nephrolithiasis (kidney stones), endoscopic procedures for ureteropelvic junction obstruction, endoscopic procedures for upper tract transitional cell cancer, and the prevention of nephrolithiasis.

Carolyn Snyder is an American Dietetic Association registered and Ohio licensed dietician who has worked in nephrology and urology for more than 20 years. She is currently providing her services to the Metabolic Kidney Stones Clinic for the Glickman Urological & Kidney Institute.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Manoj Monga and Carolyn Snyder. We are thrilled to have them here today for this chat. Let’s begin with some questions.


Kidney stones and pain

pineledge: I have had a few episodes of painful kidney stones requiring a visit to the ER for pain control. Is there a pain medicine I can ask my primary care physician for (to keep on hand) so I don't have to make another costly visit to the ER?

Dr__Monga: First would be to keep an alpha-blocker on hand [for example, tamsulosin (Flomax®)] to help the ureter relax and stones pass. Second would be to keep ketorolac (Toradol®, a non-narcotic), which can be used for 5 days at a time. Most physicians will not provide narcotic to keep on hand due to concerns about addiction.

lonny3: What should one do if they have a kidney stone attack? Do you call a doctor? Do you go to the ER, or do you wait and see if there are problems first?

Dr__Monga: If the pain is severe, go to the ER as that is where you will hopefully be able to get the fastest relief. If you have had stones before and recognize the pain, and you feel it is not too bad, then you can wait and see if it will pass. Start an alpha blocker like Flomax to help the stone pass. If you have a doctor who has recent images to document the size and location of your stones, you should call that doctor to discuss the best approach.

chuck44857: I have lived with stones since I was 25 years old. I am 51 years old now. Do you think someone could get disability due to having so many stones?

Dr__Monga: It is unlikely that kidney stones will lead to renal failure and cause chronic disability. With that said, there is no question that the pain associated with frequent stone passage can have a major impact on a person's life.

never_ever: My doctor told me that kidney stones CANNOT cause pain until they drop into the ureter. I have a 9mm stone in the lower pole of my left kidney and severe flank pain. Is this stone causing the pain, or is there some other problem I should be looking for?

Dr__Monga: It is sometimes difficult to know if a stone is causing pain. Though we understand why stones in the ureter that are causing blockage cause pain, it is less clear if the stone is in the kidney. Sometimes it is helpful to have the stone treated (especially if it is a large one as in your case), and see if the pain improves. The other common cause for flank pain is musculoskeletal. It may also be helpful to see a pain specialist.

busy_bee: I recently went to the doctor for lower abdominal pain that would not go away. They did a CT scan, and a large kidney stone was found. How often is this type of pain associated with stones? Is this type of pain indicative of a kidney stone?

Dr__Monga: It is often difficult to determine if a stone is the cause of a patient's pain. If the stone is on the same side as the pain, then it is certainly possible that the pain is caused by the stone even if it is in the lower abdomen. It would also depend on the location of the stone within the kidney (i.e., is it causing an obstruction or not?). Sometimes, we have to remove the stone with the understanding that the pain may or may not improve.

age_first: My doctor has said that when the pain stops, the stone has moved into the bladder. That happened 5 days ago, and I still have not passed the stone. How long does this typically take?

Dr__Monga: Once it reaches the bladder, the stone typically passes within a few days, but may take longer, especially in an older gentleman with a large prostate. However, pain may subside even if the stone is still in the ureter, so it is important to follow up with imaging if you do not pass the stone within 4-6 weeks.


Diagnosis

alexm: A kidney stone was detected during a recent echo exam, with estimated size of 7-10 mm. Then I had an X-ray of the stone, and this time the stone’s size was estimated to be only 3-4 mm. In your opinion, do I need any other diagnostic exam to clarify the discrepancy between these two conflicting results?

Dr__Monga: CT scan is the most accurate but also uses more radiation. Would only recommend CT if you are having pain. Otherwise KUB (plain X-ray) is more reliable than US (ultrasound) for stone size. This is good news for you!


Dietary recommendations

MikeLR: I have passed 2 calcium oxalate stones (2.5m on left side in 2008 and 3.0m on right side in 2012). I had been told to avoid oxalate-rich foods, red wine, and to drink more water and lemonade. Do you have any other specific recommendations as far as my diet to avoid another occurrence?

Dr__Monga: General guidelines are:

  • drink plenty of fluids - target is to make 2 liters of urine a day
  • limit your sodium
  • increase citrates (lemonade is only 15% lemon juice)
  • oxalates - main issues are spinach and rhubarb. Other oxalate foods should be avoided only if your oxalates are high in the urine.
  • additional dietary recommendations should be based on a 24-hour urine collection

songcanary: Forty years ago as a teenager I had one calcium oxalate stone lodged in the ureter, which required major surgery to remove. I was told to drink more water and have not had a recurrence since then. However, I am currently taking vitamin D3 1000 IU every day since I was diagnosed with osteopenia 2 years ago. Does this increase my risk for another stone?

Dr__Monga: One study from the University of Wisconsin shows no increased risk with vitamin D. The best way to answer this is for you to do a 24-hour urine collection to assess your stone risk.

clara: I have read drinking lemons in water helps kidney stones. Also, I have been told not to drink city water. What is the best water to drink?

C_Snyder_RD: One-half cup of lemon juice concentrate added to drinking water over the course of the day is a preventive therapy for calcium oxalate stone formation.

As for city water, it is safe to drink but the concern is with water softened using a sodium ion exchange. Softened water should not be used for cooking, drinking, or for ice dispensers.

DeeC: What is the best diet for oxalate stone prevention? I eat a bowl of fruit every day as well as salads and vegetables; I ate this way before and after my stones were found (3 weeks ago). I have already taken beef, pork, pops and sugary juices, nuts, chocolate, and most dairy (cow, skim, and soy milk, yogurt and huge amounts of cheese) out of my diet. Thanks.

Dr__Monga: The most important foods to limit if you have high oxalate in the urine are spinach and rhubarb. A good resource for oxalate and diet is: https://regepi.bwh.harvard.edu/health/Oxalate/files. You might consider a vitamin b6 supplement if your oxalates remain high despite dietary modification.

robtoby: Hello! I have had a few kidney stones. I've passed one and 'blasted' a couple others. I now have one left that I'm leaving alone for now. I drink a LOT of water and have cut back on my protein intake. I have also increased my vitamin D due to a high PTH level which has now come back down. Any other suggestions from a medical or nutritional aspect? Thanks!

Dr__Monga: General guidelines are:

  • drink plenty of fluids - target is to make 2 liters of urine a day
  • limit your sodium
  • increase citrates (lemonade is only 15% lemon juice)
  • oxalates - main issues are spinach and rhubarb. Other oxalate foods should be avoided only if your oxalates are high in the urine.
  • additional dietary recommendations should be based on a 24-hour urine collection

lauschke: I have read of many foods that are said to contribute to stone formation. How strong are these associations really?

Dr__Monga: Most studies are based on epidemiologic studies. The level of evidence is usually fair to poor. Only a few studies have had patients follow a regimented diet and compared outcomes to those who didn't follow those diets. From these studies, the only solid recommendation is DRINK MORE FLUIDS!

Cami: Do I have to refrain from eating so many antioxidants like strawberries, spinach, and so on, in order to avoid more stones?

C_Snyder_RD: Make sure you are not confusing oxalates with antioxidants. Foods high in antioxidants may not be high in oxalates. While you do not have to eliminate these foods from the diet, having a dairy product that is calcium-based will bind the oxalates in the gut and reduce the oxalate load for the kidneys.

joker: Does alcohol consumption have anything to do with kidney stones?

Dr__Monga: Alcohol is not a direct contributor to stone formation, but the dehydrating effects of the alcohol can be an issue. The mixes used for the alcohol such as dark carbonated beverages can lead to stone formation.

Conversely, beer (not draft beer) is protective for men, and wine is protective for women. Limit use to within recommended guidelines, and replace each ounce of alcohol consumed with an ounce of compensatory water to prevent dehydration side effects.


Other conditions (vitamin D deficiency, osteoporosis, hypercalciuria, urinary tract infections)

DianeF: I would like to discuss the relationship between hypercalciuria (high levels of calcium in the urine), osteoporosis, calcium oxalate stones, and current treatment options.

Dr__Monga: Hypercalciuria is an important cause of calcium oxalate stones. First-line therapy is sodium restriction and fish oil supplements. If you remain hypercalciuric, then a thiazide diuretic is usually the next step. It is important to check a parathyroid hormone (PTH) level to make certain this is not the cause. Dietary calcium is the best, but if you need calcium supplements due to osteoporosis, then it is best to take calcium citrate.

jumping_beans: When someone has vitamin D deficiency and low calcium, can that cause stone formation?

Dr__Monga: Bone metabolism and stone risk are closely linked. I would encourage you to have your vitamin D deficiency treated. It may help and is unlikely to hurt your stone risk. If you need calcium supplements, calcium citrate is the best.

llison: I am 72 years old and have osteoporosis and a history of kidney stones. Taking calcium for the osteoporosis seems to cause me to get a lot of kidney stones. What can I do to stop bone loss and not have to deal with recurrent kidney stones?

Dr__Monga: Hypercalciuria is an important cause of calcium oxalate stones. First line therapy is sodium restriction and fish oil supplements. If you remain hypercalciuric, then a thiazide diuretic is usually the next step. It is important to check a PTH level to make certain this is not the cause. Dietary calcium is the best, but if you need calcium supplements due to osteoporosis, then it is best to take calcium citrate.

my_oh_my: Is it common for women who get kidney stones to also have frequent UTI's? Does one cause the other?

Dr__Monga: Kidney stones and UTIs can be linked. Certainly, stones made up of "struvite" are stones caused by infections from certain organisms. This is a relatively uncommon type of stone (less than 5%). Other more common stones are less likely to cause infection. If a stone is blocking the ureter and the patient has an infection, the situation becomes more of an emergency.


Treatments

partners: I have had multiple stones for years, and the doctors can’t seem to help. My thyroid and parathyroid have tested normal. We have been playing the trial and error game. I have tried hydrochlorothiazide (HCTZ) but had to go off. Any suggestions? What can a person do to prevent them from forming; that seems like the best proposal to me!

Dr__Monga: I typically rely on a 24-hour urine test to guide what diet and medication to try: allopurinol if the uric acid is high; potassium citrate if the urine pH or citrate is low; HCTZ or other thiazides if the calcium is high; Vitamin B6 if the oxalate is high. These are all performed in conjunction with dietary modification (usually tried first before starting a medication) and follow-up urine tests to see if we are having a positive impact.

zoobee: Flomax for kidney stones? Does it work?

Dr__Monga: It works for stones in the ureter; it will increase the chance that they will pass spontaneously by about 20%, decreases the need for surgery and the time it takes for stones to pass, as well as the amount of associated pain.

let_go: What is an IVP?

Dr__Monga: Intravenous pyelogram. Contrast is given intravenously (through the veins) and then monitored as it is excreted. It is not used as commonly now - CT scans are more commonly used for stone disease.

just_so: I have had two litho procedures on the same stone in the lower pole, without success, and there is also a stone in the upper pole. I would like to know whether a single PCNL (percutaneous nephrolithotomy) procedure could retrieve the stones in both the upper and lower pole with a single incision/hole into the kidney.

Dr__Monga: A PCNL would have a 95% chance of a stone-free result through a single incision. It is often a good alternative if attempts at less invasive approaches have not been successful.

robtoby: My urologist says that once stones get to about 5mm in size, lithotripsy should be considered. I'm inclined to not go through yet another one of those (I've had 3 already over the past few years). What's your take on this? My nephrologist says to 'wait and see' for right now.

Dr__Monga: Both options are reasonable - it depends on your preference. Once a stone gets above 5mm in size, the likelihood of passage if it moves into the ureter is less than 40%. With this in mind, if you don't mind the 60%+ risk of needing a more invasive procedure (i.e., ureteroscopy and stent), then leaving the stones alone is the right thing to do. On the other hand, if you prefer to limit the amount of procedures you undergo, then waiting is the best option. The good news is that we can now do lithotripsy with sedation, so you don't need to go to sleep. However, lithotripsy is only effective if the stone is in the kidney or upper portion of the ureter; once it drops to the lower ureter, ureteroscopy is required.

hilo: When is surgery necessary to remove a stone(s)?

Dr__Monga: First, surgery is needed if:

  • you are having pain because of the stone and would prefer not to wait to see if it will pass
  • the stone is too large to pass
  • you have waited for it to pass, and it has not

Second, if the stone is not causing pain but you are worried about the risks of watching it which are:

  • it may grow
  • it may move and cause pain
  • it may be associated with infections or (very rarely) problems with kidney function

This is obviously a very complex question that has to factor in the size and location of the stone, if it is causing blockage, how healthy you are, and what your preferences are (observation vs. intervention).

ohohoh: Can the Clinic help my son? He has had debilitating stones for a few years now. His life is on hold right now. He has seen several doctors who have not been able to help him. What is new out there that may be of use to him? He is 25. I'm not really seeking a diagnosis here; I know you can't do that. What I'm looking for is hope for my son.

Dr__Monga: We would be glad to see your son. One of my partners, Dr. Mark Noble, has pioneered a new procedure (autotransplant) specifically for those few select stone patients who have debilitating disease. There may be other dietary, medical, or surgical options that we could consider.

klp876: My brother has over a thousand kidney stones. His doctors have told him that the situation was inoperable. He trusts his doctors and is following along with their advised treatment. The question I have is, with this many stones growing within the "meat" of his kidneys, is there a risk of some of the larger stones eroding through the kidney's wall? (Some of these stones are now 13mm in diameter.) He has medullary sponge kidneys, with ptosis of right kidney (not really sure what that means.)

Dr__Monga: With medullary sponge kidney, a "thin lining" typically covers the stones and, yes, eventually the stones may erode through the lining, leading to stone passage. There are a few surgical options that may be helpful - one can unroof the stones with a laser or an autotransplant will help with easier passage of stones when they do occur. Working on diet and medications is also important to prevent stone growth.


General

moore3: Is there any way to completely prevent kidney stones?

Dr__Monga: No. Part of your risk is genetics. Part of it is environment (your diet, etc.) You can decrease your risk, but unfortunately cannot "guarantee" that stones will never recur. Keep trying your best!

Pirates: Does vitamin D3 or whey protein cause stones?

C_Snyder_RD: Vitamin D3 does not cause stones and is actually needed for calcium absorption. As for whey protein, the literature does point to the fact that the whey does play a role in stone formation but may not be the single cause. This is only as relates to whey supplementation.

clara: I have an osmosis type tank for drinking water that a filter is replaced every year. Is that safe for someone with kidney stone problems?

C_Snyder_RD: Osmosis-type water filtration is acceptable for use by stone patients. The issue for water treatment is using sodium ion exchange whereby the sodium molecules are still in the water that is used for cooking, drinking, and ice making.

poppies: Can you get kidney stones at any age?

Dr__Monga: You can get kidney stones at any age. For males, the risk rises at age 20 and peaks between age 40 and 60, then decreases. For females, the peak is in the late twenties and then decreases thereafter.

gotta_go: What makes one more prone to getting stones?

Dr__Monga: A combination of genetics and diet. When we studied identical twins, about 80% of the risk of stones was related to genes. However, there is much you can do with diet and, on occasion, medications to decrease your risk of stones.

half_way: How long does it usually take to pass a kidney stone? Does it depend on the size?

Dr__Monga: On average, it takes a stone less than 4mm stone 1 to 2 weeks to pass and a stone greater than 4mm stone 2 to 3 weeks to pass.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Manoj Monga and Carolyn Snyder is now over. Thank you again for taking the time to answer questions about Treatment Options and Prevention for Kidney Stones.

Dr__Monga: Thank you for participating in our web chat today. Great questions! Keep drinking your fluids.

C_Snyder_RD: Thank you for joining Dr. Monga and myself today for the kidney stone web chat. We appreciate your questions and interest in stone prevention.


More Information

If you would like to make an appointment with Dr. Monga or any of our other urologists in the Glickman Urological & Kidney Institute, please call 800.223.2273 or request an appointment online by visiting www.clevelandclinic.org/appointments. Thank you!

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