Online Health Chat with Juan Calle-Cano, MD and Sri Sivalingam, MD
March 31, 2014
Kidney stones cause debilitating pain in both men and women. Each year in the United States, people make more than a million visits to health care providers and more than 300,000 people go to emergency rooms for kidney stone problems. It is important to not only understand the symptoms and treatment options for kidney stones, but also the best ways to prevent them from recurring.
Many people also suffer from recurrent or complex kidney stones that are often debilitating to their lives. The majority of these 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. 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. Additionally, it is important to know what is causing the stones and how to prevent them from recurring.
Juan Calle-Cano, MD is co-director of Cleveland Clinic’s Kidney Stone Clinic and an associate staff physician within Glickman Urological & Kidney Institute’s Department of Nephrology and Hypertension at Cleveland Clinic. Dr. Calle is board certified in internal medicine and nephrology. He completed a fellowship in nephrology and hypertension at Mayo Clinic, in Rochester, Minn after a residency in internal medicine at Mount Sinai Medical Center, in Miami Beach. Dr. Calle completed medical school at the Instituto de Ciencias de la Salud CES in Medelin/Antioquia, Colombia. His specialty interests include kidney stones, hypertension and glomerulonephritis. Dr. Calle sees patients at Cleveland Clinic main campus.
Sri Sivalingam, MD is an associate staff physician within Glickman Urological & Kidney Institute’s Department of Urology. Dr. Sivalingam completed a fellowship in endourology and minimally invasive surgery at the University of Wisconsin, Madison, after a residency in urology at the University of Manitoba in Winnipeg, Manitoba, Canada. He completed medical school at the University of Toronto in Toronto, Ontario, Canada. Dr. Sivalingam’s specialty interests include endourology and urinary stone disease and minimally invasive surgery. He currently sees patients at Cleveland Clinic main campus, Hillcrest Hospital and Twinsburg Family Health & Surgery Center.
Let’s Chat About Understanding, Treating and Preventing Kidney Stones
Moderator: Welcome to our chat today with Cleveland Clinic experts Dr. Juan Calle and Dr. Sri Sivalingam. We are thrilled to have them here with us to share their knowledge about understanding and treating kidney stones.
Let's begin with the questions.
ronlowe: I have had 35 kidney stone operations over the past 16 years and I do not want anymore! Please help me! I have passed many on my own—ouch! Litholink Corporation has determined them to be brushite stones. Any and all of your advice would be greatly appreciated!
Juan_Calle,_MD: I am sorry to hear about your experience. Brushite stones are some of the most difficult to treat and prevent. There may be other factors associated with it (primary hyperparathyroidism, sarcoidosis, renal tubular acidosis, etc.). Not only should the 24-hour urine collection be carefully analyzed, but also some other blood work. Your mainstay therapy remains sufficient fluid intake, control of hypercalciuria (high calcium in your urine) and less salt (sodium)—all of which are necessary.
Narrowed Ureter and Kidney Stones
Tac: I have had stone issues for years. Usually an episode about every six years. One will pass one or get treated, and then it will be fine. During the past year I have had about 12. I have passed approximately five stones, and have had one stone measuring 8 mm blasted and placement of a stent. I have been scoped approximately five times with stents. I now have stents in both sides and I am going back to work on the left side. I have been told that I have issues with narrowed ureters on both sides, which has caused issues with them getting into the kidneys to remove stones. The CAT scan showed multiple stones. I have not been out of pain for nine months. My doctors saw a spot and took a biopsy from my bladder. There have been no results yet, but I also had a test to find out the root cause for all of these stones (and everything was negative). My doctor thinks it could be hereditary. Could the narrowed ureter be causing my pain and stones? Are there any other options other than getting scoped every other month? I was told stones embedded in the kidney should not cause pain—do you agree? Do you have any suggestions on prevention, treatment or other options?
Sri_Sivalingam,_MD: A narrowed ureter can actually be causative in some cases as it can hold up urine in the kidneys (stasis), which can increase the risk of stone formation. Kidney drainage studies can be done to assess if this is in fact a problem for you. You can be followed with simple kidney ultrasounds and X-rays depending on the type of stones you form. Getting scoped every other month seems a bit extreme. You will also need to have a complete metabolic evaluation to ensure that all of your risk factors are adequately managed.
Osteoporosis and Kidney Stones
Paulee810: I have been recently diagnosed with osteoporosis and have had four kidney stones in the last three years. Could there be a connection between the two? How might I balance my needs for calcium for bone health with caution for not causing more stones?
Sri_Sivalingam,_MD: The link between osteoporosis and urinary stone disease has been studied—with mixed results. It would be important to adjust your diet and medications. For example, salt reduction and thiazide diuretics (water pills) may help retaining calcium for the bones and reduce urinary excretion. Similarly, bisphosphonates are medications that prevent bone loss and lower urinary calcium excretion.
Hypercalcemia and Kidney Stones
EllenW: I have hypercalcemia that was discovered while dealing with kidney stones. Lithotripsy and percutaneous nephrolithotomy (PCNL) have successfully dealt with the calcium oxalate stones. My blood work and 24-hour urine saturation test all came back within normal range indicators, except for 388 units of calcium in my urine. My urologist prescribed chlorthalidone to help with the excessive calcium, but I have an allergy to sulfa and developed hives on my face. I currently try to drink at least 64 ounces of fluids daily and limit my intake of oxalates. I have not formed any new stones within the last nine months. What other options do I have to treat the hypercalcemia? What are the long-range complications if further treatment is not available?
Sri_Sivalingam,_MD: Dietary modification can also help, for example salt reduction can lead to lower urinary calcium. Similarly, other dietary modifications can further help lower urinary calcium excretion. Unfortunately, some of the alternative medications are also sulfa based, which you may not tolerate. However, maintaining copious urine volume is integral and may successfully prevent stone growth.
Juan_Calle,_MD: If your calcium has remained high in the blood, it would also be prudent to check your vitamin D levels and parathyroid hormone. There are other several conditions that can be associated to hypercalcemia and they should be investigated.
Unilateral (one-sided) Kidney Stones
bweiss: For about five years or so I have been battling kidney stones in my left kidney only (calcium stones). I have had two percutaneous nephrolithotomies (PCNLs) and probably six to eight lithotripsies. I am currently on Lozol® (indapamide) and Midamor® (amiloride), vitamin D, potassium, drink more than 64 ounces of fluid a day, eat less animal proteins, and consume a low sodium diet. I am very frustrated. Do you have any ideas of what else I can do? Do you have any idea why it is only in the one kidney? (I am not complaining that it affects only one and not both.) My urine pH is usually between five and seven. My last three 24-hour urine collections have been pretty good. My blood work has been great except for low potassium.
Sri_Sivalingam,_MD: It seems like you are doing all the right things to prevent stone recurrence. I assume your urine volume is greater than two liters per day? This would be very important. The fact that you are forming stones only on one side makes me wonder if there are any anatomic issues on that side, such as a ureteral stricture or ureteropelvic junction obstruction. Some imaging studies can help answer these questions, but if these are normal, I’m afraid there is no clear answer to this—except to continue persistent optimization of your urine parameters.
Effect of Medications on Kidney Stone Formation
DawnDPT: Are there certain medications that predispose someone to kidney stones? I take aspirin, Plavix® (clopidogrel), Crestor® (rosuvastatin calcium), Toprol-XL® (metoprolol), Pepcid® (famotidine), fish oil, vitamin D, biotin and a multivitamin.
Sri_Sivalingam,_MD: There are certain medications that can increase stone risk, but none of the ones you are on in particular. However, avoid excessive vitamin C supplementation as there is increased risk of calcium oxalate stones.
Inoperable Kidney Stones
mathisfun: I have several kidney stones in both kidneys and recently had a lithotripsy to remove one that was blocking the ureter. I have dermatomyositis with many calcinosis lumps throughout my body. My urologist believes that due to this condition there is nothing I can do to stop more kidney stones from forming. He is only treating the stones that cause problems. He said it would take several surgeries to remove them all. Do you agree with his opinion or is there something I can do to stop future stones from forming?
Sri_Sivalingam,_MD: It would be prudent in your case to identify any modifiable risk factors based on your 24-hour urine studies, such as hydration, dietary or medical changes to optimize your urine. While removing all the stones in your kidney may not be practical or possible, it would be more important to remove those that are causing problems, or those that are in a position to eventually pass and cause problems.
Genetic Basis of Kidney Stones
mdaugsbury: There are seven people in my immediate family who have had kidney stones. Is there a genetic connection?
Sri_Sivalingam,_MD: There is a definitely a genetic connection with urinary stone disease. However, the genetic basis for stone disease is uncertain and genetic testing is not done for the purpose of diagnosing stone predisposition.
Juan_Calle,_MD: What can be done in your case is to check for specific abnormalities such as hypercalciuria (high calcium in the urine), which is the most common risk factor for stones and also the most common genetic or family related condition for stones. Other factors may be seen with imaging of the kidneys for conditions such as medullary sponge kidney also associated to kidney stones.
Prognosis of Chronic Kidney Stones
Gray: Can unnoticed kidney stones remain in the kidney for years with no adverse impact to kidney health?
Sri_Sivalingam,_MD: Unnoticed stones that are non-obstructing can sometimes remain indefinitely without causing any damage to the kidneys. However, in most cases, the stones may continue to grow and eventually obstruct—especially when they try to pass. There may be a higher risk of functional loss to a small part of the kidney—or even the whole kidney. Therefore, it is important to monitor these stones, and exercise preventative approaches (i.e. drinking plenty of fluids to ensure two to three liters of urine output, and eating a low sodium diet) in order to prevent further stone growth and eventual kidney damage.
eelgifted: Will I have to worry about stones forming the rest of my life—even if I have made drastic changes in diet and liquid intake?
Sri_Sivalingam,_MD: This will depend on the type of stone you have and also your stone risk factors as identified on your 24-hour urine study. Additionally, your repeat 24 hour urine study can show the improvement in your risk factors. Some follow-up imaging like an ultrasound or X-ray can be used to periodically assess whether you have further stone growth.
Testing for Kidney Stone Prevention
Bobb: I have had stones several times in the past and would like to know how to prevent them.
Sri_Sivalingam,_MD: We do a complete metabolic evaluation for those patients who have recurrent stone episodes. This would include 24-hour urine studies, stone analysis, possible blood tests and imaging studies. Based on these tests, we can guide individualized therapy to prevent future stones.
Juan_Calle,_MD: We would also recommend to increase the amount of fluid intake, moderate sodium (or salt) consumption, eat a more healthy diet and exercise.
Gail Ann: Before a lithotripsy is performed, what tests are required and what is the time line for these tests? After a lithotripsy is performed, are there any follow up tests (such as X-rays, blood test and urine test), and when should they be done?
Sri_Sivalingam,_MD: Before a lithotripsy, a plain abdominal X-ray is necessary to ensure that the stone can be seen for the treatment itself. Also, a urine test must be done to ensure you do not have a urinary tract infection. Sometimes blood work is needed to ensure you do not have any bleeding issues. After the treatment, stone analysis might be done if you are able to catch a passing stone fragment. Also, 24-hour urine studies after lithotripsy may be needed to identify any metabolic issues that predispose you to stones.
Gail Ann: After having a lithotripsy, at what point should one be checked to see if further stone formation has taken place? What test would be used?
Sri_Sivalingam,_MD: I usually arrange for a kidney ultrasound and X-ray within four weeks to ensure there is no blockage. Afterwards, generally a follow-up X-ray with or without ultrasound can be done in one year, assuming there are no other stones requiring treatment. Further stone analysis and 24-hour urine studies may be helpful in identifying risk factors for future stones.
Gail Ann: Why would a doctor require an intravenous pyelogram (IVP) before performing a lithotripsy?
Sri_Sivalingam,_MD: Currently, the majority of stone diagnosis is done with (non-contrast) CT scan. Therefore, if a CT scanner is available, the IVP is rarely done. However, in some unusual cases, an IVP can help confirm the diagnosis of certain pathologies, such as medullary sponge kidney, or show the anatomy of the kidney drainage system.
Urine Oxalate Levels
Paulee810: I have been taking hydrochlorothiazide to control excessive calcium in my urine along with eating a low-sodium diet. My doctor told me it is not necessary for me to follow a strict low oxalate diet any longer, which was a huge relief to me since I could add healthier foods to my diet. I do have two very small stones bilaterally. Do you agree with that advice? I do avoid the real high oxalate foods like spinach, but I do eat small quantities of formally forbidden foods like whole grains, potatoes, tomatoes, berries, beans, and nuts.
Sri_Sivalingam,_MD: Your doctor may be quite right, depending on your oxalate levels. Generally, the best method of reducing oxalate levels in the urine is to pair your meals with calcium-rich foods in order to eliminate any oxalate in the diet via the bowels. Repeat 24-hour urine studies can indicate the oxalate content in your urine.
Dietary Modifications for Kidney Stone Prevention
there4jsweetie: Can you advise as to what food or drink can best help eliminate the presence of— or possible occurrence of—kidney stones?
Juan_Calle,_MD: There are general rules for almost every patient with kidney stones, but treatment and dietary advice may change on every single case. It is safe to recommend drinking liquids in the amount of two to three liters (about 60 to 100 ounces) everyday. The best fluid is water. A low-salt diet with less animal protein is also a safe bet. Also, the majority of patients would benefit from more fruits and vegetables in their diet.
caroldorothys: Will drinking lemon water regularly prevent kidney stones?
Sri_Sivalingam,_MD: Lemon water helps prevent kidney stones in certain individuals that are deficient in urinary citrate, which is a known inhibitor of stones. More importantly, it is the increase in fluid consumption that helps by increasing urine volume. For many patients, the added flavor of lemon to the water encourages fluid intake.
pazepher: How can I quantify how much lemon in the lemon water? Is bottled lemon juice acceptable?
Juan_Calle,_MD: Bottled lemon juice does help. I would recommend at least four to six ounces per day.
Lmg93: Do you think drinking lemonade daily helps with kidney stones. This would include Crystal Light® to avoid too much sugar in the concentrate or bottles.
Juan_Calle,_MD: The best evidence to prevent stones comes from water. I would still advise almost any type of fluid except sweetened and sugar drinks (like pop or sodas).
pops502: Is there any benefit of water vs. decaffeinated tea?
Juan_Calle,_MD: The best evidence to prevent stones comes from water. I would still advise almost any type of fluid except sweetened and sugar drinks (like pop or sodas).
ckrift: Could tap water cause kidney stones?
Sri_Sivalingam,_MD: I do not know of any studies that suggest tap water increases kidney stone risk. Hydration is key in preventing stones, so increasing fluid intake (whether tap or bottled water) should help.
moneymatters69: I have had 48 calcium oxalate kidney stones. If I can minimize my salt intake, will I have longer periods between stones? I use lemon concentrate in most water that I drink. Does this seem like my best hope?
Juan_Calle,_MD: Calcium oxalate are the most common type of stones, and usually have a lot to do with diet and fluid intake. It is not associated that much with other conditions although there are some special cases in which this may happen—such as genetic conditions known as primary hyperoxaluria, which is a very rare disorder. Low salt definitively helps to prevent stones, and lemons and limes are also known to be beneficial.
EllenW: What level of sodium is considered a low-salt diet?
Juan_Calle,_MD: There is a diet called DASH (Dietary Approaches to Stop Hypertension), which provides excellent information. You can do a general internet search for the specifics.
TomPainter: What is the best diet for stones and the heart?
Juan_Calle,_MD: The DASH diet has been shown to be effective for both issues. Again, low salt (sodium) is a common factor in almost all recommendations.
gabbyme3: I have a history of kidney stones for over 60 years. So, I stopped eating everything that contains calcium and now because of that I have thinning bone structures (osteoporosis). What can I do to reverse this problem?
Juan_Calle,_MD: I would not advise to have a low-calcium diet. Although it may seem counterintuitive, studies have demonstrated that people who have low calcium diet have a higher chance to have recurrence of the disease. Especially with osteoporosis, I would advise you against that.
ckrift: What foods and drinks should I avoid to prevent calcium stones? I have had three, five millimeter stones this past year and all required stents, which was very painful.
Sri_Sivalingam,_MD: Therapy is based on your personal risk factors. However, generally speaking, increased hydration (that produces urine output greater than two liters daily), salt reduction, and pairing your meals with calcium-containing foods are good initial approaches.
robtoby: I passed a kidney stone back in 2007. I've had three lithotripsies to break up a few remaining stones. The last one I had on ultrasound has now “disappeared,” so I'm now “stone-free” (knock on wood). I drink water with lemon and I don't eat anywhere near as much protein as I used to. Are there any other dietary recommendations you can provide for me to prevent the recurrence of stones? I read a lot about oxalates. Do you have recommendations for daily limits in that regard? I also having my vitamin D and parathyroid hormone (PTH) checked regularly. Is there anything else to be wary of?
Juan_Calle,_MD: What you are doing right now is exactly right—more fluids with lemon or limes for a goal of two to three liters of urinary output. A low salt (sodium) diet is also advisable. Regarding oxalates, it depends on the type of kidney stone you've had. I always recommend moderation to my patients more than just completely dropping all oxalate-containing foods. If PTH has been normal in the near past, it may not need to be checked that often unless there are some subtle abnormalities.
grd1022: I take Zyloprin® (allopurinol), but the side effects (including eye problems, swollen eyes, itchy eyes, and upset stomach) caused me to quit taking it. Are creating stones related to medicines or diet? I take Avodart® (dustasteride), Cozaar® (losartan), Uroxatral® (alfuzosin), Prilosec OTC® (omeprazole).
Juan_Calle,_MD: Diet plays a huge role in the formation and recurrence of kidney stones. A healthy diet is usually associated with better outcomes as well as a low salt (sodium) diet. The medications you mentioned are usually not associated to stones, although there may be a theoretical effect by the losartan but has not been proven.
jfkacres: My husband has been following the low oxalate-reduced sodium diet for eight months. He is 13 months after passage of a 9 mm kidney stone and was made aware of six other stones at that time. Could those stones remain small on this restrictive diet? He also takes hydrochlorothiazide and potassium citrate daily.
Juan_Calle,_MD: Yes, that is the whole purpose of the treatment to try to prevent growth and formation of new stones with the diet advice and the medications he's on.
there4jsweetie: I am a 66-year-old male who weighs about 200 pounds. Four years ago I had a bad experience with a kidney stone that moved, but got stuck and would not come out. The doctor went in with a tool that retrieved the stone. I had a CT scan and it was noted on the radiology report that there were numerous calcifications in the kidneys. It has been four years since this analysis and I have not had any other occurrence of passing stones. I drink one to two liters of water a day and will not take any calcium supplements, which I had been taking for about one year before the problem in 2010. I also eat some citrus fruit daily thinking this might also help. What else might I do to try to avoid future problems?
Juan_Calle,_MD: The amount of fluid is good, but the main goal is to have at least two to three liters of urinary output every day. A low salt (sodium) diet is always advisable. Regarding calcium supplements, although debated and not very clear in the medical literature, it may not have that much of an effect on kidney stones. However, it all depends on how much and the timing (when taken with food may have less of deleterious effect). What is definitively recommended is to have a normal calcium intake in your regular diet. Calcium restriction in the diet is not advised.
DawnDPT: I have two stones that are believed to be uric acid. I am currently taking potassium citrate pills. I am already on a low-sodium diet due to coronary artery disease and do drink a lot of fluids. Are there certain risk factors particular to stones that are uric acid? I cannot drink lemonade due to reflux.
Juan_Calle,_MD: Yes, diet has a lot to do with that type of stone. Low animal protein is highly recommended to prevent these. A low-fat diet has also been shown to increase the pH in your urine which it may also prevent formation of the stones.
Emergency Department Care of Chronic Kidney Stones
PS: I have a history of kidney stones. Every time I go to the emergency department, there is a very long wait before the doctors will order any pain medications. They want to do tests before they will give me anything, even though I am in such excruciating pain. I cannot lie still for the tests they want done. I understand wanting to know what they are treating, but given my history—I know what kidney stones feel like and that is always what it ends up to be. I am 67 years old and do not think that I fit the profile of someone looking for drugs. Do you have any suggestions on how I can get pain medication prescribed quickly when I have my next episode of kidney stones?
Sri_Sivalingam,_MD: Unfortunately we are constrained by the health care system and every patient is attended to as soon as possible. In order to determine the type of pain the workup has to be completed before pain medication is provided. I wish there was a better answer.
eelgifted: I have been rushed by ambulance on a number of occasions—mostly from a flight—in intense pain with a history of kidney stones. It was an hour or more before any relief was administered and I knew what would eliminate the severe pain. It seems like "starting over" every time. It was needless pain and needless expense.
Juan_Calle,_MD: My best advice would be to come to our clinic to get prevention of the stones.
Citrates and Urine Alkalization Treatment
grd1022: Over the past 15 months I have had four surgeries for either kidney stones or many bladder stones. Three surgeries were bladder stones with the last having four stones. They have been diagnosed as uretic acid stones. I keep thinking it's a diet thing, but my current doctor and Cleveland Clinic continue to say drink, drink and more drink. One of my first surgeries for bladder stones I had so many they couldn't count and could not get them out in one surgery. I've done the Litholink tests and have another coming up. Can you help?
Juan_Calle,_MD: Although your doctors are right to recommend as much fluid intake as possible, there are other treatments that may need to be instituted. For uric acid stones, alkalization of the urine should be first-line therapy along with fluid intake. This is usually obtained with potassium citrate or bicarbonate medications. Other means to decrease the uric acid in your urine if is high may also be needed.
janiece: I know that citrates are helpful in preventing the bonding process and the formation of kidney stones. But what if your citrate test level exceeds the maximum range? Can you have too many citrates? And what can that cause?
Juan_Calle,_MD: Not only do citrates play a role in prevention of the stone formation, but there are other factors such as the supersaturation of the urine with certain elements. In other words, how concentrated or saturated the urine is. Too many citrates may usually not cause any problems, but again there are some cases in which it may not be the best option. If the citrates are only elevated in the urine, there are usually no side effects. The issue may arise if the blood or serum show signs of alkalosis (less acid).
Kidney Stone Treatment Selection
guest2: How do you decide which procedure to use to remove stones—percutaneous nephrolithotomy (PCNL), shock wave lithotripsy or ureteroscopy? Please explain the differences.
Sri_Sivalingam,_MD: The treatment choice must be based on evidence-based outcomes, and accordingly certain factors such as stone size, stone type and stone location need to be considered. For stones that are greater than 2 cm, either ureteroscopy or shockwave lithotripsy are options. Generally, for shock wave lithotripsy, the stone must be visible on a plain X-ray. However, for shock wave to be successful, other considerations must be undertaken, such as stone density, skin-to-stone distance, and stone location—which can all be obtained from a CT scan. Keep in mind, it is important to understand the number of treatments needed with each technique to clear your stone. PCNL is used for larger stones (greater than 1.5cm) and can be used for stones that consume the entire kidney. It is the most successful treatment approach for larger stones.
vassilia: There are three stones sitting on my left kidney that have not changed for the last three years. The largest is 6 mm. Do I leave them alone or go for lithotripsy—at least for the biggest one? I am located at the southeast corner of the state. How easy or realistic is for someone like myself to start a medical relationship with someone in your area like yourself who has the valuable expertise on stone formation? If it isn’t easy or practical, how do I find any comparable colleagues located in the central part of the state? I have been to specialists in my area, but they do not seem to know what to do with my 24-hour urinalysis results like you do.
Juan_Calle,_MD: A stone less than 6 mm will have a chance of passing without any procedures of up to 90 percent of the time, but it all depends on the location as well. As far as the medical relationship, we have plenty of patients who come even from out of state and we develop a good working team. Usually, and it depends on a case-by-case basis since follow-up may be months apart. Communication goes smoothly too via phone and fax when needed. Cleveland Clinic also offers MyChart®, a system for you to access your results online.
Gail Ann: Can lithotripsy successfully break up any type of stone? Is it necessary to determine the type of stone a person has before the procedure can be done? If yes, how is the stone makeup determined?
Sri_Sivalingam,_MD: Shock wave lithotripsy cannot break certain types of stones very well, such as cysteine stones, calcium oxalate monohydrate (COM) stones, or brushite stones. Fortunately, we can actually measure several parameters on a CT, which can tell us which stone type will be successfully treated. The CT attenuation measurement of the stone will tell us the hardness of the stone. Also, the distance from the skin to stone is very important to measure in order to predict whether lithotripsy treatment would be successful.
Gail Ann: Once a lithotripsy is performed, how long does it take to be free of the stone fragments?
Sri_Sivalingam,_MD: The time for complete stone clearance depends on the size, location and type of stone. It can take up to four weeks for stone fragments to pass. Fortunately, there are medications that are given after a lithotripsy procedure that can improve stone fragment passage.
Stone Passage Treatment After Lithotripsy
Gail Ann: Specifically, what are the medications that can be given after a lithotripsy procedure that can improve stone fragment passage?
Sri_Sivalingam,_MD: Flomax® (tamsulosin) has been shown to improve stone passage on multiple studies.
Shock Wave Lithotripsy Risks
guest2: What are the risks with having shock wave lithotripsy (SWL)? Does SWL cause kidney damage? If you have two large kidney stones each measuring 7 mm that won't pass on their own, what problems can arise if they are not removed? Can kidney stones dissolve or breakdown on their own and then pass?
Sri_Sivalingam,_MD: The risks of SWL include pain, infection, some bleeding, and incomplete treatment that would require multiple treatments. SWL can cause some bruising of the kidney. There are some studies suggesting a risk of high blood pressure in the long run, but these studies are inconclusive at the moment. Stones that measure 7 mm can actually continue to grow and cause further problems. They may also drop into the ureter and cause severe pain as the try and pass.
jfkacres: Please explain percutaneous nephrolithotomy (PCNL), and what size stone is considered large?
Sri_Sivalingam,_MD: PCNL involves making a small 12 mm incision on your back and placing a hollow tube (access sheath) directly into the kidney under X-ray guidance. This allows us to go in and out of the kidney and treat larger stones (greater than 1.5 cm). I use an ultrasound probe (and/or laser) that not only breaks up the stone, but also suctions out fragments so you don't have to pass any pieces afterwards. We can treat any type of stone with this approach. This technique has successes rates for complete stone clearance of greater than 95 percent after one treatment
Kidney Donation and Kidney Stones
cjbryant4409: Can recurrent kidney stones do any long-term, permanent damage to the kidney? I donated a kidney eight years ago and have now had a couple of occurrences with kidney stones. One was fairly large and the emergency department emphasized the importance of getting immediate treatment to preserve the health of the kidney. I was not clear if the damage would be due to the acute episode, or if there is the potential for any damage to the kidney over the long run in someone with the propensity for kidney stones.
Sri_Sivalingam,_MD: Thank you for donating a kidney! It would indeed be very important to treat any obstructing stones, especially in your case as you only have one kidney. These can cause damage to kidney function even if you are not having pain. Fortunately, most obstructing stones cause some degree of pain which can alert the patient. Other risks of leaving stones behind include ongoing stone growth, urinary tract infection and bleeding.
guest2: Can you be a kidney donor if you have had kidney stones?
Juan_Calle,_MD: This is a very tricky question as it may vary from program to program. Also, it may depend on how big your stones were, how many stones there are, and whether you have active metabolic disease (how often you are forming them and the type) as well as other associated conditions. Some programs do have this as selection criteria not to pursue donors with these problems.
Alcohol and Kidney Stones
PMORA: Does alcohol (casual drinking) contribute to the formation of kidney stones?
Juan_Calle,_MD: The short answer is not that much. However, if drinking is too often and there are periods of dehydration that follow, then it may pose a problem. The other issue comes mainly for your general health in terms of consumption of alcohol. Remember, don't drink and drive!
Herbal Medicines and Supplements
Inpain: Why isn't there a medication to help breakup small calcium stones? Are there any known herbal remedies that will do this?
Sri_Sivalingam,_MD: Unfortunately, there aren't any medications that can dissolve pure calcium stones effectively. I do not know of any evidence-based herbal medications that can do this either. However, certain types of stones such as uric acid stones can indeed dissolve with medications. The best way to prevent further calcium stone growth is to identify your risk factors and drink plenty of fluids to keep the urine dilute.
sw4health: During the March 26 online chat about natural products, I asked about natural products that could prevent the occurrence of calcium oxalate kidney stones (or reduce or eliminate existing ones). The expert’s response mentioned that there is a Chinese herb that does this—are you familiar with this herb? I have also read that magnesium citrate and vitamin B6 are helpful in preventing stone formation. Do you agree? If so, in what daily dosage?
Juan_Calle,_MD: The best thing to do is to have a consult with the integrative medicine herbalist to determine what is best for you as an individual. Some Chinese herbs may actually cause kidney failure, but some can prevent stones. So, it is best to be seen.
lady di: My brother has had multiple occurrences of kidney stones that are the type that they tell him to avoid tea, chocolate and caffeine. He was also told to drink a lot of fluids and drink lemonade. His kidney stones are multiple when they occur. The last time he had 15 at one time. After this occurrence the doctors added vitamin D to his treatment plan. What may be causing so many stones at one time, and is there any additional suggestions you may have to help him? Does vitamin D play a role in kidney stone prevention?
Sri_Sivalingam,_MD: Some of your questions are answered in other responses. However, regarding the vitamin D, there is no strong evidence one way or the other regarding its impact on kidney stone formation. There are specific circumstances, such as hyperparathyroidism or in osteoporosis, where vitamin D supplementation may be helpful for bone health, etc.
PMORA: I am taking a supplement called Theralith® XR (multivitamin with minerals) which is to promote normal urine chemistry. Is this supplement helpful?
Juan_Calle,_MD: Unfortunately, there are no good research studies to support the use of this supplement.
Exercise with Chronic Kidney Stones
ajlacombe: I am an endurance cyclist and my hydration levels go up and down. On a long ride I cannot help but get dehydrated to some extent. In order to maintain thirst to allow me to want to drink, I have to maintain my electrolytes. I am trying to limit my sodium intake during off bike times. I tend to get batches of stones about every six months with no correlation to riding that I have found. Is it possible that dips in hydration are aiding in the formation of the stones? My current method to counter the in-ride dehydration is to flood myself post-ride. My theory is to clean out excess sodium and to flush the system. I am in very good health, and wanted to know any tips for dealing with my stone formation. The good news is that passing them is no longer an ordeal like it used to be. I have been to a urologist and have had a 24-hour test, but that type of testing is not during any strenuous activity days.
Juan_Calle,_MD: Although you may not see the relationship of your periods of dehydration to go hand-in-hand, it may have a delayed effect as stones may take up to months to form. The key is to try to do what you're doing trying to catch up with fluids afterwards, but the crystallization process may have already started. Also as you mentioned, the test results vary a lot depending on your diet and also on physical activity. If there are other major abnormalities in your 24-hour urine, it may be addressed on the days you are not cycling.
Cleveland Clinic Appointment Scheduling
vassilia: What is the advisable route for out-of-town patients to schedule a consultation visit with either one of you? How long is the waiting list for an appointment at your clinic?
Juan_Calle,_MD: You can call our appointment line directly at 800.223.2273 ext. 45600. Please let them know that you would like to make an appointment with me and our schedulers will work with your schedule to get you in as fast as possible.
Moderator: I am sorry to say that our time with Dr. Juan Calle and Dr. Sri Sivalingam is now over. I would like to thank both of you for sharing your time to answer questions today.
If you would like to make an appointment with Dr. Calle or Dr. Sivalingam, or any of our other kidney stone specialists in the Glickman Urological & Kidney Institute, please call 800.223.2273 or request an appointment online by visiting www.clevelandclinic.org/appointments.Thank you.
For More Information
On Kidney Stones
On Cleveland Clinic
Cleveland Clinic’s Stevan B. Streem Center for Endourology and Stone Disease is located within the Glickman Urological & Kidney Institute. Through a multidisciplinary approach, urologists and nephrologists explore all medical and surgical treatment options to ensure the most successful possible outcome for each patient.
Experienced urologists and nephrologists investigate the causes of kidney stone formation through 24-hour urine analyses and blood tests. They then develop prevention strategies tailored to individual patients, such as tailored dietary recommendations based upon the 24-hour urine evaluation. Our patients receive a better understanding of why their kidney stones develop and what lifestyle changes they can make to prevent them.
At Cleveland Clinic, our urologists are trained in performing shockwave lithotripsy under conscious sedation. Cleveland Clinic urologists were among the first in Ohio to use shockwave lithotripsy.
Percutaneous nephrolithotomy is used for larger stones, and is a procedure our urologists perform regularly. Cleveland Clinic urologists also employ a ‘tubeless’ approach in select patients.
To learn more about the treatment options for kidney stones, we invite you to download our free Kidney Stones Treatment Guide by visiting www.clevelandclinic.org/kidneystones.
On Your Health
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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.
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