Online Health Chat with Sri Sivalingam, MD, and Fernando Cabrera, MD

August 1, 2016

Description

Welcome to our chat on Kidney Stones Treatment Options with Dr. Sri Sivalingam at our Main Campus location in Cleveland, Ohio, and Dr. Fernando Cabrera at our Cleveland Clinic Florida location in Weston. Thank you both for taking the time to be with us and share your thoughts and expertise on this subject.

To begin, let's first set the stage for today's chat.
What do you really know about kidney stones, other than they are painful? Today, we will be discussing this topic with both physicians from Cleveland Clinic. Kidney stones are small crystals that form in the kidneys and are a very common urinary tract disorder. The most common symptoms of kidney stones are back or abdominal pain and blood in the urine. Although kidney stone attacks can be very painful, the majority of stones can pass on their own. However, when a stone becomes lodged and cannot pass, there are specialized, minimal invasive surgical treatments available. These treatments include ureteroscopy, shock wave lithotripsy and percutaneous nephrolithotomy.

About the Speakers

Sri Sivalingam, MD, MSc, FRCSC, is assistant professor of surgery at Cleveland Clinic Lerner College of Medicine at Case Western Reserve University. He is also director of the Center for Endourology and Stone Disease at Cleveland Clinic’s Hillcrest Hospital. Originally from Canada, he earned his Bachelor’s, Master’s and medical degrees at the University of Toronto and subsequently completed his urology residency at the University of Manitoba. He then completed a two-year fellowship in advanced endourology and minimally invasive surgery with a strong focus on urinary stone disease at the University of Wisconsin. He is board certified by both the American Board of Urology and the Royal College of Physicians and Surgeons of Canada.

Fernando Cabrera, MD, is an attending physician at Cleveland Clinic Florida in Weston, Florida. He specializes in the surgical and medical management of stone disease and minimally invasive urologic surgery. He completed his Bachelor’s and medical degrees in Puerto Rico at the University of Puerto Rico and Ponce School of Medicine. He then completed a five-year residency in urology in New York City at SUNY Downstate. He subsequently completed a two- year fellowship focusing on stone disease at Duke University Hospital. While at Duke, he published in multiple peer-reviewed journals and authored many chapters regarding stone disease.


Let’s Chat About Kidney Stones Treatment Options

Maybe Medications

Cackie:I recently suffered four kidney stone attacks (one 5-6 mm stone) with excruciating pain in the span of one week. The last attack was five hours of unrelenting pain followed by lithotripsy. Are there no medications that can relax ureters to allow for easier passage of a stone?

Sri_Sivalingam,_MD:Hello. I’m sorry to hear of your pain episodes. Actually, there are some validated medications that can help with stone passage, such as tamsulosin, which is taken once a day. This medication is usually well-tolerated and has been shown to improve time to passage of stones by three to five days.

Tom:What does potassium citrate ER 10 meq do?

Sri_Sivalingam,_MD:Potassium citrate is used for a number of reasons to prevent stone formation. Usually a higher dose is required, given two to three times/day. This medication is used to raise the urinary citrate levels in patients with low urinary citrate, as citrate is an inhibitor of stones (can help prevent stone formation). Also, citrate is used to alkalinize the urine by raising the urinary pH in patients with uric acid stones.


Symptoms and Diagnosis

DebNsatx :Can you tell me some of the classic symptoms in a male who might have a kidney stone? Are the symptoms the same for a male as for a female? If you suspect that you might have a kidney stone, does drinking cranberry juice, apple cider vinegar mixed with water or lemon water help to dissolve the stone if it is done on a daily basis? If not, what would help a person? Thank you for your response.

Fernando_Cabrera,_MD:Pain from a kidney stone generally occurs when the stone passes and obstructs the ureter. The ureter is a long tube that connects the kidney to the bladder and allows urine to drain. When this tube is blocked, the classic symptoms are generally the same despite gender. These include pain on the side of the abdomen or flank, which can radiate to the groin. In men, the pain can travel down to the testicles. There are also associated symptoms that include nausea, vomiting, fever, chills, burning during urination and/or blood in the urine. Not all of these symptoms need to present during a stone episode. Cranberry juice has been shown to prevent urinary tract infections, but no data has shown any benefit with stones. Vinegar can sometimes be used to change the acidity and make the urine alkaline, which can help with some stones, but not all. Lemon has citrate, which has been shown to block the formation of new stones and prevent stones that you already have from getting bigger. The most important recommendation is to increase fluids to more than 2.5 L daily and limit your salt intake.

Patty02:If I have some kidney stone symptoms, how do I proceed? Are any tests needed?

Sri_Sivalingam,_MD:During an acute episode of a kidney stone attack, we would recommend a non-contrast, low-dose CT scan (provided you have not had a scan done in the preceding six to 12 months). If you have had a recent CT as above, you can get a kidney ultrasound and plain x-ray (KUB x-ray). These imaging studies help identify a stone and also the size and location, and with a CT, possibly the type of stone by measuring the stone density. Imaging is also necessary to plan the optimal treatment approach in each specific case.


Causes and Complications

Jbennett:Are kidney stones more prominent in a profession with minimal physical activity?

Fernando_Cabrera,_MD:There are known risk factors for stone disease that include: family history, diabetes, obesity, history of bowel disease or surgery, low fluid intake or dehydration, excessive consumption of animal protein, and limited fruit and vegetable consumption. Inactivity can lead to obesity and diabetes, which are known risk factors for stones.

loveitaly:In the past, my husband has had several kidney stones, mostly from oxalate. He passed out from pain a couple of times, even though he has a high tolerance for pain (more than 20 years ago). Others he was able to pass without any treatment at all. When he had one left, the physician told him to eliminate it with a procedure that I don't remember the name of right now, but it pulverized the stone with ultrasound from outside. For two days, the area was red and a little bruised, and that was the end of it. He was also prescribed a medication called Urocit K to prevent the formation of stones. He still takes it. After many years, he has a very little one, which is under control. The doctor always told him that the main culprit in the US for kidney stones was the consumption of iced tea, which he never has because he doesn't like it. I just wanted to share this information and to have the speakers' input. Thank you so much.

Sri_Sivalingam,_MD: It sounds like he had a shock wave lithotripsy procedure, which can certainly cause some bruising of the skin. Urocit k is the same as potassium citrate, which I wrote about for another question. Potassium citrated is used to treat patients who are low in urinary citrate or who have a uric acid stones. Ice tea in and of itself is not a specific cause for kidney stones, and while it may contain some oxalate that can increase the  risk, a cup a day is likely not going to cause any harm. In your husband's case, he doesn't even drink ice tea, so definitely it is not the cause for him.

Shannonx21:What are the possible complications that may result from kidney stones?

Sri_Sivalingam,_MD:Kidney stones can move into the ureter and cause obstruction of the ureters (the tubes that drain the urine from the kidney to the bladder). This can lead to extreme pain, vomiting and a urinary tract infection during an acute attack. Kidney stones can also continue to grow in size and damage the kidneys (in cases where the stone can fill the entire kidney.) In some patients, kidney stones can harbor bacteria that can become a source of recurrent urinary tract infections.

DebNsatx :I was wondering if there is a genetic component to kidney stones. Do they run in families? Do a specific ethnic group of people get kidney stones? Thank you for your response.

Fernando_Cabrera,_MD:There are multiple genes related to kidney stones, and the importance of these is currently being studied. We know that there is a strong family history component, and if you have a first degree family member with stones, you are more likely to have them. We know that cystinuria is a genetic metabolic disease that leads to frequent formation of stones. These lead to recurrent stone, typically in patients less than 30 years old.


Talking About Treatments

Cackie:What are the side effects of lithotripsy on surrounding organs such as the colon, small intestine, ovary and pelvic bones?

Sri_Sivalingam,_MD:Shock wave lithotripsy is known to be relatively safe, and the impact on the surrounding organs you mentioned are minimal to none. There were earlier reports of potential collateral damage to the pancreas, causing a slightly higher risk of diabetes and high blood pressure, but follow-up large scale studies have refuted this. Shock wave lithotripsy, therefore, remains a safe treatment approach.

jmmish500:I have an 8mm kidney stone remaining after I had lithotripsy. My doctor suggested a manual retrieval. Will this cause any damage to my ureter or result in spasms after the procedure? I am in a wheelchair due to muscular dystrophy, and it is difficult for me to go to the bathroom often.

Fernando_Cabrera,_MD:Some stones may be resistant to shock wave lithotripsy due to their location (lower part of the kidney) or composition (hard, calcium oxalate monohydrate). These stones respond well to treatment with ureteroscopy and fragmentation with a laser. New technology has made our scopes really small, and the risk of permanent injury to the ureter is rare. Following the procedure, a stent is placed that facilitates urine drainage down to the bladder, which is then removed in two to seven days. This can cause temporary discomfort and spasms, which can be controlled with medication.

CarolinaC11:Are there other effective surgical treatments for kidney stones other than lithotripsy? If so, what are they?

Sri_Sivalingam,_MD:Yes indeed. Shock wave lithotripsy is one available option, but should be used in select patients with specific criteria to be effective. Other treatment options include ureteroscopy (a tiny scope used to enter the urinary tract) with laser fragmentation of the stone, and for larger stones percutaneous nephrolithotomy (a small 1 cm incision is made in the back to gain direct access into the kidney) and removal of the stone with an ultrasonic probe. In extreme cases, we do robotic surgery to treat the stones, and rarely, open surgery. We have some videos available on our website that explains these different procedures.


Possible Prevention

DebNsatx :Thank you for having this web chat. Is it true that if a person hasn't had any kidney stones by the age of fifty, then most likely they won't get them? But say they do have one, then what would you do so they don't get any more in the future. Thank you for your response.

Fernando_Cabrera,_MD:It is true that the incidence of kidney stones peaks between the ages of 30 and 50 years old, but they can occur at any age. I have had patients in their 90s with stones. Once you are diagnosed with a kidney stone, there is a 30 percent chance of having another one in the next five years. Once you are diagnosed with stones, we can perform tests that can help us determine the risk of producing more stones. These tests can also direct treatment, either dietary changes or medications that can prevent further episodes.

gabbyme3:I have a history of kidney stones since my late teens. I stopped taking all dairy products, but now that has caused osteoporosis. How can I stop these painful kidney stones from forming? Thank you for your help.

Sri_Sivalingam,_MD: It sounds like you may have a complex metabolic issue that needs careful review with blood work, a 24-hour urine study and stone analysis, along with a thorough dietary assessment. We do have dedicated stone clinics with the support of dietary specialists and nephrologists to coordinate your care. To put this simply, there is no one quick remedy for stone prevention, and typically we do not advise cessation of all dairy products to prevent stones. In fact, we do advise supplementation of calcium-fortified foods.

DebNsatx :Good afternoon, doctors. I have a son who is 24 years of age and passed a kidney stone a few months back. By the time he saw a urologist, it had already passed, so we don't know what kind of stone he passed. Is there a particular kind of stone that he would have passed at this age? Also, what kind of advice would you give him to prevent him from getting any future stones; for example, drinking more water or staying away from salt? Thank you so much for your response.

Fernando_Cabrera,_MD:Thanks for your question, and I hope your son is doing well now. Kidney stones are very common. They peak between 30 and 50 years old, but they can occur at any age. Over 90 percent of all stones are composed of calcium, either calcium oxalate or phosphate. The remaining 10 percent include uric acid, cysteine and matrix stones. These are more rare, but important because some of these can be dissolved with medications. Since we don't have a stone analysis, general stone prevention recommendations are good at preventing further stone episodes. These include increasing fluids to more than 2.5L a day and limiting salt, animal protein and oxalate. Otherwise, a more comprehensive metabolic work up, which includes blood work and a 24-hour urine, can give us more information to pinpoint risks factors for further stones.


Diet Component

derosy:Are all nuts and berries bad for kidney stones?

Sri_Sivalingam,_MD:There are certain nuts (such as peanuts) that are high in oxalates that can contribute to calcium oxalate kidney stones, which are the most common type of stone. However, in moderation, these should not pose a threat. So, the quick answer is: No, not all nuts and berries are bad for kidney stones. We actually have some online videos and material to guide you on our website.

Moderator:Here is a health information document about diet:

Kidney Stones: Oxalate Controlled Diet
http://my.clevelandclinic.org/services/urology-kidney/treatments-procedures/kidney-stones-oxalate-controlled-diet

cz8kxq:Has any dietary change displayed efficacy in dissolving stones, or is this a myth?

Sri_Sivalingam,_MD:There is definitely good evidence to support certain dietary changes that can help prevent stone formation/growth. The idea of dissolving stones with diet alone is a bit more difficult. With uric acid stones, for example, potassium citrate can sometimes help dissolve stones by raising the urine pH. While citric fruits can increase the urinary citrate levels, they typically cannot achieve the goal of adequately alkalinizing the urine to dissolve these uric acid stones.


Painful Expressions

Meg:What do ureteral spasms feel like, and what can be done about them?

Sri_Sivalingam,_MD:The pain is usually caused by an obstructing stone. The pain can be excruciating at times, and can range from flank pain or pain in the abdomen, which radiates down to the groin, and in males can travel down to the testicles. Pain medication can help, especially anti-inflammatory medications such as naproxen (Aleve) or ketorolac (Toradol). Also, narcotic medications can help during an acute attack, and medications such as tamsulosin (Flomax) can help with relaxation of the ureter, which may help with stone passage also.

EMac:I’ve had pain in my left testicle with no hernia that has been going on for six month or more. My general practitioner says it could be kidney stones?

Sri_Sivalingam,_MD:It is possible, but not likely. You can get an imaging study such as a kidney/bladder ultrasound with x-ray or a non-contrast, low-dose CT scan to confirm this.


Closing

That is all the time we have for questions today. Thank you, Dr. Sivalingam and Dr. Cabrera, for taking time to educate us about kidney stones.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.

Sri_Sivalingam,_MD:Thank you very much for taking the time to ask these insightful and educated questions, which have enabled a great discussion. Hopefully, we have provided you a better understanding of kidney stones and the treatment thereof!
Sincerely,
Sri Sivalingam

Fernando_Cabrera,_MD:Thank you very much for joining us today.


For Appointments in Ohio

To make an appointment with Sri Sivalingam, MD, or any of the other urology specialists in Cleveland Clinic’s Glickman Urological & Kidney Institute, please call 216.444.5600, toll-free at 800.223.2273 (extension 45600) or visit us at clevelandclinic.org/urology for more information.

For Appointments in Florida

To make an appointment with Fernando Cabrera, MD, or any of the other specialists in the Urology Department at Cleveland Clinic Florida, please call 877.463.2010. You can also visit us online at www.clevelandclinicflorida.org.

For More Information

About Cleveland Clinic
The Department of Urology within the Glickman Urological & Kidney Institute is ranked No. 2 in the nation by U. S. News & World Report. Urologists in this institute are also recognized worldwide for excellence in patient care, teaching and research in all aspects of urology.

Cleveland Clinic Health Information
For more information about a variety of health topics, please visit clevelandclinic.org/health.

Kidney Stones Overview
http://my.clevelandclinic.org/services/urology-kidney/diseases-conditions/kidney-stones-overview

Kidney Stones: Oxalate Controlled Diet

http://my.clevelandclinic.org/services/urology-kidney/treatments-procedures/kidney-stones-oxalate-controlled-diet

Cleveland Clinic Treatment Guide
Kidney Stone Treatment Guide
Please use this guide as a resource to learn about the causes of kidney stones and your treatment options.

Cleveland Clinic Health Information
For more information about a variety of health topics, please visit clevelandclinic.org/health.

Clinical Trials
For additional information about clinical trials, visit: ClinicalTrials.gov.

Your Health
MyChart® is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org.
 
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.


Contact Information

If you need more information, click here to Live Chat with a health educator (click on Questions and then Live Chat) or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272, ext. 43771, to speak with a Health Educator.
 
Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link clevelandclinic.org/webcontact or email healthchats@ccf.org.

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician’s independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2016. The Cleveland Clinic Foundation. All rights reserved.