Time And Shock Wave Lithotripsy
We and others have noted an increasing percent of CaP in stones over the past 30 years. In women CaP percent is always higher than in men, but it has risen in both. For those of a quantitative bent, the time trend of stone CaP tested by ANOVA with post hoc contrasts was significant for both sexes, and women were higher than men throughout.
In the publication, we found a relationship between CaP percentage and numbers of shock wave lithotripsy procedures. Use of potassium citrate, however, did not seem to increase stone CaP.
The number of shock wave procedures per patient adjusted for the number of stones and the years of stone disease rose with the percent of CaP in stones and the percent of CaP likewise adjusted for number of stones and duration of stones and sex rose progressively with the number of shock wave procedures .
Not shown here, but of interest, the number of shock wave treatments was higher among BRSF than HASF suggesting a link between shock wave treatment and brushite stones.
One might infer from this set of graphs that the advent of shock wave lithotripsy caused the increase in phosphate stones, and there is nothing to contradict the idea. In fact, the very physiology of phosphate stone formation and the effects of shock waves on kidney function strongly support that idea as I shall show you.
My Dog Is Not Showing Any Signs What Will Happen If I Do Nothing
In cases where only a few small bladder stones are present and the dog is not experiencing clinical signs , it might seem reasonable to do nothing. The most common scenario for this situation is when bladder stones are found as an ‘incidental’ finding when an X-ray is performed for another reason. Since calcium oxalate bladder stones are most commonly diagnosed in male dogs, and male dogs are at an increased risk of urinary obstruction due to a small stone becoming lodged in the urethra, it can be extremely risky to adopt a “wait-and- see approach”. However, if for some reason the patient cannot undergo surgical treatment or non-surgical stone removal, and you are willing to assume the risks, it may be acceptable to delay the treatment for a short while. During this time the diet is often changed to one less likely to contribute to calcium oxalate stone formation. However, if there is ANY indication that your dog’s condition is worsening, or if the dog develops a urinary obstruction, you must seek immediate veterinary attention.
Low Citrate In Cap Stone Formers
Food increased urine citrate is normal women and all three male groups . With food, CaP stone formers of both sexes have urine citrate excretions below their same sex normal counterparts as did female CaOx stone formers.
As is well known, citrate is lower in normal men than women .
Adjusted for GI alkali and urine sulfate, low citrate is concentrated among male CaP and female CaOx stone formers. Normal men remain below normal women.
Male CaOx stone formers have abnormally high urine citrate with and without adjustment for systemic acid balance.
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Prevention Of Calcium Phosphate Stones
The objective is to lower CaP SS reported with respect to brushite below 1.
The main modifiable factors are urine volume, and calcium and citrate excretion. Because we cannot lower urine pH, the most crucial factor, we have to use what is left to achieve our goal. Likewise, because citrate regulation is abnormal in CaP stone formers, use of potassium citrate may not raise urine citrate so much as it raises urine pH, and therefore this otherwise valuable treatment can be ineffective.
Should I Cut Out All Foods That Have Oxalate Or Calcium
No, this is a common mistake. Some people think that cutting out all foods that have oxalate or all foods with calcium will keep stones from forming. However, this approach is not healthy. It can lead to poor nutrition and can cause other health problems. A better plan? Eat and drink calcium and oxalate-rich foods together during a meal. Doing this helps oxalate and calcium bind to one another in the stomach and intestines before reaching the kidneys, making it less likely for kidney stones to form in the urine.
Plan Your Plate For Kidney Stones
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Oxalate Restriction In Hyperoxaluria
People who have hyperoxaluria will be advised to limit the amount of oxalate in their diet.
- Foods high in oxalic acid include beets, soy, black tea, chenopodium, chocolate, cocoa, dried figs, ground pepper, lamb, lime peel, nuts, parsley, poppy seeds, purslane, rhubarb, sorrel, spinach, and Swiss chard.
- Foods containing moderate amounts of oxalates include beans , blackberries, blueberries, carrots, celery, coffee , concord grapes, currants, dandelion greens, endive, gooseberries, lemon peel, okra, green onions, oranges, green peppers, black raspberries, strawberries, and sweet potatoes.
Know Your Kidney Stones
Knowing what makes up a patient’s kidney stones determines how an internist might treat the problem. But, one expert cautions, while 1 type of kidney stone is far more prevalent, there are 4 other kinds, and they may require subspecialty treatment.
Kidney stone treatment and prevention depend on the type of stone you’re dealing with, according to Gary C. Curhan, MD, ScD.
When I see a patient I always ask them what type of stone they had, and usually they raise their voice a little bit and say, A kidney stone, as if I didn’t hear them the first time, he said. But what you and I really want to know is what the stone’s made out of.
Calcium oxalate is the most common type of stone, seen in 74% of first-time stone formers and 66% of recurrent stone formers. Overall, if you are not sure of the stone composition, you should always guess calcium oxalate, far and away, said Dr. Curhan, who is a professor of medicine at Harvard Medical School and a member of the Renal Division at the Brigham and Women’s Hospital in Boston.
Most of Dr. Curhan’s talk pertained to calcium oxalate stones, but he also mentioned 4 other types, 2 of which, cystine and struvite, should always indicate referral to a subspecialist. Cystine stones are caused by an autosomal recessive disorder and are unrelated to diet. They are evaluated by measuring 24-hour cystine excretion and prevented by using tiopronin or penicillamine and raising urine pH.
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Causes Of Kidney Stones
Kidney stones happen when your pee has a high concentration of minerals and other substances — like calcium, oxalate, and uric acid — that come together to make crystals. Crystals stick together to make one or more stones. Stones happen when your urine doesnât have enough fluid and other substances to keep them from happening.
A kidney stone can be as tiny as a grain of sand, and you can pass it without ever knowing. But a bigger one can block your urine flow and hurt a lot. Some people say the pain can be worse than childbirth.
Different things can bring on kidney stones, including what you eat and certain medications. If you or someone in your family has had a kidney stone, youâre more likely to have them.
Causes Of Struvite Stones
Struvite stones are almost always caused by urinary tract infections. Certain bacteria produce urease, which breaks down urate and raises the concentration of ammonia in the urine. Ammonia makes up the crystals that form struvite stones. The bacteria that promote stone formation are most often Proteus, but they may also include Ureaplasma urealyticum, as well as Pseudomonas, Klebsiella, Providencia, Serratia, and Staphylococcus species. Women are twice as likely to have struvite stones as men.
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Overview Of Calcium Phosphate Stones
Kidney stones composed predominantly of calcium phosphate constitute up to 10% of all stones and 15%20% of calcium stones, 80% of which are composed of calcium oxalate. Calcium phosphate is a minor component of up to 30% of calcium oxalate stones as well . The importance of calcium phosphate as an initiator of calcium stones has been highlighted by recent work showing that the vast majority of calcium oxalate stones form as overgrowths on Randalls plaque. Randalls plaque is an amorphous apatite that forms in the interstitium of the papillae, and it grows until it ruptures through the papillary urothelium and becomes exposed to urine calcium oxalate crystals nucleate and grow into kidney stones . Some data suggest that calcium phosphate stones have increased in prevalence. If true, the reasons are uncertain and have been attributed to treatment with citrate supplements or adverse effects of extracorporeal shockwave lithotripsy . Lithotripsy has been hypothesized to lead to defective urinary acidification, but this effect is highly speculative.
Who Gets Kidney Stones And Why
The lifetime risk of kidney stones among adults in the US is approximately 9%, and it appears that global warming may be increasing that risk. There are four major types of kidney stones: calcium oxalate/calcium phosphate, uric acid, struvite , and cystine.
A risk factor for all stones, regardless of type, is dehydration. Anyone who is prone to kidney stones should pay attention to good hydration. A randomized trial has shown that drinking 2 liters of fluid a day reduces the likelihood of stone recurrence by about half. The American Urological Association guideline for medical management of kidney stones recommends that patients who form kidney stones should aim to drink more than 2.5 liters of fluid per day.
Anyone with symptoms of kidney stones should be referred to a urologist. The initial evaluation will often include blood, urine, and imaging studies. Decisions about testing, and ultimately treatment, should be made jointly by the physician and the patient. Lets look at specific risk factors and treatment for each of the major stone types.
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Are There Any Other Treatment Options
In some selected referral centers, another option may be available to treat bladder stones. This option is ultrasonic dissolution, a technique in which high frequency ultrasound waves are used to disrupt or break the stones into tiny particles that can then be flushed out of the bladder. It has the advantage of immediate removal of the offending stones without the need for surgery. Your veterinarian will discuss this treatment option with you if it is available in your area.
Avoiding Recurrence Of Kidney Stones
If you have had one kidney stone, some tips that may help to prevent a second stone forming include:
- Talk to your doctor about the cause of the previous stone.
- Ask your doctor to check whether the medications you are on could be causing your stones. Do not stop your medications without talking to your doctor.
- Get quick and proper treatment of urinary infections.
- Avoid dehydration. Drink enough fluids to keep your urine volume at or above two litres a day. This can halve your risk of getting a second stone by lowering the concentration of stone-forming chemicals in your urine.
- Avoid drinking too much tea or coffee. Juices may reduce the risk of some stones, particularly orange, grapefruit and cranberry. Ask your doctor for advice.
- Reduce your salt intake to lower the risk of calcium-containing stones. Dont add salt while cooking and leave the saltshaker off the table. Choose low- or no-salt processed foods.
- Avoid drinking more than one litre per week of drinks that contain phosphoric acid, which is used to flavour carbonated drinks such as cola and beer.
- Always talk to your doctor before making changes to your diet.
Drinking mineral water is fine it cannot cause kidney stones because it contains only trace elements of minerals.
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Dietary Calcium And Kidney Stones
Only lower your calcium intake below that of a normal diet if instructed by your doctor. Decreased calcium intake is only necessary in some cases where absorption of calcium from the bowel is high.
A low-calcium diet has not been shown to be useful in preventing the recurrence of kidney stones and may worsen the problem of weak bones. People with calcium-containing stones may be at greater risk of developing weak bones and osteoporosis. Discuss this risk with your doctor.
Calcium Kidney Stones: Pathogenesis Evaluation And Treatment Options
Helen L. Figge, RPh, PharmD, MBA, Lean Six Sigma CertifiedSenior Director, Career ServicesChicago, Illinois
US Pharm
Nephrolithiasis occurs in more than 5% of the U.S. population and accounts for more than $5 billion in direct and indirect costs annually, related to hospitalization, surgery, and lost work time.1 The prevalence appears to be rising over time.2 The presence of nephrolithiasis is concentrated among working adults about one-third of employees treated for nephrolithiasis miss work, averaging 19 hours per afflicted person. The incidence peaks in the third and fourth decades of life. By age 70 years, approximately 11% of men and 5.6% of women will have experienced a symptomatic kidney stone, and about 40% to 50% of initial stone formers will have a recurrence within 5 years.1,3 The risk of recurrence within 20 years is as high as 75%. Risk in white individuals is roughly three times higher than in the African American, Hispanic, and Asian American populations.4 Geographic location also appears to impact stone formation, with higher rates in the southeastern U.S., possibly related to greater sunlight exposure, resulting in increases in insensible fluid losses and increases in vitamin D production.
In addition to causing severe pain resulting in emergency room visits and sometimes hospitalization, stone formation is associated with increased rates of chronic kidney disease and hypertension.5,6
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Bicarbonate Losing Raised The Ph
The higher urine pH could have been due to damage of final urine acidification in the collecting ducts or to high delivery of bicarbonate from higher up in the nephron so that acid secreted lower down was neutralized by a flood of bicarbonate.
To tell these apart we gave the pigs an acid load that lowered their blood bicarbonate and therefore filtration and downstream delivery . Acid load brought urine pH and almost all other measurements to equality between the shocked and control kidneys .
The tissues from the pigs showed widespread injury to the thick ascending limbs, and you can read the paper for details.
How Common Are Kidney Stones
Each year, more than half a million people go to emergency rooms for kidney stone problems. It is estimated that one in ten people will have a kidney stone at some time in their lives.
The prevalence of kidney stones in the United States increased from 3.8% in the late 1970s to 8.8% in the late 2000s. The prevalence of kidney stones was 10% during 20132014. The risk of kidney stones is about 11% in men and 9% in women. Other diseases such as high blood pressure, diabetes, and obesity may increase the risk for kidney stones.
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Six Steps To Control Oxalate For Kidney Stones
The following six steps can be taken to reduce the risk of forming calcium oxalate stones:
1. Eat fewer high-oxalate foods.
The first suggestion is the most obvious. The more oxalate that is absorbed from your digestive tract, the more oxalate in your urine. High-oxalate foods to limit, if you eat them, are:
- Spinach
- French fries
- Nuts and nut butters
You do not need to cut out other healthy foods that provide some oxalate. In fact, oxalate is practically unavoidable, because most plant foods have some. Often a combination of calcium from foods or beverages with meals and fewer high-oxalate foods is required.
2. Increase the amount of calcium in your diet.
Low amounts of calcium in your diet will increase your chances of forming calcium oxalate kidney stones. Many people are afraid to eat calcium because of the name “calcium oxalate stones.” However, calcium binds oxalate in the intestines. A diet rich in calcium helps reduce the amount of oxalate being absorbed by your body, so stones are less likely to form. Eat calcium rich foods and beverages every day from dairy foods or other calcium-rich foods.
Also, eating high calcium foods at the same time as high oxalate food is helpful for example have low fat cheese with a spinach salad or yogurt with berries. If you take a calcium supplement, calcium citrate is the preferred form.
3. Limit the vitamin C content of your diet.
4. Drink the right amount of fluids every day.
5. Eat the right amount of protein daily.
Stone Former Sex Ratio
The blue bars show male to female ratios among stone formers. Remember this is counted from the sex of the person whose stone was analyzed. A survey based on symptomatic rates of stone passage, by contrast, might give different results altogether.
In childhood, men have slightly more stones than women . In the teen years and up to age 39, women predominate over men . After age 40 men predominate, until at age 90 and more, in this and perhaps most things, the sexes come into a near perfect alignment. Averaged over all of life, men have more stones, which appears to be because of their midlife excesses .
The fraction of all stones formed for both sexes combined is highest from age 20-69, with only a small fraction in childhood or old age.
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What Are The Signs Of Calcium Oxalate Bladder Stones
The signs of bladder stones are very similar to the signs of an uncomplicated bladder infection or cystitis. The most common signs that a dog has bladder stones are hematuria and dysuria . Hematuria occurs because the stones rub against the bladder wall, irritating and damaging the tissue and causing bleeding. Dysuria may result from inflammation and swelling of the bladder walls or the urethra , from muscle spasms, or from a physical obstruction to urine flow. Veterinarians assume that the condition is painful, because people with bladder stones experience pain, and because many clients remark about how much better and more active their dog becomes following surgical removal of bladder stones.
Large stones may act almost like a valve or stopcock, causing an intermittent or partial obstruction at the neck of the bladder, the point where the bladder attaches to the urethra. Small stones may flow with the urine into the urethra where they can become lodged and cause an obstruction. If an obstruction occurs, the bladder cannot be emptied fully if the obstruction is complete, the dog will be unable to urinate at all. If the obstruction is not relieved, the bladder may rupture. A complete obstruction is potentially life threatening and requires immediate emergency treatment.