Transcription:
Kidney Stones-Treatment & Prevention

Melanie Cole (Host): According to the National Kidney Foundation, more than half a million people visit emergency rooms each year for kidney stones. My guest today is Dr. Steven Johnson. He’s an adult and pediatric urologist and a member of the medical staff at Texoma Medical Center. Welcome to the show, Dr. Johnson. What are kidney stones?

Dr. Steven A. Johnson, MD (Guest): Kidney stones are particulate matter, or solid matter, that form within the urinary tract and the kidney. Sometimes they can stay in the kidney for many years without growing, but unfortunately, oftentimes they will get larger and break out of the kidney and start down the ureter towards the bladder, and that’s where the pain begins.

Melanie: So, why should we be concerned about kidney stones?

Dr. Johnson: About 10% of the U.S. population will develop kidney stones in their lifetime. It’s more common in what we call The Stone Belt, the hotter Southern states where people tend to become dehydrated. People can be concerned about them for a variety of reasons and the worst case scenario – it can cause damage to the kidney. If infection is superimposed on the kidney stone, people can become very, very sick. They can develop a condition called sepsis where bacteria actually gets into the bloodstream and that can turn the kidney stone into a life-threatening emergency. More commonly, though, it interferes with people’s work or their vacation plans or their everyday life because they have pain that keeps them from doing their day to day things.

Melanie: So, who is most at risk besides the people in the Southern Belt states that might be dehydrated or in that hot weather? Who else might be at risk and what puts them at risk?

Dr. Johnson: Generally speaking, kidney stones don’t really respect anyone. We even see them in children fairly commonly. Anyone who has a job that’s outside, or if they’re in an environment that’s a high-heat environment, they definitely are at risk. Sometimes, we see pregnant women can be at risk of kidney stones because as the fetus grows, and it puts pressure on the ureters, the urine may not drain quite as readily and that slow drainage of urine can sometimes set up a situation where kidney stones are more prone to form.

Melanie: So, then how would somebody know? Would it start as a certain type of pain? How would you even know and what are some of the symptoms?
Dr. Johnson: Well, typically pain is the hallmark symptom that people experience, and it's usually a sudden, crushing type of pain. If you talk to women who have had a kidney stones and women that have given birth, they say that the pain from the kidney stone is worse than the pain with – that they have with childbirth, but pain is the hallmark feature. It’s typically what we refer to as a colicky type pain which means it tends to come in waves. You may have pain for a few minutes or an hour or so and then the cycle of pain will try to break and then the wave of pain will start back a short time thereafter. So, it's a colicky type of pain. Oftentimes, people can see blood when they're passing a kidney stone. That’s not a reliably present symptom, but it can occur. People have nausea and vomiting many times associated with the kidney stone which compounds the problem because if you get dehydrated from that, you're not going to be able to push the stone through if you can’t keep fluids down because you're vomiting. The most dangerous thing that people need to be watching out for when they have or suspect they have a kidney stone would be a fever. If you have a high-grade fever – 101, 102 – that could imply that there's an infection superimposed on the kidney stone, and again, that is a life-threatening emergency. If you suspect a kidney stone and you have a high-grade fever, get to the nearest urologist or emergency room without delay.

Melanie: And that’s when you should worry about sepsis, yes?

Dr. Johnson: That’s exactly right. We see patients – particularly diabetic patients – can become septic very, very quickly. Sometimes just within a matter of hours or half a day. I've had patients that come into the hospital that don’t look particularly sick, but they're diabetic, and they develop a fever. They can wind up on the intensive care unit between morning and noon if they are predisposed and if they actually experience sepsis.

Melanie: Well, sepsis is certainly an emergent condition, but what about kidney stone elimination? Is this emergent if you suspect that you have one? Is it something you have to go to the emergency room for? Will it pass? Or is there something that the doctor needs to do to help it along?

Dr. Johnson: Other than sepsis, there are some conditions that we would classify as an emergency associated with a kidney stone, which you might wind up in the emergency room, and you might wind up hospitalized. Those conditions would be – if your pain cannot be controlled with medication. As I mentioned before, if you're having nausea and vomiting, and you can’t keep fluids down, you're at risk of dehydration. That would be a criteria in which you would need to come to the hospital or go to the emergency room, and then we have some cases that we consider kind of special circumstances. If a woman’s pregnant, for example, and she’s having kidney stone type pain, that can sometimes be treated as an emergency, and it's because the stress and the pain associated with the passage of kidney stones can sometimes induce premature labor. So, that’s a special circumstance in which women would probably need to come to the emergency room, contact their obstetrician, or be hospitalized if they're passing kidney stones, and then finally patients whose immune system might be compromised. Perhaps they're an HIV patient, or perhaps they're on steroids for rheumatoid arthritis, or they’ve been on chemotherapy for some type of cancer – all of those things can suppress your immune system, and if you’re passing a kidney stone, then you have to be treated a little bit more urgently.
Your question spoke to – how do we know when to put people in the hospital? How do we know when to treat people? If you don’t have any of those circumstances, and you don’t need to be hospitalized, but your pain can be controlled, particularly if you don’t have a particularly large stone – let's say the stone is less than four or five millimeters in size – it's often safe to try to pass the stone at home. We utilize a program that we refer to as Medical Expulsive Therapy which consists of drinking lots of fluids, giving the patient pain medication to take as needed, having them strain their urine so that they can catch the stone if they pass it, and then we’ll typically use a class of medication called an alpha blocker which will help relax the ureter and hopefully help the stone pass more readily. Patients generally grow tired of that after about a week or two if they're still having pain or if they have any of those other conditions that we spoke to. Then, they usually get moved over to a treatment program that usually involves some type of surgery to eradicate the stone.

Melanie: If they're passing it at home, will they see it? Will they know that it's passed, and they’ll see it come out?

Dr. Johnson: Sometimes we do see patients that see the stone in the commode before they flush it or they’ll hear it. You know, we used to talk about patients if they have a larger stone sometimes in the night, they’ll pass the stone, and they’ll hear it hit the water in the commode. We try to encourage our patients and make them aware that they really needed to pass the stone through a strainer. I mean, nobody wants to reach into the commode and pick the stone out of the commode, but if you're using the strainer, you can urinate through the strainer, and the strainer will catch the stone and then you can actually just bring the strainer to the doctor’s office with the stone still in it, and we’ll send the stone off to be analyzed. That’s a very important part of looking at a patient with kidney stones to find out why they get them to know what the stone’s made out of.

Melanie: Well, that’s a great tip because then you need to bring it to your doctor so that you can look at it and biopsy it, and what's next for the patient, doctor? Are they now at risk for more stones?

Dr. Johnson: About 50% of people that have a kidney stone will have another one within two years. One of the things that we stress to patients is that they have some control over which percentage they fall into – do you fall into the 50% that has a stone? Do you fall into the percent that doesn’t have a stone within the next two years? You have some control over that. So, we stress to those patients a very strict dietary program that they need to follow. It includes a minimum daily fluid intake to try to maintain a copious amount of dilute urine. In that environment, it's more difficult for stones to form if you drink a lot of fluid and stay well hydrated. So, we spell those goals out for you. There are certain dietary things that you need to restrict in your diet if you have kidney stones. You should restrict your sodium intake. Calcium follows sodium through your body. So, if you take in excess sodium and your kidneys have to excrete it in your urine – guess what it’s going to pull with it? It’s going to pull calcium with it. That’s going to increase your risk of stone formation.
There's another substance in a lot of leafy green vegetables like rutabagas and cabbage and spinach called oxalate. Nuts are also high in oxalate. A high oxalate intake in your diet is going to increase your risk of kidney stones so you want to reduce those foods in your diet. There’s another substance in the diet like citrate – you get this in citrus fruits like grapefruit, oranges, lemons, limes. If you can increase your citrate level perhaps by putting lemon juice in all of your water, then that will actually decrease your risk of stone formation, but in some patients we actually prescribe them citrate medication that they can take to reduce the risk of stone formation.

Melanie: What great information, Dr. Johnson. So, wrap it up for us. What would you like people to know about kidney stones and reducing their risk of developing them?

Dr. Johnson: The most important thing is hydration. I tell people when they urinate they should pay attention to the color of their urine. The well-hydrated person – the urine will almost be colorless – it’ll almost be clear. If your urine has the consistency or color of apple juice or certainly tea, you are way behind on your hydration, and you need to really, really drink more fluids. You need to try to avoid salt. Don’t add any salt to your foods. You have to be aware that processed foods and restaurant-prepared foods are usually extremely high in sodium. If you have an app on your phone or a way to track your daily sodium intake, you should really limit that to about 3,000 milligrams of salt daily. That sounds like a lot, but you really reach that very quickly, and American diets are very high in sodium content, so you should try to cut that down to below 3,000. Protein can also increase your risk of stones and so if you wanted to count your calories and the amount of protein that you take in daily, about 1.3 grams per kilogram of protein daily is the limit for kidney stone prevention. You want to try to hold the protein intake down and make sure it does not exceed 1.3 grams per kilogram daily. So, those are some finer points of stone prevention that we give patients if they want to be really proactive and lower their risk of kidney stones.

Melanie: And why should they come to Texoma Medical Center for their care? Tell us a little bit about your team.

Dr. Johnson: Dr. Ruddell and I have been here for probably a combination of over 25 years. I trained at UTMB in Galveston. Dr. Ruddell trained at Scott & White in Temple. These are two of the premiere urology programs in Texas. The two of us combined probably do between three and four hundred stone cases a year. We are fully equipped and fully trained with the most modern surgical instruments, most modern surgical techniques, and also importantly is our imaging capability – our imaging capabilities with CAT scans to look at kidney stones in the emergency room and the type of x-ray imaging that we use in the operating room when we perform surgical procedures. They are state of the art, but there literally is no form of kidney stone surgery that we are not trained and equipped to perform at Texoma Medical Center.

Melanie: Thank you so much, Dr. Johnson, for being with us today. You're listening to TMC Health Talk with Texoma Medical Center. For more information, you can go to texomamedicalcenter.net. That's texomamedicalcenter.net. Physicians are independent practitioners who are not employees or agents of Texoma Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks so much for listening.