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Kidney Stones: Prevention and Treatment for a Painful Condition

Carmin Kalorin, MD, discusses why kidney stones form, ways to minimize your risk, how to differentiate kidney stone pain from other conditions, and treatment options.
Kidney Stones: Prevention and Treatment for a Painful Condition
Featured Speaker:
Carmin Kalorin, MD
Dr. Kalorin earned his undergraduate degree from Emory University in Atlanta, GA. He attended medical school at Albany Medical College in Albany, NY. His internship was completed at the United States Naval Medical Center (Balboa Hospital) in San Diego, CA. He served in the US Navy as a Flight Surgeon in California, Florida, and Jacksonville, NC. He completed his residency in Urology at Albany Medical Center. 

Learn more about Carmin Kalorin, MD
Transcription:
Kidney Stones: Prevention and Treatment for a Painful Condition

Prakash Chandran (Host):  Each year more than half a million people go to the emergency room for kidney stone problems. But what exactly are kidney stones? How do you know if you have them? And what do you need to know about this painful condition? We’re going to talk about it today with Dr. Carmin Kalorin, a Urologist at WakeMed Health and Hospitals.

This is WakeMed Voices, the podcast from WakeMed Health and Hospitals. I’m Prakash Chandran. So, first of all Dr. Kalorin, tell us what exactly are kidney stones.

Carmin Kalorin, MD (Guest):  Sure. Kidney stones are crystallizations of the different molecules that inevitably wind up in our urine. So, your kidneys filter your blood and they make urine and we wind up with different molecules in there. And if you think of your kidneys like a swimming pool and there are 20 people inside that pool; if the pool is getting smaller, inevitably those people are going to bump into each other. And if you think of those people as molecules; some of those molecules will bump into each other and they’ll stick, and they will crystalize. It’s like making rock candy. And when they crystallize crystals like to stick to other crystals and the next thing you know, you have got a big crystal that turns into a rock and that’s a kidney stone.

Host:  I absolutely love the pool metaphor. But as those molecules or people get closer and closer together; what factors actually contribute to them crystallizing and becoming stones?

Dr. Kalorin:  Well that’s the thing. What makes that swimming pool shrink? If it’s your kidney; the pool is going to shrink when you produce less urine and that’s the number one cause no matter where you live, no matter where you are or what your genetics are; the number one cause is low urine volume. So, basically dehydration. And people ask me all the time, how much should I be drinking in order to avoid kidney stones. And I say well, it’s really how much urine you should be producing because you want to keep that pool nice and roomy for all those molecules. And if you look at the studies; every study that’s been done on kidney stones shows that two liters of urine production per 24 hours is the break point. So, you want to keep your urine production above two liters.

So, people naturally ask me, okay doctor, how much should I drink in order to make two liters of urine and my answer is, well, it’s at least two liters going in you and usually more. Because all of us sweat, all of us metabolize water and any time you sweat, and fluid leaves your body and doesn’t wind up in your kidneys; that’s your swimming pool getting smaller. So, I tell people who have got a history of stones you want to drink at least two and a half to three liters of water per day to keep your kidneys nice and hydrated. If you don’t have a history; if you are producing two liters a day; you are doing better than most people.

Host:  Yeah, that’s quite a bit of water and I know for a fact that we’re not taking in or the majority of us are not taking in two and a half liters of water a day. So, do you have any recommendations around the best ways to do that, like do you have like a certain schedule that you like patients to follow?

Dr. Kalorin:  Yeah. I tell them to break it down. People get a little overwhelmed when you tell them that because they picture a giant two liter bottle of soda or something like that. I say think about it. if you start your day with one of those little 16. Something ounce bottle of water that you get at a convenience store or gas station. That’s basically half a liter. So, if you drink one of those in the morning, you get two midday and you drink one in the evening. You just drank two liters of water. And then there’s water in other things that we consume throughout the day. So, then you get a little bit extra doing that. So, if you break it down and you think about it, it becomes a little bit less formidable and that’s what I tell my patients to do is just kind of drink it throughout the day but just picture those four different bottles of water. I mean anyone of us can just chug ones of those pretty quickly and if you start your day like that, you have already got one of those four that you need down and you just get three more in you throughout the rest of the day.

Host:  Okay, so let’s say someone isn’t listening to this advice and drinking lots of water; and they start experiencing some of the symptoms of kidney stones, can you describe what they might be going through?

Dr. Kalorin:  So, the most common presentation is pain and stones cause pain when they block the flow of urine. So, I tell this to my patients all the time. I could have ten stones in my kidneys right now and I wouldn’t know it. Because there’s plenty of room inside a kidney for urine to flow around it and then down the ureter and then into your bladder. And that’s a normal state. But as soon as one of those stones breaks loose in the hollow part of your kidney; there’s only one outlet tube and that tube leads down to your bladder, that’s your ureter. As soon as one of those stones breaks loose and gets stuck, it’s going to start to hurt. Because the ureter typically will be pushing – it’s a conveyor belt of muscle if you will. It’s not just an open drain pipe.

And when a stone gets stuck in there, the ureter is not used to pushing a rock. It’s used to pushing fluid, urine, so it spasms. And when that ureter starts to spasm, that’s when the pain kicks in. Typically it’s flank pain, so it’s pain on your side, relatively high up. Most people think your kidneys are down low, but they’re actually relatively high on your back and they start – it starts with pain there and that pain wraps around to the front and then goes down towards the bladder, towards your groin, your lower abdomen. That’s the first thing that they experience.

The classic presentation of kidney stones and we teach this to medical students when we are trying to teach them how to assess patients with different types of pain. The classic thing about kidney stones is there is no comfortable position. So, if you threw out a muscle in your back; you move in a certain direction, it’s going to hurt. But if you stay still, it doesn’t hurt. Well kidney stones don’t care what position you are in. It’s an internal mechanism. It’s an internal muscle that is spasming so you can’t find a comfortable position. And people kind of wriggle around and they try to find a comfortable position and they just can’t find one and nothing makes it better, nothing makes it worse. It’s just there. And it comes in waves but there is nothing you can do from a positional standpoint to make it get any better.

That’s the first thing that happens. A lot of patients also get nauseous. The nausea is not necessarily from the pain. So, when I ask my medical students – we go to the emergency room and we are assessing a patient who has a kidney stone and the patient is in a lot of pain, but they are also throwing up. I’ll ask a new medical student why are these kidney stone patients always throwing up? And they will say well it’s from the pain. And I’ll say okay. A couple of months ago, I was building something in my garage with my son and I smashed my thumb with a hammer and I literally invented new curse words, I was in so much pain. But I did not throw up. I never puked.

So, it’s not necessarily pain that makes us throw up with a kidney stone. It’s the blockage of the flow of urine again because that pressure will eventually back up and make the kidney stretch. Remember the kidney is trying to make urine and push it down the tube into your bladder. And when that kidney can’t do that, it will stretch like a balloon and the kidney hates that and it will fire these nerves that go to kidney and those nerves go to a little relay station that goes to your stomach and it slows it down. That’s a little idiosyncrasy of the kidney’s nerve supply and it slows your stomach and it makes you nauseous until eventually you throw up.

So, that’s how I tell people you can differentiate stones from other types of back pain. For example, some of my patients have had spine surgery in the past and they say well doc, I always have back pain. How do I know if it’s a kidney stone versus back pain? I say well the nausea is usually the differentiating factor and the lack of ability to find a comfortable position. If you have got those two things; I got flank pain radiating towards my abdomen, my lower belly and I’m nauseous; you have got to think kidney stone. So, those are the two main things. If you see blood in your urine, that’s always an attention getter. It’s kind of shocking people pee, and they are going to go get checked no matter what even if they are not having pain because that’s scary when you see blood in your urine. But a lot of patients don’t have it right away. They just have the pain and the nausea. So, that’s when you want to think kidney stones.

Host:  Yeah, wow. And obviously, you need to remove that blockage somehow. So, I’m curious as to what you need to do. So, say you are experiencing this pain, you identify, you know what, I might have a kidney stone. I can’t get in a comfortable position. I’m in excruciating pain. How do people first get this diagnosed? I imagine that they go to the emergency room and then finally what are the treatment options available to them?

Dr. Kalorin:  Most people will go to the emergency room when their pain is not getting better. This is the main reason why we at WakeMed have formed a Kidney Stone Center. So, we actually have a hotline and anyone, you don’t have to necessarily be a patient in our practice but if you suspect that you have kidney stones and you are having pain that I just described; you can actually call out hotline. It’s 919-350-ROCK, R-O-C-K. someone answers that 24/7. You tell them your symptoms and your story and if one of our locations is available to get you in immediately, meaning it’s relatively normal working hours, we are going to get you in to see one us without you having to go to the emergency department. We can give you pain medicine. We can get x-rays. We can get a CAT scan. And we can make the diagnosis or diagnose you with what you actually have if it’s not a kidney stone.

We’re working on having that ability to have patients come in on the 24/7 basis but we’re not quite there yet. So, in that case, if your pain is not controllable and we’re suspicious that you have a stone; we are going to guide you into the emergency department where we’re going to meet you there and the best test is a CAT scan of your abdomen. It has 99.9% accuracy for stones. Obviously, we will check your urine to see if there’s blood in it even if you can’t see it. But if you’ve got a little bit of blood in your urine under the microscope and you’ve got the symptoms consistent with a kidney stone; we’re going to get a CAT scan on you. We might start with a regular x-ray or an ultrasound. But the most accurate diagnostic test is a CAT scan.

So, if the scan shows that there is a stone; the main thing we want to know is how big is that stone, how much obstruction of your kidney is there and is it a size that is likely passable. And it all breaks down to size and statistics. So, if you’ve got a 5 millimeter stone, there’s a 50-50 chance that you are going to pass it. And that’s the best case scenario. Yes, it will be uncomfortable. We can give you pain medicine. We can give you medicine that actually helps you pass stones and there are medicines that relax that tube, that ureter to help give it a little bit more room for that stone to get down into your bladder so that you can then urinate it out.

So, we give you pain medicine. We’ll give you some nausea medicine. And we’ll give you some medicine to help you pass the stone and if you’re comfortable, then we’ll let you go home and try and pass the stone with a follow up appointment to see us. If it’s too big to pass; stones bigger than 5 millimeters, 6 millimeter stone has a 40% chance you’ll pass it, 7 millimeter stone 30%, 8 millimeter 20% and it obviously goes down. So I never say zero. I saw a little old lady who one time passed a 15 millimeter stone which is 1.5 centimeters. Pretty impressive and she passed it. and she reminded me that I told her it was highly unlikely she would pass it and she showed it to me. But the likelihood goes down as the stone size goes up. So, if we determine it’s a stone that is highly unlikely to pass; then we are going to offer you treatment right there.

And the treatments range from shocking the stone which isn’t removing it. we can do shock was lithotripsy where we apply shock wave energy. In the olden days which weren’t that long ago; 25-30 years ago; people got into a water bath because it would amplify the shock waves. And you basically – it almost vibrates the stone if you will until it breaks into smaller pieces and then you go from one big stone to a couple of smaller stones that are passable size. We put you on those medicines and we let you try and pass it.

Alternative to that, is we go to the operating room, but we don’t cut people open for kidney stones anymore. It’s been 40-50 years since people did that. We go in with little tiny flexible fiberoptic scopes into the urinary system, into the bladder while they are asleep and we can thread that fiberoptic scope up the tube, up the ureter until we can physically see the stone and we pass a little laser fiber through the scope and we break it into smaller pieces and then we can remove the laser fiber and put a micro-basket in and we can actually grab those pieces and extract them. So, some people want to take the chance of shocking the stone and passing the pieces. That’s got about an 85% success rate. Because some people the pieces get stuck together and they don’t want to pass and then some people want to say I just want to be done with it. I want to know the pieces are gone. I want to know the stone is gone. So, they’ll say go ahead and do the ureteroscopy and laser it and I’ll deal with the discomfort from the stent for a few days afterwards.

Host:  All right Dr. Kalorin, well we really appreciate this comprehensive explanation and it is really good to know that there are so many different treatment options to help you if you are experiencing this. but I think the big takeaway here is drink lots of water and citrus water if you can to keep that swimming pool nice and big. So, that’s Dr. Carmin Kalorin, a Urologist at WakeMed Health and Hospitals. Thanks for checking out this episode of WakeMed Voices. Visit www.wakemed.org/kidney-stone-center to learn more about the services and treatment options we offer to people suffering with kidney stones or call 919-350-ROCK to get diagnosed.

If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. I’m Prakash Chandran with WakeMed Voices brought to you by WakeMed Health and Hospitals in Raleigh, North Carolina. Thanks and we’ll see you next time.