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Rocky Business: Why Kidney Stones Form — and How to Treat Them · Meaningful Medicine with Novant Health

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  Carl Maronich (Host): This is Meaningful Medicine, a Novant Health podcast bringing
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  you access to leading doctors who answer questions they wish you would ask.
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  I'm your host, Carl Maronich.
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  And with me today is Dr.
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  Michael Perttunen, a urologist with Novant Health.
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  And we're going to be talking about kidney stones, what they are, how they
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  develop, how they're treated and maybe, most importantly, how to prevent them.
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  Doctor, welcome to the podcast.
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  Michael Perttunen, MD: Hey, Carl.
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  Thanks for having me.
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  It's a pleasure to be here.
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  Host: Yeah.
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  Well, we're glad to have you.
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  And let's start maybe with the basics and talk about just what a kidney stone is
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  and what causes them in the first place.
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  Michael Perttunen, MD: Yes, sir.
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  So, kidney stones or nephrolithiasis, as we like to call it, to make it
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  sound more complicated, they're just small, hard mineral deposits
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  that you find in your kidneys.
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  They typically happen when your urine becomes what we call supersaturated
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  with certain substances, and then you can have crystal growth in your
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  urine leading to kidney stones.
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  The most common type is calcium oxalate.
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  That's up to about 80% of the stones, and there's a few other types, but
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  that's kind of the heavy hitter.
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  Host: Often you hear that hydration is an effective way to prevent kidney stones.
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  How much water should somebody realistically be trying to drink in a day?
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  Michael Perttunen, MD: So, it's not so much about how much you're
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  trying to drink, it's about how much you need to pee, right?
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  So if you're out and working in the hot sun, you're going to have
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  to drink more to stay hydrated.
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  Our goal is to about two and a half liters of urine a day.
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  That's a lot of pee.
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  I don't make that much pee in a day, but I always tell my patients to.
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  So usually, you have to drink about 84 to 100 ounces of fluid at least per day.
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  Host: Do all fluids count or is really water the main thing
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  that you want to be taking in?
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  Michael Perttunen, MD: Water is best, especially if you can incorporate a
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  little bit of lemon or lime juice in the water, particularly lemon juice.
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  I prefer any fluid over no fluid, but water's preferred.
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  Things like tea and dark sodas can always contribute to stones,
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  but it's better than nothing.
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  Host: Are there certain types of food, or you just mentioned some beverages
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  that can increase the risk of kidney stones and, you know, what should most
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  people kind of be wary of in that regard?
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  Michael Perttunen, MD: Yeah.
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  So, there definitely are some foods and drinks that can
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  contribute to stone formation.
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  Particularly if you look up online what a stone diet is, it's
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  all about limiting your oxalate intake, which is a stone compound.
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  You'll find these things in things that you may think are particularly
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  healthy like spinach, rhubarb, nuts.
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  So, I actually tend to try to stay away from the stone diet because of that,
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  because you're going to be left scratching your head not knowing what you can eat.
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  So in general, I tell people to, you know, a heart-healthy diet,
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  lots of fresh fruits and vegetables.
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  That's kind of the basic tips I tell people.
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  Host: High protein seems to be the healthy way to go, but is there a link between
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  some protein intake and kidney stone risk?
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  Michael Perttunen, MD: Correct.
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  Yeah.
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  So, animal-based protein is worse than plant-based protein.
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  So, we generally tell people try to limit their animal intake, their
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  animal protein intake, so beef, pork, chicken, fish, and try to
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  incorporate a more plant-based diet.
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  Host: Does hereditary or genetics play a role in the development of kidney stones?
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  And if someone has a family history, what should they be looking to do or not to do?
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  Michael Perttunen, MD: So, genetics can increase the risk of stones, but it is
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  not going to guarantee you get stones.
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  And so they've done actually some studies on twins, and they found
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  that about the heritability of kidney stones is about 45% to 60%.
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  But the main thing is diet, hydration, and then other rare metabolic
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  conditions that you may inherit.
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  But those are pretty rare, few and far between
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  Host: Does age—you know, can young people develop kidney stones, or is it something
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  that mostly happens as we get older?
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  Michael Perttunen, MD: Oh, yes.
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  It can definitely happen in younger individuals, and it's actually happening
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  in the youth at an increasing rate.
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  So, I'm more commonly seeing like 19, 18, 20-year-olds with
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  kidney stones for the first time.
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  But usually, it does increase with age.
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  Host: What are they attributing that to?
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  Or have they figured that out yet?
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  Michael Perttunen, MD: Diet, diet and hydration status.
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  So, you know, Mountain Dew in particular is not great for, kidney
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  stones, and people just don't stay as hydrated as they used to.
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  Host: How should someone know when to seek medical treatment if they're
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  suspected they may have a kidney stone versus just trying to pass
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  the stone at home and give it time?
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  Michael Perttunen, MD: So if you're a first time stone former, if you have
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  a kidney stone, you're most likely going to seek care in the emergency
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  room just due to degree of pain, right?
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  But if you know what stones feel like and you've passed them before,
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  kind of the warning signs that may indicate you need something done
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  urgently, the main one's fever.
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  So if you have a fever greater than 100.4
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  degrees Fahrenheit, you need to be evaluated emergently.
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  Otherwise, you can get pretty sick and septic from it.
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  Otherwise, if you can't tolerate the pain, you need to go to the emergency room.
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  Or if you can't eat or drink anything, because of the pain, you need to
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  go to the emergency room, right?
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  There are a few other rare cases, like if you have stones on both sides blocking
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  both kidneys, that's an emergency.
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  Or for one reason, you only have one kidney and that kidney's blocked with
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  a stone, that's also an emergency.
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  Host: Let's talk a little about treatment.
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  What are the various treatment options and how do you as a doctor
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  decide which approach you're going to use for which patient?
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  Michael Perttunen, MD: Good question, right?
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  So, there are a few different treatment options here.
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  The mainstay that we always prefer is called medical expulsive therapy.
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  Essentially, that means we allow you to try to pass the stone, right?
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  So, you drink plenty of fluids, pain control, and then we give
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  you a medication called Flomax that helps you pass the stone.
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  That can take four to six weeks to actually occur.
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  So, I mean, your pain has to be controlled for those four to six
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  weeks to undergo a trial of passage.
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  Additionally, you know, that needs to be a ureteral stone.
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  So, not sitting up in the kidney, not causing issues, but blocking
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  the tube, draining your kidney.
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  And in general, it needs to be less than 10 millimeters in diameter
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  to consider to be passable.
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  Anything bigger than that, you're looking at some sort of intervention.
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  So when it comes to interventions, we do have a few different options.
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  One is called extracorporeal shock wave lithotripsy.
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  That's where we essentially blast the stone from the outside
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  with a high-powered ultrasound.
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  So, there's no cuts in your body, no cameras in anywhere.
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  It's outpatient surgery.
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  You go home the same day.
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  Recovery's pretty good.
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  The one caveat to that is it needs to be visible on X-ray, because not all stones
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  are visible on X-ray, and then also needs to be in the right size and location.
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  If you start getting too big, like greater than 1.5,
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  2 centimeter stones, not a great option for shockwave.
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  The main workhorse for stone disease is called ureteroscopy.
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  So, that involves a small telescopic camera that goes up your pee channel,
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  and then we go and find the stone.
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  If it's small enough, we just remove it with a basket.
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  If it's big, we need to use a laser, break it up into smaller
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  fragments, get those fragments out.
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  And the most invasive option we have is called the PCNL, which is
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  a percutaneous nephrolithotomy.
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  We typically use this for large stones in the kidney, so greater than
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  1 centimeter, if not 2 centimeters.
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  And this involves putting a larger camera through the back directly into
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  the kidney, through the meat of the kidney, and using essentially a jackhammer
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  to break up the stones that way.
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  It is very effective.
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  It is quick at, you know, dissolving or getting rid of large
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  stones, but it is more invasive.
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  You're in the hospital for one night usually.
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  You do have a tube coming out of your back for a day or so.
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  So, we kinda reserve that for larger, more problematic stones.
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  If you're going to have something done, typically it's either you're passing
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  the stone, you're getting a shock from the outside, or I'm going up with
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  a camera and a laser to get it out.
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  Host: For someone who has had a kidney stone, what long-term strategies do
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  you recommend to prevent future stones?
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  Michael Perttunen, MD: So again, the biggest thing is hydration,
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  aiming for about two and a half liters of urine a day.
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  That can help limit stone formation in the future.
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  Also, having a low sodium diet.
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  So, less than 2 grams of sodium a day is what we recommend to help prevent stones.
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  That's also what the, I think, American Heart Association
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  recommends for a heart-healthy diet.
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  There used to be a thought that you need to limit your calcium intake.
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  That's actually not true.
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  We recommend normal calcium intake of about a gram.
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  Then you have to limit, you need to try to limit your oxalate-rich
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  foods, which is what I was talking about before with the stone diet.
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  But I usually just tell people a heart-healthy diet with lots
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  of fresh fruits and vegetables.
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  And then, limiting your non-dairy protein, so animal-based proteins There's also
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  something we can do called a 24-hour urine study where you pee into a jug for a full
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  day, breaks down all the metabolites in your urine, the volume of your urine.
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  You do a little bit of blood work with it, and it kind of tells us
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  exactly why you're forming stones.
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  And so, we can generally help tailor a diet or medications
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  to help prevent stones.
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  Probably about 95% of the time what we end up telling people is you're not drinking
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  enough and you need to incorporate some citrus fruit into your diet.
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  Host: Now, the test you mentioned, that's really for folks who have had a stone and
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  what they might do with it going forward.
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  Somebody who's never had a stone wouldn't go through something like that.
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  Michael Perttunen, MD: Correct.
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  No, This is really for the repeat stone formers.
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  And so, the way I was trained, the way I do it, I give everybody a freebie.
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  You get one free stone before we start talking about doing an expensive workup.
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  After that first stone, if it keeps recurring, then we'll consider doing
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  some more, you know, non-invasive testing, but it is a handful for patients
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  to pee into a jug for a full day.
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  Host: Earlier, Doctor, you mentioned you're seeing younger patients, an
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  increasing number of younger patients.
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  Is that also true all the population?
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  You're just seeing more patients with stones these days?
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  Michael Perttunen, MD: The prevalence is definitely increasing.
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  I think a lot of it has to do with climate.
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  You know, the more dehydrated you are, the higher risk of stones you have, right?
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  And so, especially here in the South, we actually live in the
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  Stone Belt, is what we call it.
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  It aligns with roughly the Bible Belt in America, just because
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  it's the South and it's hot.
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  But yeah, you see a lot of stones in the South where heat is a major factor.
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  Host: Well, doctor, before we let you go, what final words of advice would you give
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  folks when it comes to kidney stones?
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  And I think I know what they're going to be, but I'll let you deliver it.
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  Michael Perttunen, MD: Drink more water and try to incorporate some citrus fruit.
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  Host: Dr.
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  Perttunen, thanks so much for being with us and sharing your expertise today.
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  Michael Perttunen, MD: No problem.
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  It was my pleasure.
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  Happy to be here anytime.
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  If you have any four more questions, feel free to reach out
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  to me and I'm happy to reach out.
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  Host: And to find a physician, visit novanthealth.org.
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  And for more health and wellness information from our experts,
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  visit healthyheadlines.org.
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  If you enjoyed this podcast, please share it on your social channels and check out
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  the entire Meaningful Medicine library for topics that may matter to you.
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  And this is Meaningful Medicine.
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  Thanks for listening.