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Scott Webb: Kidney stones can be painful. And if they don't pass and are left untreated, we can develop sepsis and that can be deadly. The good news is that they often pass on their own and, when they don't, there are minimally invasive surgical options to help remove them. And joining me today to help us understand kidney stones and how we can prevent them is Dr. Joseph Dankoff. He's a physician with the Summa Health Urology Medical Group.

This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Doctor, thanks so much for your time today. I know you just got out of surgery, so I appreciate it. What are kidney stones and what causes them?

Dr. Joseph Dankoff: Well, I could certainly win the Nobel prize if I could tell you absolutely what causes kidney stones. The kidneys filter a lot of poisons out of our system and the poisons go down into your bladder and you expel it to the outside world. And if calcification and other products clump together and don't let the river of urine flow normally from the kidneys out to the bladder, then those clumping, those stones will cause blockage inside the urinary tract and that's what causes pain that people perceive.

There's different kinds and what causes them. We don't know exactly the reasons. We have things that people do that puts them more at likelihood for getting stones, but we don't know absolutely what's going to be able to predict one person having a stone versus another.

Scott Webb: So that's a good baseline to start with and are some people at greater risk for kidney stones? Is family history, lifestyle somewhere in the middle there?

Dr. Joseph Dankoff: Absolutely. Those are very important factors. So family history, it's not a genetic disorder where if the parents get it, the kids are definitely going to get it, but it does raise a person's risk higher than the average person walking down the street. And there are certain stone types that children, for example, are more likely to get and those do tend to have a genetic basis. So as a general rule, if children start forming kidney stones, then we really have to start looking into there being some kind of a familial or genetic background to it.

Lifestyle, people that tend to do things that make them get dehydrated because the main factor with kidney stone formation is that the urine becomes concentrated and is not diluted enough to flush out those salts to the outside world. So people that have jobs that are out in the hot sun, people that have a variety of things that put them at risk for being dehydrated, people who have been through surgeries that put them at risk for being dehydrated, people who have medical conditions, things like inflammatory bowel disease, Crohn's disease or ulcerative colitis, where the person may have chronic diarrhea and be in a chronic state of partial dehydration all the time. Those people are at more risk of having stones.

Scott Webb: Okay. So hydration is key, obviously. Is there anything else that we can do to prevent stones?

Dr. Joseph Dankoff: When we're counseling people, when they ask, "What can I do to keep from forming stones?" and we do tests such as having them save all their urine for a full 24 hours, the most important factor is hydration. The most important factor is the volume of urine that a person makes in a 24 hour period. And people may tell us, "Oh, I drink a lot of water. I make a lot of urine," but then when we actually go and quantify it, they really aren't making as much urine as they think they are.

So hydration, no matter what the stones are made of, because, again, stones have different compositions, but all stones, no matter what they're made out of, are more likely to be soluble in the urinary tract the more water is there. It's trying to dissolve a sugar cube in a gallon of water versus a cup of water. The more water going through the kidneys, the more it's going to flush those salts way.

Other factors, just about everybody in the United States takes in more salt than they should. Salt acts as a magnet to hold on to calcium in the urinary tract. So another thing that we'll recommend is that people not eliminate salt completely from their diet, but to consciously think about the amount of processed food and the amount of heavily salted food and the amount of salt they add to their diet and to try and do things to reduce that as much as possible. Red animal protein in some people can be a factor and we have people think about their diet and are they having too much of that?

The most important thing is though, when people look on the internet to see, "Oh, what's the perfect solution?" And they see on some website, it says, "Oh, eat this and don't eat that. And you'll never make another kidney stone," A, I wish it was that simple. And, B, it's always different answers for different people. So when people ask What can they do, hydration, cutting back on salt. But the other thing is we'll do metabolic testing to figure out what's true for that particular person's metabolism and try to individualize the plan moving forward.

Scott Webb: Yeah. I've never had stones, but I've had them described to me. And I certainly seen them portrayed on television shows and movies, and it seems quite painful. So I'm assuming that's the common sign, the pain, and, as a part of your answer for that, how do you treat kidney stones?

Dr. Joseph Dankoff: Well, it depends on the size, the location and other factors that are playing into that person's past medical history. We had people come into the emergency department last night that got surgery today because of concerns of possible infection that is built upstream from where the stone is blocking things off, potentially putting the person at risk for sepsis, risk of the infection getting into their bloodstream. So those people would be promptly taken to the operating room versus if somebody is diagnosed with a stone.

And, yes, they're incredibly painful. I've had women who have gone through childbirth telling me they would prefer to have 10 babies than one more kidney stone. I had a lady tell me one time she would have rather delivered all of her children simultaneously rather than go through another kidney stone attack. So yes, it is incredibly painful. And that's what brings people to the emergency room usually. Sometimes the nausea that the stones create is the main factor that brings people in, the unrelenting nausea and vomiting.

So, if we can bring a person's symptoms under control in the emergency department and they're not showing any signs of impending sepsis, they're not showing any signs that their kidneys are being compromised because of the partial obstruction, we will give people a chance to try and pass the stone, depending on the size and how close from the kidney the stone has gotten to the person's bladder. But there are certain stones that aren't going to pass, and then we make arrangements to go in surgically and take care of those.

Scott Webb: Yeah. And you mentioned sepsis. My mom had a kidney infection and it nearly killed her. So I know how serious the consequences can be. And so when you talk about passing stones, what's your recommendation, your best recommendation on people? If they're pretty sure it's a kidney stone, should they stay home and try to pass the stone? Or would your advice to be to just go right to the emergency department?

Dr. Joseph Dankoff: Well, it depends if they've had a lot of stones before. A gentleman I operated on today has had stones over the last 20 years and he's had, you know, by his count probably 50 stones. He knew that this was a stone. Now, this one just didn't pass easily. So he came into the emergency department, but most of the other ones, he said he's able to pass. And he knows they're happening. And he'll give it a couple of days and it'll usually pass on its own. But if the person's pain or nausea isn't able to be brought under control or if they have never had one before and they're not exactly sure what it is, you know, then they need to have some imaging, some x-rays to determine if that's what it truly is.

You can partially obstruct the kidney for weeks and not cause any kind of permanent damage. So the analogy I'll use is that if a car is running and you pinch the tailpipe of the car, the exhaust won't come out the way it's supposed to. And if you do it long enough and pinch the tailpipe off severely enough, that exhaust is going to back up into the engine and cause the engine not to function right. But if you partially block it off, you can go for a while.

We'll usually give a rule of thumb four to six weeks and that's if the person's feeling perfectly fine. And we do an x-ray and we know the stone is still there, but the person is feeling perfectly fine. At some point, we are going to electively just want to get the stone out of there because if we leave it in there too many months, it can lead to long-term problems with obstruction.

We don't cut people open for stones nowadays. That's something that was done decades ago. Nowadays, we have scopes that go up through where the person urinates with the person of course asleep in the operating room, go to where the stone is, and then either deliver the stone to the outside world like delivering a baby or use a laser device and break the stone up to sand particles, which then can then be extracted out of the urinary tract.

Scott Webb: You mentioned a guy having 50 stones or thereabouts, are people more likely to get stones after they've had them the first time?

Dr. Joseph Dankoff: They are. Their risk is probably about a 50% chance over the next five years that they'll have another stone, which is why once the stone surgery is all done, they're all fully recovered, we'll see them back in the office when they're living happily ever after again, to try to figure out if there's any kind of underlying metabolic etiology for why the stone formed and what we can do moving forward so they don't make any more.

We have our standard recommendations as I mentioned before, increasing fluids, cutting back on salt, cutting back on animal protein. Lemonade is a very strong recommendation. There is a substance in lemonade made from real lemons that is inhibitory against stone formation. So we'll have people that we'll say, "Your summer drink is a pitcher of water and a couple of slices of real lemon in there and that's what you're going to drink all summer long. And try cutting back on the sugar on that."

So those are our standard recommendations, but then we'll do testing, blood tests and studies where they'll save all of their urine for a full 24-hour period, run it for very specific tests and look to see if we can come up with some kind of individualized metabolic pattern to see, based on the foods that people eat, is there something that we can offer some dietary restrictions that might lessen their risk of future stones?

Scott Webb: Doctor, this has been really educational today. You have a great way of explaining things. As we wrap up here, anything else you want to tell listeners about kidney stones?

Dr. Joseph Dankoff: They are more likely to happen in the summertime. When it tends to be warmer out, people get outside. And let's hope that this summer of 2021, people are going to be outside more and finally living our lives again. But people tend to be more active, tend to be outside and get more likely to become dehydrated and that's when stones are more likely to happen when the urine is more concentrated. Stones form at a greater likelihood in different parts of the country that are warmer than others. So those Southern parts, especially the Southwest parts of the United States, kidney stone formation is much greater incidence than it is at other parts of the country.

But the summertime tends to be our busy season with this. So as we're moving towards the summer months, we're going to have people just increasing their fluid intake, especially if they're going to be outside and hope we don't see them. They hope they don't see us.

Scott Webb: Absolutely. And I'm with you, doctor. I can't wait to get outside the summer, watch my daughter play softball, even if I have to wear a mask to do it. But I'll take your advice and stay hydrated. And thank you so much for your time. You stay well.

Dr. Joseph Dankoff: All right. You too. Take care. Thanks so much.

Scott Webb: Visit SummaHealth.org/urology for more information. And if you found this podcast helpful and informative, please share it on your social channels and be sure to check out the entire podcast library for additional topics of interest.

This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Stay well, and we'll talk again next time.

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