Urological

This episode is an announcement that this podcast is set to close at the end of this month, August 2023. Thank you so much for listening to these episodes of Urological and to my previous episodes from the Why Urology podcast here on this feed.  You still have time to go back to relisten to or save the episodes you really enjoyed or found particularly helpful.  Thank you so much for listening. Be well and do good.

Thank you for listening to this episode of Urological.   

This podcast is an open ended conversation of ideas and topics that center around the practice of medicine and the field of urology.  Recently, one of my younger partners asked me the following question, “Todd, do you have a spot?” IHere is a quote from Stephen King.  “It starts with this: put your desk in the corner, and every time you sit down there to write, remind yourself why it isn't in the middle of the room. Life isn't a support system for art. It's the other way around.” I love my spot at a small desk in the corner of my screen porch. I cherish the time I get to spend here. As an introvert this quiet time fills me. Having a spot is critical to our lives if we are professionals, We need places to be quiet, to think, and to work to solve the world’s problems and even some of our own. Life does not exist to support our art. Its the other way around.  As physicians our “art” is medicine.  Life does not exist to support our practice of medicine. It's the other way around. Our practice of medicine exists to support our lives.        

In this podcast we explore topics and ideas center around the practice of urology and the field of medicine. I am a urologist based in Woodbury and St Paul MN.   Patients ask me all of the time if anything is “new” since their last visit as they try to figure out what options they have as they consider treatment for whatever condition ails them. This is a challenging question because something is always “new.” There is always innovation, ideas, and new iterations. Change is constant. The reason this is top of mind for me is because within the last couple of weeks my partners and I have been exploring and discussing opportunities to innovate within our practice, as well as seeing some significant changes outside of our practice in our local medical community that have the potential to significantly change the way we practice. And I have lost a lot of sleep because of the expected changes. I am concerned that some of the ideas I have heard are a bit too much, impractical if not damaging to our practice if not executed or navigated properly.  There are only two responses to innovation, ideas, and iterations. The first response is to be skeptical, to find the fault in the ideas and to figure out all of the holes in the idea and to determine all of the ways in which the idea doesn’t work. The second opposite response is to look at a half baked idea and to say, “Maybe there is something here” and then to build it despite its imperfections I wonder which of the two I am, a skeptic or a dreamer. The reason I have been thinking about this is that I have spent a fair amount of time this past couple of weeks shaking my head, skeptical of ideas, concerned about radical change, I see and essentially asking over and over again, “Why? why, why, why?” I am afraid that as an older physician, one who views myself as starting the last phase of my career, I am too resistant to change, and afraid of the new, the bold, and the crazy. But I think I should still be dreaming, to see the things that never were and ask, “why not?”  

In this episode, we will be  talking about kidney stone prevention and a very common problem for kidney stone formers, idiopathic hypercalciuria, or having too much calcium in the urine but otherwise normal body calcium metabolism.  This condition is often referred to as renal-leak hypercalciuria.  Calcium is one of the most important minerals in the body. The average adult body contains in total approximately 1 kg of calcium, 99% of which is stored in our bones and teeth.  In our bloodstream calcium also has many regulatory functions. Calcium enables our blood to clot, our muscles to contract, and our hearts to beat. Because calcium is a mineral that is so necessary for life our bodies regulate its metabolism very closely. The system monitoring calcium balance in the body is elaborate and our bodies sense when there is too little or too much calcium in the blood and will work hard to restore balance. Our bodies cannot produce its own calcium. We get our calcium from our food. When we don’t get the calcium our bodies need in our diets, calcium is taken from our bones if our bodies need to maintain calcium balance. A lack of calcium in the diet, or disorders of calcium metabolism, can lead to osteopenia and osteoporosis. What is adequate calcium? Around 800mg-1200mg of calcium is adequate for most healthy, active men and women. Calcium supplementation is used for patients with bone loss or at risk for osteopenia or osteoporosis.   Because calcium is so important in our bodies our kidneys hold on to as much calcium.  That’s a good thing that our kidneys work to resorb the filtered calcium because elevated levels of calcium in the urine can lead to kidney stones.  Calcium readily binds to other minerals in the urine, combining with oxalate and phosphate to produce the common calcium oxalate or calcium phosphate stones. Calcium oxalate stones form the most common form of kidney stones. 80-85% percent of kidney stones are calcium-based. People with normal kidney function lose very little calcium in the urine, less than 150 mg a day, as measured by 24 urine collection. But in kidney stone formers a common finding on 24-hour urine collections is hypercalciuria, higher than normal calcium excretion. A person’s risk of forming kidney stones increases as the calcium levels in the urine rise.  There are a number of reasons there may be too much calcium in the urine but the most common one is idiopathic hypercalciuria. Idiopathic Hypercalciuria is not a disease per se, it is a condition and a risk factor for other diseases, kidney stones being one of them, but also long term, osteopenia and osteoporosis.  No red line determines when a patient has or needs treatment for Idiopathic Hypercalciuria. We know that values above 200mg of calcium excretion for 24 hour is a risk factor for kidney stones but historically we have used cutoffs slightly higher for patients to determine when to start or use medication, as high as 250 mg/day for women and 300 mg/day in men. Often simple dietary changes can be enough to lower kidney stone recurrence risk in patients with only a slightly increased level of calcium in the urine. Increasing fluid intake, moderating salt, animal protein and oxalate consumption, focusing on adding fresh fruits and vegetables and adding Lemonade (often in the form of Crystal Light to decrease sugar load), orange juice or even Lemon juice to increase citrate in the urine may be all a patient needs to help prevent stone formation.  If dietary changes are not effective, however, or if the calcium excretion is very high, then medication is advised. Medication to treat idiopathic hypercalciuria to prevent kidney stones is an ongoing medication, one that is needed indefinitely. The most common medication used for idiopathic hypercalciuria is a class of medications called thiazide diuretics, but another diuretic call indapamide can also be used.   Chlorthalidone is the most commonly used thiazide diuretic because of its long half life but hydrochlorothiazide is effective as well. Thiazide diuretics decrease the calcium levels in the urine. Dose adjustment, increasing or decreasing the dose, is done according to results on 24-hr urine testing. Repeat 24 hour urine test are needed initially to see if the medication is effective but also on an ongoing basis because some kidneys become tolerant to the medication. A short vacation from the diuretic often resets the body and resets the medication’s effects. Thiazide diuretics can have side effects. Thiazide diuretics can be potassium wasting and cause low potassium levels in the blood. A plant based diet or increasing fruits and vegetables in the diet (I joke that I’m a fan a the banana) can increase the potassium in your diet but some patients taking the medication will need to take potassium supplements, either in the form of potassium pills or in some kidney stone formers,  Potassium Citrate. Potassium Citrate has the advantage of not only preventing hypokalemia (low potassium levels) but also increasing urinary citrate excretion.  So there you have it. Some of us have too much calcium in our urine leading to an increased risk of kidney stones as well as other conditions. For some kidney stone formers a simple diet change will be enough to offset the risk of a slightly increased amount of calcium, but for other people with very high levels of calcium in the urine medication may be needed.