Preventing A New Stone Age

Image: Amanda Camp for Doximity

Kidney stones are common. Even if you have not experienced them yourself, there is a good chance the pain of kidney stones has afflicted someone you know. The agony and misery associated with stone passage is widely recognized; yet, for all of the morbidity and turmoil a stone event can cause, stone disease itself rarely receives the attention it deserves. As a result, kidney stone disease is poised to become a public health epidemic.

Most people don’t think they are at risk for forming kidney stones, but over the past 20 years, the likelihood of suffering from a stone in the United States nearly doubled from 1 in 20 to 1 in 11. The exact cause for this rise remains unclear. Changing diets, larger waistlines, and rising temperatures have all been blamed. Even those who have had the misfortune of experiencing a stone event often don’t appreciate the high likelihood for another one. In fact, half of stone formers will experience another event within 35 years. Nonetheless, interest in trying to figure out why a stone has formed in the first place and what can be done to prevent another one usually diminishes the moment it is no longer causing symptoms.

Prevention is often not considered in kidney stone disease because the emergency room has become the focal point for stone management. The goals of stone care in the ER are entirely focused on the acute aspects of kidney stone disease such as controlling pain, managing nausea, and facilitating stone passage. The long term aspects of the condition, which include strategizing prevention and managing the disease when it is not acutely symptomatic, are largely ignored. This might not be a problem if patients ultimately have the chance to discuss these parts of the disease process at a later date, but that chance often does not occur. In fact, a study published this past year from the University of California San Francisco found that only 30% of patients seen in the ER for a stone were ultimately seen by a urologist. Sadly, even proper follow-up does not ensure preventative efforts against stones as studies have shown that fewer than 10% of those at the highest risk of stone formation undergo a preventative workup.

Another problem with stone management is that kidney stones are frequently ignored in the absence of symptoms. Stones have become so common that occasionally patients are not even informed of their presence when identified on CT scans performed for unrelated reasons. This is dangerous as most patients with asymptomatic stones will ultimately experience stone related events. Early consultation with a urologist can be useful in working on prevention strategies, providing education regarding potential problems, and establishing appropriate follow-up as opposed to turning a blind eye and playing the odds in hopes that the stone does not cause future problems.

Finally, urologists themselves are well suited to decrease the likelihood of recurrent stone events. Historically, success in stone treatment, whether it be shock wave lithotripsy, ureteroscopy, or percutaneous nephrolithotomy, has been measured based on the removal of a symptomatic stone. However, there is increasing awareness that stones left behind at the time of surgery have high potential to become symptomatic at a later date. As such, it is time to adjust our expectations and strive to remove all stones at the time of a given procedure, in turn providing the patient the highest likelihood of freedom from subsequent stone events in the years to follow.

The future of stone management in the United States is concerning, especially considering that as the number of patients affected by this condition continues to rise, access to urologists is projected to become more limited. Multidisciplinary efforts to help better identify, prevent, and manage stones are not only welcome but soon will be necessary if we hope to prevent the looming health crisis of a new stone age.

Michael Borofsky, MD is a urologist in Minneapolis, MN and a 2016-2017 Doximity Fellow.

This article first appeared in Doximity's Op-(m)ed, a collection of articles contributed by Doximity members. If you'd like to contribute an original article for consideration for Op-(m)ed, please email opmed@doximity.com.

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