In stone disease, everything is measurements. What the laboratory cannot tell you, you will not know; what it tells you in error, you will not correct by using your instincts, your medical experience, or your art; what you take from the measurements directs your treatment. No expense is as unreasonable as years of misdirected treatment, as great as the cost of treating the urologic consequences of preventable stones."
--Fredric L. Coe, M.D.
If you haven't had a metabolic stone risk test usually consisting of a 24-hour urine collection and analysis, then you don't have a medical diagnosis for your kidney stone disease. What other disorder of the human body would a physician treat without a specific medical diagnosis? The success of new technological treatments, like lasers and extracorporeal shock wave lithotripsy has caused some physicians to suggest that evaluating blood and urine chemistry (metabolic testing) is no longer necessary. Adopting this argument is a terrible mistake. Without a diagnosis, there can be no specific medical preventive treatment for stone disease.
In no other branch of medicine would reasonable preventive measures take precedence over surgery. The surgical approach does not totally eliminate pain or affect the rate of stone recurrence. It's relatively expensive compared to the medical preventive approach, and there is always the risk of complications.
Finding the Cause Saves Health Care Costs
Kidney stone disease is a process which almost guarantees progression and recurrence unless the underlying cause is identified and eliminated. This can now be accomplished in virtually every case with appropriate chemical testing, often called metabolic testing, and specific preventive therapies. These preventive measures usually begin with specific dietary changes, with nutritional supplements and medications added as necessary to correct the underlying risk factors for future stone formation.
New advances in the field of blood and urinary chemical analysis and computerized evaluation of laboratory data have made it possible for any interested physician to offer his patients a state-of- the-art kidney stone prevention plan at a reasonable cost. Such a program can be expected to find at least one correctable or treatable risk factor in over 95 percent of patients. While on therapy, most patients will not develop any new stones and existing stones will take longer to grow and thus are more likely to pass spontaneously. Preventive therapy avoids the terrible pain of kidney stones called "colic." Unless you have experienced it yourself, it's almost impossible to describe the intensity of this particular type of pain.
Not all stones are easily removed or treated. An example might be cystine stones which are notoriously difficult to fragment or remove. Any significant reduction in stone formation in these patients would be of substantial benefit. Other patients at high risk would be those with a solitary kidney, renal transplant or any type of chronic diarrhea.
Avoiding Inappropriate Treatment and Preventing Unexpected Complications
Today, non-specific stone prevention advice, such as limiting dietary calcium in calcium stone disease, is no longer adequate. In other words, limiting dietary calcium can actually increase the patient's risk of calcium stone recurrence! Other problems are discussed in chapters throughout this book, including hyperparathyroidism, hypervitaminosis D, renal phosphate leak, problems with oxalate, citrate, magnesium, renal tubular acidosis and uric acid go undiagnosed and untreated unless comprehensive chemical studies are performed to identify them.
The correct identification of underlying abnormalities will avoid inappropriate treatment and prevent unnecessary complications.
Physicians are primarily responsible for informing their patients who develop recurrent stones about the availability of stone prevention programs. Unfortunately, no significant effort is made to determine the underlying chemical cause or provide specific corrective therapy in many cases. While there may be several reasons why physicians are often reluctant to recommend metabolic evaluations and testing, we believe the patient has to become responsible for demanding certain tests and preventive measures if the physician fails to offer them.
The immediate focus of most physicians is the treatment of any existing stones. This is exciting because physicians get to use all the latest technological gadgets likes lasers and ESWL machines to pulverize and remove stones. This is where the emphasis has always been in medical school and residency.
Stone prevention has not always been considered important and some physicians would rather treat new stones as they form rather than stop them from developing in the first place. Some think chemical testing and analysis are too difficult, complicated and expensive. None of these arguments are sound or correct.
Preventing Stone Attacks
Using the latest technological stone removal tools may be fun for the surgeon, but it is unfair to subject the patient to the pain, discomfort and disability of preventable stone attacks. While stone prevention is not emphasized in many training programs, it is the responsibility of every physician who deals with kidney stone patients to become familiar with metabolic testing and preventive therapies. There are a number of post- graduate courses on kidney stone disease and prevention that any interested physician can attend as well as books and medical articles.
Metabolic testing and preventive therapy selection is no longer difficult, complicated, or expensive. Several excellent commercial programs are available nationally that combine many chemical tests in one comprehensive package. Some even offer computerized interpretation and analysis.
The standard of medical care as defined by the National Institutes of Health Consensus Conference on kidney stones, which is as close to a definitive universal standard as we can get in medicine, clearly states that metabolic testing and preventive therapy is in the best interests of patients and should be discussed with any stone patient who is willing to follow treatment recommendations.
Kidney stone preventive testing and treatment is cost effective. The most comprehensive initial laboratory evaluation only costs about $400 which is covered by most health insurance policies. By comparison, a single visit to the hospital emergency room for a kidney stone attack costs about $1,500 and a typical hospital admission for a stone is at least $3,000. Obviously the cost increases even more if surgery is required. Lithotripsy costs about $7,500 for each session. The cost of hospital treatment and surgery multiplies by the number of stone recurrences, while the benefits of a preventive evaluation and treatment plan remain long after the evaluation is completed. On the average, active stone formers who have comprehensive preventive therapy and treatment can save over $2,000 per year in total health care costs!
Problems with Preventive Testing
There remain some problems with chemical evaluations and preventive treatment programs. There is the potential for side effects from the use of medications and patients may fail to follow all the instructions, particularly over time. The patient must continue the therapy for years even when he or she doesn't feel any immediate pain, discomfort or sickness if treatment is stopped. Frequent follow-up evaluations are required. The initial treatment plan may fail due to poor compliance, lack of proper effect or failure to stick with the treatment plan.
Despite these few difficulties, preventive chemical evaluations and specific treatment plans are clearly in the best interest of patients who suffer from kidney stones. They promote good health, avoid the costs and possible complications of surgery, identify and prevent possible medical complications, and eliminate the pain associated with kidney stones. Fortunately, a lack of availability of the laboratory testing and deficiencies in interpretation expertise are no longer obstacles to obtaining good preventive chemical studies and appropriate, specific medic therapy.
How to Obtain Stone Prevention Testing
If your physician is not interested in pursuing stone prevention testing for you, consult another physician. To find a doctor interested in kidney stone prevention, you can call 1800- 2-KIDNEYS where a national database of such physicians is kept.
We encourage patients to show this chapter to their urologists. Recognize that you might have to demand prevention testing and treatment. Remember that you are still the consumer and that it isn't the physician who will have to suffer the pain of unnecessary kidney stone attacks. If your physician willingly offers prevention testing, then proceed. But if not, remember that you may have to ask for this help in order to receive it. Below are some of the recommended metabolic testing laboratories. While the blood tests may be performed in the physician's office, the urine is collected as a 24-hour, or sometimes two 24-hour collections and then sent out to one of the specific laboratories below:
Top Six Commercial Programs for Metabolic Stone Prevention Testing
DIANON:
Located in Connecticut, Dianon is a smaller, specialty laboratory that is the newest member of the group of laboratories offering kidney stone metabolic workups. It essentially per- forms a urine-only examination and provides a graphic outline of the results which is similar to Mission's " StoneRisk" (see below). Additional blood tests are available separately but not as part of the package. Obviously abnormal urine results will receive a one page general summary report about that particular disorder. There is limited consumer information available. Their phone number is 1-800-328-2666.
LABORATORY CORPORATION OF AMERICA (LABCORP):
LabCorp was formed by the merger of two of the larger national medical reference labs: Roche Biomedical and National Laboratories. While they offer a package similar to Mission's (as all of the other programs do) their premier profile called the "Comprehensive Kidney Stone Prevention Program" includes virtually every known potential blood and urine chemical risk factor involved in kidney stone disease and extensive computerized analysis. There is a brief clinical questionnaire that must be filled out by the patient to obtain their comprehensive report, but the result is well worth the extra effort. The excellent report outlines all significant risk factors and provides detailed information, analysis of risk groups and summaries of treatment regimens for that particular patient's stone disease. The program is also unique in that it uses an advanced, proprietary computer "expert" system to analyze the clinical history and laboratory data, including blood chemical abnormalities, instead of the standard urine only "formula" used by other laboratories. A patient version of their report is under development. This is the kidney stone program we usually recommend. There is limited consumer information available. Their phone numbers are 1-800-2227566, Ext. 3125 or 1-800-533-0564, Ext. 3124.
LITHOLINK:
Located in Chicago, this lab only does urinary chemistry profiles for stones. Their prices are competitive. Their phone number is 1-800-338-4333.
MISSION:
Mission Pharmacal's "StoneRisk" profile was the first metabolic program available for analyzing urine chemistries for risk of forming new kidney stones. It was commercially released in 1987 and since then has become the leading profile in the United States. The graphic outline is easy to understand and clear, but doesn't include any blood tests which would have to be obtained elsewhere. Some consumer information on diagnosis and treatment is available. Mission Pharmacal makes many of the kidney stone prevention medications mentioned throughout this book. Their phone number is 1-800-533-3333.
QUEST (NICHOLS):
Quest Diagnostics is one of the country's largest medical reference laboratories. Their Nichols Laboratory in California provides a urine-only profile similar to Mission's at somewhat lower cost. The graphic is easy to read, but only obvious problems can be identified. Other blood tests can be obtained, but are not coordinated or analyzed with the urine chemistries. No consumer information is available. Their phone number is 1-800-642-4657.
UROCOR:
This smaller laboratory normally concentrates just on urologists. Their urine-only profile is similar to that of Mission, Quest and Dianon's. Additional blood tests are available but the analysis includes only the urine tests. General educational one page summaries of the significant problems identified are included in the profiles. Their phone number is 1-800-634-9330.