Kidney Stones - Part II

Last week, we talked about kidney stones, focusing on the causes and symptoms.  Today we'll talk about how kidney stones are diagnosed and treated.  

How is the diagnosis made?

Diagnosis always starts with a good medical history and physical exam.  If your doctor believes you could have a kidney stone, here are the tests that might be done to make the diagnosis:

• Urinalysis - To look for blood in the urine, which is usually present with kidney stones.
• High-resolution CT scan of the kidneys down to the bladder - This is the preferred test for diagnosis.  It can show even tiny stones.  It also shows if the stone is blocking the flow of urine.
• KUB X-ray - This is an X-ray that shows the kidney, ureter, and bladder.  It can show the size and position of a kidney stone.   It is not often used for diagnosis of a stone because it can miss some smaller stones.  However, it may be used to help determine if the stone is suitable for shock-wave treatment or to monitor a kidney stone before and after treatment.
• Intravenous Pyelogram (IVP) - This is a special type of X-ray of the urinary tract that is done after an injection of dye.  Although it is still occasionally used, with the availability for high-resolution CT scans, this test is not done very often anymore.

What other tests might be done?

After a kidney stone is diagnosed, your doctor may want to do other tests to determine what type of stone it is, or if there are any underlying conditions that have caused you to develop stones.

• Blood tests - Testing for calcium levels and uric acid levels is usually done.  If calcium levels are high, you may have additional blood tests to check your parathyroid hormone levels.
• Urine tests - A 24-hour urine collection can show if you have too many stone-forming minerals in the urine or too few stone-preventing chemicals.
• Stone analysis - Your doctor may ask you to urinate through a strainer to try to catch the stone that you pass.  This stone can then be sent to the lab to determine the makeup of the stone.
  

How are kidney stones treated?

Treatment depends on many things, including how large the stone is, whether there is potential damage to the kidney from urine backup, or whether you have a urinary tract infection.  

If you have a small stone, treatment may include:

• Drinking plenty of water - Up to 2-3 quarts a day.
• Medications for pain - The pain from small stones usually responds well to ibuprofen or naproxen.  Occasionally, stronger pain medications are necessary.
• Other medications - Sometimes medications are given to relax the muscles in the ureter (the tube from the kidney to the bladder where most stones get stuck).  This can help you pass the stone more quickly with less pain.

If you have a large stone, that is too large to pass on its own, treatment may include:

• Shock wave treatment - Also called lithotripsy or ESWL.  This treatment uses sound waves to create strong vibrations that can break the stone into tiny pieces, which can then be passed in your urine.
• Using a scope to remove the stone - If the stone is not too large, it can be removed with a lighted tube that is passed through your urethra and bladder.  A snare is passed through this tube to pull the stone out through the tube.
• Laparoscopic surgery - Very large stones may require surgery through a small incision in the back, through which small instruments are passed to remove the stone.  This is done under general anesthesia.

Can kidney stones be prevented?

You can reduce your risk of developing kidney stones by doing the following:

• Drink plenty of water throughout each day 
• Eat fewer food that are rich in oxalates - This includes rhubarb, beets, okra, spinach, Swiss chard, sweet potatoes, nuts, tea, chocolate, black pepper, and soy products. 
• Eat a diet low in salt and animal protein
• Continue to eat foods that are rich in calcium but avoid calcium supplements unless your doctor recommends them.  

There are also some medications that can be prescribed by your doctor to prevent stones.  If you have frequent kidney stones, your doctor might recommend one.  The medication used will depend on the type of kidney stones that you make. 

If you have any questions about kidney stones, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Kidney Stones

You may have had a kidney stone or know someone who has had one.  They are becoming more common, with the prevalence of kidney stones in the US jumping from 3.8% in the late 1970s to 10% or higher over the past several years.  Each year in the US, kidney stones are responsible for more than a half a million people going to the emergency room.  Let’s talk more about what a kidney stone is, what causes them, and how you might prevent them from happening to you.

What is a kidney stone?

A kidney stone is a hard object that is made up of salts and minerals that form within urine.  They can be as small as a grain of sand or as large as a pea.  They have a pebble-like appearance, which is the reason they are called stones.  

What causes a kidney stone?

There is not a single specific cause for a kidney stone, but several things can increase your risk for developing them.  Kidney stones develop when the urine contains more substances that can form into crystals than it has liquid to dilute them.  Sometimes the urine may not have enough of the necessary substances to prevent crystals from sticking together.

Things that may increase your risk of developing kidney stones include:

• Family history (or personal history) – If you have a family member with kidney stones, or if you have had a kidney stone in the past, then you are more likely to develop them.
• Dehydration – Not drinking enough water every day increases your risk.  The amount of water that you need daily depends on many things, including weather conditions, your level of exertion (how much you are sweating), the medications you take (such as diuretics), etc.
• Dietary factors – Too much salt in your diet increases the amount of calcium your kidneys need to filter, and significantly increases the risk of kidney stones.  Diets high in protein or sugar also increase your risk.  Sugar includes table sugar and high-fructose corn syrup.
• Certain supplements and medications – This includes vitamin C, calcium-based antacids, laxatives, some migraine medications, some antidepressants, and other dietary supplements.
• Obesity – High body mass index (BMI), significant weight gain, and large waist size, are all associated with an increased risk of kidney stones.
• Certain medical conditions – Certain kidney diseases, parathyroid overactivity, inflammatory bowel disease, chronic diarrhea, and frequent urinary tract infections can all increase your risk.  People who have had gastric bypass surgery are also at increased risk.
  

Are there different types of kidney stones?

There are four main types of kidney stones:

• Calcium oxalate – This is the most common type, which develops when calcium and oxalate combine within the urine.  You may think this would be from getting too much calcium, but it actually happens when your diet does not contain enough calcium, or enough water.  Some other conditions may contribute to these stones as well.
• Uric acid – Another common type of stone, these are more common in people who have gout, or people whose diets are high in purines (high in foods such as organ meats and shellfish).
• Struvite – Caused by infections in the upper urinary tract.
• Cystine – A rare cause of stones, which is usually hereditary.  

What are the Symptoms of a Kidney Stone?

Pain from a kidney stone usually starts after the stone leaves the kidney and gets into the ureter (the tube that connects the kidney to the bladder).  The ureter is a fairly small tube and is easily irritated by a stone.  The stone may get lodged within the ureter, causing a blockage of urine.  Pain from a kidney stone often builds rapidly to severe pain.  The bigger the stone, the worse the symptoms will be.  Here are the possible symptoms:

• Severe pain on either side of your flank or lower back, which may radiate to the lower abdomen or groin.  Pain often comes in waves, fluctuating in intensity.
• Vague pain in the abdomen that does not go away
• Blood in the urine, which gives the urine a pink, red, or brownish color
• Urinating more often, feeling a persistent need to urinate, or urinating small amounts
• Nausea and/or vomiting
• Fever and chills
• Urine that is cloudy or has a bad smell

Next week, we will talk more about how the diagnosis of a kidney stone is made and how they are treated. 

If you have any questions about kidney stones, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Complications of Diabetes

We have talked about the different types of diabetes over the past few weeks.  Today we will talk about the complications that can develop in people with diabetes.  The risk of long-term complications gets higher the longer you have diabetes, but how well diabetes is controlled is also an important factor in your risk of developing complications.  

What are the short-term complications of diabetes?

Short-term complications of diabetes are complications that happen acutely, even in patients that have only had diabetes for a short time.  They can be quickly remedied without lasting problems if they are recognized early.  These include:

• Diabetic ketoacidosis - Results from increased levels of ketones in the blood.  Blood sugar will be dangerously high as well.  It happens due to lack of insulin and is more common in type 1 diabetes.  It can be dangerous, even life-threatening, if not treated appropriately and early.  Symptoms include excessive thirst, frequent urination, fatigue, vomiting, weakness, rapid breathing, confusion, and a fruity breath smell.
• Hypoglycemia - Low blood sugar, which can be the result of diabetes medications or not eating when taking diabetes medications.  Can result in death if not recognized and treated quickly.  Symptoms include excessive sweating, dizziness, fatigue, sudden feeling of hunger, irritability, confusion, and fast heart rate or palpitations.
• Diabetic coma - An unconscious state resulting from either dangerously high, or dangerously low blood sugar.  Symptoms that happen before developing diabetic coma will either be the same as those of ketoacidosis or those of hypoglycemia that I listed above.

What are the long-term complications of diabetes?

All types of diabetes can affect many body organs and systems.  Long-term complications usually develop gradually.  In type 2 diabetes, some complications may even start developing before you know you have diabetes.  Here are some of the long-term complications of diabetes:

• Nerve damage (also called neuropathy, or diabetic nerve pain) - Can cause tingling, numbness, burning, or pain.  It usually starts in the tips of your toes and later fingers, and gradually spreads upwards, like a stocking or glove.  It is the result of damage to the capillaries that nourish your nerves caused by high sugar levels in the blood.  If not treated, you can lose the feeling in your feet and hands completely.  Damage to the nerves in the abdomen can cause problems with digestion.  It can also cause erectile dysfunction in men.
• Cardiovascular disease - This includes coronary artery disease and peripheral artery disease (hardening of the arteries outside the heart).  It causes a high risk of stroke, heart attack, and loss of circulation to various parts of the body.  For this reason, it is even more important for people with diabetes to work with their doctor to maintain good cholesterol and triglyceride levels to keep heart disease risk in check.
• Kidney damage - High blood sugar damages the delicate filtering system within the kidneys.  It can lead to kidney failure resulting in the need for dialysis or kidney transplant.
• Eye damage - High blood sugar damages the blood vessels in the retina at the back of the eye, which can lead to blindness.  Diabetes also increases the risk of glaucoma and cataracts.  90% of blindness caused by diabetes is preventable with timely diagnosis of diabetes, good blood sugar control with treatment, and regular eye exams to recognize and treat eye damage early.
• Skin problems - High blood sugar levels make the skin more prone to infection and poor healing of cuts or scrapes. 
• Foot problems - The feet can be seriously affected by cardiovascular, nerve, and skin complications noted above.  Damage in the feet is a common problem in diabetes.  A simple blister on the foot of a diabetic, if not treated properly, can lead to serious infection that may not heal easily.  This may lead to amputation of a toe, foot, or even the leg below or above the knee.  Diabetics can also have changes in the structure of their feet due to neuropathy, with fallen arches and worse, even leading to fractures in the feet without any trauma.  A person with diabetes should check their feet every day to look for cuts, scrapes, or blisters that need attention.  They should wear good quality shoes that are supportive and do not put undue pressure on any one place.  Your doctor should regularly check your feet as well.  
• Dementia - Type 2 diabetes increases your risk of developing dementia, including Alzheimer's disease.  The risk is greater with blood sugar that is poorly controlled.  
• Hearing problems - Are more common in people with diabetes.
• Depression - Is common in people with all types of diabetes.  When a person is depressed, it can be harder to manage blood sugar levels for several reasons, leading to more complications.

If you have diabetes, good blood sugar control is an important part of preventing complications from developing.  It is important to work closely with your doctor to manage your diabetes and maintain good control of your blood sugar.    

Next week, we will finish our series on diabetes with a discussion of nutritional considerations in diabetes by one of our dieticians. 

If you have any questions about diabetes, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Gestational Diabetes

Diabetes that is diagnosed for the first time during pregnancy is called gestational diabetes.  According to the American Pregnancy Association, between 2 and 5 percent of women develop diabetes during pregnancy.  It can cause some serious complications for both mom and baby if it is not recognized and treated.  

What causes gestational diabetes?

During pregnancy, the placenta produces hormones to sustain pregnancy.  Unfortunately, these hormones also make your cells more resistant to insulin.  Your pancreas will respond by making more insulin.  Normally, the pancreas can make enough extra insulin to overcome the resistance in the cells, but sometimes the pancreas just can't keep up with the demand.  When this happens, not enough glucose gets into the cells, and blood glucose levels get too high.  

What are the symptoms of gestational diabetes?

Most women don't notice the symptoms of gestational diabetes.  They usually blame the more frequent urination on the pregnancy itself.  It may also cause some increased thirst, but this is also usually not that noticeable.  

What are the risk factors for gestational diabetes?

• Being overweight or obese
• Having a sedentary lifestyle with low level of physical activity
• Having prediabetes, or having had gestational diabetes with a prior pregnancy
• Polycystic ovary syndrome
• Family history of diabetes in a close relative
• Women who are Black, Hispanic, American Indian, or Asian American have a higher risk 
• Previously delivering a baby that weighed more than 9 pounds

How is gestational diabetes diagnosed?

Because of the seriousness of the condition and the fact that it causes few symptoms, all pregnant women are screened for gestational diabetes as a part of routine prenatal care.

• If you are at average risk, the screening is typically done between 24-28 weeks of pregnancy.
• If you have any of the risk factors mentioned above, your doctor may want to screen for diabetes early in pregnancy, even at your first prenatal visit, and may screen you more than once during pregnancy.

Screening tests can vary slightly but in general the screening test is a glucose challenge test.  For this test, you will drink a syrupy drink that is a concentrated glucose solution.  One hour later, your blood will be drawn to test your blood sugar.  If your blood sugar result is in the normal range, that's great.

If your blood sugar falls into the high range, then you will have another test called a glucose tolerance test.  This test uses a higher concentration of glucose solution.  After drinking the solution, your blood sugar will be checked every hour for 3 hours.  If two or three of the blood sugar readings are higher than expected, you will be diagnosed with gestational diabetes.

How is gestational diabetes treated?

• Lifestyle changes - Eating a healthy diet and being more physically active.
• Monitoring your blood sugar regularly - Your doctor will tell you how often.
• Medication, if necessary - When diet and exercise do not keep your blood sugar down, medication is required.  Insulin is the usual medication used during pregnancy.
• Close monitoring of your baby - You may have additional ultrasounds to monitor the baby's growth and development.  Your doctor may also want to induce labor if you do not go into labor by your due date.
  

What are the complications that can happen if gestational diabetes is not carefully managed?

Complications that may affect the baby:

• Excessive birth weight - From high glucose levels going to the baby.  Babies weighing 9 pounds or more are more likely to get wedged in the birth canal, have birth injuries, or require a C-section birth.
• Premature birth 
• Serious breathing difficulties shortly after birth
• Low blood sugar shortly after birth - This can be serious and even cause seizures in the baby.
• Higher risk for obesity and type 2 diabetes later in life.
• Stillbirth - Untreated gestational diabetes can result in a baby's death either before birth or shortly after birth.

Complications that may affect the mother:

• High blood pressure
• Preeclampsia - A serious complication of pregnancy that causes high blood pressure and other serious symptoms including seizures, which can threaten the lives of both mother and baby.
• Having a C-section delivery is more likely.
• Future diabetes - Women who have gestational diabetes have a higher risk of gestational diabetes in future pregnancies, as well as a higher risk of developing type 2 diabetes over time.

Gestational diabetes is a serious condition.  To lower your risk, try to form healthy habits before getting pregnant and try to start pregnancy at a healthy weight.

If you have any questions about gestational diabetes, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Type 2 Diabetes - Part II

Over 30 million Americans have type 2 diabetes.  We will continue our discussion of this topic today, focusing on diagnosis and treatment.

How is type 2 diabetes diagnosed?

Unlike type 1 diabetes, the symptoms of type 2 diabetes can come on gradually and sometimes may not even be noticed.  Also, sometimes symptoms are presumed by patients to be from another cause, and they might not see their doctor about the symptoms or even mention them to their doctor.  For instance, frequent urination might be blamed on an overactive bladder, or blurry vision might be blamed on age-related far-sightedness.  For these reasons, the American Diabetes Association (ADA) and the U.S. Preventive Services Task Force have recommended screening for type 2 diabetes.  The primary purpose of any screening test is to detect early disease in large numbers of apparently healthy individuals.  Screening allows us to make a diagnosis earlier and treat earlier.  In diabetes, this can help prevent complications, which helps to prevent blindness, kidney failure, and premature death.

The ADA guidelines recommend that the following people should be screened for diabetes:

• Anyone with a body mass index (BMI) higher than 25 (23 for Asian Americans), regardless of age, who has additional risk factors, such as high blood pressure, abnormal cholesterol levels, a sedentary lifestyle, a close relative with diabetes, a history of polycystic ovary syndrome (PCOS), or a history of heart disease.
• Anyone older than age 45 should have an initial blood sugar screening test.  If the results are normal, they should be screened every 3 years after that.
• Women who have had gestational diabetes should be screened every 3 years after the pregnancy.
• Anyone who has been diagnosed with prediabetes should be tested every year.
  

The tests for diagnosing type 2 diabetes are the same as those done for type 1 diabetes, which includes:

• Blood tests - To check the blood sugar level and/or the hemoglobin A1c test.
• Urine tests - To test for glucose and/or ketones in the urine.
  

How is type 2 diabetes treated?

There is nothing that can cure type 2 diabetes.  However, it can be treated to manage blood sugar levels and decrease the risk of complications.  Some of the treatments include:

• Lifestyle changes - Including eating a healthy diet, increasing physical activity, and losing weight if you are overweight.  Sometimes these lifestyle changes alone can keep blood sugar levels managed well at normal levels.
• Medications taken by mouth - There are six types of diabetes pills.  They work in different ways.  Metformin is generally the first medication prescribed for type 2 diabetes.  It inhibits the production and release of glucose from the liver.  Other oral medications work by preventing the kidneys from reabsorbing sugar into the blood, by making your cells more sensitive to insulin, by increasing production of insulin in the pancreas, or by blocking breakdown of carbohydrates in the digestive tract.
• Insulin - Many people with type 2 diabetes are treated with insulin, usually in combination with oral medications.  Adding insulin helps to overcome insulin resistance when the pancreas can't make enough insulin to keep up with the demand.  There are many types of insulin available now.  They all need to be given by injection or by an insulin pump.  
• Other injectable medications - There are some newer medications for type 2 diabetes that are injected once a week.  They work by stimulating insulin release and lowering another hormone that is responsible for raising blood sugar.
• Blood sugar checks - Done regularly, this can help you and your doctor manage your blood sugar levels.
• Bariatric (weight loss) surgery - While this is not considered a specific treatment for type 2 diabetes, people with type 2 diabetes who have a BMI over 35 may benefit from surgery such as gastric bypass.  The weight loss associated with bariatric surgery has been shown to result in significant improvements in blood sugar levels.  The long-term risks and benefits of this procedure for diabetes are still unknown.  
  

If you have type 2 diabetes, you and your doctor will work together to find the best treatment for you.

Next week, we will continue our discussion of diabetes.

If you have any questions about diabetes, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor

Diabetes - Type 2

I hope you have had the chance to read the last two Health Tips on diabetes - where we first covered the basics, then did a deeper dive into type 1 diabetes.  We will continue our discussion of diabetes today, focusing on type 2 diabetes.  Over 34 million Americans have diabetes, and approximately 90-95% of them have type 2 diabetes.  Type 2 diabetes used to be called "adult-onset" diabetes, because it most often develops in adults over age 45.  However, more and more children, teenagers, and young adults are developing type 2 diabetes.

What is type 2 diabetes and what causes it?

In type 2 diabetes, the cells in your body don't respond normally to insulin, which is called insulin resistance.  This means that although your pancreas is making insulin like it should, the insulin is not effective at helping the glucose move into the cells.  Your pancreas makes more insulin to compensate for the resistance, but eventually the pancreas is not able to keep up because the resistance becomes too great.  Over time, the pancreas may sort of "burn out" because it is working so hard, which may lead to lower insulin production.

We don't know exactly why this happens.  We believe that it is due to a combination of genetic and environmental factors.  Being overweight is one environmental factor that is strongly linked to the development of type 2 diabetes, although not everyone with type 2 diabetes is overweight.

What is prediabetes?

Prediabetes is a condition where your blood sugar levels are higher than normal, but not high enough to be classified as diabetes.  It is often the precursor to diabetes unless you take action to control it.  Prediabetes is reversible if appropriate measures are taken to prevent progression to type 2 diabetes.  The causes and risk factors are the same for prediabetes as they are for type 2 diabetes.

What are the risk factors for developing type 2 diabetes?

• Being overweight or obese - The more fat your body carries, the more resistant your cells become to insulin.
• Physical inactivity - Physical activity on a regular basis uses up glucose as energy, makes your cells more sensitive to insulin, and helps keep your body weight under control.
• Family history - Having a parent or sibling with type 2 diabetes increases your risk.
• Race or ethnicity - It is not clear why, but certain groups of people are at higher risk for type 2 diabetes, including Black, Hispanic, American Indian, and Asian American people.
• Age - Your risk increases as you get older, maybe because you tend to be less active, have less muscle mass, and gain weight as you get older.  But as I mentioned earlier, we are seeing increasing numbers of cases of type 2 diabetes in children, teens, and young adults.
• Polycystic ovary syndrome (PCOS) - Women with PCOS are at higher risk of type 2 diabetes.
• High blood pressure - Blood pressure over 140/90 is linked to increased risk of type 2 diabetes.
• Abnormal cholesterol and triglyceride levels - People with high triglyceride levels and people with low levels of good cholesterol (HDL) are at higher risk for type 2 diabetes.  This is another reason to have your doctor check these levels with a lipid panel.
• Gestational diabetes - We will talk more about this type of diabetes next week.  If you have this when you are pregnant, you are at higher risk of developing type 2 diabetes later in life.
  

Can type 2 diabetes be prevented?

Yes.  Here are things you can do to help prevent type 2 diabetes:

• Eat a healthy diet with plenty of fresh fruits and vegetables and less carbohydrates and sugars.
• Be more physically active - try to get at least 150 minutes of moderate level exercise each week.
• Maintain a healthy weight - aim for a body mass index (BMI) of 25 or less.

These measures can help to prevent the development of type 2 diabetes and can also reverse prediabetes.

We will talk more about type 2 diabetes next week including diagnosis and treatment options.

If you have any questions about diabetes, please log into your account and send us your question. We are here to help.

Dr. Anita Bennett MD - Health Tip Content Editor