 Good day. I am Dr. Sanjay Garg, consultant urologist in Manipal Hospital, Gazebath. So today we are going to talk about kidney stone disease. As we all know that we are living in sub-Himalayan zone, northern zone of India. So this is a zone where stone formation is very frequent. We live in an environment which is stone formation is seen frequently. What are the causes of stone formation? Here it can be multiple factors. Environmental factors, family factors. Family factors means sometimes this stone is runs in families. If parents, mother and brother or sister are having stone disease, then there are sometimes high chances that a person will have kidney stone disease. Dietary factors plays a very important role. Sometimes our lifestyle is such that we don't drink water. We ingest too much of food which contain high amount of oxalates or certain preservatives are there which are detrimental for our kidney or form stones. So in all we can say that it is multifactorial. And there is not a single factor that we can say that this is the cause of stone formation. Now what our kidney does? Kidney works like a filter. It filters our blood. It filters all the waste materials that enters into the blood. Blood enters into the kidney. There are filtration units. And finally urine formation is there. In between, when the things are filtered, if there is a super saturation level of certain things like calcium, oxalate, phosphate, then these things accumulate in the kidney. Whereas if there is less amount of inhibitors, what are the inhibitors like magnesium, sorry, citrate, especially citrate. This works as an inhibitor of stone formation. If inhibitors are less, aggregators are more, then there are high chances of a stone formation which occurs in the kidney. It starts as a small nitrous, just a small dot of calcium accumulation. Thereafter it grows. If the saturation level is high, then this calcium formation occurs and stone size grows. That one finding from the tip of the papilla which is a structure in the kidney, it falls into the urine where urine accumulation is there. Then that size increases. Symptoms occur when either there is an obstruction or infection. Kidney stone falls into the ureter. Ureter is a tube which connects the kidney to the bladder. Then there is an obstruction. This obstruction causes kidney to cry basically. It cries. It tries to push that stone but is unable to. Then it cries and we perceive it as a pain. This is which is the most common symptom. Kidney stone, we perceive a pain and it can be associated with blood in urine or fever. Sometimes it is vomiting. All the symptoms may not be present in a particular patient but the most common symptom is pain. Sometimes there are silent stones which are more dangerous because if the stone is obstructing and it is not causing any pain or any other symptom, then it can gradually cause kidneys to function less and even lead to damage of the kidneys. So what should we do? We should first of all, if there is a pain or if there is some symptoms and then linking to this kidney stone, we should especially go to a doctor and consult and further get ourselves investigated. What are the investigations that we can do? First of all, basic investigation includes urine examination, blood examination and ultrasound. Second is the primary investigation in which we can continue or we can come to know about the condition of the kidney, presence of a stone, if there is some infection, some swelling on the kidney and thereafter, if there is any doubt that stones are present, then we should go for some special investigation. What are those? Like CT scan. CT scan nearly tells that nearly more than 99% cases, we come to know that what is the like presence of the stone, size of the stone, location of the stone and sometimes we can also know that how hard the stone is. So thereafter, we can plan our treatment. Now, what are the treatment modalities? Treatment modalities are medical as well as surgical. Medical treatment means when the kidney stones are present either in the kidney or they are very small in size, causing, they are not causing obstruction or infection, then we can definitely go for medical treatment. And in medical treatment, certain drugs are there, which helps us for the elimination of the stone and or stone formation that can increase the cause of stone formation. Whereas if the stone is stuck up in the ureter causing infection, causing obstruction, then we have to get it removed. Normally, we can wait for certain days like from 7 to 10 days if the stone size is small, say less than 5 mm, then we can give certain medication that helps us to dilate the ureter. Kidney function itself, there are certain pacemakers in the kidney which flushes the urine. So, stone passes along that urine with the help of our medicines. So, which is only suitable to a certain extent in small stones that too, it is not complete obstruction and given for a certain period of time. So, along with that, we also gave certain painkillers obviously to elevate the pain. That painkiller should be kidney friendly because analgesic we know that can cause kidney damage. So, we should not prescribe or we should not take those analgesics which are not kidney friendly. Number 3, if stone is stuck up causing infection, causing severe obstruction, then we should not wait whether the size is small or large. Then we have to go for the removal of the stone. Normally, with the advent of newer technologies, now we have you can say minimally invasive surgeries or very very less invasive. So, either we can go approach from retrograde that is down below from the urinary tract or from our backside. So, when we go from down below via the investigation, the operation is called as urotoscopy or RIRS, Retrograde Intrauriline Surgery. Urotoscopy is done for the stone which is stuck up in the ureter. Whereas, if the stone is in the kidney, they are not of very big size that we can approach from down below from the ureter, go inside the kidney, fulcrate it with laser, break it with laser and take it out. This technique is called RIRS, Retrograde Intrauriline Surgery. If the stone size is large, then we have to approach it from our backside, from the flanks. In that, we have to puncture the kidney and go directly to the stone, break it into pieces and take it out. This technique is called as PCNL. There are many other modernities like extra corporeal shockwave, EASWL. But nowadays, primarily either we go with URS, RIRS or PCNL. So, apart from this, now we should know what should we do? There are certain facts and myths which are commonly prevalent in our society. What should we eat? What should we not eat? Which nowadays, even every other person becomes a doctor and tells us that don't take this, don't take that. Then I'd like to clear certain things, especially in diet. Number one medicine, number one thing that we should remember is water intake. Our water intake should be educated and during the period of pain, we should not over-hydrate ourselves. We should take water as our body requires it. So, when we are not in pain, but to prevent the stone, regular water intake that is nearly approximately 8 to 10 liters, 8 to 10 glasses of water, approximately 2 to 2.5 liters of water per day is required. That too in divided intervals. We should regularly take water. We should take one glass of water every year. So, this water will flush the kidney. It won't allow certain sediments. It won't allow calcium or other things to go to a supersaturated level and we won't be forming the stones. This is the number one medicine which everyone can take and helps us to prevent the stone. There are certain foods which I would say can cause stone formation, especially minerals in which I would say sodium. Sodium like Namak, which is a common salt that we take, which is high in sodium. That we should... Our excess salt should be avoided. It should be taken when whatever it presents in our vegetables or dal etc. what we are eating. But we should not take it. Sprinkle it means table salt should be avoided. Number one. Number two. We should not have food which have... We are high in preservatives or packed food like or you can say junk food. Pizza, burger, certain noodles, they are high in salt and auxiliary content. We should avoid those foods. If we are vegetarian then it's okay. But if non veg then we should try to avoid red meat. In dry fruits we should try to curdle down the intake of cashew nuts, cashew. We can eat it but if we are eating too much of it then we have to curdle it down. In foods mainly I would say Chiku and Angoor like grapes should be taken in a moderate amount. We should not over-indulge in these two foods. Otherwise other foods can be taken. Now coming to the most important thing. That is the calcium intake or food which are rich in calcium like milk products, cheese. Then these things should be taken, should not be avoided. And it should be taken at a great amount. Because this is very important for the growth of our body. Especially for ladies, for females. Because low calcium intake can cause obviously the weakening of bones and other things. Calcium what we ingest does not directly go to the kidney and deposit over there. In only 5% cases high intake of calcium causes hyperaccumulation of calcium in the kidneys. So in 95% cases we should not avoid it. And how to know about those 5% cases in recurrent stone farmers. Like those persons who are forming stones again and again. We specifically go for certain investigations, certain tests. Then we come to know that this person if he takes calcium more. More ingestion of calcium that can go into the kidney and cause harm. So that is only seen after certain investigation. Otherwise we should take normal amount of calcium that is required for the body. Now most important other thing is intake of green vegetables. Or vegetables which are vegetable fruits which contain nuts. Nuts or beech I would say. Normally oxalates, the green vegetables they contain oxalates. And as we know that most commonly our stone is considered of calcium oxalate. So common myth is that avoid these vegetables. We should not. We should take it but in moderation. There should not be over analysis. Why? Because in 80% of oxalates they form inside our body. Inside our liver. Only 20% cases if high intake of oxalate is present. That can go and cause accumulation of oxalates in the body. So we should not directly avoid it. We should take it but not too frequently. Same with the vegetables or fruits which contain beech seeds. Most important thing which is commonly practiced. I have seen it and I always hear that everyone tells that if stone is present or stone is obstructed or obstructing then drink alcohol or beer. That is vice versa. That is a common myth. We should not take beer. Why? Because beer contains high amount of oxalates. If a person is regularly consuming beer then instead of stone dissolution it will increase stone formation. The only thing that happens when a person takes alcohol or beer is that there is lot more amount of urine formation is there. Which is not good. So my advice is totally to avoid beer. And as far as other things are concerned we should see like we can have regular take off calcium products. We should avoid red meat. We should avoid cashew nut. Not avoid. Taken moderate amount. And other fruits like chiku and angut should be taken lesser quantity. Otherwise we can have normal healthy diet. If we are going to curtail our diet then it has got to have detrimental effects on our body. Because there will be deficiency of certain minerals and other things. And most important thing is water intake. Water intake should be adequate approximately 2 to 2.5 liters. This can increase in certain cases when there is like in summers or in conditions when there is some dehydration is there. Then we have to increase the water intake. Otherwise around 2.5 liters is sufficient. So this is the I would say the medicine which help us in prevention of stone formation. And if somehow stone formation is there and it causes obstruction pain. Then we have to consult a urologist for the proper management. Thank you. So now we will be answering the questions from the audience. Yeah some questions which is generally asked. Okay so as someone is asking function of the kidney. As I mentioned function of the kidney is for filtration. It filters all the waste that are formed in our body. Specifically like urea certain minerals are there excess amount of sodium. So these are the waste material which should not be kept inside the kidney or inside the body that filtered by the kidney. Kidney stones are there most commonly calcium oxide stones. In India nearly more than 95% cases of calcium oxide monohydrate or dihydrate stones. Whereas certain other stones are also there. Uric acid stones are there. Magnesium ammonium phosphate. So most commonly calcium oxide stones are there. And how is it diagnosed? As I mentioned earlier when a person is having pain which is present in the flank which is radiating down to the urine area or the urinary passage. Then we should suspect that a person is having kidney stone. For which we have to further investigate. This pain can be associated with blood in urine, fever or vomiting. How long does it take for a person to recover from kidney stone? Normally if a stone is smaller in size it is causing obstruction. And it is an investigation we find that is not totally obstructing. Then we can give a try period with the medication for around 10 days. But if the size of the stone is bigger than 5mm or more so than that. Then we should not go for conservative or the medical treatment. We should go for removal of a stone with the help of the newer methods like rotoscopy or RIRS and sometimes PCLN. Do kidney stones dissolve naturally? Certain stones which are I would say softer stones like having more uric acid content in them. So they can be dissolved. But for that we should know that this stone is most of the content is uric acid. We can have CT scan. In CT scan there are certain parameters. If the household unit of the stone is less like 200 HU then those stones can be dissolved. But for that matter we have to monitor the kidney like pH in the urine. We have to give certain medication that period is long maybe 3-6 months. But if the stone is obstructing or associated with infection we should not go for this resolution therapy. Role of stone analysis. Definitely when we capture the stone or we have the stone we can go for a stone analysis. Normally we find that calcium oxalate, monohydrate or tihydrate stones are present. Whereas if a stone has a show that it contains high amount of urates then we can definitely cut down on certain food that contains high amount of urates. So stone analysis help us to know what is the exact constituent and does our diet will help in restricting that is stone formation. So we should go for stone analysis. But for getting the perfect picture there are certain tests which are performed when the patient is pain free or stone free. Those are few blood parameters, getting calcium magnesium, creatinine tested in blood, uric acid tested in blood. Then special hormone which is called parathyroid hormone. Whereas there is special analysis of urine which is called as 24 hours urine analysis for kidney stone disease. We again collect urine sample for 24 hours check for certain parameters as I mentioned like calcium, oxalate, magnesium, phosphate, urates. These are the certain parameters. We come to know what is the constituent which is causing super saturation urine. So these are the tests which are performed. This gives us the complete picture and helps us in curdling down the lifestyle or the dietary factors. So thank you.