1. Knock out Kidney Stones
By: Heather K. Mackie, MS RD, LD
Many bariatric patients have had a kidney stone or know someone who has and know all to well how painful they can be.
There are many myths related to the cause of kidney stones so let’s take a look at a few dietary preventative measures to reduce the risk of developing kidney stones.
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2. What is a Kidney Stone? Deposit of minerals in the kidney
Stones can grow in size
Stones can block the duct that moves urine from the kidney to the bladder
Can be extremely painful

3. What is a Kidney Stone, cont?
Typically, stones less than 5 mm will pass on their own
Those 6 mm or larger will often not pass on their own
X-rays and other scanning devices can detect kidney stones

4. Types of Kidney Stones Calcium oxalate stones Uric acid stones
¾ of individuals who develop kidney stones, develop this variety
Uric acid stones
Another type which contains uric acid and is related to urinary tract infections
Cystine stones
Caused by genetic abnormality
Research has shown once someone has a kidney stone, they have a greater risk of developing them again
Calcium oxalate stones – ¾ of individuals
This stat is related to those individuals in the United States
Urinary tract infections – AKA: bladder infections

5. Treatment of Kidney Stones
Medical Options
Pain management
Calcium-channel blocking agents
Surgery
Common type uses sound waves
Utereroscopy
Percutaneous stone removal – large stones
Ca-channel blocking agents – disrupt the movement of calcium
Surgery using sound waves – pulverizes stones into small pieces so they can pass on their own
About 60-80% of stones that need to be removed via surgery, can be removed through this shock wave or lithotripsy method
Utereroscopy – small scope is passed through the urinary system; small, but strong helium laser is used to break apart the stones
Percutaneous – a small access tube is placed into the kidney through the back and a small device breaks up the stone and removes it at the same time

6. Preventing/Treating Kidney Stones
Medications
Thiazide diuretics (e.g., HCTZ)
Probiotic
Oxalobacter formigenes
HCTZ = hydrochlorothiazide – may prevent risk of kidney stones; AKA “water pills”
This class of medications decreases calcium in the urine, which decreases the risk of kidney stones
When prescribed this medication, many patients are also prescribed potassium supplementation
The potassium is commonly potassium citrate, which provides more citrate, which also decreases the risk of kidney stones
Oxalobacter formigenes – an organism that relies completely on oxalate as its source of energy.
This probiotic could be a promising treatment for too much oxalate in the blood.

7. Preventing Kidney Stones
There are several recommendations the medical community will make to reduce the risk of developing kidney stones.
Let’s take a look at what you can do to help keep your kidneys healthy.

8. Stay Well Hydrated!
Keeps waste flowing through the body and allows it to exit
Some experts suggest 8 glasses per day
Especially important during hot summer months
Some experts recommend drinking a glass of water before bed
Hydration is something many bariatric patients already struggle with, especially immediate post-op.
8 glasses of water per day – this recommendation may vary for each patient; talk to your healthcare provider to determine your personal hydration goals and how to best determine your hydration status.
Hot summer months – dehydration is more common, especially in hot, humid climates.
Drinking water before bed as sleeping may be a more common time for stones to form (due to the fasting state during sleeping heightens the ability of crystallization/development of stones)

9. Be Considerate of Caffeine!
Beware of caffeinated beverages
Coffee, tea (hot or iced), soda, energy drinks, and some protein supplements
Caffeine is a diuretic
Colas may contribute to build-up of calcium oxalate
Diuretics – flush fluid out of the body, increasing the risk of dehydration.
Build-up of calcium oxalate increases risk of kidney stone formation.

10. Like Lemonade?
Those individuals with uric acid stones, may benefit from lemonade due to the high concentrate of citrate
Make your own:
Mix 2-3 tbsp of lemon juice to 8 oz glass of water
Or squeeze half a lemon into a glass of water
Talk to your bariatric surgeon/health care team before drinking lemonade
Citrate reduces stone formation risk.
Mixture is what some experts recommend.
Talk to your healthcare team first as this may increase the acid content and they may want you to limit acidic foods immediately following surgery (or other time periods).

11. The Salty Truth!
Consuming too much salt or sodium will increase your risk of kidney stone formation
By lowering your overall sodium intake
Lowers the calcium in the urine
Calcium excretion (through urine) is linked to sodium excretion
Therefore, less sodium means less calcium available in the urine to form kidney stones
As we know, most salt intake comes from prepared foods, rather than the saltshaker.

12. Foods High in Oxalate
Individuals prone to oxalate stones may choose to reduce foods high in oxalate
Chocolate, rhubarb, strawberries, spinach, nuts, grape juice
However, most dietitians might agree the overall nutritional value of these foods (except for maybe chocolate) outweigh any concerns of kidney stone risk in most cases
Pair oxalate-rich foods with calcium-rich foods
Drink fluids throughout the day
Pairing – you can reduce the effect of oxalate-rich foods by pairing them with food sources of calcium to lower the oxalate absorption.
Drinking fluids throughout the day will reduce effect of oxalate-rich foods.
Interesting fact – spinach contains oxalate, but also contains calcium!

13. Go Vegetarian for Protein!
Meat, fish, and poultry increase the amount of acid in your urine
This increases the risk of kidney stones
Consider decreasing meat intake by 30%
Meatless Mondays
Protein intake is very important for bariatric patients.
Do not decrease total intake of protein, but considering substituting alternative proteins sources a few times throughout the week if you don’t already.
This substitution will also decrease the intake of saturated fats, cholesterol, and possibly calories.
Easy way to decrease meat intake by 30% is to institute meatless Mondays; consider implementing vegetable sources of protein – tofu, soy, beans, etc.

14. Lower the Fat Intake
Oxalate in the urine increases with the amount of fat in the stool
With some types of bariatric procedures, fat is malabsorbed
Increases the amount of fat in the stool
Increases the risk of kidney stones
Following a low fat eating plan will help to decrease the amount of fat in the stool if you had a malabsorptive procedure.

15. Caution with Calcium???
Some studies have shown calcium supplements may increase the incidence of kidney stones
However, there is also research showing that calcium-rich foods reduce the risk of kidney stone formation
Most experts agree that the risk of kidney stones is greater with calcium carbonate when compared to calcium citrate
Bariatric patients should be using calcium citrate anyway when it comes to supplementation of calcium

16. Calcium Intake
Experts do agree that those at risk for osteoporosis should not restrict calcium intake for fear of kidney stones
Those individuals with the lowest dietary calcium intake have an increased risk of kidney stones
Aim for at least 3 servings per day of calcium-rich foods
Bariatric patients are at risk for osteoporosis.

17. Calcium & Oxalate
Calcium may bind with oxalate before it reaches the kidneys
Both oxalate and calcium are increased when the body does not have enough fluids and has too much salt
This increases the risk of kidney stones
Because of the binding of calcium & oxalate before they reach the kidneys is why experts still recommend that patients follow their doctor’s recommendation for calcium intake.

18. Calcium Bottom Line Continue taking recommended dose of calcium
Via foods and supplements
Take calcium supplements with meals
Ensure supplements are calcium CITRATE
NOT carbonate
Eat 3 servings per day of calcium-rich foods
Citrate helps increase urinary citrate excretion.

19. “C” Caution Vitamin C supplementation can be converted to oxalate
Which increases the risk of kidney stones
Therefore, it is recommended by some professionals to limit vitamin C to less than 1,000 mg per day
Just for comparison sake – Celebrate Vitamins’ multivitamin has 180 mg of vitamin C.
This level (1000 mg) of supplementation is going to come from a stand-alone vitamin C product.

20. Weight & Kidney Stones
Recent research has suggested a strong prevalence between weight and the prevalence of kidney stones
The more weight one gains, the more likely they are to develop kidney stones
Again, one more great reason to have bariatric surgery, lose the weight, and maintain that weight loss!

21. Gastric Bypass & Kidney Stones
However, some recent studies have shown gastric bypass patients, specifically have an increased risk of kidney stones post-operatively
Keep in mind:
Increased risk of kidney stones in presence of obesity
Increased risk of kidney stones in presence of diabetes
With this said, it is extremely important for gastric bypass patients to modify all they can in their healthy eating plan to reduce the risk of kidney stones
Obesity – maybe increased risk in years that one was obese prior to having weight loss surgery
Diabetes – many bariatric patients had diabetes prior to weight loss surgery
Higher-fat diet – did they eat a higher-fat diet prior to weight loss surgery?
Did they eat 3 servings of dairy (calcium-rich foods) per day?
Did they eat a high-sodium diet?
Did they get adequate fluid each day? How much caffeine did they drink each day
All of these – maybe increased the patient’s risk of kidney stones for years while waiting to have weight loss surgery and maybe they would have had the kidney stones anyway (just a thought).

22. Overall Risk
There is a risk of kidney stones for all bariatric patients
The incidence of kidney stones has increased in the general population over the last years
13% of men and 7% of women will have kidney stones at some point in their life
Risk for all bariatrics patients, simply because the prevalence of kidney stones has gone up overall.
Overall risk increasing – possibly due to obesity epidemic, increased intake of sodas, increased caffeine intake, decreased fluid intake, increased salt intake, increased fat intake, etc.

23. Remember… Oxalate is NOT good Citrate IS good
Calcium IS good in the intestines
Calcium is NOT good in the urine

24. Overall Bottom Line Continue recommended dose of calcium
Ensure supplements are calcium citrate & take with meals
Eat 3 servings per day of calcium-rich foods
Ensure adequate fluid intake
Decrease caffeine intake
Follow low-fat, low-sodium eating plan
Consider implementing Meatless Mondays
Maintain weight loss

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