Stones of the Kidney

Stones of the Kidney, Ureter and Bladder

Stones in the urinary tract are common. Often these do not produce symptoms and are detected accidentally. Some of the conditions causing stones are genetic in nature. Recurrence of these stones is common, although difficult to diagnose correctly but if not treated in time may lead to permanent damage to the kidney.

Recurrent stone disease should always be investigated thoroughly to find out the underlying cause.

Investigations Involve

Analysis of the stone if it has been passed spontaneously or removed surgically.

Urine routine examination to look for crystals of oxalates, uric acid, cystine or other salts.

Blood tests are done for levels of calcium, uric acid, oxalate, acid content, phosphorus, magnesium, parathormone levels etc. Kidney function also needs to be evaluated at the time.

X Rays are carried out to know whether the stones are radioopaque (seen on X Rays) or radiolucent (seen only on USG).

Urine tests are done to know specific gravity, acidity, calcium excretion, urate excretion, citrate excretion etc.

For urine tests, 24 hour collection of urine is collected in acidic and alkaline media and then analysed.

In most cases of recurrent stone formations, a cause can be found or excluded and a proper therapy is instituted.

Nutritional Content of Indian Foods

Foods provide calories (energy), bodybuilding material (proteins), oils and fats (provide energy in a concentrated form), carbohydrates (energy providers in less concentration compared to fats), salts and minerals including those in very small quantities (micronutrients) and vitamins both essential and not so essential.

Energy content is high in lipids: fats and oils. Fats are solid oils and each gram of these provide about 9 kilocalories. Fats also contain vitamins A, D, E and K (also called fat-soluble vitamins). Some commercially available oils and fats may be enriched with these vitamins.

Proteins provide building blocks of the body and also form various enzymes. Proteins which are easily digestible, have a composition similar to human requirements and contain essential amino acids are proteins of high biological value. These are mostly proteins of animal origin e.g. milk, eggs, poultry, meats etc.

Carbohydrates are sugars, starches, and these may be in simple and complex forms. The ones which raise blood sugar rapidly are called foods with high glycemic index.

The nutritional content of common Indian foods rich in various nutrients are as follows :

Energy in kilocalories provided by 100 g of food material:-

Meetha Tel, Ghee, Vegetable ghee:- 900 cal

Makhan (Butter) 730 cal

Akhrot (Walnut) 690 cal

Coconut dry 660 cal

Moongphali (Peanut) 568 cal

Cheeni (Sugar) 400 cal

Gurh (Jaggery) 383 cal

Chana (Chickpeas)370 cal

Bajra (Millet) 360 cal

Protein content of foods per 100 gm of food:-

Dry Bombay Duck 62 gm

Soybean 43 gm

Milk powder 38 gm

Moongphali (Groundnut) 25 gm

Mung Dal (Petite yellow lentil), Masur (Orange lentils), Urad (Black gram), Rajma (Kidney Beans), Chana (Chickpeas) 20 -25 gm

Calcium content of foods (in mg per 100 gms of food):-

Dried milk powder 1370 mg

Khoya (Curd) 650 mg

Dahi (Yoghurt) 150 mg

Cow milk 120 mg

Egg 60 mg

Potassium content in mg/100 gm of foods

Moong Dal (Petite yellow lentil) 1150 mg

Arhar (Pigeon Peas) 1100 mg

Chana dal (Split Chickpea) 720 mg

Mausambi (Limetta) 500 mg

Shaker Kandi (Sweet Potato) 400 mg

Kela (Banana) 350 mg

Kharbuja (Muskmelon) 340 mg

Bajra (Millet) 310 mg

Iron content of various foods in mg/100 gm

Kala Til (Black Sesame) 57 mg

Poha (Flattened Rice) 20 mg

Chana roasted (Roasted Chickpea)  10 mg

Bajra (Millet) 8 mg

Tarbooj (Watermelon) 8 mg

Khajur (Dates) 7.3 mg

Fibre content  in gms/100 gms of food

Kala til (Black Sesame)  11 gm

Methi (Fenugreek) 7.2 gm

Anar (Pomegranate) 5 gm

Narial  fresh (Green Coconut) 3.6 gm

Iron Balance and Deficiency

Iron is an essential part of hemoglobin (heme portion), myoglobin in muscles, certain enzymes in mitochondria etc. It is stored in the form of ferritin in the body and transported in the blood as transferrin.

The average body of adult humans has 3 to 4 gms of iron, women have about ½ gm less than their male counterparts. About 2.5 gms of iron is in the redblood cells (formed or forming) and ½ to 1 gm is in the storage form. Circulating iron in plasma is 5 to 7 mg and about ½ gm is in myoglobin and various enzymes.

Diet in western countries contains about 10-15 mg of iron daily. In the Asian countries quantity of iron is about ½ to 2/3 of the western diet. Non-vegetarian food iron is absorbed to the extent of 30 % while in vegetarian food only about 10 % of iron is absorbed. Phytates, tannates, phosphates reduce iron absorption while vitamin C enhances it. Iron in vegetarian food is in ferric form and absorption is mainly in ferrous form.

25 to 30 mg of iron may be released from dying RBCs and most of this is very efficiently reused by the body. Iron is lost from the body in sweat, skin and gastrointestinal cells which are shed continuously from the lining of skin and GIT.

Iron is absorbed mainly from duodenum and absorption increases in iron deficiency states. It is decreased in iron surplus states.

Iron deficiency results in anemia with small RBCs which have  reduced hemoglobin. The deficiency states are diagnosed by S Iron , S ferritin, S transferrin level and RBC indices.

Common causes of Iron Deficiency are

Reduced dietary intake

Increased losses in the body from bleeding (menstruation, worms, GI bleeds, nose bleeds , injuries )

Reduced absorption (antacids, GI diseases)

Most woman are chronically deficient in Iron due to menstrual losses and their Hemoglobin is closer to 13 compared to 15 in men. Iron deficiency anemia is a common cause of poor health , fatigue, pregnancy complications etc.

Treatment of Iron deficiency

By increasing dietary Iron (fortified wheat flour) etc and iron supplements in the form of oral and injectable iron preparations. Oral drugs are safer but may cause GI Side-effects. Most Injectable preparations available nowadays have few serious reactions but these have to be administered under supervision.

Chest Pain

Chest Pain is a common yet difficult condition to diagnose. Most chest pains or discomforts are benign, however, some may be a harbinger of serious cardiac emergencies. It is often alarming as the 1st episode may result in instantaneous collapse and sudden death.

About 2/3rds of chest pain are non-organic. Non-organic means not due to heart, lungs, esophagus diseases. About 30 % are due to muscular or rib conditions and about 10% are due to esophagus related disorders. Serious chest pains only form about 10% of the patients attending a doctor. However as the 1st episode itself may be due to a “heart attack” or Acute Myocardial Infarction, all chest pain cases need to be dealt with in detail. The episodes which also include heart attacks, unstable anginas or similar pains due to suspected heart ischemia are clubbed together as Acute Coronary Syndrome or ACS. This helps in deciding which patients need to be admitted or observed.

Ischemic chest pains may be recurrent, appear after a certain quantity of physical exercise, get relieved by rest or nitrate tablets under the tongue are called angina or stable angina.

The ones due to Myocardial Infarctions may be difficult to describe, occur only once or a few times in the life of an individual. These may spread to one or both arms, shoulder/shoulders or jaws. This can be accompanied by nausea, vomiting, collapse, profuse sweating or fatigue. These increase over minutes to hours. In case a myocardial infarction is suspected, aspirin in a dose of about 300 mg is given to the patient to be chewed. In case blood pressure is stable, he or she is given a sublingual nitrate and oxygen is administered if blood levels are low or not available.

Chest pains which have increased in frequency, occur at night, have become more severe or longer lasting, occur at night may suggest Unstable Angina.

Women may describe the pain as more severe and sharp compared to men.

The diagnosis of most of these cases is based on meticulous history, ECGs, Cardiac enzymes and serial observations of these. Based only on clinical evidence the diagnosis may often be wrong.

In cases of chronic stable angina, stress testing, isotope scan (Stress Thallium), provocation tests or angiography may be required.

It is important to know the risk factors for the likelihood of ischemic disease. These are age, male sex, smoking, high blood pressure, diabetes, high levels of lipids in the blood, sedentary lifestyle etc. The more the risk factors, the more likely is the occurrence of ischemic heart disease.

Non-organic cases may be due to anxiety, panic disorders etc. Musculo-skeletal causes include costochondritis (inflammation of rib cartilages). Acid peptic disease, diseases of lungs are also common but relatively simpler to diagnose. Very severe tearing pain may rarely be due to a tear in the aorta (called aortic dissection) and in hospitalized patients, Pulmonary Thromboembolism may be the underlying cause. These are rare but result in fatalities if remain undiagnosed.

Headache

Headache is one of the commonest symptoms causing significant distress to patients. Chronic headaches may recur for years and cause economic, social, psychological and physical issues. 90% of the headaches are benign.

Headache includes pain in the area above the neck including the face. Chronic headaches are common and affect about 40 to 45 % of the population. Chronic headaches may be called tension headaches, migrainous or cluster headaches. The pain may be cutting, shearing, burning, dull or sharp, deep or superficial, throbbing, waxing or waning and of many other types.

Tension headaches often produce a band like sensation or tightness in the head. These are not due to tension in the muscles as is commonly believed. These are also not due to “ Tension or Stress”. The exact mechanism is not clear.

Migrainous headaches are usually throbbing, maybe in one half or both sides, usually last for a few hours to 1 or 2 days, and may be relieved by vomiting or sleep. A patient may know few hours before the onset of a headache that he or she is going to get one. These may affect up to 40 % of the population. These can be effectively prevented and decreased by medicines in most patients.

Cluster headaches are rare (about 1% of all headaches), occur in groups occurring daily for a few weeks to months, last for lesser duration (few minutes to 2-3 hours) and are throbbing. These are severely disabling in nature.

Sinus headaches are usually localized to the area around sinuses. These may be aggravated by sniffing or deep breathing.

Headaches due to meningeal irritation or infection are rare but serious and if not treated rapidly may be fatal. These are usually localized to the back of the head and upper part of the neck up to the shoulders. These may be aggravated by bending the neck forwards. These are often severe, occur with fever or in epidemics, have associated vomiting and cause prostration very early.

Headaches due to brain tumours are often deep-seated, worse at night and worsen with time over days, weeks and months. Associated vomiting (forceful and often sudden) are common.

Most fevers can have headaches associated with them. The headache may increase and or decrease with temperature.

Dangerous Signs of Headaches :

Severe headache coming on suddenly and worsening over seconds to minutes and occurring for the 1st time in life may suggest a bleeding in the brain. Headaches progressively worsening may be due to tumours. Headaches with neurological signs i.e paralysis, double vision, loss of vision or hearing on one side, fits or changes in the level of consciousness, change in voice, inability to speak or comprehend etc usually mean organic (affecting structures of the brain) headaches.

Psychiatric conditions like depression may cause headaches or headaches may cause depression. Headaches may be a side effect of various drugs.

The diagnosis of headaches is usually by a detailed history and relevant clinical examination. X-Ray Skull, CT Scan of the brain and neck spine or MRI may be required for the diagnosis of brain tumours or bleeding.

Chronic headaches are difficult to treat and test the patience of the doctors and the patients both.