Api Chewcharat Profile picture
Jul 7 21 tweets 8 min read
1/ 🧵 Hey #NephTwitter #MedTwitter Tweetorial alert!
If you have ever had a kidney stone, you probably don't want another one. Let's explore the risk factors for kidney stone

Game of Thrones is over and winter is gone. Jon Snow presents to the ED complaining of left flank pain
2/ Jon Snow was found to have a kidney stone. What is the most likely composition of his kidney stone?
3/ The best answer is calcium oxalate. pubmed.ncbi.nlm.nih.gov/25278549/
4/ Jon Snow is curious🤔as this is his third time having kidney stones. He noticed that all of his stone episodes occurred during summertime. Are stones more common during different seasons?
5/ The incidence of kidney stones appears to be higher in summer. Why is it? There is no clear explanation. Previous data suggest that stone formation mainly starts during winter as urinary calcium is higher during winter time compared to summer.
6/ When summer☀️hits, ↑ temperature → ↓ extracellular fluid → ↑ urinary concentration and ↓ urinary volume → urine supersaturation → ↑ growth of kidney stones

pubmed.ncbi.nlm.nih.gov/21451456/
pubmed.ncbi.nlm.nih.gov/29757578/
7/ Eventually, Jon Snow passed the stone. Stone analysis showed 90% calcium oxalate and 10% uric acid. 24 hour urine collection (Litholink) was performed along with a basic metabolic panel, calcium, phosphate, iPTH, and uric acid. Bloodwork was unremarkable. Litholink was pending
8/ John Snow asks if kidney stones can affect long-term kidney health❓
9/ Yes! Kidney stones are associated with chronic kidney disease, cardiovascular disease and osteoporosis. Pathogenesis of kidney stones and CKD are not clearly identified (UTI, analgesic nephropathy, shock wave lithotripsy, recurrent obstruction)
pubmed.ncbi.nlm.nih.gov/25635032/
10/ The goal for Jon Snow right now is not just to help Daenerys claim the Iron Throne but to prevent recurrent kidney stones. Which of the following is the most appropriate preventive measure?
11/ The best answer is ↓ animal protein intake. Here are some other interventions to prevent stone formation
pubmed.ncbi.nlm.nih.gov/23535174/
pubmed.ncbi.nlm.nih.gov/25411295/
pubmed.ncbi.nlm.nih.gov/23381591/
12/ Jon Snow is upset as he mainly consumes a large portion of protein from animals. He is wondering why ↑ animal protein intake is associated with a ↑ risk of kidney stones. If we were to measure his 24-hour urine prior to his dietary modification, what would we expect to see?
13/ The correct answer is all. Non-Dairy animal protein consists of sulfur-containing amino acids → sulfuric acid generation → which is buffered in part by bone salts → calcium release from bone → increased urinary calcium excretion
14/ The proximal tubule tries to augment citrate reabsorption to buffer the acidity leading to a reduction in urine citrate. Urine pH is low as a result of the high acid load.
pubmed.ncbi.nlm.nih.gov/12148098/
pubmed.ncbi.nlm.nih.gov/27445166/
15/ Jon Snow read on the news that there are some dietary patterns that he can follow to reduce the risk of recurrent kidney stones. What diet is he referring to?
👩‍🍳👨‍🍳
16/ Correct answer is all. Of note, the vegan diet is poor in calcium and may be rich in oxalate from plants only which could theoretically lead to a higher risk of kidney stones.
pubmed.ncbi.nlm.nih.gov/32183500/
17/ Jon Snow decided to follow a Mediterranean diet. His 24 hr urine collection shows: Volume 2,600 ml, pH 6.0, calcium 400 mg, citrate 800 mg, oxalate 35 mg, and uric acid 650 mg. Which of the following is the most appropriate additional management? 💊
18/ The best answer is CLD. Thiazide diuretics (TZD) → ↓calcium excretion by up to 50% and can be used to manage recurrent calcium oxalate stones. Many patients require at least 50-100 mg of HCTZ or CLD to achieve adequate lowering urinary calcium.
pubmed.ncbi.nlm.nih.gov/12846750/
19/ Jon Snow has normal urinary citrate; thus potassium citrate may not be of additional benefit.
Check @amyaimei's tweetorial for more details
20/ Take away
Most common kidney stones are CaOx and occur in the summer through unclear mechanisms
Mgmt CaOx: Diets ↑fruits🍊 & vegetables 🍅, ↓salt, ↓animal protein & adequate calcium. Otherwise can add TZD to help ↓urinary calcium and add KCitrate to ↑urinary citrate
21/ Thank you to the NSMC group for helping with this tweetorial!!!
@NSMCInternship @RenalFellowNtwk @TheSkeletonKG @MAHIMRes

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