Question
Dr. Shah,
I am a 40 year old female with a history of 3-4 kidney stones within the past 22 years. The first stone consisted of calcium oxalate. For ten months, I have experienced recurrent episodes of painless gross hematuria and persistent microscopic hematuria. On three occasions, I have had renal colic in my right kidney, and edema in fingers and ankles is common. I have noticed an elevation in blood pressure from 125/85 last year to 140/95 on recent visits. A urologist performed a cystoscopy and retrograde pyelogram, which were normal. Recently, a nephrologist ordered several blood tests, a 24 hour urine test, and an ultrasound. The results of those tests are as follows:
CBC - all normal, except:
HCT 37.3 L % (L=37.7 H=47.9)
CMP
Albumin 3.9 g/dl (L=3.4 H=5.0)
Total Bili 0.9 mg/dl (L=0.40 H=2.0)
Calcium 9.2 mg/dl (L=8.8 H=10.50)
Urea Nitrogen 12 mg/dl (L=8 H=20)
Creatinine 0.8 mg/dl (L=0.60 H=1.10)
Glucose 96 mg/dl (L=74 H=118)
Sodium 139 mmol/L (L=136 H=144)
Potassium 3.6 mmol/L (L= 3.6 H=5.20)
Chloride 104 mmol/L (L=100 H=108)
Total CO2 28.0 mmol/L (L=22.0 H=32.0)
Total Protein 7.3 g/dl (L=6.10 H=7.90)
GOT (AST) 18 IU/L (L=15 H=41)
GPT (ALT) 14 IU/L (L=14 H=54)
ALK PHOS 66 IU/L (L=38 H=126)
BUN/CRE Ratio 15 (L=8 H=30)
Osmo 268 L (L=273 H=304)
Globulin 3.4 g/dl (L=1.50 H=3.50)
C4 Complement 44 mg/dL (16 - 47)
CH50 Complement 56 U/ml (22 - 60)
C3 Complement 131 mg/dl (115 - 230)
ANA Negative
Lipid Profile
Cholesterol 167 mg/dl (L=50 H=200)
Triglyceride 92 mg/dl (L=30 H=200)
HDL 38 mg/dl (L=29 H=89)
LDL (Calc) 114 mg/dl (L=0 H=130)
Coronary Risk 4.39 ratio (L=0 H=4.44)
Uric Acid (Serum) 4.2 mg/dl (L=2.3 H=6.60)
Uric Acid (Urine, 24hr) 702 mg/24 hr (250 - 750)
Total Volume 1800 ml/24 hrs
Calcium (Urine, 24hr) 243 mg/24 hr (25 - 275)
Total Volume 1800 ml/24 hrs
Magnesium (Urine, 24hr) 86 meq/24 hr (20 - 210)
Total Volume 1800 ml/24 hrs
Citrate (Urine, 24hr)
Citrate 24 hr Urine 698.00 mg/24 hr(280 - 1240)
Creatinine 24 hr Urine 1.38 g/24 hr (0.63 - 2.50)
Total Urine Volume 1800.00 mL
Oxalate (Urine, 24hr)
Oxalate 34 mg/24 hr (0 - 45)
24 Hr Urine Creat 1.8 g/24 hr (1.0 -2.0)
Total Urine Volume 1800 mL
Creatinine Clearance
Creatinine 0.8 mg/dl (L=0.60 H=1.10)
Urine Creatinine 1640 H MG/24hrs(L=600 H=1600)
Creatinine Clearance 142 H MLS/MIN (L=75 H=115)
Collection Period 24 hrs
Total Urine Volume 1900 MLS
Sodium (Urine, 24hr) 261 H mmol/24 hr (40 - 200)
Total Volume 1800 ml/24 hrs
Protein (Urine, 24hr) 234 H mg/24 hr (25 - 150)
Total Volume 1800 ml/24 hrs
IFE Evaluation w/ Prot Elect, Urine
Albumin 100
Alpha 1 Concentration see interp
Alpha 2 Concentration see interp
Beta Concentration see interp
Gamma Concentration see interp
Interpretation:
Faint albumin band detected on Urine Protein Electrophoresis. No Bence-Jones or other
Abnormal proteins detected, but Immunofixation is more sensitive.
Immunofixation, Urine
Polyclonal light chains are detected, however no monoclonal immunoglobulin or free
Light chain (Bence-Jones Protein) is detected.
Urine Total Protein 209 H mg/24 hrs (1 - 150)
Total Urine Volume 1900 MLS
US Renal UltraSonogram: Impression: Negative renalultrasonogram
The kidneys are normal in size, smooth contour and no abnormal renal mass. The right kidney is 4.9 x 5 x 11.6cm. The left kidney is 5.5 x 5.7 x 11.2cm. The renal cortical substance thickness is in the limit of normal. No abnormal strong echogenicity that is suggestive of renal calculus. No sign of abnormal dilatation of the pelvicaliceal system. No abnormal perirenal mass or fluid collection. Aorta is unremarkable.
I have been given a diagnosis of Renal Stone Disease and placed on the following medications:
Hydrochlorothiazide 12.5mg (HCTZ) - diuretic, with some effect on calcium?
Allopurinol 100mg - (for uric acid)
The doctor also mentioned that I may have kidney disease; however, he would not consider a renal biopsy.
I wonder how likely it is that I have Renal Stone Disease, considering that the ultrasound was negative.
I wonder why I am being treated for elevated uric acid levels, when mine are within range.
I wonder why I am being given a diuretic, which the doctor explained would encourage my kidneys to not filter calcium - again, my calcium levels are within range.
I am concerned about the elevated protein, sodium, and creatinine levels. (Contrary to the doctor?s suggestion, I do not eat out often and do not salt my food at the table, and use salt sparingly in cooking. I also do not eat meat in excess.)
Question: Considering the information I have provided, what is your professional opinion concerning my diagnosis? And would you suggest any additional testing at this point?
I realize this is lengthy, but I am quite confused and concerned. I really appreciate you taking the time to consider my situation. I look forward to hearing from you.
Michelle
Answer
Hi Michelle,
Thanks for your question on "Allexperts".
Although your question is lengthy, it provided all details, especially the lab values with their proper units and the normal reference ranges.
Ultrasound is not a very sensitive test to detect stones. CT will give optimum information regarding stones.
You have a slightly elevated (microalbuminuria) urinary protein level which is consistent with the history of stone disease.
Most kidney stones are calcium oxalate and hydrochlorothiazide helps in preventing formation of these stones. Considering your history, I am surprised nobody had started it earlier.
I am also surprised that you are being treated with Allopurinol when you have normal uric acid levels. Please discuss it with your Nephrologist.
At this point, I do not suggest any other tests. Keep following up regularly with the Urologist.
Sincerely,
Dr. Shah
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