PHM: What are the most common myths about kidney stones? 
Dr. Borofky: People used to think that older men were the ones most frequently affected. While this may have been true decades ago, we have certainly seen changes in who is getting kidney stones over time to the point that it is about a 50/50 split by gender.  Alarmingly, we’re seeing substantial rises in the rates of kidney stones affecting young people, even children.  No one knows why for sure, but we suspect that dietary changes (more processed foods, high salt and sugar diets) as well as environmental changes (increased heat and humidity leading to fluid loss and dehydration) may be contributing factors. 
 
PHM: What effect does diet and drinking habits have on recurring stones and their formation? What drinks help or prevent kidney stones from forming?   
Dr. Borofsky: Traditionally, dietary fluid habits have been the cornerstone of kidney stone prevention.  Intuitively it just makes sense.  Since kidney stones are essentially just minerals that solidify in free fluid - the more fluid there is for the minerals to wash out, the less likely the risk of stones growing.  
   This concept was proven in a very famous study published in the late 1990's where people who were instructed to drink sufficient amounts to achieve over two liters of urine volume per day decreased their risk of kidney stones by 50%.  Since a certain percentage of what we drink does not end up as urine and is lost to things like sweat, stool and respiration, it takes more than 2 liters of fluid intake to achieve this goal.  We typically recommend someone take in over 100 fluid ounces of liquid per day. While there are many myths on the ‘best’ fluid, it's pretty hard to just beat water.  In some cases, there are fluids that can paradoxically be bad for kidney stone risk - in particular sports drinks which can have high sodium content as well as some black teas which carry high amounts of oxalate.  

PHM: Have you found that modern diets/lifestyles (vegan for example) lead to an increase or decrease in stone formation? What part does genetics play in someone’s risk? 
Dr. Borofsky: In general, I would say yes, although diet is something that’s only one component of someone's risk of forming a kidney stone, which can be influenced by non-dietary factors such as genetics, medical conditions, prior surgeries, social factors, and anatomy.  I advise anyone with a history of kidney stones to start a dietary change, meet with their urologist or a dietitian that has some familiarity managing kidney stone risk. 

One thing that’s likely having a negative influence is salt. Excess salt leads to an increase in kidney filtration of calcium (a key mineral in most kidney stones).  
  Modern convenience diets typically center on people grabbing food in a hurry - either via a fast-food restaurant, convenience stores and microwave or ready-made packages.  Unfortunately, these foods typically have HUGE amounts of sodium, in some cases a single serving carrying more sodium than the daily recommended value (less than 2000 mg).  Even foods thought to be "healthy" are often mislabeled or poorly characterized.  For example, breads, soups, cheese, instant oatmeal all can have very high sodium loads. Sometimes, the food you eat is healthy but there can be huge amounts of salt in the sauces, spices or dressings used for flavor.   Other diets that may have an underappreciated influence on kidney stones include low carb paleo or keto diets which can increase calcium stone risk by featuring high and excess protein.  
   To answer the question about vegan diets in particular, they may be beneficial, but it is important to be aware that some vegetables have very high oxalate content, the mineral notorious for causing kidney stones.  Spinach, beets and rhubarb can be problematic.  High oxalate can be mitigated by adequate hydration and paradoxically, calcium, which some people may become deficient in if they cut out dairy.  Almond milk is another high oxalate food so this replacement may actually cause more harm than good. 
    People may not know this, but weight loss surgery like gastric bypass can also lead to high oxalate levels in the urine which can increase kidney stone risk as well. 

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PHM: Can you speak on Dolly Parton's growing health concerns and the most dangerous aspects of treating kidney stones? 
Dr. Borofsky: While I can’t comment directly on Dolly Parton's personal health or circumstances, I’m aware from reading news reports that her kidney stone had a more damaging effect on her health and lifestyle than many might have immediately expected.  This is something we see commonly, and I am often taken aback at just how injurious a tiny little stone can be on someone's health. 
   The most dangerous aspect, without a doubt, is the combination of an obstructing kidney stone - which is blocking someone's kidney - and a urinary infection.  In many cases, this combination can actually be life threatening.  The other issue is that treatment carries its own morbidity.  Usually, small stones are able to pass without surgery, but this can take time - sometimes weeks - and prevent people from doing their normal activities, being available for their families or for their jobs. Kidney stones have actually been shown to be the single most costly urologic condition.  The other challenge is in surgical care.  Many stones are too large to pass naturally and when surgery is needed, oftentimes it takes two procedures to fully clear a stone in some cases with a couple of weeks between episodes of care.  

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PHM: What causes kidney stones to get worse? 
Dr. Borofsky: Kidney stones get worse when they move.  Most people with kidney stones in the US currently have no idea that they even have one; the majority of stones grow silently until they move.   It's often when they dislodge from the kidney and cause a blockage in the tube that drains the kidney (the ureter) that they become symptomatic.  If this happens in the presence of an infection, it can be a very serious condition and that’s when a temporizing drainage tube - called a stent - may be required to drain the infection, stabilize the situation and come back for surgery to remove the stone at a later date. 
 
PHM: Are there more efficient treatments/cures/surgeries that have come out recently to give patients relief?  
Dr. Borofsky: One of the best parts of being an endourologist who specializes in kidney stone care is knowing this is a very rapidly evolving field where technology is happening at amazing speeds.  The main evolution in our field over the past decade has been miniaturization.  Whereas we used to have to perform large surgeries that involved making incisions in the body, holes in the kidney, or stretching of anatomy that did not want to be opened - we are now frequently able to use very tiny instruments with cameras on them to access the entirety of the urinary tract wherever a stone might be hiding.  
    Once we get to the stone, we have a variety of different devices we can use to treat it including various types of high energy lasers that can smash stones into dust and sand as well as tiny extraction baskets or vacuums that allow us to remove stones in their entirety.  There are also efforts underway to treat stones non-invasively with ultrasound energy and in some cases apply robotics to facilitate treatment. I believe this is an appealing area for AI tools as well.  Needless to say, the future of our field and for our patients is exciting! 
  While Dolly Parton may have a long road to recovery before she’s rockin’ on stage again, but her journey battling some rolling stones - and not the band - can be an educational health experience for millions of fans. 
 

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Michael Borofsky, MD, has been practicing for over a decade and is a board-certified urologist specializing in minimally invasive urologic surgery with expertise in prostate disorders and voiding dysfunction. He completed his urology residency at New York University and a fellowship in Endourology at Indiana University. Dr. Borofsky cares for patients at the University of Minnesota—where he directs the Endourology Fellowship—and at the 

Northstar Prostate Center 
8401 Golden Valley Rd.
Suite 340
Golden Valley, MN 55427
 https://northstarprostate.com/