NEPHROLITHIASIS

• 12 percent of men and 5 percent of women will have at least one symptomatic stone by
the age of 70.
• Male - 2 times more common, middle-aged white men

Types
Calcium oxalate/phosphate: 60-80%
Struvite (triple phosphate): 5-15%
Uric Acid: 5-10%
Cystine: 1%
Other (xanthine, indinavir etc): 1%

Risk Factors
Dietary: Low fluid intake, High sodium intake, High protein intake, Low calcium intake
Metabolic:Hypercalciuria, Hypocitraturia, Hyperuricosuria, Hyperoxaluria
Medical Conditions: Gout, Obesity, Renal tubular acidosis, Sarcoidosis, Primary
hyperparathyroidism, Medullary sponge kidney, Horseshoe kidney, HIV/AIDS with
protease inhibitors, Metabolic syndrome/type 2 diabetes mellitus
Genetic: Polycystic kidney disease, Dent's disease, Cystinuria, Primary hyperoxaluria

Clinical features
Urinary tract symptoms
• Pain—classic colicky loin to groin pain or renal pain, • Haematuria, gross or
microscopic (occurs in 90%) • Dysuria
Systemic symptoms
• Restless patient, often writhing in distress, • Nausea, vomiting• Fever and chills (if
associated infection)
Asymptomatic
• Incidental stones (one third may become symptomatic) - The likelihood of developing
symptoms was approximately 32 percent at 2.5 years and 49 percent at 5 years

Diagnosis
Urinalysis in patients with nephrolithiasis reveals blood, and the urine sediment has
intact, nondysmorphic erythrocytes.
* The majority of kidney stones are radio opaque and visualized on kidney, ureter, and
bladder film.
* Renal ultrasonography detects kidney stones and urinary tract obstruction but is less
sensitive for smaller stones.
* Intravenous pyelography is highly sensitive and specific for kidney stones but is
contraindicated in patients with renal insufficiency.
* Noncontrast helical abdominal CT is the gold standard for diagnosing
nephrolithiasis.
In a patients with recurrent stones, in addition to the baseline investigations (U/A, BMP),
consider PTH, Vit D, a 24 hour urine assessment for urine volume and calcium, oxalate,
uric acid, citrate, urine sodium, and creatinine excretion.

Treatment
Hydration and pain control with NSAIDS or narcotics if renal insufficiency is present
in the acute setting.

Kidney stones <5 mm in diameter typically pass spontaneously, whereas stones >10 mm
often require invasive measures

Shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy have

replaced open surgery for treating urolithiasis
Most simple renal calculi (80-85%) can be treated with shock wave lithotripsy
Percutaneous nephrolithotomy is the treatment of choice for complex renal calculi
Staghorn calculi should be treated, and percutaneous nephrolithotomy is the preferred
treatment in most patients
Ureteroscopy is the preferred treatment in pregnant, morbidly obese, or patients with
coagulopathy

Prevention
15% have recurrence at 1 year, 35% to 40% at 5 years, and 50% at 10 years

Fluid consumption >2 L/d and restriction of sodium intake

Targeted therapy is recommended for patients with an identifiable metabolic abnormality

that favors stone formation

Quiz

______________ (alone or in combination) is the most common type of urinary stone.

Most ureteral stones under ________ pass spontaneously.

______________ is the most common abnormality and the single most important factor
to correct so as to avoid
recurrences.