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nephrolithiasis; kidney stone

see urinary calculus. Etiology: - see urinary calculus - staghorn calculus - oral antibiotics increase risk [11] - risk factors for recurrent stones [12] - younger age - higher body-mass index - male sex - family history of stones - pregnancy at last stone episode - stone composition other than calcium oxalate - asymptomatic stones noted incidentally on previous imaging - additional stones in the kidney (especially in the renal pelvis or lower pole) at the time of a symptomatic episode Clinical manifestations: - presents as colicky flank pain with radiation to groin [16] or lower quadrant pain* - does not present as upper quadrant pain [10] - hematuria* - nausea/vomitng & dysuria may be present* [16] * if the stone is stable & not moving, may be asymptomatic Laboratory: 1) serum chemistries - basic metabolic panel* - serum calcium, serum albumin, serum phosphate, serum uric acid - serum PTH [15] 2) 24 hour urine*: a) 24 hour urine calcium b) 24 hour urine creatinine c) 24 hour urine uric acid - increased risk of uric acid stones if > 1000 mg/24 hrs d) phosphorous, citrate, oxalate, cystine 3) stone profile* a) calculus composition analysis b) inhibitor content c) 75-85% of stones contain calcium 4) urinalysis: hematuria* - urine microscopy: non-dysmorphic erythrocytes* * hematuria may not be present if stone is stable Radiology: - renal ultrasound (preferred modality in pregnant women) [16] - non-contrast CT of kidneys, ureters, bladder (initial test of choice) [19] Complications: - recurrent stones - hypercalcemia, hyperparathyroidism Management: - prognosis & treatment - kidney stone < 5-6 mm usually pass sponataneously [16] - passage of stones 4-10 mm may be facilitated by tamsulosin, nifedipine, silodosin, or tadalafil; efficacy is controversial (see urinary calculus) [16] - thiazide diuretics have been recommended to decrease recurrent nephrolithiasis in people with calcium stones; a randomized trial failed to find benefit [18] - NEJM [19] recommends thiazide diuretics for hypercalciuria & alkaline urine - 28% of asymptomatic renal stones will become symptomatic in 3.5 years [1] - removal of small asymptomatic stones when removing a larger symptomatic stone prevents subsequent symptomatic renal colic [17] - prevention - adequate hydration > 2.5 L/day* (enough to produce > 2L urine /day) [16,21,26] - increase calcium & magnesium intake to bind oxalate in the gut & prevent its absorption (calcium oxalate most common stones) - replacement of inhibitor substances - potassium citrate* 10-30 meq BID [20] - reduces risk of calcium, uric acid, & cystine stones [21] - NEJM [19] claims potassium citrate may increase risk of calcium phosphate stones in alkaline urine - pyrophosphate - magnesium oxide, magnesium citrate - physical activity reduces risk of nephrolithiasis [25] - see urinary calculus - urology consultation - pyelonephritis or urosepsis (associated with nephrolithiasis) - acute kidney injury - large stone (> 1 cm) requiring surgical removal - bilateral urinary obstruction - urinary obstruction of a solitary kidney

Interactions

disease interactions

Specific

staghorn calculus

General

urinary calculus (stone, nephrolithiasis, urolithiasis) kidney disease; renal disease

References

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  2. Brener ZZ, Winchester JF, Salman H, Bergman M. Nephrolithiasis: evaluation and management. South Med J. 2011 Feb;104(2):133-9. Review. PMID: 21258231
  3. Eisner BH, Goldfarb DS, Pareek G. Pharmacologic treatment of kidney stone disease. Urol Clin North Am. 2013 Feb;40(1):21-30. Review. PMID: 23177632
  4. Fink HA, Wilt TJ, Eidman KE et al Medical management to prevent recurrent nephrolithiasis in adults: a systematic review for an American College of Physicians Clinical Guideline. Ann Intern Med. 2013 Apr 2;158(7):535-43. Review. PMID: 23546565
  5. Heilberg IP, Goldfarb DS. Optimum nutrition for kidney stone disease. Adv Chronic Kidney Dis. 2013 Mar;20(2):165-74. Review. PMID: 23439376
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  9. Semins MJ, Matlaga BR. Kidney stones and pregnancy. Adv Chronic Kidney Dis. 2013 May;20(3):260-4. Review. PMID: 23928391 - Semins MJ, Matlaga BR. Kidney stones during pregnancy. Nat Rev Urol. 2014 Mar;11(3):163-8. Review. PMID: 24515090
  10. Casey J, Vaidya A, Frank N et al Dissecting a Case of Abdominal Pain N Engl J Med 2016; 375:e35. October 27, 2016 http://www.nejm.org/doi/full/10.1056/NEJMimc1516704
  11. Tasian GE, Jemielita T, Goldfarb DS et al Oral Antibiotic Exposure and Kidney Stone Disease. JASN May 10, 2018 PMID: 29748329 http://jasn.asnjournals.org/content/early/2018/05/09/ASN.2017111213
  12. Vaughan LE, Enders FT, Lieske JC et al. Predictors of symptomatic kidney stone recurrence after the first and subsequent episodes. Mayo Clin Proc 2019 Feb; 94:202. PMID: 30527866 https://www.mayoclinicproceedings.org/article/S0025-6196(18)30757-2/fulltext
  13. Pfau A, Knauf F. Update on Nephrolithiasis: Core Curriculum 2016. Am J Kidney Dis. 2016 Dec;68(6):973-985. PMID: 27497526
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  15. Ganesan C et al. Analysis of primary hyperparathyroidism screening among US veterans with kidney stones. JAMA Surg 2020 Sep; 155:861. PMID: 32725208 PMCID: PMC7391180 https://jamanetwork.com/journals/jamasurgery/article-abstract/2768496
  16. Medical Knowledge Self Assessment Program (MKSAP) 19. American College of Physicians, Philadelphia 2021 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  17. Sorensen MD et al. Removal of small, asymptomatic kidney stones and incidence of relapse. N Engl J Med 2022 Aug 11; 387:506 PMID: 35947709 https://www.nejm.org/doi/10.1056/NEJMoa2204253
  18. Dhayat NA, Bonny O, Roth B et al. Hydrochlorothiazide and prevention of kidney-stone recurrence. N Engl J Med 2023 Mar 2; 388:781-791 PMID: 36856614 https://www.nejm.org/doi/10.1056/NEJMoa2209275 - Alexander RT. Do thiazides reduce the risk of kidney-stone recurrence? N Engl J Med 2023 Mar 2; 388:841-842 PMID: 36856621 https://www.nejm.org/doi/10.1056/NEJMe2300120
  19. NEJM Knowledge+ Nephrology/Urology
  20. Robinson MR et al. Impact of long-term potassium citrate therapy on urinary profiles and recurrent stone formation. J Urol 2009 Mar; 181:1145. PMID: 19152932
  21. Qaseem A et al Dietary and Pharmacologic Management to Prevent Recurrent Nephrolithiasis in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161(9):659-667 PMID: 25364887 http://annals.org/article.aspx?articleid=1920506
  22. Paik JM et al. Sodium-glucose cotransporter 2 inhibitors and nephrolithiasis risk in patients with type 2 diabetes. JAMA Intern Med 2024 Jan 29; [e-pub]. PMID: 38285598 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2814491
  23. Liu Y, Ku PW, Li Z et al Intensity-Specific Physical Activity Measured by Accelerometer, Genetic Susceptibility, and the Risk of Kidney Stone Disease: Results From the UK Biobank. Am J Kidney Dis. 2024 May 14:S0272-6386(24)00760-1. PMID: 38754804 https://www.ajkd.org/article/S0272-6386(24)00760-1/fulltext
  24. McCormick N, Yokose C, Lu N et al Comparative effectiveness of sodium-glucose cotransporter-2 inhibitors for recurrent nephrolithiasis among patients with pre-existing nephrolithiasis or gout: target trial emulation studies. BMJ. 2024 Oct 30;387:e080035. PMID: 39477370 PMCID: PMC11524131 Free PMC article.
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