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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 & prevention: - 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] - 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 - in patients with diabetes mellitus type 2, SGLT-2 inhibitors associated with lower risk for kidney stones vs GLP-1 receptor agonists or DPP-4 inhibitors [22,24] - physical activity reduces risk of nephrolithiasis [23] - 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

  1. Dropkin BM et al. The natural history of nonobstructing asymptomatic renal stones managed with active surveillance. J Urol 2015 Apr; 193:1265 PMID: 25463995
  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
  6. Pearle MS, Goldfarb DS, Assimos DG et al Medical management of kidney stones: AUA guideline. J Urol. 2014 Aug;192(2):316-24. PMID: 24857648
  7. Sakhaee K, Maalouf NM, Sinnott B. Clinical review. Kidney stones 2012: pathogenesis, diagnosis, and management. J Clin Endocrinol Metab. 2012 Jun;97(6):1847-60. Review. PMID: 22466339 Free PMC Article
  8. Frassetto L, Kohlstadt I. Treatment and prevention of kidney stones: an update. Am Fam Physician. 2011 Dec 1;84(11):1234-42. Review. PMID: 22150656 Free Article
  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
  14. Brisbane W, Bailey MR, Sorensen MD. An overview of kidney stone imaging techniques. Nat Rev Urol. 2016 Nov;13(11):654-662. Review. PMID: 27578040 Free PMC Article
  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
  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.