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urinary calculus (stone, nephrolithiasis, urolithiasis)

Concretions of crystals in the urine, more commonly stones. Etiology: 1) composition a) calcium oxalate* b) calcium phosphate* c) uric acid (radiolucent) d) cystine (may be intermediate in radio-opacity) e) ammonium magnesium phosphate (struvite, staghorn calculi, pyelonephritis) f) less common - xanthine - oxypurinol 2) predisposing factors a) dehydration b) stress c) supersaturation of urine with crystal - hypercalciuria (calcium oxalate, calcium phosphate) - hyperoxaluria (calcium oxalate) - uricosuria (uric acid) - cystinuria (cystine) d) alterations in inhibitors of crystal formation - pH - calcium phosphate & struvite stones form in alkaline urine - uric acid & cystine stones form in acidic urine - low citrate (RTA type 1) - pyrophosphates - low magnesium e) urine stasis from obstruction f) repeated infection by urease-containing organisms - high urine pH - Proteus, Klebsiella, Pseudomonas & others - struvite stones - staghorn calculus g) diet high in animal protein (Atkin's diet) h) polycystic kidney disease i) medullary sponge kidney j) renal tubular acidisis (RTA) type 1 k) hyperparathyroidism (calcium phosphate) l) gout (uric acid) m) pharmaceutical agents - carbonic anhydrase inhibitors - acetazolamide for glaucoma (calcium phosphate) - calcium carbonate (milk alkali syndrome) - allopurinol (xanthine or oxypurinol stones) - triamterene - methoxyfluorane (calcium oxalate) - vitamin D, non thiazide diuretics, steroids (hypercalciuria) - indinavir - topiramate [3] calcium phosphate stones - zonisamide [3] - chemotherapy (increased uric acid load) - oral antibiotics increase risk of nephrolithiasis [38] n) intestinal hyperoxaluria (calcium oxalate stones) - bowel surgery - Crohn's disease - ileostomy - Roux-en-Y gastric bypass surgery [15] o) migraine headaches (RR=1.6) [21] p) genetic predisposition: family history q) pregnancy: 3rd trimester & 1st 3 months postpartum (RR=3) [40] * calcium stones comprise 75-80% of all stones [3,20] - most are composed of calcium oxalate - calcium phosphate (hydroxyapatite) if pregnancy associated [40] Epidemiology: 1) 13% of men & 7% of women will develop urinary calculi at some point in their lives [20] 2) annual incidence is 0.1% 3) men have twice the risk as females 4) if untreated 50-75% will have recurrence within 7 years - 35% to 50% with 5 years [20] Genetics: - susceptibility to uric acid nephrolithiasis caused by defect in ZNF365 gene Clinical manifestations: 1) acute flank pain a) costovertebral angle (CVA) tenderness b) acute colic to dull, persistent pain 2) pain may be localized along the urinary tract to the groin 3) pain may be abdominal 2) nausea/vomiting 3) pain not relieved by position 4) fever &/or persistent UTI may suggest urinary calculi specially struvite 5) hematuria (may be painless) Laboratory: 1) urinalysis a) hematuria (biphasic manifestation) [4] 1] prevalence highest on the day symptoms begin then declines over several days, then increases 2] absence of RBC does not rule out nephrolithiasis b) WBC c) RBC & WBC observed with calculi & UTI d) urine calcium: hypercalciuria e) urine oxalate: hyperoxaluria f) urine citrate: hypocitraturia 2) urine culture: - urease-containing organisms (Proteus, Klebsiella) 3) 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 4) serum chemistries - basic metabolic panel* - serum calcium, serum phosphate, serum uric acid - serum PTH 6) stone profile* a) calculus composition analysis b) inhibitor content c) 75-85% of stones contain calcium 7) also see ARUP consult [10] 8) also see crystals in urine * choices of NEJM [44] Radiology: 1) abdominal ultrasound a) initial diagnostic test in pregnant women - initial diagnostic test for all patients [3,19,42] b) detects distal ureteral calculi [9] 2) computed tomography (CT) of abdomen (without contrast) a) gold standard [3] & initial diagnostic test (NEJM) [44] - ultrasound should be initial diagnostic test [19] - indicated if ultrasound negative, hematuria associated with pain suggesting urolithiasis [3] b) can identify every type of urinary stone throughout its path through the urinary tract [3] c) may be useful in identifying type of stone (especially calcium stone) [3] d) should not be used to assess children & adolescents with suspected nephrolithiasis [37] 3) plain abdominal X-ray (KUB) - of no use for diagnosis of acute nephrolithiasis [3] 4) intravenous pyelogram (IVP) 5) urography with nephrotomography 6) infared spectroscopy of stone 7) X-ray diffraction of stone Differential diagnosis: 1) cholecystitis 2) appendicitis 3) diverticulitis 4) UTI concurrent with calculus 5) urinary tract tumor 6) acute renal failure suggests a) obstructive uropathy 1] bilateral obstruction 2] obstruction in a solitary kidney b) volume depletion c) sepsis Complications: - may be an association between kidney stones & progression to chronic renal failure [3,11] - reported increase in risk of hypertension, diabetes mellitus, metabolic syndrome [18] - modest increase in risk of cardiovascular disease in women [18] - also see specfic urinary stone Management: 1) asymptomatic kidney stone found on imaging do not require urgent intervention 2) treatment of symptomatic individuals a) pain control: - NSAIDs may be preferable to opiates [5] - parenteral ketoralac (Toradol) for acute renal colic b) relief of nausea/vomiting c) rehydration with IV saline if volume depleted d) stone removal or passage - stones < 5-6 mm in size usually pass spontaneously - tamsulosin 0.4 mg QD expedites passage of ureteral stones 4-10 mm in size [34] - no benefit for smaller stones - NNT = 5 to expedite passage of 1 stone [34] - nifedipine SA 30 mg or tamsulosin 0.4 mg QD for 5-7 days may reduce ureteral spasms & diminish pain [6] - tamsulosin superior to nifedipine [7], reduces median time ofstone passage from 5 days to 3 days [14] - tamsulosin (0.4 mg QD), nifedipine (30 mg QD) for 4 weeks no better than placebo [23,24] - tamsulosin (0.4 mg QD) reduces time to passage of stones 5-10 mm (7 vs 11 days with placebo) [28]; - no benefit for smaller stones - alfuzosin reduces median stone passage time 8 days to 5 days & reduces pain - corticosteroids reduce ureteral edema & facilitate passage of stones - hydration - roller coasters may help patients pass kidney stones [35] - stones > 10 mm require surgery [3] - ureteroscopy - stones in the mid-distal ureter - removal of stone fragments resulting from lithotripsy - lithotripsy (extracorporeal shock wave therapy) - stones < 1-1.5 cm in kidney or upper urinary tract (renal pelvis or upper ureter) - percutaneous nephroscopic removal - stones >= 1.5 cm - staghorn calculi - cystine stones resistant to lithotripsy - patients with urinary tract abnormalities - open surgery - indications for stone removal - hydronephrosis - unrelieved pain - deteriorating renal function - pyelonephritis - removal of small asymptomatic kidney stones when removing a larger symptomatic kidney stone prevents subsequent symptomatic renal colic [41] e) antibiotic therapy for concurrent UTI f) long-term antibiotics may be needed for large struvite stones 3) bladder stones - transurethral cystolitholapaxy - open cystostomy if very large stone(s) or very large prostate 4) prevention a) adequate hydration > 2.5 L/day* (enough to produce > 2L urine /day) [20] b) diet - reduced animal protein (uric acid stones) - increased vegetable fiber - decreased salt (dietary sodium) intake - calcium oxalate stones - reduce dietary oxalate - see oxalate for oxalate content of foods [36] - reduce animal protein, dietary sodium - do not restrict calcium intake - dietary calcium of 800-1200 mg/day - calcium restriction does not prevent stones, but may actually increase stone formation - dietary calcium paradoxically decreases risk of calcium oxalate stone formation & recurrence [3] - calcium restriction contributes to osteoporosis - increase intake of citrate & potassium - magnesium is a protective factor in stone formation via binding to oxalate in the intestines & urinary tract, decreasing oxalate absorption & crystallization, respectively [39] - reduced calorie diet - avoid colas, which are acidified with phosphoric acid - does not apply to fruit-flavored soft drinks, which are often acidified with citric acid [20] - regular riding on a roller coaster may facilitate passage of microscopic & very small calculi passage before symptomatic renal stones can recur [35] c) an equivalent amount of ingested calcium (mass/mass) minimizes urinary oxalate [27] - calcium carbonate supplements effective d) increase urine pH - pH > 7 increases uric acid solubility - pH > 8 increases cystine solubility e) thiazide diuretics* reduce urinary excretion of calcium - a randomized trial failed to find benefit [43] - recommended for treatment of nephrolithiasis associated with idiopathic hypercalciuria even the absence of hypertension or edema [3] - NEJM [44] recommends thiazide diuretics for hypercalciuria & alkaline urine - thiazide diuretics have been recommended to decrease recurrent nephrolithiasis in people with calcium stones; however, a randomized trial failed to find benefit [43] f) replacement of inhibitor substances - potassium citrate* 10-30 meq BID [1,8] - reduces risk of calcium, uric acid, & cystine stones [20] - NEJM [44] claims potassium citrate may increase risk of calcium phosphate stones in alkaline urine - pyrophosphate - magnesium oxide g) allopurinol* decreases formation of uric acid * thiazide diuretic, citrate, or allopurinol recommended if adequate fluid intake is not feasible [20] * urine alkalinization preferable to allopurinol for uric acid stones unless 24 hour urine uric acid > 1000 mg/day [3]

Related

2,8-dihydroxyadenuria crystals in urine hereditary nephrolithiasis hyperoxaluria idiopathic hypercalciuria xanthinuria

Specific

calcium stone cystine stone nephrolithiasis; kidney stone struvite (magnesium ammonium phosphate) stone ureteral stone uric acid stone (urate nephropathy, gouty nephropathy)

General

urologic disease stone

References

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