SEMINAR I
growing into a stone.
RENAL CALCULI
Introduction
Kidney Stones
Renal Calculi (pebbles)
Nephrolitiasis Renal Stones
Formation of rock like pieces in the
urinary system, usually in the
collecting systems of the kidneys
4 more times common in men
Predominant age of onset 3rd to 5th
decade of life
Urolithiasis
Ureterolithiasis
Kidney stones typically leave the
body by passage in the urine stream,
and many stones are formed and
passed without causing symptoms
If stones grow to sufficient size
before passage on the order of at
least 2-3 millimeters- they can cause
obstruction of the ureter
There are several conditions that can
contribute to the formation of kidney
stones:
A high concentration of stone
forming mineral salty in the urine.
When high levels of stone, Forming
substances such as calcium oxalate,
calcium phosphate, or struvite are
present in the urine, one or more
crystals may form and become
trapped within the urinary tract. The
crystal may attract other crystals
and bind together with them
An uneven balance of acid in the
urine. The acidity or alkalinity of the
urine affects the ability of stone-
forming substance to remain
dissolved. Some types of stones will
form in acid urine; others will form
only in alkaline urine.
A lack of substances in the urine
that prevent the growth of crystals.
Normally, substances that inhibit the
formation and growth of crystals
such as pyrophosphates, citrates,
and magnesium are present in the
urine. A decrease in or absence of
those substances may cause a stone
to develop.
Etiology
Stasis of urine over a long period of
time
Deficiency of vitamin a and excess
of vitamin D
Endocrine disorders
May be due to:
underlying conditions renal tubular
acidosis, and Hyperparathyroidism
Signs and Symptoms:
Asymptomatic
Acute flank pain (lower abdomen
and groin- renal colic
Nausea and vomiting
Restlessness and dull pain
Hematuria (due to damage of the
urinary tract)
Fever (if infection is present)
Colicky pain
Other symptoms:
-Dysuria- burning on the urination
when passing stones (rare). More
typical of infection.
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 -Oliguria- reduced urinary volume
caused by obstruction of the bladder
or urethra by stone, or extremely
rarely, simultaneous obstruction of
the both ureters by a stone.
Types of Calculi
Based on the type of crystal they
consist:
Calcium stones
Phosphate stones
Uric acid stones
Cysteine stones
Rare stones
Calcium stones
The most common is the calcium
oxalate
Very hard, often dark colored and
typically rough
Forms approximately 75% of renal
stones
Hyperparathyroidism, sarcoidosis,
milk alkali syndrome
Excessive dietary intake of vitamin
D, multiple myeloma and renal
tubular acidosis
Phosphate stones
Pale and friable, resembles clay or
chalk
Composes 15% of stones
Usually formed in the presence of
urea splitting bacterial infection like
Proteus and Pseudomonas
Uric acid
Yellow to brownish red, moderately
hard
Forms 6-10 % of renal stones
Always colored can be seen in gout,
Lesch-Nyhan syndrome, glycogen
storage disease
Struvite (magnesium, ammonium
and phosphate)
The formation of struvite stones is
associated with the presence of
urea-splitting bacteria, most
commonly Proteus mirabilis(but
also Klebsiella, Serratia, Providencia
species)
These organism are capable of
splitting urea into ammonia,
decreasing the acidity of the urine
and resulting in favorable
conditions for the formation of
struvite stones.
Struvite stones are always
associated with urinary tract
infections.
Cystine stones
Pale yellow with white granules
Feel greasy
Forms 1-2% renal stones
Defective transport of cysteine,
ornithine, lysine aand arginine
(COLA)
Hexagonal plates can be seen in
microscopic urine analysis
Formation of cysteine stones is
uniquely associated with people
suffering from cystinuria, who
accumulates cysteine in their urine.
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Cystinuria can be caused by
Fanconis syndrome.
Fanconi syndrome is a disorder in
which the proximal tubular fuction
of the kidney is impaired, resulting
in decreased reabsorption of
electrolytes and nutrients back into
the bloodstream
Rare Stones
Xanthine
- Formed from a rare autosomal
recessive hereditary condition.
- Deficiency of the enzyme
xanthine oxidase
- Can be seen as complications of
allopurinol therapy
Adenine
- Can be formed upon multiple
transfusions using acid citrate
dextrose as preservative
- Deficiency of enzyme adenine
phosphoribosyl transferase
leading to the formation of
dihydroxy adenine
Noncontrast helical CT scan
- A special x-ray in which a
computer to take pictures of the
kidneys
Abdominal ultrasound
- Uses a soundwaves to view
picture of the abdomen
Laboratory Test
- Routing urinalysis (hematuria)
- Urine culture (exclude possibility of
infection)
- CBC (increased neutrophil,
suggestive of infection)
- Renal function test BUN, Crea,
Calcium and Uric Acid
- 24 hour urine (magnesium, sodium,
uric acid, calcium citrate, oxalate
and phosphate)

Diagnosis & Testing

IVP (intravenous pyelogram)
- An IVP is an x-ray of the
kidneys, bladder and ureters
and uses a dye given
intravenously, this make the
organ shows up better in x-ray
pictures
KUB Cytoscopy
- An x-ray machine take - Endoscopy of the urinary bladder
pictures of the kidneys, via the urethra is called
cystoscopy
ureters, and bladder

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 - The cytoscope has lenses like a - Divide into 10 plate/tube
telescope or microscope. These
lenses let the doctor focus on CALCIUM
the inner surfaces of the urinary OXALATE
CARBONATE
tract.
URIC ACID
Kidney stone analysis PHOSPHATE
Test done on kidney stone to see MAGNESIUM
what chemicals are in it. AMMONIA
It shows the type of stone which can CYSTINE
guide treatment and give XANTHINE
information that may prevent more SULFONATES
stones from forming.
Knowledge of the composition of Principle
calculi yields fundamental - Dissolve a sample as homogenous
as possible of the urinary calculus to
information concerning the
be analyzed
pathogenesis of the disease,
- From this solution the various
including metabolic abnormalities, components of the calculus are
possible artifacts and even drug determined quantitatively, the
metabolism. titrimetric method being used for
Physician notes: oxalate, phosphate, magnesium,
- Weight ammonium, uric acid and cysteine
- Size
- Shape of stones Calcium
- Constituents of the stone & their - Acid extract (10% HCl)
order of deposition - 3 drops of NaOH
- (+) fine white precipitate
Qualitative gross examination or calculi
- If not done previously, wash the
Oxalate
stone free from blood, mucus,
- 3-4 drops of acid extract
preservation solution and so on.
- 2 drops of KMnO4
- Place the stone in a beaker and
- (+) violet color of KMnO4 disappear
cover with several thickness of
after one minute
gauze held firmly in place woth
rubber band wash under cold
Carbonate
running water. Drain
- Pulverized stone (large amount)
- Dry in hot air oven or simply air dry
- 10 drops of HCl
- Record the dimension of the stone
- (+) foaming effervescence
- Describe briefly the color and
texture of the stones exterior
Uric Acid
surface.
- Pulverized stone
- Break the stone to examine the
- 1 drop of 20% sodium
interior and layers if present.
- 2 drops phosphotungstic acid
Spot plate analysis
- (+) prompt deep blue
- Reduce small stone to fine powder
- (-) pale blue
by pulverizing with mortar and
pestle
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 Phosphate the stone into tiny pieces. These
- Pulverized stone pieces are then small enough to
- 5 drops of ammonium molybdate pass out of the body during
- Heat over flame urination.
- (+) distinct mustard yellow
precipitate Percutaneous Nephrolithotripsy
- In this procedure, performed in an
Magnesium operating room after a person has
- Acid extract been given anesthesia, a small
- 3 drops of NaOH incision is made in a persons flank.
- 3 drops of magnesium oxide The surgeon guides a special scope
- (+) slow formation of precipitate to the kidney and punctures it.
Using the pathway created, the
Ammonia surgeon inserts a small instrument
- Acid extract into the kidney to break up the
- 3 drops of NaOH stone and remove the stone
- 3 drops of Nesslers reagent fragments.
- (+) yellow orange precipitate - This technique can be used to
removed large stones and staghorn
Cystine stones.
- Pulverized stone
- 1 drop ammonium hydroxide Open surgery
- 1 drop sodium cyanide - In this procedure, performed in an
- Wait for 5 minutes operating room after a person has
- 3 drops of sodium nitroprusside been given anesthesia, the surgeon
- (+) beet red color makes an incision in the skin and
opens the pelvis of the kidney or
Xanthine the ureter so that the stone can be
- Pulverized stone manually removed. Because open
- 7-10 drops of conc HNO3 surgery is a major operation,
- Evaporate to dryness recovery may require 4-6 weeks
- 2-3 drops of conc NH4OH
- (+) greenish yellow orange
- Reddish on warming

Sulfonamides
- Pulverized stone
- 7-10 drops of conc HCl
- Evaporate to dryness
- 2-3 drops of NH4OH
- (+) yellow turning mahogany brown

Treatment
Extracorporeal Shock Wave Lithotripsy
(ESWL)
- ESWL focuses high-energy shock
waves from a source outside the
body and uses this energy to crush
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