Urine:

a complex aqueous solution

of organic and inorganic solutes
More of a given solute can remain
in solution in urine than in water
due to the complex interactions
among the various constituents of
urine

Urine is commonly supersaturated with

crystalloids
Observation of individual crystal types in
urine does not necessarily mean the
patient is at risk for developing urolithiasis

 Supersaturation

(solubility
product exceeded) of urine
with a crystalloid depends on:
Amount of solute ingested and

excreted
Urine volume
Urine pH
Promoters
Inihibitors

 Precipitation-crystallization
Matrix-nucleation

theory

theory
Crystallization-inhibition theory
Some combination of the above?

 Urine:

a complex aqueous solution

of organic and inorganic solutes
More of a given solute can remain
in solution in urine than in water
due to the complex interactions
among the various constituents of
urine

Urine is commonly supersaturated with

crystalloids
Observation of individual crystal types in
urine does not necessarily mean the
patient is at risk for developing urolithiasis

 Supersaturation

(solubility
product exceeded) of urine
with a crystalloid depends on:
Amount of solute ingested and

excreted
Urine volume
Urine pH
Promoters
Inihibitors

 Precipitation-crystallization
Matrix-nucleation

theory

theory
Crystallization-inhibition theory
Some combination of the above?

 Homogenous

nucleation: crystals
precipitate spontaneously
(unlikely in urine)
Heterogenous nucleation:
another substance acts as a
nidus for crystal precipitation
(likely in urine)
Epitaxy: Precipitation of one
crystal on the surface of another

Pyrophosphates
Diphosphonates
Citrate
Some cations (e.g. Mg+2)
Glycosaminoglycans
Nephrocalcin

 When

70% of the urolith is

composed of one type of crystal it is
named for the crystal
Mixed urolith < 70% one crystal; no
identifiable nidus or shell
Compound urolith Identifiable nidus
of one crystal with surrounding
layers of another crystal
Matrix urolith Matrix without
appreciable crystalloid

Stone type
Number
Struvite
Oxalate

Dogs
77,190
50%
31%

Cats
20,343
43%
46%

Urate
Cystine
Silicate
Calcium phosphate

8%
1%
1%
< 1%

6%
< 1%
< 0.1%
< 1%

Data from University of Minnesota Stone Laboratory 2000

TYPE
Calcium oxalate; usually with
Calcium phosphate

Frequency (%)
65

Calcium phosphate alone

15

Magnesium ammonium
phosphate (Struvite)

10-15

Uric acid

3-5

Cystine

1-2

Calcium oxalate
monohydrate

Calcium oxalate &

Ca phosphate

 Cystine

crystals

Uric acid

Struvite stones are often

large, forming a cast of the
collecting system called
Staghorn
calculus.
Usually due to
Proteus mirabilis
that hydrolyse
urea and form
alkaline urine.

60-80% calcium stones

(Ca oxalate > Ca phosphate)

15-20% struvite
(magnesium ammonium phosphate)

5% uric acid
1-3% cystine
The same patient may have more than
one type of stone concurrently (e.g..
calcium and uric acid).

Stone formation occurs when normally soluble

material (e.g.. Ca) supersaturates the urine and
begins the process of crystallization.
Crystal nidus forms at certain pH depending on
crystal type.
Epitaxy/ matrix theory
Deficiency of inhibitors of stone formation these
limit stone aggregation and growth. Citrate and
Mg most important.

It is presumed that crystals aggregates become

large enough to be anchored ( usually at the end
of the collecting ducts), and then slowly increase
in size over time.

History of prior calcium urolithiasis (One report of

Family history of urolithiasis

Dehydration and consequent increase urine
concentration
Increase enteric absorption of oxalate (short bowel

patients with a first stone estimated that the likelihood of

forming a second stone was approximately 15 % at 1yr, 35-40%
at 5 yrs, and 50% at 10 yrs.)

syndrome)

UTI
Medication that promote crystalluria (Sulfadiazine,
Triamteren, Indinavir, Acetazolamide)

Hypertension risk of stone formation incr.

x2 (? hypercalciuria?)
Dietary habits - soft drinks acidified with
phosphoric acid increase calcium stone
formation.. Mechanism ? Possible that small
acid load can increase the urinary
excretion of calcium and uric acid and
reduce that of citrate.
Grapefruit and tomato juice increase the
risk.

Uric acid lithiasis: - gout

- hyperuricosuria
- chronic diarrheal states

Struvite stones: -UTI due to urease splitting

organisms(Proteus , Klebsiella)

Cystine stones: -Pt with cystinuria due to

insolubility of cystine in the urine

Focused history ( family history of

calculi, duration and evaluation of
symptoms, signs or Sx of sepsis)
Clinical presentation
Urinalysis
Radiologic tests
KUB, IVP, US, CTscan (including spiral
CT)

Should be performed in all patient

with suspected calculi.
Microhematuria, pH, crystals,bacteria
Uric acid stones acidic urine
Infection alkaline urine
Limited pyuria is fairly common
response to irritation caused by a
stone, and in the absence of
bacteriuria is not generally indicative
of coexistent UTI.

Sensitivty19%, specificity 97%

Accessible
Good for diagnosis of hydronephrosis
and renal stones
Poor visualization of ureteral stone.
Procedure of choice for patients who
should avoid radiation, including those
with known allergy to IV contrast,
pregnant women and woman in
childbearing age.

Accessible and inexpensive.

May be sufficient to document the size and
location of radiopaque urinary calculi ( Ca
oxalate, Ca phosphate), but not radiolucent
stones such as pure uric acid, cystin or
magnesium ammonium phosphate.
Unfortunately stones are frequently obscured
by stool or bowel gas, ureteral stones overlying
the bony pelvis or transverse processes of
vertebrae .
Furthermore, nonurologic radiopacities, such as
calcified mesenteric lymph nodes, gallstones,
stool and phlebolits may be misinterpreted as a
stones..

Relatively safe despite the need for contrast

Provides information about obstruction the
stone (size, location, radiodensity) and
degree of obstruction.
Serum Cr must be measured before the test
Nephrotoxic effect is minimized by adequate
hydration, minimum amount of contrast
material used.
DM patient to stop Glucophage before the
procedure and hold for next 48 hrs. May
resume Metformin therapy after reevaluating
renal function.

Fast, accurate, and readily identifies

all stone types in all location.
Sensitivity 95-100% , Specificity 94-96%.
Give some information about other
pathologies.

Patient presenting with abdominal and

flank pain who are suspected of having
a kidney stone should first have a UA.
If hematuria is present (r/o GN, no red
cell casts or heavy proteinuria) order KUB
in those without a history of urolithiasis.
In contrast, no further evaluation in the
emergency setting beyond the finding of
hematuria is needed in patient with a
known history of stones.

Acute therapy
IV hydration
analgesics (NSAIDs - ketorolac)
Narcotics if no response to
NSAIDs
Patient can be managed at home if they
are able to take oral medication and
fluids. Hospitalization is required for those
who cannot tolerate oral intake or have
severe pain or complicated condition.
Patient should be instructed to strain their
urine and bring in any stone that passes

Patient with first stone (symptomatic or

asymptomatic) do not need metabolic
evaluation other than a serum Ca in those
with radiopaque stones and serum uric acid
in those with radiolucent stones.
Increase oral fluid intake to 2-3L/d.
Subsequent monitoring with KUB or US at 0
and 1year and if negative every 3-5 years
thereafter (optional).

Patient who have recurrent stones

need a detailed metabolic and
radiologic eveluation.
Screening for hypercalcemia and
hyperuricemia is indicated.
Two 24-hour urine collection should be
obtained in the outpatient setting
when the patient is on regular diet.
Urine volume and excretion of Ca, uric
acid, citrate, oxalate,creatinine, pH,
and Na should be measured.

Long term therapy should be initiated to

prevent future stone formation.
For calcium stones combination of drug
therapy
Thiazide for
hypercalciuria,
allopurinol for
hyperuricosuria,
K-citrate
for hypocitraturia
Uric acid stones K-citrate to alkalinize the
urine or
Allopurinol
Cystine stones high fluid intake ,urinary
alkalinization, and drugs such as
penicillamine or captopril.
Treatment with struvite stones is difficult,
and usually requires ESWL or surgery.