KIDNEY STONES

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KIDNEY STONES
most common type in the urinary tract
There are among the most painful urologic disorders
Stones occur more frequently in men
Affects 1 - 3 % of adult population
Annual incidence 1% in white males
Life - time risk in adult males – 20%
Recurrent stones in 63% after 8 years

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NEPHROLITHIASIS
NATURAL HISTORY & RISK
FACTORS
Peak incidence age 30 - 60
Gender (Male : Female) 3:1
Family history 3 - fold ↑ risk
Body size ↑ risk with ↑
weight
Recurrence after first stone:
Year 1 10 - 15%
Year 5 50 - 60%
Year 10 70 - 80%
Signs and Symptoms
Vary depending on the size of the kidney stones
Small stones (< 4 mm)
- are smooth can pass without pain, hence also called
“silent stones”
Stones can also get stuck in the ureters, leading to
spasms and pain
Pain more dependent on the location of the stone
Hematuria
Increased frequency of painful, burning urination
Nausea and vomiting
Urinary tract infections

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Types of Stones that Form
1. Calcium Stones
2. Cystine Stones
3. Uric Acid Stones
4. Struvite Stones
Calcium Stones
 Comprise 85% of kidney stones
 Excess calcium build-up in the urine
 Excess build-up of calcium in body
 Excessive intake of animal protein
 Calcium is often chemically bound to
oxalate or phosphate (More commonly
oxalate)
Cystine Stones
 Account for 1% of all kidney stones
 Cystinuria
an inherited genetic disorder of amino acid transport, which leads to a
build-up of poorly soluble cystine in the body
 SLC 3A1 or SLC 7A9 gene mutations inhereted from parents
 Gene defect interferes with kidneys’ ability to dissolve cystine and take it
back to the bloodstream
 Cystine forms hexagonal-shaped crystals, which are painful
Uric Acid Stones
 Account for 10% of stone diseases
 Genetics may predispose individuals
 High levels of uric acid in the urine, if too much acid
excreted or if the volume of urine is low
 Purine metabolism leads to uric acid
 Acidic urine pH,crystal precipitates and stone formation
may occur
 Especially common in people with gout
Struvite Stones
 Infection stones or magnesium ammonium phosphate
stones
 Occur at alkaline urine pH and when ammonia present,
causing stone precipitation
 Occur when a urinary tract infection affects chemical
balance in urine:
 Bacteria neutralize the acid in the urine allowing
bacteria to thrive, hence promoting struvite stone
development
 convert urea to ammonium, combines with phosphate
and magnesium to form stones
 Magnesium ammonium phosphate crystals
(MgNH4PO4•6H2O) are admixed with carbonate apatite
(Ca10 (PO4) 6•CO3) in varying proportions
 Stones are usually jagged edge and can become very
large

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Causes of Stone Diseases
Risk Factors:
 Inadequate fluid intake, dehydration
 Reduced urinary flow and volume
More risk factors- What’s in the
urine?
 High calcium (hypercalciuria)
 Presence of cystine (cystinuria; caused by a genetic
disorder)
 High oxalate (hyperoxaluria)
 High uric acid (hyperuricosuria)
 High Sodium (hypernatremia)
 Low Citrate (hypocitraturia)
 DIET
 Diet high in sodium, fats, meat, sugar, and low in fibre & whole
carbs

 High doses of Vitamin C can result in high levels of oxalate in

the urine, which increases risk of stone formation

 Oxalate is found in berries, certain veggies, nuts, chocolate &

tea,
Work-Up
 Urinalysis:
 Evaluate the urine for evidence of hematuria and
infection.
 Approximately 85% of patients with urinary calculi
exhibit gross or microscopic hematuria.
 15% of patients with urinary stones do not exhibit
hematuria.

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Work-Up
 Complete blood cell count
 Serum electrolytes, creatinine, calcium, uric acid, parathyroid
hormone (PTH), and phosphorus
 Assess renal function and metabolic risk for future stone
formation.
 High serum uric acid: indicate
gouty diathesis or hyperuricosuria,
 Hypercalcemia: renal-leak hypercalciuria (with secondary
hyperparathyroidism) or primary hyperparathyroidism.
* Serum calcium level is elevated, serum PTH levels should
be obtained.

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Twenty-four–hour urine
collection
 pH, calcium, oxalate, uric acid, sodium, phosphorus, citrate,
magnesium, creatinine, and total volume

 provide information on exact nature of the chemical

problem that caused the stone.

 identify patients with renal calculi who might have other

significant health problems.

 The following are objective indications for a metabolic

evaluation with a 24-hour urinalysis:

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 Residual calculi after surgical treatment
 Initial presentation with multiple calculi
 Initial presentation before age 30 years
 Renal failure
 Family history of calculi
 More than one stone in the past year
 Bilateral calculi
 Patient preference:

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Calcium, oxalate, and uric acid
 Elevation of the 24-hour excretion rate: predisposition to form
calculi
 Hypercalciuria: absorptive, resorptive, and renal-leak
 avoidance of excessive dietary calcium (600-800 mg/d),
modest limitation of oxalate intake, and thiazide therapy
 Hyperoxaluria may be primary, enteric or idiopathic
 Calcium citrate:
 serves as oxalate binder, reducing oxalate absorption
from the intestinal tract
 optimal 24-hour urine oxalate level is 20 mg/d or less

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 Hyperuricosuria
 formation of calcium-containing calculi
 Therapy involves potassium citrate supplementation,
allopurinol, or both
 patients with pure uric acid stones and hyperuricemia
are treated with allopurinol, and those with
hyperuricosuric calcium stones are treated with citrate
supplementation
 optimal 24-hour urine uric acid level is 600 mg/d or less.

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Sodium and phosphorus
 Excess sodium excretion can contribute to hypercalciuria
by a phenomenon known as solute drag.
 Decreasing the oral sodium intake can decrease calcium
excretion, thereby decreasing calcium saturation
 elevated phosphorus level: marker for a subtype of
absorptive hypercalciuria
 Renal phosphate leak: high urinary phosphate levels, low
serum phosphate levels, high serum 1,25 vitamin D-3
(calcitriol) levels, and hypercalciuria

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Citrate and magnesium
 Hypocitraturia:
 citrate therapy as primary or adjunctive therapy to
almost all patients who have formed recurrent
calcium-containing stones
 24-hour urine citrate levels of 320 mg/d as the
normal threshold
 A pH level of 6.5 considered optimal.
 A pH level over 7.0: prompts calcium phosphate
precipitation.
 Potassium citrate is the preferred type of
pharmacologic citrate supplement

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 Creatinine
 control that allows verification of a true 24-hour sample. Most individuals
excrete 1-1.5 g of creatinine daily

Total volume
 urine output of more than 2 L daily in order to reduce the risk of stone
formation.

pH:
 Uric acid and cystine: acidic
 Calcium phosphate and struvite: alkaline

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Diagnostics and Imaging
 Plain abdominal radiography, KUB
 useful for assessing total stone burden,
 Calcium-containing stones: 85% are radiopaque,
 radiolucent : uric acid, and cystine calculi
 Renal ultrasonography
 adequate to determine the presence of a renal stone
 Pregnancy
 to determine hydronephrosis or ureteral dilation
 Ureteral calculi, in distal ureter
 Stones smaller than 5 mm are not easily observed with
ultrasonography.

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Diagnostics and Imaging
 Intravenous pyelography (IVP),
 determining the size and location of urinary calculi
 provides both anatomical and functional information.
 Up to 6 hours may be required to complete the study
in the presence of severe obstruction.
 Delayed nephrogram: hallmark signs of acute urinary
tract obstruction
 CT scanning with delayed contrast series, thin slices
has reduced the need for IVU

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Diagnostics and Imaging

Computerized tomography (CT Scan)

 Gold standard: Non contrast enhanced helical CT.
 One study of 417 patients presenting with acute flank
pain suggested that CT: 95% sensitive, 98% specific,
and 97% accurate.
TREATMENT

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Urological consultation
 Urgent referral for urosepsis or ARF
 >5mm, or failure to pass stone within 2 to 4 weeks.
 Current surgical options:
 Extracorporeal shock wave lithotripsy (ESWL)
 Open pyelolithotomy
 Percutaneus nehprostomy

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STONE MANAGEMENT
OPTIONS
Open surgery
Percutaneous nephrolithotomy
Ureteroscopy
Shock wave lithotripsy
Medical therapy
Stone prevention
stone formation before age 30 years,
family history of stones
multiple stones at presentation
renal failure
residual stones after surgical treatment.

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General guidelines for emergency
management
 Determine the presence or absence of obstruction or infection.
 (+) Obstruction (-) infection:
 analgesics and with other medical measures to facilitate passage
of the stone.
 (+) Infection (-) obstruction
 antimicrobial therapy
 (-) obstruction (-) infection:
 Analgesics
 medical measures to facilitate passage of the stone
 (+)obstruction (+) infection:
 emergent decompression of the upper urinary collecting system is
required

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medical expulsive therapy (MET)
 reducing the pain of stone passage
 increasing the frequency of stone passage
 reducing the need for surgery
 MET is probably most useful for stones 3-10 mm in size
 65% greater likelihood of stone passage
 calcium channel blocker nifedipine
 relaxes ureteral smooth muscle and enhances stone passage
 alpha-blockers, terazosin, and the alpha-1 selective blockers,
such as tamsulosin,
 relax musculature of the ureter and lower urinary tract,

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Acute therapy
 pain medication and hydration until the stone passes.
 Likelihood that ureteral stones will pass depends on size
and location.
 Smaller (less than 5mm) and more distal stones are
likely to pass.
 Average time to pass stone is anywhere from 8-22 days
depending on size of stone

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Acute therapy
 NSAIDs and narcotics.
 Caution with NSAIDs in pts with obstruction or preexsisting
renal disease.
 Hospitalization is required for those who cannot tolerate
oral intake or have very severe pain.
 Urine should be strained for further stone analysis.

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Uric acid and cystine calculi
 Sodium bicarbonate can be used as the alkalizing agent
 potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a
high sodium load.
 dosage of the alkalizing agent should be adjusted to
maintain the urinary pH between 6.5 and 7.0.
 Roughly 1 cm per month dissolution can be achieve
 allopurinol (300 mg qd) 

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 MEDICAL
MANAGEMENT OF
NEPHROLITHIASIS
SELECTIVE TREATMENT APPROACH
Reverse underlying physicochemical
and physiologic abnormalities
Inhibit new stone formation
Overcome non-renal complications
Bone disease in RTA
Free of serious side effects
METABOLIC EVALUATION

SELECTION OF PATIENTS
Simplified evaluation Comprehensive evaluation
Metabolically inactive Metabolically active
Single stone, low risk Single stone, high risk
Positive family history
Early age of onset
Nephrocalcinosis
Associated medical conditions
METABOLIC EVALUATION
URINARY CRYSTALS
 IMPACT OF
MEDICAL THERAPY

NEED FOR STONE REMOVAL

Pre-
On
Treatment
Treatment
Duration (yr/pt) 3.0 3.7
Surgery rate (no/pt) 0.21 0.01
Patients requiring 58% 2%
Surgery

Preminger & Pak, 198

ESWL
Treatment of choice in 85% of patients.
 Particularly good for stones in the renal pelvis
and upper ureter.
Stone larger than 1.5 cm in diameter or one
located in the lower section of the kidney is
treated less successfully

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ESWL
 Shockwaves focused on the calculus, energy released
as Shockwave impacts the stone produces
fragmentation.
 The shock head delivers shockwaves developed from an
electrohydraulic, electromagnetic,source.
 may not be optimal in large patients, especially if the
skin-to-stone distance exceeds 10 cm.

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 ESWL - complications

 Most common=persistent stone fragments.

 May reversibly damage all parenchymal components.
 May raise blood pressure.
 However, all observations suggesting such complications
have limitations (i.e.only studied acute effects, failed to
consider the “bilateral” nature of kidney function etc.)

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SHOCK WAVE LITHOTRIPSY
STONE FRAGMENTATION
SHOCK WAVE LITHOTRIPSY
INDICATIONS

Surgical stone

No obstruction
Reasonable chance
of expeditious removal
SHOCK WAVE LITHOTRIPSY
RELATIVE CONTAINDICATIONS
Large stones
Calcium oxalate > 20 mm
Struvite > 30 mm
Cystine stones
Distal obstruction
SHOCK WAVE LITHOTRIPSY
REALITY
<15mm 15-29mm
>30mm

Multiple SWL 5% 10% 15-

30%

Stone-free rate >80% 60%

50%

Auxiliary procedures 2% 5-7%

15%

Repeat procedures 1-2% 10-15% 15-

20%
SHOCK WAVE LITHOTRIPSY
IDEAL CANDIDATES

Small stone (< 1.5 cm)

Mid or upper pole location

Normal renal anatomy

No distal obstruction
SHOCK WAVE LITHOTRIPSY

STONE FREE RATES

100%
95%
80% 87%
60%
%
40% 48%
Ston 35%
20%
e 0%
Free < 1 cm 1-2 cm 2-3 cm > 3 cm

Lingeman and Newman, 1990

Other techniques
Open stone surgery:
done rarely
(<1%) for complex stones
Percutaneous nephrostolithotomy
Reserved for extremely large or complex
calculi or in pts with some anatomic
abnormalities
Good for cystine stones which are fairly
resistant to ESWL.

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STONE MANAGEMENT
OPEN NEPHROLITHOTOMY
Percutaneous
nephrostolithotomy
 allows fragmentation and removal of large calculi from
the kidney and ureter
 In some cases, a combination of ESWL and a
percutaneous technique is necessary to completely
remove all stone
 sandwich therapy:
 staghorn or other complicated stone cases.
 final procedure should be percutaneous
nephrostolithotomy.

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STONE MANAGEMENT
PERCUTANEOUS NEPHROLITHOTOMY
STONE MANAGEMENT
PERCUTANEOUS NEPHROLITHOTOMY
STAGHORN CALCULI
STONE FREE RATE
100%

80%
81% 82%
60% 73%
%
40% 50%
Ston
e 20%
Free 0%
SWL PNL Combo Open

AUA Guidelines Panel, 199

STAGHORN CALCULI

SANDWICH THERAPY

Allows debulking of large stones

SWL reserved for inaccessible fragments
Flexible nephroscopy to insure stone-free status
URETERAL CALCULI
URETERAL CALCULI

TREATMENT CONSIDERATIONS

Location
Size
Chronicity
Equipment
Expertise
URETERAL CALCULI

TREATMENT OPTIONS
Observation
Shock wave lithotripsy
Ureteroscopy
Percutaneous approach
Open surgery
 URETERAL CALCULI
SPONTANEOUS PASSAGE

Of all stones that pass spontaneously, 95% will pass

within 6 weeks

Miller & Kane, 1999

SWL FOR
URETERAL CALCULI
Ureteroscopy
 may be rigid, semirigid, or flexible
 Treatment of choice for the majority of middle and distal uretral stones.
 passed into the bladder and up the ureter to directly visualize the stone.
 “Intracorporeal lithotripsy” (with pneumatic pressure, or laser, or ultrasound)
can be used to break up larger stones.
 ureteral stent must be placed following this procedure in order to prevent
obstruction from ureteral spasm and edema.

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URETERAL STONE MANAGEMENT
URETEROSCOPY
Advantages
Highest success rate
Definitive Rx - No waiting for stone
passage

Disadvantages
More invasive than SWL
Higher complication rate
Requires greater technical expertise
URETEROSCOPY
URETERAL CALCULI
PERCUTANEOUS APPROACH
SHOCK WAVE LITHOTRIPSY

RECURRENT STONE FORMATION

One Year Two

Years
Post SWL Post
SWL
Stone Free
New stones 8% 10%
Residual Stones
Stone growth 22% 21%
Lingeman, et al, 198
Evaluation and Subsequent Treatment

Retrieve stones and send for analysis.

Subsequent therapy depends on stone and

biochemical abnormalities that are present.

ALL patients should increase fluid intake to >

2L/day, including drinking at night

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What to do after the first
stone?
There remains disagreement as to whether a
complete metabolic evaluation is indicated in all
patients.
Three approaches to consider:
Limited evaluation,
complete evaluation
targeted approach.

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FOLLOW-UP
A follow-up examination, including abdominal
radiography, is often adequate after an
uncomplicated stone-removal procedure
standard radiographic follow-up care includes
abdominal radiography every 6-12 months
If medical therapy is instituted
24-hour urinalysis:
 3 months after starting any new therapy
 to assess the degree of patient compliance and the
adequacy of the metabolic response

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Checking all possible metabolic
parameters
Once a stable regimen has been
established, annual 24-hour urinalyses are
adequate.

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Limited evaluation
Includes: blood chemistries,
including multiple measurements of serum
Ca.
advised to drink at least 2L per day of
fluids.

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Complete evaluation
Recommended by many due to the potentially
high rate of recurrence and potential morbidity.

Includes: chemistries, 24 hour urine collections.

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Targeted approach
 Do a complete evaluation in patients with moderate to
high risk:
 Middle-aged, white males with +FH
 Patients with chronic diarrheal states and/or
malabsorbtion, pathological fractures, osteoporosis,
UTIs, or gout.
 Patients with stones composed of cystine, uric acid,
calcium phosphate or struvite.

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Complete metobolic
evaluation
Blood tests:
 routine chemistries + serum Ca + uric acid.
 For increased Ca obtain iPTH.
Urinalysis:
 Ph > 7 + phosphate crystals suggests calcium
phosphate or struvite calculi
Hexagonal cystine crystals is diagnostic for
cystinuria
Uric acid crystals and calcium oxalate crystals are
often normal.

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24 hour Urine Collections
 Obtain the measurement of urine volume, pH, and
excretion of Ca, uric acid, citrate, oxalate, and creatinine

 Because of the daily variations in dietary intake, it is

recommended that 2 or 3 24 hr collections be obtained.

 Collections should be obtained in the outpatient setting

and approx. 2-3 months after a stone event.

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Treatment of Recurrent Calcium Stones
Dietary modifications:
Increase fluid intake to greater that 2L per day.
Minimize soft drinks, grapefruit juice.
Reduce protein intake to about 1g/kg (a high protein
causes a high acid load to kidneys which favors
stone formation).
Limit sodium intake

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PROGNOSIS
 recurrence rate:
 50% within 5 years
 70% or higher within 10 years
 Metabolic evaluation and treatment are indicated for patients at
greater risk for recurrence
 Medical therapy is generally effective at delaying stone formation.
 The most important aspect of medical therapy is maintaining a high
fluid intake and subsequent high urinary volume.
 increasing fluid intake and dietary moderation can cut the stone

recurrence rate by 60%.

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 THANK YOU!!!

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