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Kidney stones

Kidney stones are an aggregation of crystalline structures amalgamated with proteins , that build up in the nephrons of the kidney.

 

Renal calculi means kidney stones and having a stone in any location of the urinary tract is called urolthiasis Third most common disorder of the renal tract ( after UTI and prostate problems ) The problem is increasing globally ( both developed and developing world ) and now it is thought that about 12 % of the world population will suffer with urolithiasis at some point of their life Geographic , racial and gender variations in its occurrence can be noticed Men seen to suffer more although this gap is narrowing Children are rarely affected with highest incidence rate seen in 40-60 age group In the US the lifetime risk of stone formation is reported to exceed 12 % for men and 6 % for women All ethnic groups are equally represented in the affected population Urolithiasis can now be deemed as a public health concern also called as a disease in evolution

 

What happens – Pathogenesis is poorly understood Etiology is possibly multifactorial Mechanism of stone formation ( calculogenesis ) is complex -interplay of several physiochemical processes described as
- supersaturation
- nucleation growth
- aggregation
- retention of urinary stone constituents within tubular cells Risk factors which are thought to play greatest role can be divided into 4 main categories (1 ) dietary (2 ) genetic (3 ) environmental (4 ) lifestyle

Based on above the following risk factors can be found in literature

 

Family h/o urinary stones An abnormality of the urinary tract Obesity / Overweight with higher body fat percentages Hyperparathyroidism Metabolic syndrome Lack of physical activity Diet ( for e.g excessive animal protein consumption , high salt diet , extreme fasting ) Hypertension , diabetes and CKD Climate changes ( global warming ) , geographical conditions and seasonal fluctuations and the type of profession Water intake ( low fluid intake ) H/O bowel resection or inflammatory bowel disease ( incd enteric oxalate absorption due to malabsorption ) UTIs ( struvite stones ) Chronic diarrhoea & gout ( acidic urine )

 

Calcium stones- most common in most countries account for 75 % to 80 % of global stone prevalence specifically linked to obesity most Ca stones composed of calcium oxalate or calcium phosphate

 

Uric acid stones- accounts for about 3% to 10 % of all stone types supersaturated urea due to multitude of factors often 2ary to high purine diets most common cause is idiopathic

 

Struvite stones- also called infection stones & triple phosphate stones form in alkaline urine from infection with urea splitting microorganisms people with chronic urinary infections are prone to struvite stones

 

Cysteine stones- rare direct result of a genetic mutation that causes impairment in transport of an amino acid and cysteine cystinuria in urinary excretion

 

Drug induced – responsible for 1 % of all stone types drugs responsible include topiramate , Calcium + Vit D , steroids

 

Presentation- Symptoms would depend upon stone location if it is in the kidney , ureter or the urinary bladder may be asymptomatic in initial stages later signs can include
- renal colic
- flank pain
- haematuria 
- obstructive uropathy
- UTI
- hydronephrosis.

 

History- History- taking would focus to cover if the patients has had a previous history of stones or any risk factors which contribute towards nephrolithiasis Previous problems for e.g UTIs , stones ( chance of recurrence following initial presentation is up to 30-40 % within 5 yrs ) , pyelonephritis
 Family history Any known anatomical defects for e.g solitary kidney , horseshoe kidney or h/o surgery
 Systemic co-morbidities for e.g diabetes , 
1ary hyperparathyroidism , gout , inflammatory bowel disease , CKD, renal tubular acidosis , myeloproliferative disorders
 Drugs which can affect stone disease

 

Differentials – papillary necrosis with passage of a 
sloughed papilla renal emboli renal tumour UTIs pyelonephritis ovarian cyst torsion ectopic pregnancy GI conditions as obstruction , appendicitis , diverticulitis , cholecystitis , hepatitis & biliary colic herpes zoster

 

Renal colic- Renal colic may often be the 1st presentation – this happens when the stone moves from the renal pelvis into the ureter , causing ureteral spasm and possible obstruction.

 

Essentially obstruction of the ureter and several papers suggest that ureteric colic is a better term Spasm of the ureter around the stone is responsible for the pain which is accompanied by distension of the ureter , pelvicalyceal system and the renal capsule 
( mediated by prostaglandin secretion ) Pain is generally of sudden onset and described by patients as the worse pain they ever had ( compared often to labor pain ) Pain may come in waves of various intensity ( colic ) and is accompanied by nausea and vomiting or patients may report a constant dull pain interrupted with exacerbations Classic location is in the costovertebral angle , lateral to the sacrospinous muscle and beneath the 12th rib- this may radiate to the flank , groin , testes or labia majora The patient is restless and unable to find a comfortable position ( pain from peritonitis conditions the patient would remain still ) – you may find the patient pacing around the examination table Patients may have painfree spells in between Haematuria may be noted.

 

Check vitals including temperature , examine the patient ( including testes in male patients ) , check urine ( dipstick ) and if possible consider NSAID by any route to relieve pain.

There are no clear guidelines on management of suspected renal colic in primary care and given the wide differentials it may be difficult to ascertain who can be managed in primary care and who needs to be referred. A group of Durham GPs had addressed the issue in 2002 ( PJ Wright BMJ 2002 ) and their recommendations are still valuable – you may consider admission for the following group of patients
.

 

age > 60 ( leaking abdominal aneurysm may present with similar symptoms ) persistent pain not relived by analgesia diagnostic uncertainty women of reproductive age and h/o delayed menstruation ( risk of ectopic pregnancy ) dehydration unable to take oral fluids/ medications due to nausea and / or vomiting symptoms of systemic illness , infection or anuria , fever > 37.5 CKD B/L obstructing stones are suspected personal preference h/o solitary or transplanted kidney.

 

Patients often require strong opiates ( e.g Morphine ) via para-medics , A&E to control the pain . The current NICE guidance on pain management recommends.

 

NSAID by any route IV paracetamol if NSAID contraindicated or are not providing adequate pain relief Consider opioids if both NSAIDs & IV paracetamol are contraindicated or are not providing adequate pain relief Do not offer antispasmodics to adults , children and young people with suspected renal colic.

 

Management – Management is complex and by specialist urology teams who will take into account
- size , number , location and type of stone ( composition )
- presence of anatomical abnormalities or infection Associated complications ( like obstruction ) & / co-morbidities & suspected etiology National guidelines & local expertise in offering treatment The fact that up to 80 % of stones will pass spontaneously and increasing evidence now supports medical expulsive therapy ( MET )

 

NICE guidance – Offer urgent – ie within 24 hrs of presentation low dose non contrast CT to adults with suspected renal colic. for pregnant women within 24 hrs for children and young people with suspected renal colic. In children and young people if the US remains inconclusive. CT is the imaging of choice – it most accurately delineates ( high sensitivity and specificity ) stone size and location IVU is now historical and has been largely replaced by CT-KUB.

 

Medical expulsion therapy- Using an alpha-blocker like tamsulocin to facilitate spontaneous expulsion.

 

Shockwave lithotripsy
 ( ESWL ) Use of sound waves to fragment stones into small pieces which can be expelled easily- for smaller stones

 

Percutaneous nephrolithotomy-For complex , larger stones particularly those composed of cystine or struvite- allowing direct visualization and intracoprporeal lithotripsy.

 

Uretroscopic stone removal For stones in ureter & renal pelvis -particularly for pregnant , obese or coagulopathic patients

 

Open stone surgery -When other treatment fails + complexities.

 

Complications -Significant pain due to renal colic UTIs Urosepsis / abscess formation Urinary fistula Uretral scarring and stenosis CKD increased risk and ESRF CVD , diabetes and hypertension ( ^ ed risk ) Recurrence after initial episode ( high rate ) Treatment related complications.

 

+ ve family hx young age at onset nephrocalcinosis recurrent UTIs underlying conditions as renal tubular acidosis and hyperparathyroidism.

 

Preventative surgery – Increased water intake Primary dietary changes Pharmacological treatment ( for e.g potassium citrate or thiazide diuretic )

PATIENT INFORMATION LINKS

A comprehensive patient information page from the British Association of Urological Surgeons https://www.baus.org.uk/patients/conditions/6/kidney_stones/

Another useful page with plenty of diagrams from the Urology Care Foundation https://www.urologyhealth.org/urology-a-z/k/kidney-stones

National Kidney Foundation on kidney stones with useful videos https://www.kidney.org/atoz/content/kidneystones

Prevention of Kidney Stones – advice from  North Bristol NHS Trust https://www.nbt.nhs.uk/sites/default/files/attachments/Advice%20for%20patients%27%20prevention%20of%20kidney%20stones_NBT002640.pdf

European Association of Urology has an excellent section on kidney and ureteral stones https://patients.uroweb.org/other-diseases/kidney-and-ureteral-stones/

Kidney Care UK on all matters related to kidneys – on kidney stones https://www.kidneycareuk.org/about-kidney-health/conditions/kidney-stones/

Treatment overview from NHS https://www.nhs.uk/conditions/kidney-stones/treatment/

A comprehensive guide to kidney stones and treatment from American Kidney Fund https://www.kidneyfund.org/kidney-disease/kidney-problems/kidney-stones/

 

References

  1. CKS NHS – Rebal or ureteric colic-acute Scenario: Management | Management | Renal or ureteric colic – acute | CKS | NICE
  2. Rule AD, Lieske JC, Pais VM. Management of Kidney Stones in 2020. JAMA. 2020;323(19):1961–1962. doi:10.1001/jama.2020.0662
  3. Wright, P J et al. “Managing acute renal colic across the primary-secondary care interface: a pathway of care based on evidence and consensus.” BMJ (Clinical research ed.) vol. 325,7377 (2002): 1408-12. doi:10.1136/bmj.325.7377.1408
  4. Renal and ureteric stones: assessment and management NICE guideline [NG118]Published date: 

  5. Kidney stone disease: an update on its management in primary care
    Christopher R WilcoxLily A WhitehurstPaul CookBhaskar K Somani
  6. Bartoletti R, Cai T, Mondaini N, Melone F, Travaglini F, Carini M, Rizzo M. Epidemiology and risk factors in urolithiasis. Urol Int. 2007;79 Suppl 1:3-7. doi: 10.1159/000104434. PMID: 17726345. ( Abstract )
  7. Shin, Samuel et al. “Confounding risk factors and preventative measures driving nephrolithiasis global makeup.” World journal of nephrology vol. 7,7 (2018): 129-142. doi:10.5527/wjn.v7.i7.129
  8. Barnela, Shriganesh R et al. “Medical management of renal stone.” Indian journal of endocrinology and metabolism vol. 16,2 (2012): 236-9. doi:10.4103/2230-8210.93741
  9. Miller, Nicole L, and James E Lingeman. “Management of kidney stones.” BMJ (Clinical research ed.) vol. 334,7591 (2007): 468-72. doi:10.1136/bmj.39113.480185.80
  10. Worcester, Elaine M, and Fredric L Coe. “Nephrolithiasis.” Primary care vol. 35,2 (2008): 369-91, vii. doi:10.1016/j.pop.2008.01.005
  11. Patti L, Leslie SW. Acute Renal Colic. [Updated 2020 Nov 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431091/
  12. Nojaba L, Guzman N. Nephrolithiasis. [Updated 2020 Aug 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559227/
  13. Bultitude MatthewRees JonathanManagement of renal colic 
  14. Curhan, Gary C. “Epidemiology of stone disease.” The Urologic clinics of North America vol. 34,3 (2007): 287-93. doi:10.1016/j.ucl.2007.04.003
  15. Romero, Victoriano et al. “Kidney stones: a global picture of prevalence, incidence, and associated risk factors.” Reviews in urology vol. 12,2-3 (2010): e86-96.
  16. Tilahun Alelign, Beyene Petros, “Kidney Stone Disease: An Update on Current Concepts”, Advances in Urology, vol. 2018, Article ID 3068365, 12 pages, 2018. https://doi.org/10.1155/2018/3068365 
  17. William J.H. (2019) Epidemiology of Kidney Stones in the United States. In: Han H., Mutter W., Nasser S. (eds) Nutritional and Medical Management of Kidney Stones. Nutrition and Health. Humana, Cham. ( Abstract https://doi.org/10.1007/978-3-030-15534-6_1
  18. Wróbel, Grzegorz et al. “The role of selected environmental factors and the type of work performed on the development of urolithiasis – a review paper.” International Journal of Occupational Medicine and Environmental Health, vol. 32, no. 6, 2019, pp. 761-775. doi:10.13075/ijomeh.1896.01491. ( Abstract )
  19. Sterling M, Ziemba J, Mucksavage P. Acute management of symptomatic nephrolithiasis. World J Clin Urol 2014; 3(3): 161-167
  20. Eastern Mediterranean Health Journal | Past issues | Volume 12, 2006 | Volume 12, issue 6 | Prevalence and etiology of urinary stones in hospitalized patients in Baghdad

 

 

 

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