Nephrolithiasis (Kidney Stones)

Two theories for etiology:

1) Stone formation occurs when normally soluble material (calcium, oxalate) supersaturates the urine and
begins the process of crystal formation and then becomes anchored
2) Stone formed in renal medullary interstitum and get extruded at the renal papilla

Stone Types:
1) Calcium oxalate (majority)/ Calcium phosphate: 70-90% of stones
a. Urine findings: elevated Ca, elevated oxalate (calcium ox stones), elevated pH (calcium
phosphate), decreased citrate, decreased volume
b. Secondary hypercalciuria can be due to: primary hyperparathyroidism, distal RTA, sarcoid
c. Secondary hyperoxaluria can be due to: Crohns, ileal disease with intact colon, gastric bypass
2) Uric acid: 5-10% of stones; radiolucent on plain film
a. Urine findings: increased uric acid, decreased pH
3) Magnesium ammonium phosphate (struvite)
a. Associated with chronic upper UTI with urease + organisms (Proteus, Klebsiella)
i. Check via increased urine ammonium, pH > 7
4) Cysteine
a. Inherited defects of tubular amino acid reabsorption

Clinical Manifestations:
1) Class signs: renal colic, hematuria
2) Hematuria, flank pain, N/V, dysuria, urinary frequency
3) Ureteral obstructions (stones > 5 mm unlikely to pass spontaneously
4) UTI: increased risk of infection proximal to stone

Workup:
1) Noncontrast helical CT (97% sensitivity; 96% specificity)
2) Urinalaysis: electrolytes, BUN/Cr, Ca, phosphate, PTH
a. 24 hour urine x 2 for Ca, phosphate, oxalate, citrate, Na, Cr, pH, K



Differential:
1) Renal cell carcinoma: may present with renal colic
2) Pyelonephritis: flank pain, fever, pyuria
3) Ectopic pregnancy (rule out with ultrasound)
4) Dysmenorrhea
5) Acute intestinal obstruction, diverticulitis, appendicitis
6) Biliary colic and cholecystitis: associated with flank pain but NOT with hematuria
7) Malingering or attention seeking

Acute Treatment:
1) Analgesia (narcotics +/- NSAIDs, combination found to be superior)
2) Alpha blocker (better than calcium channel blocker) to promote ureteral relaxation
3) Red flags to warrant immediate urology consult or hospitalization:
a. Urosepsis, intractable pain or vomiting, prior acute kidney injury
4) Urology treatment: lithotripsy, stent, percutaneous nephrostomy, ureteroscopic removal

Chronic Treatment:
1) Increase fluid intake (over 2 L/d)
2) Calcium stones:
a. Decrease sodium and meat intake, use thiazide diuretics (reduce Ca amount in the urine)
b. L-citrate, dietary oxalate restriction, allopurinol
3) Uric acid stones:
a. Alkalization of the urine with K-citrate; allopurinol
4) Magnesium ammonium phosphate stones:
a. Treat UTI with antibiotics
5) Cysteine stones:
a. Alkalization of urine via K-citrate; D-penicillamine; tiopronin