NEPHROLITHIASIS
Introduction
Nephrolithiasis are kidney stones. It hard deposits of calcium oxalate or
calcium phosphate, or occasionally, other salts. Ureterolitiasis
sometimes referred to the stones in ureters but most of the time it
originate from the kidney
Types of kidney stones
• 1. Calcium oxalate or calcium phosphate stones : Comprise 70-80% of all
kidney stones;
• main causes include: a. High calcium levels in the urine (eg, from
hypercalcemia, high dietary sodium and phosphate intake, chronic metabolic
acidosis)
b. Low urine volumes (eg, from chronic dehydration, hot climates)
c. High uric acid levels (eg, high purine, high protein diets; gout)
d. Hyperoxaluria (high urinary excretion of oxalate) (eg, low dietary calcium,
high oxalate diets, genetic hyperoxaluria)
e. Low urine citrate (eg, chronic metabolic acidosis, renal tubular acidosis,
inflammatory bowel disease)
Types of stones
• 2. Uric acid stones: Comprise 10-15% of all kidney stones, causes
include:
• Low urine pH
• Defects in renal ammonia secretion
• Chronic metabolic acidosis
• Hyperuricosuria
• Obesity
• Metabolic syndrome.
Types of stones
3. Magnesium ammonia phosphate stones (also called struvite
stones)
• Comprise 10-15% of all kidney stones, caused by urea-splitting
bacteria associated with a urine infection.
4. Cystine stones
• Caused by cystinuria, which is an autosomal recessive disorder of
cystine, ornithine, arginine, and lysine metabolism.
Risk factors
• Family or personal history.
• Dehydration.
• Certain diets. high in protein diet , sodium (salt) and sugar.
• Obesity. High body mass index (BMI).
• Digestive diseases and surgery. Gastric bypass surgery, inflammatory bowel disease or chronic
diarrhea.
• Other medical conditions such as renal tubular acidosis, cystinuria, hyperparathyroidism and
repeated urinary tract infections.
• Certain supplements and medications, such as vitamin C, dietary supplements, laxatives,
calcium-based antacids.
• Drugs ---- Indinavir,Atazanavir,Guaifenesin,Triamterene Sulfa drugs, including sulfasalazine,
sulfadiazine, acetylsulfamethoxazole, acetylsulfasoxazole, and acetylsulfaguanidine Ceftriaxone
(rarely)
Signs and symptoms
• Classical symptoms of acute colic is sudden onset of severe flank pain.
Pain may radiate inferiorly or anteriorly or to the back depending on the
location.
Stones obstructing ureteropelvic junction: Mild to severe deep flank pain
Stones within ureter: Abrupt onset of severe, colicky pain in the flank and
ipsilateral lower abdomen; radiation to testicles or vulva area; intense nausea
with or without vomiting
Upper ureteral stones: Pain radiates to flank or lumbar areas
Signs and symptoms
• Haematuria
• Urgency
• Frequency
• vomiting ,
• fever(if there is infection).
Pathophysiology
Formation of stones
• Renal stones form by an initial crystallisation of the nidus ( termed nucleation) from a
supersaturated urine with subsequent crystal growth and aggregation of the nidus into
macroscopic stone. The kidney stone have an organic matrix that gives form ,
cohesiveness and sometimes remarkable regular structure to the stone.
• Pyrophosphate, magnesium, citrate and certain organic macromolecules (such as
glycosaminoglycan) impede the crystallisation and supersaturation .
• All patients with stones are presumed to have some physiological derangement that
makes them susceptible to stone formation.
• These derangements alter urinary conc.of stone – forming constituents and of inhibitors
to cause supersaturation and facilitated nucleation , crystal growth, and aggregation
• Urinary tract stone disease is likely caused by two basic phenomena
1. supersaturation of the urine by stone-forming constituents, including calcium, oxalate
and uric acid.
Pathophysiology
Formation of stones
2. The second phenomenon, which is most likely responsible for calcium oxalate stones, is
deposition of stone material on a renal papillary calcium phosphate nidus, typically a
Randall plaque (which always consists of calcium phosphate). and uric acid. Calcium
phosphate precipitates in the basement membrane of the thin loops of Henle, erodes into
the interstitium, and then accumulates in the subepithelial space of the renal papilla. The
subepithelial deposits, which have long been known as Randall plaques, eventually erode
through the papillary urothelium. Stone matrix- calcium phosphate, and calcium oxalate
gradually deposit on the substrate to create a urinary calculus.
3. Lack of citrate (a chelating agent) also contribute to formation of calcium
stones.
Other factors that may be important in stone pathogenesis beyond the concentration of
the stone crystalloid in the urine : 1. urine pH . 2. stasis 3. reduction in the concentration
of inhibitors of crystallisation in the urine. 4. heterogeneous nucleation .
Complications
• Abscess formation
• Serious infection of the kidney that diminishes renal function
• Urinary fistula formation
• Ureteral scarring and stenosis
• Ureteral perforation
• Extravasation
• Urosepsis
• Renal loss due to long-standing obstruction
Investigations
• Plain abdominal X-ray for stone that are radiolucent
• Renal ultrasonography – non invasive and is the first choice radiologic test
• Intravenous pyelography (IVP)
• Abdominopelvic computed tomography (CT) – form small stones and stone at the
proximal part of the ureters
• Urinalysis – hematuria
• Urine microscopy – calcium. Oxalate, pus cells etc
• Serum E/Cr/ urea
• Urine culture- for possible infection
• FBC- May reveal infection
• C- Reactive protein.
Treatment
• Life style modification
• Liberal fluid intake up 3 liters in 24 hours
• Vegetables and fruits to encourage alkalization of urine
• Reduction of supplementary calcium
• Intake calcium from natural source
• Reduction red meat consumption
• Treat urinary tract infection if any.
• use of alpha blocker to relaxes the muscles in ureter, helping you pass the kidney stone
more quickly and with less pain. Examples of alpha blockers include tamsulosin
• The following drug classes are used for stone prevention/chemolysis:
• Uricosuric agents (eg, allopurinol)
• Alkalinizing agents (eg, potassium citrate, sodium bicarbonate) - for
uric acid and cysteine calculi
• Thiazide diuretics - help treat hypercalcicuria
• Surgical(percutaneous nephrolithotomy, Shock wave lithotripsy, or
open abdominal surgery)–
Indication 1. large stone more than 2cm
2. stone with severe uncontrollable pain
3. stones with significant hydronephrosis
• Parathyroidectomy is the stone is as a result of hyperparathyiodism.
