STONE DISEASES

Presented by: Mandeep Dubb

(mandeep.dubb@utoronto.ca)
Laura Narducci (laura.narducci@utoronto.ca)
Jessie Niu (jessie.niu@utoronto.ca)
Rania Saghir (rania.saghir@utoronto.ca)
Presented on: Tuesday March 25th /08
 Common Types of Stone
Diseases
• Nephrolithiasis – Kidney stones: Can lead to
hydronephrosis (swelling) and potential renal failure,
predispose the patient to pyelonephritis (infection)
• Urolithiasis – Bladder stones: Often occur secondary to
kidney stones, that travel through the urinary tract to the
bladder ; Cause pain and difficulty urinating
• Cholelithiasis – Gallstones: Can lead to cholecystitis
(infection), cholangitis (biliary tree infection),
inflammation of the pancreas
• Rhinolith – Nasal Cavity Stones: Uncommon, cause
nasal obstruction
 Kidney Stones
• They are the most common type,
especially in the urinary tract (1 in
10 people develop kidney stones
during their lifetime)
• There are among the most
painful urologic disorders
• Each year, people make almost 3
million visits to health care
providers and more than half a
million people go to emergency
rooms for kidney stone problems
• Stones occur more frequently in
men
• Once a person gets more than
one stone, other stones are likely
to develop
• People that live near large bodies
of water are more susceptible
 Signs & Symptoms
• Vary depending on the size of the kidney stones
• “Small” stones (ie. Less than 4 mm) that 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
and how it is positioned rather than its size
• Lower back pain and pain at the groin region
• Hematuria: urine containing blood
• Increased frequency of painful, burning urination
• Nausea and vomiting
• Tenderness in the abdomen and kidney region
• Urinary tract infections
 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
• Result due to excess calcium build-up in
the urine (50% of stone formers have
hypercalciuria).
• Excess build-up of calcium in body will act
as a scavenger for oxalate. (Ingestion of
2000mg or more of calcium may lead to
hypercalciuria or stone formation).
• Excessive intake of animal protein leads to
excess acid in the body; Acid is buffered by
the bone, leading to excess release of
calcium, and stone formation.
• Calcium is often chemically bound to oxalate
or phosphate (More commonly oxalate)
Pathway of Calcium Stone
Formation
 Cystine Stones
• Account for 1% of all kidney stones
• Occur secondary to 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 – affect the
transport system for reabsorption of basic
amino acids into blood
• Gene defect interferes with kidneys’ ability
to dissolve cystine and take it back to the
bloodstream – cystine builds up in urine,
and because of its low solubility, leads to
stone formation.
• Cystine forms hexagonal-shaped
crystals, which are painful
Pathway of Cystine Stone
Formation
 Uric Acid Stones
• Account for 10% of stone diseases
• Genetics may predispose individuals
• Form when there are 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
(alcohol, shellfish, mushrooms,
spinach etc.)
– Acidic urine pH undissociated form
exists, crystal precipitates and stone
formation may occur
• Especially common in people with
gout - if gout is treated, chances of
stone formation decrease
Pathway of Uric Acid Stone
Formation
 Struvite Stones
• Also known as 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 (ex bladder infection) affects chemical
balance in urine:
– Bacteria release chemicals that neutralize the acid in the urine allowing
bacteria to thrive, hence promoting struvite stone development
– Also 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 (bacteria
inside)
Pathway of Struvite Stone
Formation
 Causes of Stone Diseases
Risk Factors:
• Inadequate fluid intake,
dehydration
• Reduced urinary flow and
volume
• Anything that blocks or
reduces the flow of urine!
E.g. urinary obstruction or
some other genetic
abnormality
 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)
 Some medical conditions can
increase risk:
• Congenital defect of the
kidney that causes increased
urinary calcium loss and
stone formation (medullary
sponge kidney)
• Excessive parathyroid
hormone, which causes
calcium loss
• Gout (caused by excessive
uric acid in the blood)
• High blood pressure
• Inflammation of the colon that
causes chronic diarrhea,
dehydration, and chemical
imbalances (e.g. Crohn's &
Colitis)
• Urinary tract infections (affect
kidney function)
 DIET plays an important role
• BAD = diet high in sodium, fats,
meat, sugar, and low in fibre &
whole carbs
• Increases risk for renal stone
disease
• Note: high doses of Vitamin C (i.e.
more than 500mg per day) can
result in high levels of oxalate in the
urine, which increases risk of stone
formation
• Oxalate most common constituent
of kidney stones, white crystals that
are insoluble in water
• Oxalate is found in berries, certain
veggies, nuts, chocolate & tea,
*cranberries contain a moderate
amount, so stone formers
recommended to limit intake
 Diagnosis
• Complete medical evaluation required, look at signs &
symptoms, and if patient has a history of kidney stones
• Differential Diagnosis
• URINE TEST = check for presence of blood & bacteria;
hematuria is present in about 90% patients with kidney
stones
• BLOOD TEST = check levels of creatinine (to evaluate
kidney function)
• BUN (blood urea nitrogen) & electrolytes (to detect
dehydration)
• Calcium (to detect excess parathyroid hormone)
• Complete blood count (to detect infection)
• Once kidney stones are suspected, establishing a
definitive diagnosis is the next stage 
 VISUALIZING THE STONE…
Different kinds of Imaging tests:
ultrasound, intravenous pyelogram
(IVP), retrograde pyelogram, and
computed tomography (CT) scan.
Ultrasound
• Preferred method in pregnant
women
• Usually cannot detect small
stones, especially if located
outside the kidney
Computerized tomography (CT
Scan)
• When available, it is the test of
choice
• Higher sensitivity, faster scan
times, don’t need a contrast
• Better clarity than X-rays
Non-pharmacological Treatment
• Patients are advised be increase physical activity because
stones (especially small sized stones) can frequently
dislodge on their own
• It is recommended for patients to try and “strain their
urine” and collect the stones for analysis because the
composition can help to determine how to prevent
formation of stones in the future
• Increase the amount of fluid intake to increase urine
output
• Recommended: ½ gallon ~ approximately 2 liters of water
daily
• BUT stones bigger than 7 mm and those that do not move
through the ureter within 30 days usually require surgical
intervention (procedure performed by a urologist)
 Some Removal Techniques
• Ureteroscopy
• Lityotripsy
• Ultrasonic lithotripsy
• Electrohydraulic lithotripsy (EHL)
• Extracorporeal shock wave lithotripsy
(ESWL)
• Percutaneous Nephrostolithotomy (PCN)
• Ureteroscopic Stone Removal
• Open Surgery
 Pharmacological Treatment
• Oral analgesics can be used to minimize moderate level of pain
• ie: Tylenol with Codeine®, Percocet® (note: OTC pain killers such as advil and
aspirin are not effective for serve pain associated with kidney stones.
• For severe pain, injectable medications can be given intravenously or
intramuscularly (i.e. morphine sulfate, tramadol HCL)
• Some common side effects of the above medications are:
– nausea and vomiting
– Drowsiness
– constipation
• In severe cases, Pentosan polysulfate sodium can be used to prevent the
formations of the stones via blocking crystal formation
 Summary Slide
• Kidney stones are the most common type of stone disease and they have
a large impact on society and its health, especially affecting men,
and people living near large bodies of water.
• 4 most common types of kidney stones: nephrolithiasis, urolithiasis, cholelithiasis, rhinolinth
• Calicium stones occur secondary to hypercalciuria and are often bound to oxalate or phosophate in their
insoluble form
• Cystine stones occur secondary to cystinuria (genetic defect of SLC 3A1 or SLC 7A9 that affect amino
acid transport)
• Uric Acid Stones: High levels of purines are ultimately metabolized into uric acid, and
in the presence of acidic urine, can lead to crystal precipitation and
stone formation.
• Struvite Stones: The presence of a bacterial infection can lead to conditions such as
alkaline urine pH and high levels of ammonia hence leading to the
formation of these stones (made of magnesium ammonium phosphate).
• Some factors that increase one's risk of developing kidney stones include inadequate fluid intake,
reduced urinary flow, abnormal levels of certain compounds in the urine, such as hypercalciuria,
hyperoxaluria, hyperuricosuria and cystinuria.
• A diet high in sodium, fats, meat, sugar, and low in fibre & whole carbs also increases risk for renal stone
disease.
• Common symptoms include increased frequency of urination, nausea and vomiting, pain during urination
(stinging, burning), tenderness in the abdomen and kidney region, urinary track infection
• Stone disease may be suspected based on medical evaluation, history of disease, and laboratory values
from urine and blood tests, but they are definitively diagnosed through visualizing methods such as
ultrasound and CT scans
• Removal of stones larger than 7mm usually require various surgical procedures such as Lityotripsy,
Ultrasonic lithotripsy, Electrohydraulic lithotripsy (EHL), Extracorporeal shock wave lithotripsy (ESWL) or
open surgery
• Pentosan polysulfate sodium can be used to prevent the formations of the stones via blocking crystal
formation
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