Marlin Nouelle Sacramed

NEPHROLITHIASIS
Aka: Urolithiasis, Kidney stone, Renal Calculi, Ureteral Calculus, Renal Colic

Nephrolithiasis(from Greek  nephros, "kidney") and (lithos, "stone")) refers to the condition of

having kidney stones. Nephrolithiasis specifically refers to calculi in the kidneys.

Nephrolithiasis is a common disorder, affecting about 0.2% in U.S. The incidence in men is four
times higher than in women (4:1). Males usually

1. Males: Calcium oxalate

2. Females: Struvite
3. Both: Urate Stones and Cystine Stones

Stones due to discrete metabolic/hormonal defects (eg, cystinuria, hyperparathyroidism) and

stone disease in children are equally prevalent between the sexes. Stones due to infection (struvite
calculi) are more common in women than in men

White men have three times more attacks than black men, except for ammonium magnesium
phosphate (struvite) stones, which occur more often in black men. About 50% of patients have a single
stone with no recurrence, but the other 50% have recurrent episodes within 5 years.

Most urinary calculi develop in persons aged 20-49 years. An initial stone attack after age 50
years is relatively uncommon.

Symptoms:

A. Severe Abdominal Pain of sudden onset

1. Unilateral flank pain
2. Lower Abdominal Pain
B. Associated symptoms
1. Nausea and Vomiting

Symptoms related to stone location

A. Kidney
1. Vague flank pain
1. Hematuria
B. Proximal Ureter
1. Flank pain
2. Upper Abdominal Pain
2. Renal colic
B. Mid-Ureter
1. Flank pain
2. Anterior Abdominal Pain
3. Renal colic
 C. Distal ureter (Ureteropelvic junction)
1. Dysuria
2. Urinary frequency
3. Anterior Abdominal Pain
4. Flank pain
5. Renal colic

Causes: Most research on the etiology and prevention of urinary tract stone disease has been directed
toward the role of elevated urinary levels of calcium, oxalate, and uric acid in stone formation, as well as
reduced urinary citrate levels.

 Hypercalciuria is the most common metabolic abnormality. Some cases of hypercalciuria are
related to increased intestinal absorption of calcium (associated with excess dietary calcium
and/or overactive calcium absorption mechanisms), some are related to excess resorption of
calcium from bone (ie, hyperparathyroidism), and some are related to an inability of the renal
tubules to properly reclaim calcium in the glomerular filtrate (renal-leak hypercalciuria).
 Magnesium and especially citrate are important inhibitors of stone formation in the urinary
tract. Decreased levels of these in the urine predispose to stone formation.
 A low fluid intake, with a subsequent low volume of urine production, produces high
concentrations of stone-forming solutes in the urine. This is an important, if not the most
important, environmental factor in kidney stone formation.
 The most common findings on 24-hour urine studies include
hypercalciuria, hyperoxaluria, hyperuricosuria,hypocitraturia, and low urinary volume. Other
factors, such as high urinary sodium and low urinary magnesium concentrations, may also play a
role. To identify these risk factors, a 24-hour urine profile, including appropriate serum tests of
renal function, uric acid, and calcium, is needed. Such testing is available from various
commercial laboratories. A finding of hypercalcemia should prompt follow-up with an intact
parathyroid hormone study to evaluate for primary and secondary hyperparathyroidism.

Risk Factors: Genetics, diet, metabolism disorders such as gout and DM, presence of recurrent infection
prolonged increased atmospheric diet and immobility

Diagnosis: A number of blood and urine tests will be required to detect the presence of infection and
test the function of the kidneys. Urinary tests may also allow the type of stone to be identified, allowing
further guidance of therapy. When urinary stones are suspected, an x-ray of the abdomen is also
required to detect the stones or any other problem causing a similar set of symptoms.

Treatment goals include relief of symptoms and prevention of further symptoms. Treatment
varies depending on the type of stone and the severity of symptoms and/or complications.
Hospitalization may be required if symptoms are severe. Stones are usually passed in the urine, given
enough time to fluch through the system.
  The urine should be strained at the time of passing and the stone saved for analysis of the type
of stone.
 Fluids should be adequate to produce a large amount of urine. Water is encouraged, at least 6
to 8 glasses per day. If oral intake is inadequate, intravenous fluids may be required.
 Pain-killers may be needed to control renal colic (pain associated with the passage of stones).
Severe pain may require strong pain-killers such as morphine or pethidine.
 Depending on the type of stone, medications may be given to reduce further stone formation
and/or dissolve the material forming the stone. These may include such medications as
diuretics, phosphate solutions, allopurinol (for uric acid stones), antibiotics (for struvite stones),
and medications that make the urine alkaline such as sodium bicarbonate or sodium citrate.If
the stone does not pass by itself, surgical removal of the stone may be required.
 Lithotripsy may be an alternative to surgery. In this procedure, ultrasonic sound waves or shock
waves are used to break up stones so that they may be expelled in the urine (extracorporeal
shock-wave lithotripsy) or removed with an endoscope that is inserted into the kidney in surgery
(percutaneous nephrolithotomy).With resolution of the condition, the patient may be required
to avoid certain food types which may increase the likelihood of developing kidney stones.

Prevention

A. Maintain fluid intake >2.5 Liters per day

1. Ingest 8 to 12 ounces fluid at bedtime
2. Recommended fluids

1. Water
2. Citrus juice
B. Maintain Urine volume > 2 Liters per day

1. Periodically measure urine output in a 2 liter bottle

C. Dietary restrictions
1. Limit animal protein to 8 ounces per day (or <1 gram/kg/day)
2. Limit sodium intake to 2-4 grams per day

b. Limit Oxalate Containing Foods

c. Limit high sugar or fat content (Obesity predisposes to stone formation)
d. Avoid excessive Vitamin C

D. Dietary increases or no restriction

1. Increase vegetable Dietary Fiber
2. Maintain calcium intake at at least 1000 mg/day
a. No Dietary Calcium restriction (unless absorptive Hypercalciuria)

b. Calcium binds oxalate in intestine

Prognosis: Kidney stones are painful but usually are excreted without causing permanent damage. They
tend to recur, especially if the underlying cause is not found and treated.

Treatment: Nephrectomy
Drugs Used in the Treatment of This Disease: Morphine Sulfate Injection (Morphine sulfate) and
Zyloprim (Allopurinol)