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Kidney Stones
Jason Ryan, MD, MPH
Kidney Stones
Nephrolithiasis

1. Calcium
2. Struvite
3. Urate
4. Cystine
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Symptoms
• Flank pain (side between the ribs and the hip)
• Colicky (waxes and wanes in severity)
• Hematuria
Risk Factors
• High amount of stone substance in blood
• Hypercalcemia
• Hyperuricemia
• Low urine volume
• Usually from dehydration
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• Increases concentration of urine substances
• In general, hydration lowers risk of stones
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Calcium Stones
• Calcium oxalate (most common)
• Calcium phosphate
• Most common type of kidney stone (80%)
• Key risk factors
• Hypercalcemia
• High oxalate levels in blood
• Radiopaque
• Seen on x-ray and CT scan

Image courtesy of James Heilman, MD

Risk Factors
• Most common etiology: idiopathic hypercalciuria
• Hypercalcemia (hyperparathyroidism)
• High oxalate levels
• Crohn’s disease: Fat malabsorption → Fat binds to calcium,
leaving oxalate free to be absorbed in the gut
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• Gastric bypass patients
• Ethylene glycol (antifreeze)
• Formation of oxalate
• Increases oxalate concentration in urine
• Vitamin C abuse
• Oxalate generated from metabolism of vitamin C
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Dietary Sodium
↑ Na
More Na = More Ca Urine
High Na diet = Stone formation
↑ ECV Low Na diet = Treatment stones

↓ RAAS

↓ Na Reabsorption
Proximal Tubule

↓ Ca Reabsorption
Proximal Tubule
Calcium Stones
• Classic case
• Patient drinking less water
• Flank pain, hematuria
• Calcium stone on imaging
• Normal Ca level in plasma
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• Increased calcium level in urine
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Treatment
• Most stones pass on their own
• Large stones that do not pass require surgery
• Recurrent stone formers may take medication
• Thiazides
• Decrease Ca in urine
• Citrate (Potassium citrate)
• Binds with calcium but remains dissolved
• Lowers urinary Ca available for stones
• Inhibits of stone formation
Struvite Stones
• Ammonium-Magnesium-Phosphate stones
• 2nd most common stone type (15%)
• Consequence of urinary tract infection
• Urease-positive bacteria
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• Proteus, Staphylococcus, Klebsiella
• All hydrolyze urea to ammonia
• Urine becomes alkaline
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Struvite Stones
• Can forms “staghorn calculi”
• Stones form a cast of the renal pelvis and calices
• Looks like horns of a stag
• Won’t pass → surgery required
• Untreated → bacterial reservoir
• Recurrent infection
• Radiopaque
• Seen on x-ray and CT scan

Image courtesy of Nevit Dilmen

Struvite Stones
• Classic presentation
• UTI symptoms (dysuria, frequency)
• Mild flank pain
• Hematuria
• Large, branching staghorn stone on imaging
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• Treatment:
• Surgery
• Antibiotics
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Uric Acid Stones

• Cause by high uric acid in urine or acidic urine
• H+ + Urate- ↔ Uric acid
• Radiolucent stones
• Not visible on x-ray
• Can see with CT scan
• Lowest pH is in the distal tubule/collecting duct
Risk Factors
• High uric acid levels
• Gout
• Leukemia, myeloproliferative disease
• Acidic urine (precipitates uric acid)
• Chronic diarrhea AfraTafreeh.com
• More common in hot, arid climates
• Low urine volume, acidic urine more common
• 5-10% stones in US/Europe
• 40% stones in other climates
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Treatment
• Hydration
• Alkalization of urine
• Potassium bicarbonate
• Rarely allopurinol
• Xanthine oxidase inhibitor
• Reduces uric acid production
• Medically therapy often effective
• Usually does not require surgery
Uric Acid Stones
• Classic case
• Flank pain, hematuria
• No stone on x-ray
• Choose medical therapy, not surgery
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Cystine Stone
• Rare type of stone
• Seen in children with cystinuria
• Tubular defect → cannot absorb cystine
• Also form staghorn calculi
Cystine Stone
• Classic case
• Child
• No history of UTI (contrast with Struvite)
• Large, staghorn stone
• Treatment: AfraTafreeh.com
• Hydration
• Alkalinization of urine