RENAL CALCULI (NEPHROLITHIASIS) NOTES

BY:JUSTIN SIR

A renal calculi is the stone formation in kidneys. It is also known as nephrolithiasis.

1. Stones are formed when urinary concentrations of substances such as calcium

oxalate, calcium phosphate, and uric acid increase. This is referred to as
supersaturation and is dependent on the amount of the substance, ionic strength, and
pH of the urine.

2. Calcium oxalate and calcium phosphate stones accounts for 80% of all stones
passed, uric acid and struvite about 5-10% each and cystine about 2%.

3. The pain generated by renal colic is primarily caused by dilation, stretching, and
spasm because of the acute ureteral obstruction.

👉🏼Etiology

The exact etiology of nephrolithiasis is not clear but there are certain risk factors
which leads to stone formation. These are mentioned below:

👉🏼Risk Factors

1. Heredity: Risk of stone formation is more in men having family history of stone.

2. Cystine stones in the kidneys may occur due to cystinuria which is inherited
autosomal recessive disease.

3. Renal calculi affect males about twice as often females.

4. Diet: Diet high in animal protein, salt and sucrose may increase urinary calcium
excretion.

5. Low calcium leads to increase in oxalate absorption from diet, therefore high
oxalate excretion.

6. Obesity: Uric acid stones are prevalent in obese and diabetic patients.

7. Patient with neurogenic bladder is at risk to develop struvite stone.

8. Calcium stones are formed in case of hyper- calcemia. Hypercalcemia may be

associated with the following:

a. Hyperparathyroidism
b. Renal tubular acidosis

c. Cancers

d. Granulomatous disease

e. Excessive vitamin D intake

f. Excessive milk intake

g. Myeloproliferative disease

9. Urinary pH, solute load and inhibitors in the urine affect the formation of stone.

10. Urinary stasis and genetic factors.

👉🏼Pathophysiology

⬇️
Less fluid intake and dehydration

Deficiency of substances: Citrate, magnesium, nephrocalcin, and uropontin that

⬇️
normally prevent crystallization in the urine

Causes of hypercalcemia, hypercalciuria include the following:

. Hyperparathyroidism

. Renal tubular acidosis

• Cancers

• Granulomatous diseases (sarcoidosis, tuberculosis), which may cause increased

vitamin D production by the granulomatous tissue

• Excessive intake of vitamin D

⬇️
• Excessive intake of milk and alkali

Infection, urinary stasis, and periods of immobility (slows renal drainage and alters

⬇️
calcium metabolism)

Increased calcium concentrations in blood and urine promote precipitation of calcium

⬇️
and formation of stones

Excessive calcium deposition in renal tissues which further causes formation of

kidney stone
⬇️
Renal stone

➖ ⬇️
Renal colic

➖ Infection
➖ Renal damage

👉🏼Effects of Stone

The size and position of the stone usually govern the development of secondary
pathologic changes in the urinary tract.

Same Kidney

1. Obstruction

2. Infection

3. The epithelium of the pelvis and calyces in relation to the stone gradually loses
luster, becomes rough and thickened. Parenchymal ischemia may be caused by local
pressure due to stone.

4. Metaplasia

Opposite Kidney

1. Compensatory hypertrophy.

2. Stone formation may be bilateral. 3. Infection of the opposite kidney.

4. Calculus anuria.

👉🏼Clinical Manifestations

Sign and symptoms depend upon the location and size of stone.

1. Pain: Sudden onset of pain which may last for 30-120 minutes. Pain will not be
improved or worsened by posture or movements. When stones move to the ureter, it
causes acute colicky wave like pain radiating down to the thigh and genital organs.

2. Persistent urinary frequency with urinary tract

infection. Infection can occur by stone from irritation.

3. Pain originating in the renal area radiate towards the bladder in the female and
towards testes in male.

4. Nausea and vomiting is also present along renal colic pain. Diarrhea and
abdominal discomfort may occur.

5. Pyuria, proteinuria may also be present.

6. All these symptoms are collectively known as ureteral colic. When stones move to
bladder, it causes irritation, UTI and hematuria.

Diagnostic Evaluation

1. Physical examination in patients with nephrolithi- asis includes dramatic

costovertebral angle tender- ness.
2. Urinalysis: Crystalluria reveals presence of stone. Urinary sediment or dipstick test
is done. To demon- strate blood cells, with a test for bacteriuria (nitrite) and urine
culture in case of a positive reaction.

24 hour urine analysis is indicated for diagnosis of factors contributing to stone

formation. In recurrent calcium stone, the most common abnormality found is
elevated excretion of calcium with normal blood calcium.

3. Serum and urinary pH level: It may provide insight regarding patient's renal function
and type of calculus (eg. calcium oxalate, uric acid, cystine), respectively.

4. Blood chemistry: Its report may show high serum calcium level in blood. Serum
creatinine level testing is done to measure renal function.

5. X-ray/ultrasound of pelvis are used to detect stone.

6. Non-contrast abdominopelvic CT scan is very helpful to detect renal calculi.

7. Retrograde pyelography is the most precise imaging method for determining the
anatomy of the ureter and renal pelvis; for making definitive diagnosis of any ureteral
calculus.

8. Nuclear renal scanning is helpful to measure differential renal function.

👉🏼 Management

Medical Management

The goal of medical management is to eradicate the stone, determine stone type,
prevent nephron destruction, control infection and relieve any obstruction. Medical
treatment of nephrolithiasis involves supportive care and administration of agents,
such as:

1. Hydration therapy: In acute renal colic, IV fluids are given. As patient's condition get
stable, encourage patient to take plenty of fluids. The goal of hydration therapy is to
excrete urine in excess of 2L/day.

2. PO/IV narcotic analgesics such as codeine, butorphanol, morphine sulphate are

indicated to control severe renal pain.

3. Provide analgesics and NSAIDs, e.g. ketorolac, and ibuprofen.

4. Antiemetics, e.g. metoclopramide is given to control nausea and vomiting.

5. Antibiotics, e.g. ampicillin, gentamicin ticarcillin/ clavulanic acid, ciprofloxacin,

levofloxacin, ofloxacin) are indicated to control infection.

6. Corticosteroids, e.g. prednisone and prednisolone is also helpful to relieve

symptoms.

7. Calcium channel blockers (nifedipine) and alpha blockers (tamsulosin, terazosin).

Alpha-blocking agents, given on a daily basis, also reduce the number of recurrent
colics.

8. Hot bath also seems helpful in relieving the pain.

9. Nutritional therapy: In almost all patients in whom stones form, an increase in fluid
intake and, therefore, an increase in urine output is recommended. Patient has been
instructed to drink eight glasses of fluid daily to maintain adequate hydration and
chance of urinary supersaturation with stone- forming salts. The goal is a total urine
volume in 24 hours in excess of 2 liters.

a. The only other general dietary guidelines are to avoid excessive salt and protein
intake, Moderation of calcium and oxalate intake is also reasonable, but great care
must be taken not to indiscriminately instruct the patient to reduce calcium intake.

b. As a rule, dietary calcium should be restricted to 600-800 mg/d in patients with

diet-responsive hypercalciuria who form calcium stones. This is roughly equivalent to
a single high-calcium or dairy meal per day.

c. Uric acid stone: Prescribe low purine diet.

d. Cystine stone: Provide low protein diet.

10. Dietary management along with medication is done to normalize the specific
abnormalities and to prevent stone recurrence. Renal stone less than 5 mm can pass
through urine but larger than 6 mm needs surgical intervention.

👉🏼 Surgical Management

Surgery may be needed to remove a kidney stone, if it:

1. does not pass after a reasonable period of time and causes constant pain.

2. is too large (above 6 mm in size) to pass on its own or is caught in a difficult place.

3. blocks the flow of urine.

4. causes an ongoing urinary tract infection.

5. damages kidney tissue or causes constant bleeding.

Types of Surgical Procedure

Types of surgical procedure done for renal calculi are as follows:

1. Nephrolithotomy: In this procedure, the surgeon makes an incision in the back and
Percutaneous Nephrolithotomy (PCN) needle is passed into pelvis of the kidney
through fluoroscopy. a. Using nephroscope, the surgeon locates and removes the
stone.

b. For large sized stones, some type of energy probe, i.e. ultrasonic or electrohydraulic
may be needed to break the stone into small pieces.
c. Often, patients stay in the hospital for several days and may have a small tube
called a nephrostomy tube left in the kidney during the healing process.

2. Extracorporeal Shock Wave Lithotripsy (ESWL): ESWL, works by focusing intense

sound waves (outside the body) on the stone. Sound waves travel through the skin
and body tissues and cause the stone to shatter while minimizing the effect on
surrounding tissue. The small broken pieces of stone then wash out of the kidney
with normal urine flow, usually with little or no discomfort.

3. Ureteroscopy: A non-invasive procedure is indicated for middle and lower ureter

stones. Here, ureteroscope (small fiberoptic instrument) is passed through the
urethra and bladder into the ureter. The surgeon then locates the stone and either
removes it with a cage-like device or shatters it with a special instrument that
produces a form of shock wave. A small tube or stent may be left after operation in
the ureter for a few days to help urine flow. The stent is completely internal, and is
generally removed after 3-10 days. Removal is performed quickly and easily without
the need for anesthesia.

4. Stent placement: Ureteral stents are used to ensure the patency of a ureter, which
may be compromised by a kidney stone. It is a temporary measure to prevent damage
to a blocked kidney, until a procedure to remove the stone can be performed. Stents
may also be placed in a ureter that has been irritated or scratched during a
ureteroscopy procedure that involves the removal of a stone, sometimes referred to
as a 'Basket Grab Procedure'. Stents placed for this reason are normally left in place
for about a week. These stents ensure that the ureter does not spasm and collapse
after the trauma of the procedure.

5. Chemolysis, stone dissolution using infusion of chemical solutions for the purpose
of dissolving the stone is an alternative treatment. Sometimes, it is used in patients
who are at risk for complications with other types of therapy.

👉🏼 Complications

1. Obstruction: Acute episode of stone passage may lead to obstruction.

2. Urinary tract infection.

3. Increased risk to develop hypertension.

👉🏼 Nursing Management

Relieve Pain

1. I/V or IM administration of opioids analgesics for colicky pain is done. Patient is

closely monitored for pain relief. Administer NSAIDs or tramadol as prescribed by
physician.

2. Provide comfortable position.

3. Monitor urine output.

4. Encourage patient to take plenty of fluids as it helps in downward passage of the

stone.
Nutritional Therapy

It is also important. Atleast 2 hrs/day water is encouraged and food containing

calcium is to be avoided such as rice, milk.

1. For calcium stones, calcibine is given that absorbs the calcium into the circulation.

2. For oxalates stones, food items like chocolate, tea, spinach, etc. is avoided.

3. Proteins are also restricted.

4. Sodium restriction is also useful for calcium reabsorption.

Monitor and Manage other Complications

There is an increase risk for infection and obstruction of urinary tract. The urine
output and voiding patterns are monitored.

1. Any blood clot in the urine is sent to laboratory for studies.

2. To detect early signs of infection, vital signs are monitored.

3. Antibiotics are provided to the patient.

4. Early ambulation is encouraged.

👉🏼 Complications

1. Urinary fistula formation.

2. Ureteral perforation.

3. Urosepsis.

4. Ureteral scarring and stenosis.

5. Abscess formation.

5. Periodically, urine cultures are performed.

Complications
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