NEPHROLITHIASIS

INTRODUCTION AND DEFINITION

According to Dr. Surya Bhagwati (2020) Nephrolithiasis, or kidney stone is something

that urologist deal with most frequently, with the condition affecting an estimated12% of all
people worldwide. Nephrolithiasis is a health issue marked by the creation of solid deposits in
the kidneys. These deposits, made up of minerals and salts, come in various sizes and can lead
to intense pain, blood in urine (hematuria), and complications in the urinary tract.

Nephrolithiasis is intricately linked to a combination of factors. Dehydration emerges as a

key player, concentrating urine and promoting mineral crystallization. Dietary choices, including
the consumption of oxalate-rich foods, excessive sodium, and certain medications, contribute to
the development of these stones. The influence of genetics becomes apparent through familial
clustering, indicating a hereditary predisposition. This intricate interplay of dehydration, diet, and
genetics emphasizes the need for personalized preventive measures and targeted treatment
approaches in managing nephrolithiasis.

ANATOMY AND PHYSIOLOGY

In the anatomical context of nephrolithiasis, the kidneys play a central role in filtering
blood and eliminating waste products through urine. However, the process isn't flawless, and
minerals and salts can occasionally accumulate, forming solid deposits known as kidney stones.
These stones can disrupt the normal flow of urine and navigate through the urinary tract,
including the ureters and bladder, causing discomfort and pain during their passage.

On the physiological front, urine concentration and pH levels are pivotal factors
influencing stone formation. Dehydration amplifies urine concentration, creating an environment
conducive to mineral crystallization – a key step in the genesis of kidney stones.
Simultaneously, alterations in pH levels impact the solubility of minerals in urine, further
contributing to the formation and growth of these stones.
SYMPTOMATOLOGY

For small kidney stones, individuals may not encounter or experience any symptoms, and these
stones might pass without causing discomfort. However, as the stones increase in size or
traverse through the urinary tract, the onset of painful symptoms becomes more noticeable.
These include:

 Hematuria (blood in urine)

 Increased frequency of urination but reduced urine output
 Pain (renal colic) towards one side of the back, abdomen or the groins on men
 Painful urination
 Cloudy or foul-smelling urine
 Fever and chills, indicating a possible infection
 Nausea and vomiting

The symptoms of nephrolithiasis can vary in intensity and combination, highlighting the diverse
clinical presentation of the condition. These symptoms can vary among individuals, and not
everyone with kidney stones experiences all of them. If you suspect nephrolithiasis, seeking
medical evaluation is crucial for proper diagnosis and management.

ETIOLOGY

A.PREDISPOSING FACTORS

1. Genetics: Familial clustering suggests a hereditary influence, indicating that certain

genetic factors may predispose individuals to kidney stone formation.

2. Metabolic Disorders: Conditions such as hypercalciuria or hyperparathyroidism can

disrupt normal mineral balance, increasing the risk of stone formation.

3. Obesity: Excess body weight is associated with increased urinary excretion of calcium
and uric acid, both of which are components of kidney stones

4. Certain Medical Conditions: Gout, involving elevated levels of uric acid, and cystinuria,
a genetic disorder affecting cystine, can raise the likelihood of kidney stone
development. Conditions like Crohn's disease or ulcerative colitis can lead to changes in
the digestive system, affecting the absorption of calcium and oxalate, thereby increasing
the risk of stone formation.
B.PRECIPITATING FACTORS

1. Dehydration: Inadequate fluid intake results in concentrated urine, promoting the

crystallization of minerals and the formation of kidney stones.

2. Dietary Factors: High consumption of oxalate-rich foods, excessive sodium, and certain
medications can contribute to the buildup of substances that form stones in the kidneys.

3. Urinary Tract Abnormalities: Anatomical variations or obstructions in the urinary

system can impede the normal flow of urine, contributing to the development of kidney
stones

PATHOPHYSIOLOGY

The process begins when there's an excess of

SUPERSATURATION minerals in the urine, leading to a state of
supersaturation. This can be influenced by factors
like dehydration, where reduced fluid intake causes
urine to become concentrated with minerals.
Within the supersaturated urine, tiny crystals start
to form. These crystals serve as a nucleus or
NUCLEATION foundation for the development of kidney stones.
The formation of crystals is influenced by various
factors, including the pH of the urine and the
concentration of specific minerals.
The formed crystals don't exist in isolation. They
combine with other substances present in the
AGGREGATION urine, gradually growing into solid masses. The
aggregation process contributes to the formation of
stones with different compositions, such as calcium
oxalate, calcium phosphate, uric acid, or cystine
stones.

OBSTRUCTION As stones increase in size, they may obstruct the

urinary tract, causing pain and hindering urine flow.

The presence of stones can lead to irritation and

inflammation in the urinary tract tissues. This
INFLAMMATION inflammatory response contributes to symptoms
such as hematuria (blood in urine), frequent
urination, and a persistent urge to urinate.
MANAGEMENT

I. Clinical Management

a) Pain Management:
Nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids may be prescribed to manage
pain during stone passage.

b) Hydration:
Adequate fluid intake is crucial to prevent dehydration and reduce the concentration of
minerals in the urine, helping to prevent stone formation.

c) Medications
 Tamsulosin (flomax)
 Nifedipine
 Hydrochlorothiazide

d) Monitoring:
Regular follow-up appointments and imaging studies help monitor stone status, kidney
function, and the effectiveness of preventive measures.

e) Diagnostic Tests
Several diagnostic tests are utilized to identify and evaluate nephrolithiasis. Some
common ones include:
 CT Scan (Computed Tomography): Provides detailed images, especially
effective in detecting kidney stones of varying sizes
 Ultrasound: Non-invasive imaging using sound waves to identify kidney stones
and urinary tract obstructions.
 X-ray: Instrumental in identifying radio-opaque stones visible due to their
composition.
 Urinalysis: Examination of urine for crystals, blood, or abnormal pH levels to
indicate the presence and composition of kidney stones.
 Blood Tests: Essential for assessing kidney function and identifying factors
contibuting to stone formation

Dietary Changes:

Adjusting dietary habits, including reducing sodium intake and avoiding high-oxalate foods, can
help manage certain types of kidney stones.
II. Surgical Management

1. Nephrolithotomy - if the stones are in the kidney this is the surgery that is performed.
2. Nephrectomy- if the kidney is nonfunctional secondary to infection, this is the surgery
that is performed.
3. Pyelolithotomy - if the stones are in the kidney pelvis this is the surgery that is performed
4. Cystolithopalaxy- if the stones are in the bladder
5. Ureterolithotomy- if the stones are in the urether.
6. Extracorporeal Shock Wave Lithotripsy (ESWL) - This non-invasive procedure uses
shock waves to break kidney stones into smaller fragments, making them easier to pass.
ESWL is typically suitable for smaller stones.
7. Laparoscopic Surgery - In some cases, laparoscopic techniques may be employed for
complex stone removal. This involves smaller incisions and the use of a camera to guide
the surgeon.