2.

24 Nephrolithiasis
Type KCP: Difficulty in Urination TBL

Status Done

Studied

OBAs

1. A 26-year-old man is diagnosed with acute myelogenous leukemia.

After he underwent a few cycles of chemotherapy, he has an episode of
colicky pain in the lower abdomen with haematuria. He has no fever,
dysuria or increase frequency of urination. Physical examination is
unremarkable. Urinalysis shows a pH of 5.5 and red blood cells but no
proteins, ketones, or glucose. Abdominal radiograph is normal. What
other urinalysis finding is most likely to be expected in this patient?

a. White blood cell casts

b. Benz-Jones protein

c. Myoglobin

d. Uric acid crystals

This patient is suffering from acute myelogenous leukaemia which

has rapid cell turnover. Due to chemotherapy, cell death causes
release of purines from DNA breakdown. This leads to the
development of hyperuricemia. Since uric acid is insoluble in acidic
urine, it predisposes to uric acid stone formation. Uric acid stones are
radiolucent.
Benz-Jones proteins in urine are seen in multiple myeloma and not in
leukemia.
Myoglobin in urine is seen in rhabdomyolysis which is seen in severe
injury to skeletal muscles.
White blood cell casts are seen in pyelonephritis.

2. An image above shows the cut surface of a kidney. An arrow is pointing

towards a large, yellowish, irregular, friable stone which has a shape of
the pelvicalyceal system. What type of stone is this most likely to be?

2.24 Nephrolithiasis 1
 a. Struvite stone

b. Cystine stone

c. Uric acid stone

d. Calcium oxalate stone

This morphology and description of the stone is suggestive of a struvite

or staghorn stone.
Calcium oxalate stones are usually small, ovoid, granular with a rough
surface.
Uric acid stones are often small yellowish-brown, hard, multiple, and
laminated.
Cystine stones are small, round, smooth and multiple.

3. A 40-year-old man visits the clinic for consultation having noted some
particulate material during urination two days ago. Urine sediment
analysis was done. The findings are shown in the image above. What
type of renal calculus is most likely formed in this patient?

a. Cysteine

b. Calcium oxalate

c. Uric acid

d. Calcium phosphate

Calcium phosphate crystals are blunt-ended needles or prisms,

rosettes in shape.

Calcium oxalate dehydrate crystals are octahedral or envelope-

shaped, whereas calcium oxalate monohydrate crystals are found in
picket fence forms.

Cysteine crystals are flat plates and have a characteristic hexagonal

shape with equal or unequal sides.
Uric acid crystals are rhomboids, parallelograms, and rosettes in
shape.

4. A 58-year-old woman presents with low back pain and hematuria. She
has had recurrent urinary tract infections for the past 10 years. On
examination, tenderness is present on deep pressure over the right
costovertebral angle. Urine analysis shows haematuria and presence of

2.24 Nephrolithiasis 2
 triple phosphate crystals. On plain radiograph of the abdomen, the right
renal pelvis is distended by a staghorn calculus. Which organism is
most likely to be responsible for her previous recurrent urinary
infections?

a. Escherichia coli

b. Staphylococcus aureus

c. Chlamydia trachomatis

d. Proteus mirabilis

This patient has a staghorn calculus which is composed of

magnesium ammonium phosphate. This type of kidney stone is
associated with recurrent UTIs by urea-splitting bacteria that convert
urea to ammonia. The most common urea splitting bacteria causing
urinary infection is Proteus mirabilis.

5. A 50-year-old woman has successfully been treated for nephrolithiasis.

After the treatment, she is prescribed with low-dose suppression
antibiotics to prevent recurrence of the renal calculus.What type of
renal calculus had most likely formed in this patient?

a. Uric acid

b. Cystine

c. Calcium phosphate

d. Struvite

Struvite stones are infection stones associated with urea-splitting

organisms. Once struvite stones are identified, three principles exist
for their treatment.

Firstly, all stone burdens should be removed.

Secondly, antibiotics should be used to treat the infection so that
subsequent urine is sterile in the absence of antibiotics.

Thirdly, recurrence should be prevented, which is a function of the

other two principles.

Antibiotics have a pertinent role pre-operatively, post-operatively,

and in the presence of residual stone fragments.

2.24 Nephrolithiasis 3
 6. A 47-year-old man presents with severe writhing back pain radiating
from the loin to the groin associated with nausea. A diagnosis of
nephrolithiasis is confirmed following a plain x-ray and abdominopelvic
CT scan. The calculi are strongly opaque suggestive of calcium oxalate
stones which are more common with hypophosphatemia. The action of
which hormone is likely to produce hypophosphatemia in this patient?

a. Calcitonin

b. Aldosterone

c. Vasopressin

d. Parathyroid hormone

85-90% of the filtered phosphate is reabsorbed in the proximal

tubule by an electro-neutral sodium-dependent secondary active
transport system (2Na+ : HPO4^2-).
The transporter is inhibited by parathyrold hormone (PTH), which
increases clearance of phosphate from the plasma in addition to
inhibiting the reabsorption of phosphate from the proximal tubule.

PTH increases the reabsorption of Ca2+ from the loop of Henle.

7. A 45-year-old man is being treated for terminal stages of lung cancer.

He has metastases localised to the vertebrae of the thoracic spine. He
has worsening somatic sensory and motor signs in both his lower limbs,
but his upper limbs are unaffected. He has lost all voluntary bladder
control. Which would best describe his micturition reflex arc?

a. Sensory fibres are lost

b. Motor fibres are lost

c. The pudendal nerve is damaged

d. The reflex is intact

Cortical control of his reflex is lost due to the lesions in the thoracic
spine. However, he is most likely to have an intact micturition reflex
arc since the reflex arc involves sacral segments and there are no
signs on disease in that regions.

8. A 47-year-old man with severe back pain and fever and is diagnosed
with acute pyelonephritis. He has a history of nephrolithiasis in . On

2.24 Nephrolithiasis 4
 examination, he has renal angle tenderness on the right side.What is the
most likely cause of renal angle tenderness in this patient?

a. Irritation due to a lodged calculus

b. Spasm of the ureter

c. Blockage of urine flow

d. Stretching of the renal capsule

The case presents with local pain rather than referred pain due to
acute distention of renal capsule which elicits tenderness on
percussion of the renal angle.

9. A 40-year-old woman presents with complaints of back pain, frequent

urge to urinate and burning micturition. She is found to have struvite
stones. She is prescribed an antibiotic which inhibits bacterial DNA
gyrase with other modalities of treatment. Which is the likely antibiotic
prescribed for the patient?

a. Ampicillin

b. Cotrimoxazole

c. Cephalexin

d. Norfloxacin

Struvite stones are strongly associated with UTIs with urea splitting
organisms.

All the options given are antiblotics that can be used in UTIs.
However, among the options, Norfloxacin is the only antibiotic which
acts by inhibiting the bacterial DNA gyrase.

10. A 50-year-old man comes to the Emergency Department with flank and
abdominal pain, nausea and vomiting. He gives history of recurrent
episodes of gout for which he is not taking any treatment except for
analgesics. The physician suspects nephrolithiasis and prescribes a
drug. Which is the likely drug prescribed for the patient?

a. Hydrochlorothiazide

b. Frusemide

c. Allopurinol

d. Colchicine

2.24 Nephrolithiasis 5
 The patient has a history of gout. Hence, the likely type of stone is the
uric acid stone.

Hydrochlorothlazide is used in calcium stones.

Frusemide is not commonly used as a first choice of treatment in uric

acid stones.

Colchicine produces a lot of adverse effects therefore, not commonly

used. It is also not a choice in patients with uric acid stones.

Allopurinol is the drug of choice in uric acid stones as it decreases the

synthesis of uric acid by inhibiting the enzyme xanthine oxidase.

SEQs

1. A 32-year-old woman presents to the Emergency Department with

acute onset of severe right-side flank pain. The pain radiated down into
the groin and is associated with hematuria, urinary urgency and dysuria.
Her body temperature is 37.1˚C. The patient was prescribed Diclofenac
along with other modalities of treatment.

a. What is the most likely diagnosis in this patient?

Nephrolithiasis. Nephrolithlasis presents as renal colic,

characterised by the sudden onset of severe flank pain radiating
toward the groin. It is usually associated with haematuria, urinary
frequency, urgency, and dysuria.
Differential diagnoses:

Acute pyelonephritis which may be associated with similar

symptoms, is usually accompanied by fever and chills.

Urethritis symptoms include dysuria, urinary frequency,

urgency, and difficulty starting urination, but does not include
flank pain.

The classic symptoms of appendicitis include sudden pain

that begins on the right side of the lower abdomen, lever,
nausea, vomiting, but sudden onset of flank pain is not
typical.

b. List 3 predisposing urinary factors for her condition.

Changes in the concentration of the solute

Changes in urine pH

2.24 Nephrolithiasis 6
 Bacterial Infection

Decreased urine volume

c. Explain why she experiences pain in the flank radiating to the groin.

A calculus lodged in the ureter may cause spasm of the smooth

muscles, or the obstructed urine may cause dilatation.

These stimuli are referred to cutaneous dermatomes along the

flank towards the groin (referred pain).
The mechanism is believed to be that both structures are derived
from the same embryological structures.

Renal angle tenderness is usually elicited by percussion over the

renal angle. Any inflammation of the kidney, which is located
retroperitoneally may give rise to renal angle tenderness.

d. Explain the rationale of prescribing Diclofenac in this patient.

Diclofenac is a NSAID. It blocks cyclo-oxyrgenase enzyme and

inhibits the synthesis of prostaglandins which are responsible for
pain and inflammation. By the above mechanism diclofenac helps
in symptomatic relief of pain and inflammation in this patient.

2.24 Nephrolithiasis 7