RENAL CALCULI

Etiopathogenesis
Presentation
Investigations
Management
Prevalence and incidence
• Kidney stones are a common problem.

• National Health and Nutrition Examination Survey (NHANES) estimated that 19 %

of males and 9 % of females will be diagnosed with a kidney stone by the age of 70
years.

• Factors that may be contributing to this increase in stone prevalence

• Increase in obesity

• Rising temperatures

• Better and higher utilization of diagnostic imaging techniques

• Age – The prevalence of ever having had a stone increases with age.
Prevalence rates of kidney stones in a global platform
Major kidney
stone prevalent
states in the
Indian continent
• Sex – Overall prevalence of stone disease is approximately twice as high in
males compared with females.

• Race/ethnicity – Stone disease is most common in White then in Black and

Asian patients.

• Disability – The prevalence of stone disease is higher among persons with

functional disabilities than among those without disabilities.
MODIFIABLE RISK FACTORS
Urinary factors

• Low urine volume: accepted goal is at least 2.5 liters of urine daily

• Hypercalciuria (high urine calcium): >250 mg/day in females, >300 mg/day in males
• Hypocitraturia (low urine citrate): excretion below 320 mg/day

• Hyperoxaluria (higher urine oxalate): less than 45 mg/day

• Higher urine pH: An acid urine favors uric acid precipitation (5.5 or less). An alkaline
urine promotes calcium phosphate stone formation, (6.5 or higher).

• Hyperuricosuria: 24-hour urine uric acid excretion of > 750 mg in females or >800
• Dietary factors

• Fluid intake

• Type of fluid

• Dietary calcium

• Medications (eg, topiramate, acetazolamide, long-term glucocorticoids)

NON-MODIFIABLE RISK FACTORS

• Family history

• Genetic factors

• Medical conditions

• Other factors
RISK FACTORS

HISTORY
OF
RENAL
CALCULI
Etiopathogenesis
• Dietetic

Deficiency of vitamin A causes desquamation of epithelium forming a

nidus on which a stone is deposited. This mechanism is probably active in
the formation of bladder calculi.

• Altered urinary solutes and colloids

Dehydration concentrates urinary solutes until they precipitate. Reduction

of urinary colloids, which adsorb solutes, or mucoproteins, which chelate
calcium, might tend to crystal and stone formation.
• Decreased urinary citrate

The presence of citrate in urine, 300–900 mg per 24 hours (1.6–4.7 mmol per 24
hours) as citric acid, keeps relatively insoluble calcium phosphate and citrate in
solution.

• Renal infection

Infection favours the formation of urinary calculi. Clinical and experimental stone
formation are common when urine is infected with urea-splitting streptococci,
staphylococci and especially Proteus spp.
• Inadequate urinary drainage and urinary stasis

Stones are liable to form when urine is static.

• Prolonged immobilisation

Immobilisation is liable to result in skeletal decalcification and an increase in urinary

calcium favouring the formation of calcium phosphate calculi.

• Hyperparathyroidism

Hyperparathyroidism leading to hypercalcaemia and hypercalciuria is found in 5 per cent

or less of those who present with radio-opaque calculi. In cases of recurrent or multiple
stones, this cause should be eliminated by appropriate investigations. A parathyroid
adenoma should be removed before definitive treatment for the urinary calculi.
Stages of stone formation
I. Supersaturation

II. Nucleus formation

III. Crystallisation

IV. Aggregation

V. Matrix formation

VI. Stone
Stone composition — The frequency of different stone composition in adults :

• Calcium oxalate – 70 to 80 percent

• Calcium phosphate – 15 percent (apatite is the most common type of calcium

phosphate crystal; brushite is much less common)

• Uric acid – 8 percent

• Cystine – 1 to 2 percent

• Struvite – 1 percent

• Miscellaneous – <1 percent

 Types of renal calculus

• Oxalate calculus (calcium oxalate)

Oxalate stones are irregular with sharp projections.

A calcium oxalate monohydrate stone is hard and radiodense.

• Phosphate calculus

Calcium phosphate often with ammonium magnesium phosphate (struvite)

Smooth and dirty white

It grows in alkaline urine, especially when urea-splitting proteus organisms are

present.

The calculus may enlarge to form a stag-horn calculus.

Even a large stag-horn calculus may be asymptomatic for years until it presents
with haematuria, urinary infection or renal failure.
• Uric acid and urate calculi

These are hard, smooth and often multiple and multifaceted.

Pure uric acid stones are radiolucent.

CT will distinguish them from other causes of filling defects including tumours of the
ureter.

Most uric acid stones contain some calcium, so they cast a faint radiological shadow.
• Cystine calculus

An uncommon congenital error of metabolism leads to cystinuria.

Often multiple and may grow to form a cast of the collecting system.

Cystine stones are radio-opaque and very hard.

 Shapes of Stone Crystals in Urine

Type of crystal Shape of the crystal

a. Calcium oxalate monohydrate Dumbell shaped

b. Calcium oxalate dihydrate Envelope shaped

c. Uric acid Yellowish of varying size and shape

d. Cystine Hexagonal, very soft stones

e. Triple stone Coffin lid shaped

Investigation of suspected urinary stone disease
D
I
A S
G T
N U
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S I
T E
I S
C
Urine R/M

• Calcium, urate, cystine if suspected only, pH, specific gravity.

Urine C/S

• to identify bacteria
• X-ray
The ‘KUB’ film shows the kidney, ureters and bladder.
A branched stone is unmistakable.
An opacity maintaining its position relative to the urinary
tract during respiration is likely to be a calculus.
Calcified mesenteric nodes and opacities within the gut
will be anterior to the vertebral bodies on a lateral x-ray
and thus outside the urinary tract.
• Ultrasound scanning
Ultrasound scanning is of most
USG
value in locating stones for
treatment by extracorporeal
shock wave lithotripsy (ESWL)
• Excretion urography

IVU will establish the

presence and position of a
calculus and the function
of the other kidney.

IVP
• Contrast-enhanced CT or NCCT KUB

CT, preferably spiral, has become the mainstay of investigation of acute

ureteric colic.
 DTPA
• Nuclear imaging study
• Diethylenetriamine pentaacetate
• Evaluate relative kidney function
• Find possible obstructions to the
kidneys
CYSTOSCOP
Y
Presentation
Silent calculus
Renal failure may be the first indication of bilateral silent calculi,
although secondary infection usually produces symptoms first

Pain
Pain occurs in 75 per cent of people with urinary stones.
Fixed renal pain occurs in the renal angle, the
hypochondrium, or in both.
It may be worse on movement.
Ureteric colic is an agonising pain passing from the loin to the
groin.
Ureteric colic

• Severe exacerbations on a background of continuing pain

• Radiates to the groin, penis, scrotum or labium as the stone progresses down the

ureter

• Severity of pain is not related to stone size

• Haematuria is very common

• There may be few physical signs

Haematuria

• Haematuria, usually small in amount, is common and sometimes is the only

symptom of stone disease.

Pyuria

• Infection is particularly dangerous when the kidney is obstructed.

• Pressure builds in the system, organisms are forced into the circulation and a
septicaemia can quickly develop
Urinary Tract Infection

• Fever

• Burning Micturition
 HYDRONEPHROSIS (HN)
It is an aseptic dilatation of pelvicalyceal
system due to partial or intermittent obstruction
to the outflow of urine.
Differential Diagnosis

• Appendicitis

• Cholecystitis

• Acute epididymitis

• Diverticulitis

• Hernia

• PID
 European Guidelines for Patients with Renal Calculi
• Check urine for hematuria, pH, and bacteria.

• Obtain a urine culture.

• Order BUN and serum creatinine.

• Order serum calcium, uric acid, sodium, and potassium levels.

• Order a complete CBC and CRP.

• Obtain a coagulation profile in case surgical intervention is necessary.

• Obtain a non-contrast CT scan

Conservative management

• Calculi smaller than 0.5 cm pass spontaneously unless they are impacted.

• Surgical intervention should be avoided.

• Small renal calculi may cause symptoms by obstructing a calyx or acting as a

focus for secondary infection.

• Most can be safely observed until they pass

SURGICAL MANAGEMENT
For stones that are ≤15 mm

• Stones that are in the upper pole, middle calyx, or pelvis of the kidney,
• SWL or URS as first-line therapy

• Stones that are in the lower pole of the kidney,

• URS or PNL, rather than SWL
For stones that are >15 mm, regardless of location in the kidney,
• PNL as first-line therapy, rather than other surgical options.
• If PNL is not available or contraindicated, staged URS (ie,
performed in separate planned sessions) is an alternative option
SWL should be avoided in patients with obesity, pregnant patients,
patients with an uncontrolled bleeding diathesis, patients with abnormal
kidney/ureteral anatomy, and patients whose preoperative imaging with
CT demonstrates high attenuation of the stone (ie, >900 Hounsfield units)
Complications
• Abscess

• Urosepsis

• Ureteral scarring or perforation

• Urine extravasation

• Kidney atrophy in chronic cases

• Renal failure
RELOOK
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