Kidney Stones (Renal Calculi, Nephrolithiasis)

Race: WhiteSex: maleAge: 20 to 50 years oldGeographical location (residents of the Southeast United States have an increased risk)Family members who have had kidney stones or goutPrevious kidney stonesTaking calcium supplements, vitamin D, or vitamin C in excessive dosesPregnancyLow birth weight babies receiving intravenous feedingsFasting Other medical conditions, including: High blood pressureKidney diseaseOveractive parathyroidChronic diarrheaUlcerative colitisCrohn's diseaseLeukemiaLymphomaUrinary tract infectionsSarcoidosis Immobility, paralysis , being bedridden Medications, including: Several drugs used in the treatment of AIDS Cancer chemotherapy agents DiureticsAntacidsPrevious intestinal bypass surgeryReduced fluid intake or increased fluid loss in hot weather (dehydration)Urinary tract obstruction or failure to empty the bladder (eg, spinal cord injury, diabetes, prostate disease, urethral stricture)Foreign material in the urinary tract, including catheters and ureteral stents SymptomsOccasionally, kidney stones do not cause symptoms, and they leave the body in the urine. Kidney stones may, however, cause severe pain.

Symptoms include: Sharp, stabbing pain in the lower back that may occur every few minutes lasting from 20 minutes to one hourPain in the lower abdomen and groin area, labia, or testicles Nausea, vomiting, or diarrheaBlood in the urineFrequent urge to urinateBurning pain during urinationKidney stones may also cause fevers or urinary tract infections. Sometimes, patients may have repeated urinary tract infections because of kidney stones. DiagnosisThe doctor will ask about your symptoms and medical history, and perform a physical exam. Tests may include: Urinalysisto look for blood, pus, bacteria, and crystals in the urineBlood teststo check kidney function, calcium, and uric acid levelsUrine cultureif infection suspected Spiral CT scana type of x-ray that uses a computer to make pictures of the inside of the kidney Ultrasound a test that uses sound waves to examine the kidneys Intravenous pyelogram (IVP) special x-ray that produces images of the urinary system (less commonly used today) 24-hour urineto check levels of many factors, including calcium, phosphorus, uric acid, oxalate, and citrate TreatmentTreatment depends on the size and location of the kidney stone. Treatment may include the following:

WaterFor small kidney stones, drinking at least two or three quarts of water a day helps the body pass the stone in the urine. The doctor may provide a special cup or strainer to catch the stone when it passes so that it can be analyzed. If you are having a hard time keeping fluids down, you may need to be hospitalized to receive intravenous fluids. Medications and Nerve StimulationYou can take pain medication (ketorolac, an NSAID, or narcotic pain medications) as needed. In addition, you may need intravenous or intramuscular pain medication. There is also recent evidence that medications commonly used to treat high blood pressurecalcium channel blockers and alpha blockersmay facilitate the passage of kidney stones. * 1 Current research suggests that transcutaneous electrical nerve stimulation (TENS), which applies low-voltage electrical current to electrodes pasted on the skin (to the side of the abdomen and back, in this case) might also be effective in relieving pain. * 2 Surgery Surgery for stone removal may be necessary if it is: Very large or growing largerCausing continued bleeding or damage to the kidneyCausing infectionBlocking the flow of urine Types of surgery include:

Ureteroscopy and stone basketing or laser lithotripsyThis involves a narrow camera that is slipped up the urethra, into the bladder, and into the ureter. A tiny basket may be used to snare the stone. If needed, the stone can be broken into fragments or dissolved with a laser. Any small fragments can be removed with a basket.Stent placementIf the ureter is obstructed, a tiny tube may be placed in the ureter to allow urine to pass, and to try to avoid kidney damage. If there is an active infection, a stent may be needed to allow the infection to clear before proceeding with surgery to remove the stone. It is very important that all stents be removed. Stents are temporary, and will form more stones and cause infection if left in place for prolonged periods.Extracorporeal shock wave lithotripsy (ESWL) This procedure uses shock waves to break up stones that are too large to pass. It requires anesthesia and may cause blood in the urine and minor back pain for a few days. Percutaneous nephrolithotomyThis procedure uses a scope placed through a small tube in the back to remove a kidney stone that is too big to pass.LithotomyLithotomy is open surgery to remove a kidney stone. This procedure is rarely used now. Prevention Once you have formed a kidney stone, you are more likely to form another. Here are some steps to prevent more stones from forming:

Drink plenty of fluids, especially water. Don't change your diet without consulting your doctor. Recommendations will be based on the type of stones you've had, and the results of your 24-hour urine tests. Be sure to ask your doctor for a list of the foods you should avoid, or meet with a dietitian who can help you understand your dietary restrictions. You may be advised to do the following: Avoid apple and grapefruit juices.Increase intake of cranberry juice.Avoid foods high in oxalate, such as spinach.Eat less meat, fish, and poultry. These foods increase urine acidity.Decrease your sodium intake (especially if you have calcium stones).Increase your intake of magnesium.Drink lemonade daily.Increase your fiber intake.Avoid excess weight.If you have an enlarged parathyroid gland, you may need to have it removed surgically. Medications may include: Drugs that control the amount of acid in the urineAllopurinol or sodium cellulose phosphate to treat urine high in calciumHydrochlorothiazide (a diuretic) that alters calcium excretion in the urineThiola to reduce the amount of cystine in the urine RESOURCES: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)http://www.niddk.nih.gov

National Kidney Foundationhttp://www.kidney.org UrologyHealth.orghttp://www.urologyhealth.org CANADIAN RESOURCES: Canadian Health Networkhttp://www.canadian-health-network.ca/ The Kidney Foundation of Canadahttp://www.kidney.ab.ca References: Borghi L, Meschi T, Maggiore U, Prati B. Dietary therapy in idiopathic nephrolithiasis. Nutr Rev. 2006;64:301-312. Coe FL, Evan A, Worcester E. Kidney stone disease. J Clin Invest. 2005;115:2598-2608. Guidelines from the American Urological Association. American Urological Association website. Available at: http://www.auafoundation.org/auafhome.asp . Kang DE, Sur RL, Haleblian GE, Fitzsimons NJ, Borawski KM, and Preminger GM. Long-term lemonade based dietary manipulation in patients with hypocitraturic nephrolithiasis. J Urol. 2007;177:1358-1362. Martini LA, Wood RJ. Should dietary calcium and protein be restricted in patients with nephrolithiasis? Nutr Rev. 2000;58:111-117. National Institute of Diabetes and Digestive and Kidney Diseases website. Available at: http://www.niddk.nih.gov .

Pearle MS, Lingemann JE, Leveillee R, et al. Prospective, randomized controlled trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. J Urol. 2005;173:2005-2009. Wein A, ed. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Saunders, Elsevier; 2007. * 1 Updated section on Medications on 11/29/06 according to the following study, as cited by DynaMed's Systematic Literature Surveillance : Hollingsworth JM, Rogers MA, Kaufman SR, et al. Medical therapy to facilitate urinary stone passage: a meta-analysis. Lancet. 2006;368:1171-1179. * 2 Updated section on Medications on 7/12/06 according to the following study, as cited by DynaMed's Systematic Literature Surveillance : Mora B, Giorni E, Dobrovits M, et al. Transcutaneous electrical nerve stimulation: an effective treatment for pain caused by renal colic in emergency care. J Urol. 2006;175:1737-1741; discussion 1741. Last reviewed January 2008 by Adrienne Carmack, MDPlease be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.