RENAL STONE

                                                

INTRODUCTION

Kidney stones, also called renal calculi, are solid concretions (crystal aggregations) of dissolved minerals in urine; calculi typically form inside the kidneys or bladder.

The terms nephrolithiasis and urolithiasis refer to the presence of calculi in the kidneys and urinary tract, respectively.

In medical terminology these deposits are known as renal calculi (Latin renal, "kidney" and calculi, "pebbles").

Louis Napoleon, nephew of Napoleon Bonaparte, lost the Franco-Prussian War of 1870 due wholly or in part from impaired kidney function resulting from kidney stone formation

Kidney stones are a common cause of blood in the urine and often severe pain in the abdomen, flank, or groin. Kidney stones are sometimes called renal calculi. One in every 20 people develops a kidney stone at some point in their life.

Kidneys are a pair of organs that are primarily responsible for filtering metabolites and minerals from the circulatory system. These secretions are then passed to the bladder and out of the body as urine. Some of the substances found in urine are able to crystalize, and in a concentrated form these chemicals can precipitate into a solid deposit attached to the kidney walls. These crystals can grow through a process of accretion to form a kidney stone.

Renal calculi can vary in size from as small as grains of sand to as large as a golf ball. Kidney stones typically leave the body by passage in the urine stream, and many stones are formed and passed without causing symptoms. If stones grow to sufficient size before passage—on the order of at least 2-3 millimeters—they can cause obstruction of the ureter. The resulting obstruction with dilation or stretching of the upper ureter and renal pelvis as well as spasm of muscle, trying to move the stone, can cause severe episodic pain, most commonly felt in the flank, lower abdomen and groin (a condition called renal colic).

Renal colic can be associated with nausea and vomiting due to the embryological association of the kidneys with the intestinal tract. Hematuria (bloody urine) is commonly present due to damage to the lining of the urinary tract.

EPIDEMIOLOGY

Within the United States, about 10–15% of adults will be diagnosed with a kidney stone, and the total cost for treating this condition was US$2 billion in 2003. The incidence rate increases to 20–25% in the Middle East, because of increased risk of dehydration in hot climates. (The typical Arabian diet is also 50% lower in calcium and 250% higher in oxalates compared to Western diets, increasing the net risk.) Recurrence rates are estimated at about 10% per year, totalling 50% over a 5–10 year period and 75% over 20 years.Men are affected approximately 4 times more often than women. Recent evidence has shown an increase in pediatric cases.

CLASSIFICATION

  Basically the renal stones can be divided into two major groups

I. Primary stones

II. Secondary stones.

(I) Primary

            They appear in apparently healthy urinary tract without any antecedent inflammation.

(a)   Calcium oxalate

(b)  Uric acid calculi

(c)   Cystine calculi

(d)  Xanthine calculi

(e)   Indigo calculi

(II) Secondary

            They are usually formed as the result of inflammation.

(a)   Triple phosphate calculus

(b)  Mixed stones

AETIOLOGY

The formation of the 4 basic chemical types of renal calculi is associated with more than 20 underlying etiologies. Stone analysis, together with serum and 24-hour urine metabolic evaluation, can identify an etiology in more than 95% of patients. Specific therapy can result in a remission rate of more than 80% and can decrease the individual recurrence rate by 90%. Therefore, emergency physicians should stress the importance of urologic follow-up, especially in patients with recurrent stones, solitary kidneys, or previous kidney or stone surgery and in all children.

Calcium stones (75%):

Calcium oxalate, calcium phosphate, and calcium urate are associated with the following disorders:

• Hyperparathyroidism - Treated surgically or with orthophosphates if the patient is not a surgical candidate
• Increased gut absorption of calcium - The most common identifiable cause of hypercalciuria, treated with calcium binders or thiazides plus potassium citrate
• Renal calcium leak - Treated with thiazide diuretics
• Renal phosphate leak - Treated with oral phosphate supplements
• Hyperuricosuria - Treated with allopurinol, low purine diet, or alkalinizing agents such as potassium citrate
• Hyperoxaluria - Treated with dietary modification, oxalate binders, vitamin B-6, or orthophosphates
• Hypocitraturia - Treated with potassium citrate
• Hypomagnesuria - Treated with magnesium supplements

Struvite (magnesium ammonium phosphate) stones (15%)

• Struvite stones are associated with chronic UTI with gram-negative rods capable of splitting urea into ammonium, which combines with phosphate and magnesium.
• Usual organisms include Proteus, Pseudomonas, and Klebsiella species. Escherichia coli is not capable of splitting urea and, therefore, is not associated with struvite stones.
• UTI does not resolve until stone is removed entirely.
• Urine pH is typically greater than 7.

Uric acid stones (6%):

o   These are associated with urine pH less than 5.5, high purine intake (eg, organ meats, legumes, fish, meat extracts, gravies), or malignancy (ie, rapid cell turnover). Approximately 25% of patients with uric acid stone have gout.

Cystine stones (2%)

• Cystine stones arise because of an intrinsic metabolic defect resulting in failure of renal tubular reabsorption of cystine, ornithine, lysine, and arginine.
• Urine becomes supersaturated with cystine with resultant crystal deposition.
• These are treated with low-methionine diet (unpleasant), binders such as penicillamine or a -mercaptopropionylglycine, large urinary volumes, or alkalinizing agents.

Drug-induced stone disease:

o   A number of medications or their metabolites can precipitate in urine causing stone formation. These include indinavir; atazanavir; guaifenesin; triamterene; silicate (overuse of antacids containing magnesium silicate); and sulfa drugs including sulfasalazine, sulfadiazine, acetylsulfamethoxazole, acetylsulfasoxazole, and acetylsulfaguanidine.

Pathophysiology

·        Most calculi arise in the kidney when urine becomes supersaturated with a salt that is capable of forming solid crystals. Symptoms arise as these calculi become impacted within the ureter as they pass toward the urinary bladder.

CLINICAL FEATURES

·        Most calculi originate within the kidney and proceed distally, creating various degrees of urinary obstruction as they become lodged in narrow areas, including the ureteropelvic junction, pelvic brim, and ureterovesical junction.

·        Location and quality of pain are related to position of the stone within the urinary tract.

·        Severity of pain is related to the degree of obstruction, presence of ureteral spasm, and presence of any associated infection.

• Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin, due to distension of the renal capsule.
• Stones impacted within the ureter cause abrupt, severe, colicky pain in the flank and ipsilateral lower abdomen with radiation to the testicles or the vulvar area. Intense nausea, with or without vomiting, usually is present.
• Stones lodged at the ureterovesical junction also may cause irritative voiding symptoms, such as urinary frequency and dysuria.
• Calculi that have entered the bladder are usually asymptomatic and are passed relatively easily during urination.
• Rarely, a patient reports positional urinary retention (obstruction precipitated by standing, relieved by recumbency), which is due to the ball-valve effect of a large stone located at the bladder outlet.

Physical

The classic patient with renal colic is writhing in pain, pacing about, and unable to lie still, in contrast to a patient with peritoneal irritation, who remains motionless to minimize discomfort.

• Fever is not part of the presentation of uncomplicated nephrolithiasis. If present, suspect infected hydronephrosis, pyonephrosis, or perinephric abscess.
• The most common finding in ureterolithiasis is flank tenderness due to the dilation and spasm of the ureter from transient obstruction as the stone passes from the kidney to the bladder.
• Abdominal examination usually is unremarkable. Bowel sounds may be hypoactive, a reflection of mild ileus, which is not uncommon in patients with severe, acute pain.
• Testicles may be painful but should not be very tender and should appear normal.

INVESTIGATIONS

Clinical diagnosis is usually made on the basis of the location and severity of the pain, which is typically colic in nature (comes and goes in spasmodic waves). Pain in the back occurs when calculi produce an obstruction in the kidney.

Imaging is used to confirm the diagnosis and a number of other tests can be undertaken to help establish both the possible cause and consequences of the stone.

X-rays

The relatively dense calcium renders these stones radio-opaque and they can be detected by a traditional X-ray of the abdomen that includes the Kidneys, Ureters and Bladder—KUB. This may be followed by an IVP (Intravenous Pyelogram; (IntraVenous Urogram (IVU) is the same test by another name)) which requires about 50 ml of a special dye to be injected into the bloodstream that is excreted by the kidneys and by its density helps outline any stone on a repeated X-ray. These can also be detected by a Retrograde pyelogram where similar "dye" is injected directly into the ureteral opening in the bladder by a surgeon, usually a urologist.

About 10% of stones do not have enough calcium to be seen on standard x-rays (radiolucent stones).

Computed tomography

Computed tomography without contrast is considered the gold-standard diagnostic test for the detection of kidney stones. All stones are detectable by CT except very rare stones composed of certain drug residues in the urine. If positive for stones, a single standard x-ray of the abdomen (KUB) is recommended. This gives a clearer idea of the exact size and shape of the stone as well as its surgical orientation. Further, it makes it simple to follow the progress of the stone by doing another x-ray in the future.

Draw back of CT scans include radiation exposure and cost.

Ultrasound

Ultrasound imaging is useful as it gives details about the presence of hydronephrosis (swelling of the kidney—suggesting the stone is blocking the outflow of urine). It can also be used to detect stones during pregnancy when x-rays or CT are discouraged. Radiolucent stones may show up on ultrasound however they are also typically seen on CT scans.

Some recommend that US be used as the primary diagnostic technique with CT being reserved for those with negative US result and continued suspicion of a kidney stone. This is due to its lesser cost and lack of radiation exposure.

Other

Other investigations typically carried out include:

• Microscopic study of urine, which may show proteins, red blood cells, bacteria, cellular casts and crystals.
• Culture of a urine sample to exclude urine infection (either as a differential cause of the patient's pain, or secondary to the presence of a stone)
• Blood tests: Full blood count for the presence of a raised white cell count (Neutrophilia) suggestive of infection, a check of renal function and to look for abnormally high blood calcium blood levels (hypercalcaemia).
• 24 hour urine collection to measure total daily urinary volume, magnesium, sodium, uric acid, calcium, citrate, oxalate and phosphate.
• Catching of passed stones at home (usually by urinating through a tea strainer or stonescreen) for later examination and evaluation by a doctor.

PREVENTION

Preventive strategies include dietary modifications and sometimes also taking drugs with the goal of reducing excretory load on the kidneys:

• Drinking enough water to make 2 to 2.5 liters of urine per day.
• A diet low in protein, nitrogen and sodium intake.
• Restriction of oxalate-rich foods, such as chocolate, nuts, soybeans, rhubarb and spinach, plus maintenance of an adequate intake of dietary calcium. There is equivocal evidence that calcium supplements increase the risk of stone formation, though calcium citrate appears to carry the lowest, if any, risk.
• Taking drugs such as thiazides, potassium citrate, magnesium citrate and allopurinol, depending on the cause of stone formation.
• Some fruit juices, such as orange, blackcurrant, and cranberry, may be useful for lowering the risk factors for specific types of stones.
• Avoidance of cola beverages.
• Avoiding large doses of vitamin C.

For those patients interested in optimizing their kidney stone prevention options, it's essential to have a 24 hour urine test performed. This should be done with the patient on his or her regular diet and activities. The results can then be analyzed for abnormalities and appropriate treatment given.

Restricting Oxalate consumption

Calcium plays a vital role in body chemistry so limiting Calcium is unhealthy. Since Calcium in the intestinal tract will bind with available Oxalate, thereby preventing its absorption into the blood stream, some Nephrologists recommend chewing Calcium tablets during meals containing Oxalate foods. However, a more reliable approach is to restrict the intake of food that is high in Oxalate.

Diuretics

Although it has been claimed that the diuretic effects of alcohol can result in dehydration, which is important for kidney stone sufferers to avoid, there are no conclusive data demonstrating any cause and effect regarding kidney stones. However, some have theorized that frequent and binge drinkers create situations that set up dehydration: alcohol consumption, hangovers, and poor sleep and stress habits. In this view, it is not the alcohol that creates a kidney stone but it is the alcohol drinker's associated behavior that sets it up.

One of the recognized medical therapies for prevention of stones is thiazides, a class of drugs usually thought of as diuretics. These drugs prevent stones through an effect independent of their diuretic properties: they reduce urinary calcium excretion. Nonetheless, their diuretic property does not preclude their efficacy as stone preventive. Sodium restriction is necessary for clinical effect of thiazides, as sodium excess promotes calcium excretion. Though some have said that the effect probably fades after two years or so of therapy (tachyphylaxis), in fact it is only randomized controlled trials lasting 2 years or more that show the effect; there is really no good evidence from studies of calcium metabolism that the thiazide effect does not last indefinitely. Thiazides are the medical therapy of choice for most cases of hypercalciuria (excessive urinary calcium) but may not be suitable for all calcium stone formers; just those with high urinary calcium levels.

HOMOEOPATHIC MANAGEMENT

Repertory

Murphy – Bladder

STONES, bladder, calculi (33)

1 ant-c, 1 arg-n, 3 BENZ-AC, 3 BERB, 1 cact, 3 CALC, 3 CANTH, 1 card-m, 2 chin, 2 coc-c, 1 colch, 2 lach, 2 lith, 3 LYC, 1 mez, 2 mill, 1 naja, 1 nat-m, 1 nat-s, 2 nux-m, 2 nux-v, 2 pareir, 2 petr, 2 phos, 2 puls, 2 raph, 2 ruta, 3 SARS, 3 SEP, 2 sil, 1 tarent, 1 thuj, 1 zinc

Phatak

CALCULI (URINARY BILIARY)FORMATION OF IN GENERAL (21)

2 bell, 1 benz-ac, 2 berb, 2 bry, 2 calc, 2 chin, 1 coc-c, 2 coloc, 1 dios, 1 dulc, 1 hydr, 1 lach, 3 LYC, 1 merc, 2 nux-v, 1 oci, 1 pareir, 1 podo, 1 puls, 2 sars, 1 sep

Boericke - Urinary System

CALCULI, GRAVEL, NEPHROLITHIASIS, COLIC (34)

3 ARG-N, 3 BELL, 2 benz-ac, 3 BERB, 2 calc, 3 CANTH, 2 cham, 2 chin-s, 3 COC-C, 2 coloc, 3 DIOS, 3 EPIG, 2 erig, 2 ery-a, 3 EUP-PUR, 2 hedeo, 2 hep, 2 hydrang, 2 ipom, 3 LYC, 2 med, 3 NIT-AC, 3 NUX-V, 3 OCI, 2 op, 3 PAREIR, 2 polyg, 3 SARS, 2 sep, 3 TAB, 2 thlaspi, 2 urt-u, 2 uva, 3 STIGM

Dewey

Renal calculi:

Apoc. andr., Arn., Eryng., Chin. sulph., Ipomoea, Lyc., Sep.,

Uva, etc.

Vesical calculi:

Calc., Cann., Sarsap., Sep., etc.

Therapeutics

Arnica

·        Agonizing pains in back and hips from passage of calculi; piercing pains as if knives were plunged into renal region;

·        violent tenesmus of bladder; chillyand inclined to vomiting.

Calcarea carb

·        Stone in the bladder; copious white mealy sediment in urine; gravel and urinary calculi;

·        urine after standing looks turbid like lime-water;

·        bloody urine; cutting stitches in urethra with ineffectual desire to urinate; after urinating, renewed desire with burning; itching in glans.

Berberis vulg

·        Violent stitching pain in the bladder extending from the kidneys into the urethra, with urging to urinate;

·        frequent recurring crampy pain in thebladder; cutting constrictive pain in the bladder when full or empty;

·        burning pain in urethra; stitching pain in the female urethra, beginning in the bladder; violent stitches in the bladder, which compel one to urinate; urine dark-yellow, red, becoming turbid;

·        copious mucous sediment mixed with a whitish-gray, and later a reddish mealy sediment; greenish urine depositing mucus; blood-red urine, which soon becomes turbid and deposits a thick mucous and bright-red mealy sediment, slowly becoming clear, but retaining its blood-red color;

·        symptoms of urinary organs accompanied with pains in the loins and hips (Pareira brava, pain in thighs); renal gravel and calculi (urates, rheumarthritis); worse from slight fatigue, the aggravation increasing as the fatigue increases.

Lycopodium

·        Pain before urinating, shown in young children by crying and screaming at that time and by adults referred to the renal region;

·        very severe pain in back before urinating, which ceases when the urine flows; children awake from sleep screaming, and feel better after urinating; urging to urinate, must wait a long time before it passes; jerking, cutting in urethra after urinating; urine scanty, dark-red, albuminous, with strangury; deposits of red, sandy sediments; frequent and copious at night, scanty by day; greasy pellicle floats on urine;

·         painless haemorrhages from bladder; gravel and calculi; haemorrhoids; enlarged prostata.

Nitric acid

·        Urinary calculi, consisting of oxalates; urine cold when it passes; scanty, dark brown, smelling strong like horse's urine; haematuria, blood flows actively.

Sarsaparilla

·        Urine dribbles away when sitting, on standing passes urine freely; passes gravel or small calculi, blood with last of urine;

·        painful retention of urine; sand in urine or on diaper, child screams before and while passing it;

·        severe pain at conclusion of urination; has to get up several times at night to urinate;

·        intolerable smell of genitals and of urine; thinking of his pains causes them to return or grow worse.

Uva ursi

·        Calculi in bladder, flow of urine stops suddenly as if a stone had rolled suddenly in front of the internal orifice of the urethra; bloody urine;

·        burning after the discharge of slimy urine. Compare: urine and difficult urination.

Erigeron

·        Dysuria of teething children; child cries when passing water; frequent, painful urination; urine copious; of a strong odor, very acrid; vesical irritation from calculi (Canth.).

Cantharis

·        Blood is more or less mixed with it, urine of a deep-red color, depositing a mucous sediment; cylindrical exudations in bloody urine ;

·        haematuria from renal calculi;

·        violent pains in back extending along the ureters into the bladder; restless, uneasy feeling , with tossing about in bed.

Argentum nit

·        Nephralgia from CONGESTION OF KIDNEYS OR FROM PASSAGE OF CALCULI;

·        face dark-red with dried-up look;  dull aching across small of back and over region of bladder;

·        urine burns while passing, is dark and contains blood, renal epithelium and uric acid; urethra feels as if swollen; sudden urging to urinate.

Nuxvomica

·        Renal colic is caused by a stone in the ureter which by its irritationcauses a spasmodic clutching of the circular fibers of that canal;

·        the proper medicine relaxes these fibers and the pressure from behind forces the calculi out at once.