Updated: 6/6/2020

Nephrolithiasis

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Snapshot
  • A 36-year-old woman presents to the emergency department with severe and colicky left flank pain that radiates to the left groin. She reports increased urinary frequency and urgency. She is sexually active with multiple men and uses condoms inconsistently. On physical exam, there is left-sided costovertebral angle tenderness and lower abdominal tenderness. 
Introduction
  • Clinical definition
    • calculi (stones) affecting the kidneys; however, these stones can also affect the ureter
  • Epidemiology
    • prevalence
      • 12% in men and 7% in women
    • risk factors
      • hyperparathyroidism
      • hypocitraturia
      • sarcoidosis
      • hyperoxaluria
      • renal tubular acidosis type I
      • nephrocalcinosis
      • cystic fibrosis
      • hyperuricosuria
      • indwelling catheter
      • urinary tract infections
      • malabsorption (e,g., Crohn disease)
      • horseshoe kidney
      • obesity
      • low fluid intake
      • gout
      • medications
        • e.g., allopurinol, indinavir, acetazolamide, and topiramate
  • Pathogenesis
    • substance precipitation affecting the kidney and ureter
      • e,g., hypercalciuria and low urine volume forms calcium cystals
  • Prognosis
    • small stones are more likely to spontaneously pass
 
Nephrolithiasis Stones
Stone Type
Etiology
Imaging Findings
Stone Shape
Treatment
Calcium
  • Calcium oxalate stones (most common)
    • hypercalciuria
    • hypocitraturia
    • ethylene glycol (antifreeze)
    • vitamin C abuse
    • crohn disease
  • Calcium phosphate
    • in states of urine alkalinization
      • e.g., type I renal tubular acidosis
  • Radiography
    • radiopaque
  • Computerized tomography
    • radiopaque
  • Envelope or dumbbell shape
    • calcium oxalate 
  • Wedge-shaped prism
    • calcium phosphate
  • Hydrochlorothiazide
  • Citrate
  • Low-sodium diet
Cystine
  • Impaired cystine reabsorption in the proximal convoluted tubule
    • this results in cystinuria
      • also results in decreased reabsorption of ornithine, lysine, and arginine
  • Precipitates in acidic urine
  • Diagnosis
    • cyanide-nitroprusside test 
  • Radiography
    • radiolucent
  • Computerized tomography
    • visible at times
  • Hexagonal
  • Dietary modification
    • low sodium
  • Urine alkalinization
  • Chelating agents
    • in refractory cases
Struvite (magnesium ammonium phosphate) 
  • Urease-positive organisms such as
    • Proteus mirabilis
    • Staphylococcus saphrophryticus
    • Klebsiella
  • Urease-positive organisms subesequently alkalinizes the urine
    • this causes struvite stones due to precipitation
  • Radiography
    • radiopaque
  • Computerized tomography
    • radiopaque
  • Can result in a staghorn calculi
  • Coffin lid 
  • Removal of underlying infection
  • Surgical removal of the stone
Uric acid
  • Hyperuricemia
    • e.g., states of increased cell turnover and gout
  • Precipitates in acidic urine
  • Radiography
    • radiolucent
  • Computerized tomography
    • minimally visible
  • Rhomboid/rosette
  • Urine alkalinization
  • Allopurinol
  • Adequate hydration prior to chemotherapy treatment
 
Presentation
  • Symptoms
    • colicky flank pain
      • pain may radiate to the groin or lower abdomen
    • dysuria
    • urgency and frequency
  • Physical exam
    • low abdominal tenderness
    • costovertebral angle (CVA) tenderness
Imaging
  • Renal ultrasound
    • indication
      • in patients who are pregnant and children who are suspected to have nephrolithiasis
    • modality
      • abdomen and pelvis to visualize the kidney and bladder
  • Non-contrast computerized tomography (CT)
    • indication
      • preferred imaging for most adults presenting with signs and symptoms concerning for nephrolithiasis
    • modality
      • abdomen and pelvis
Studies
  • Labs
    • serum
      • creatinine, uric acid, and ionized calcium should be obtained
    • urine studies
      • urinalysis/dipstick
        • in order to check for red and white blood cells, nitrites, and urine pH
      • urine culture
    • stone composition analysis
      • perform in patients who developed their first stone
      • straining the urine
  • Diagnostic criteria
    • based on clinical presentation and confirmed by imaging
Differential
  • Urinary tract infections
  • Acute pyelonephritis
  • Groin hernia
Complications
  • Ureteral obstruction
  • Ureteral stricture
  • Urinary tract infection
  • Renal deterioration

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Questions (9)
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(M1.RL.15.4671) A 49-year-old African American female with a history of chronic myeloid leukemia for which she is receiving chemotherapy presents to the emergency room with oliguria and colicky left flank pain. Her serum creatinine is 3.3 mg/dL. What is the preferred preventative therapy that could have been administered to this patient to prevent her complication of chemotherapy?

QID: 107149
1

Diuresis

36%

(20/56)

2

Acidification of the urine

16%

(9/56)

3

Colchicine

25%

(14/56)

4

Steroids

5%

(3/56)

5

Dialysis

11%

(6/56)

M 3 C

Select Answer to see Preferred Response

(M1.RL.15.4671) A 12-year-old boy presents with right flank pain and hematuria. His older brother has had several similar episodes in the past. Results of microscopic urinalysis are shown in Figure A. Which of the following tests can be used to help confirm the underlying diagnosis?

QID: 107147
FIGURES:
1

Cyanide-nitroprusside test

66%

(79/120)

2

Serum uric acid concentration

8%

(9/120)

3

Urine uric acid concentration

17%

(20/120)

4

Urine culture

7%

(8/120)

5

Urease test

2%

(2/120)

M 2 D

Select Answer to see Preferred Response

(M1.RL.13.25) Following passage of a calcium oxalate stone, a 55-year-old male visits his physician to learn about nephrolithiasis prevention. Which of the following changes affecting urine composition within the bladder are most likely to protect against crystal precipitation?

QID: 101243
1

Increased calcium, increased citrate, increased oxalate, increased free water clearance

7%

(5/75)

2

Decreased calcium, increased citrate, increased oxalate, increased free water clearance

9%

(7/75)

3

Decreased calcium, decreased citrate, increased oxalate, increased free water clearance

5%

(4/75)

4

Decreased calcium, increased citrate, decreased oxalate, increased free water clearance

76%

(57/75)

5

Decreased calcium, increased citrate, increased oxalate, decreased free water clearance

1%

(1/75)

M 1 E

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(M1.RL.13.1) A 45-year-old Caucasian male with a history of chronic myeloid leukemia for which he is receiving chemotherapy presents to the emergency room with oliguria and colicky left flank pain. His serum creatinine is 3.0 mg/dL and is urine pH is 5.0. You diagnose nephrolithiasis. His kidney stones, however, are not visible on abdominal x-ray. His stone is most likely composed of which of the following?

QID: 100955
1

Calcium oxalate

8%

(5/59)

2

Calcium phosphate

2%

(1/59)

3

Magnesium ammonium phosphate

0%

(0/59)

4

Uric acid

78%

(46/59)

5

Cystine

10%

(6/59)

M 1 D

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