Updated: 4/14/2019

Nephrolithiasis

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Questions
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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 (7)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.RL.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? Review Topic

QID: 101243
1

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

13%

(2/15)

2

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

13%

(2/15)

3

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

13%

(2/15)

4

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

60%

(9/15)

5

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

0%

(0/15)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(M1.RL.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? Review Topic

QID: 107149
1

Diuresis

64%

(7/11)

2

Acidification of the urine

9%

(1/11)

3

Colchicine

27%

(3/11)

4

Steroids

0%

(0/11)

5

Dialysis

0%

(0/11)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M1.RL.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? Review Topic

QID: 107147
FIGURES:
1

Cyanide-nitroprusside test

68%

(48/71)

2

Serum uric acid concentration

10%

(7/71)

3

Urine uric acid concentration

20%

(14/71)

4

Urine culture

0%

(0/71)

5

Urease test

1%

(1/71)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(M1.RL.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? Review Topic

QID: 100955
1

Calcium oxalate

0%

(0/14)

2

Calcium phosphate

0%

(0/14)

3

Magnesium ammonium phosphate

0%

(0/14)

4

Uric acid

79%

(11/14)

5

Cystine

21%

(3/14)

M1

Select Answer to see Preferred Response

PREFERRED RESPONSE 4
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