SeminarRecurrent renal stone disease—advances in pathogenesis and clinical management
Section snippets
Pathogenesis
The mechanisms of crystallisation need to be understood to outline the basis of stone formation. The states of saturation of ions in a solution are governed by their concentrations. For example, when concentrations of calcium and oxalate reach saturation (the saturation product), stone formation begins with association of small amounts of crystalloid to form nuclei (nucleation). These nuclei normally grow and aggregate on surfaces such as collecting ducts and renal papillary epithelium.6 Renal
Calcium stones
Most stones contain calcium combined with oxalate, phosphate, or occasionally uric acid. All calcium stones are radio-opaque, and calcium oxalate and calcium phosphate stones are black, grey, or white and small (<1 cm in diameter), dense, and sharply circumscribed on radiographs. Different conditions contribute to calcium stones. Hypercalciuria (defined as >0·1 mmol/kg bodyweight of patient per day, calculated for ideal bodyweight) can be idiopathic or result from any disorder that induces even
Clinical presentation of acute stone episode
When a urinary stone moves into the renal collecting system, the resulting increase in intraluminal pressure stretches nerve endings in the mucosa, and produces a severe and often colicky pain. This pain radiates downward on the anterior from the flank toward the groin, and is often accompanied by frequent urination, dysuria, oliguria, haematuria, acute nausea, and hypotension. In the acute setting, stones can obstruct the urinary tract producing serious symptoms, or obstruction can be a
Acute setting
Documentation of stone characteristics is extremely important (type, size, and location). Although there is a risk of allergy and contrast nephropathy, intravenous pyelography remains the gold standard for such identification. Ultrasonography can indicate whether a stone is in the kidney or ureter, the degree of any obstruction, and quality of renal parenchyma. Plain abdominal radiography is useful for stones above the pelvic brim, and, with ultrasonography, is the investigation of choice in
Pain relief
Renal colic is one of the most intense forms of pain and requires prompt symptomatic treatment. Non-steroidal anti-inflammatory drugs given orally or intravenously have good analgesic properties,31 although they also have serious gastrointestinal and renal side-effects. Renal side-effects are especially important in dehydrated patients and those at risk of allergy to these drugs. Cyclo-oxygenase-II inhibitors have been developed to reduce gastrointestinal effects, but they also inhibit renal
General measures
Non-pharmacological interventions reduce 5 year rate of stone recurrence by up to 60%33 in people who adhere to a sensible diet. Patients should be encouraged to increase their basic intake of water to at least 2 L daily, and especially so during heavy exercise, pyrexial episodes, and when travelling long distances. Maximum urine output should be encouraged in patients with renal insufficiency, with careful monitoring of volume status and weight gain.
A non-animal low protein diet (0·8–1·0 g/kg
References (43)
Observations on the analysis of ten thousand urinary calculi
J Urol
(1962)- et al.
Further evidence linking urolithiasis and blood coagulation: urinary prothrombin fragment 1 is present in stone matrix
Kidney Int
(1996) - et al.
Molecular characteristics of uronic-acid-rich protein, a strong inhibitor of calcium oxalate crystallisation in vitro
Biochem Biophy Res Commun
(1993) - et al.
Factors influencing the crystallisation of calcium oxalate in urine
J Crystal Growth
(1981) - et al.
Plasma phospholipid arachidonic acid content and calcium metabolism in idiopathic calcium nephrolithiasis
Kidney Int
(2000) - et al.
Identification of two novel mutations in the CLCN5 gene in Japanese patients with familial idiopathic low molecular weight proteinuria (Japanese Dent's disease)
Am J Kidney Dis
(2001) - et al.
Selective cyclooxygenase-2 inhibitors reduce ureteral contraction in vitro: a better alternative for renal colic?
J Urol
(2000) Renal handling of citrate
Kidney Int
(1990)- et al.
The Aphorisms of Hippocrates (section IV)
Delran: Gryphon Editions
(1982) - et al.
Urinary calculi
S Afr J Med
(1973)
Diagnostic and therapeutic aspects of recurrent renal stones disease
Afr J Nephrol
Clinical approach
Lithogenic risk factors in normal black volunteers, and black and white recurrent stone formers
BJU Int
Regulation of renal epithelial cell endocytosis of calcium oxalate monohydrate crystals
Am J Physiol
Calcium oxalate monohydrate crystals are endocytosed by renal epithelial cells and induce proliferation
Am J Physiol
Effect of urate on calcium oxalate crystallisation in human urine, evidence for a promotory role of hyperuricosuria in urolithiasis
Clin Sci
Inhibitors of Stone Formation
Semin Nephrol
Crystallisation properties in urine from calcium oxalate stone formers
J Urol
Molecular abnormality of Tamm-Horsfall glycoprotein in calcium oxalate nephrolithiasis
Am J Physiol
Citrate and calcium effects on Tamm-Horsfall glycoprotein as a modifier of calcium oxalate crystal aggregation
Am J Physiol
Determinants of urinary excretion of Tamm-Horsfall protein in non-selected kidney stone formers and healthy subjects
Nephrol Dial Transplant
Cited by (181)
Motion of bacteria and CaOx particles via urine flow modulated by the electro-osmosis
2023, Physics of Fluids