Kidney Stones (Nephrolithiasis)

Nephrolithiasis is the medical term for kidney stones.

A kidney stone is a hard, crystalline mineral material formed within the kidney or urinary tract. Kidney stones are a common cause of blood in the urine (hematuria) and often severe pain in the abdomen, flank, or groin. Kidney stones are sometimes called renal calculi.

The condition of having kidney stones is termed nephrolithiasis. Having stones at any location in the urinary tract is referred to as urolithiasis, and the term ureterolithiasis is used to refer to stones located in the ureters.

Four minerals may form kidney stones. Doctors treat each type of kidney stone in the same way.

The types of kidney stones include:

• Calcium oxalate
• Uric acid
• Struvite
• Cystine

Kidney stones form when there is a decrease in urine volume and/or an excess of stone-forming substances in the urine.

• The most common type of kidney stone contains calcium in combination with either oxalate or phosphate.
• A majority of kidney stones are calcium stones.
• Other chemical compounds that can form stones in the urinary tract include uric acid, magnesium ammonium phosphate (which forms struvite stones; see below), and the amino acid cysteine.

Dehydration from reduced fluid intake or strenuous exercise without adequate fluid replacement increases the risk of kidney stones. Obstruction of the flow of urine can also lead to stone formation. In this regard, climate may be a risk factor for kidney stone development, since residents of hot and dry areas are more likely to become dehydrated and susceptible to stone formation.

Kidney stones can also result from infection in the urinary tract. These are known as struvite or infection stones. Metabolic abnormalities, including inherited disorders of metabolism, can alter the composition of the urine and increase an individual's risk of stone formation.

Several different medical conditions can lead to an increased risk of developing kidney stones:

• Gout results in a chronically increased amount of uric acid in the blood and urine and can lead to the formation of uric acid kidney stones.
• Hypercalciuria (high calcium in the urine), another inherited condition, causes stones in more than half of the cases. In this condition, too much calcium is absorbed from food and excreted into the urine, which may form calcium phosphate or calcium oxalate kidney stones.
• Other conditions associated with an increased risk of kidney stones include hyperparathyroidism, kidney diseases such as renal tubular acidosis, and other inherited metabolic conditions, including cystinuria and hyperoxaluria.
• Chronic diseases such as diabetes and high blood pressure (hypertension) are also associated with an increased risk of developing kidney stones.
• People with inflammatory bowel disease are also more likely to develop kidney stones.
• Those who have undergone intestinal bypass or ostomy surgery are also at increased risk for kidney stones.
• Some medications also raise the risk of kidney stones. These medications include diuretics, calcium-containing antacids, and the protease inhibitor indinavir (Crixivan), a drug used to treat HIV infection.
• Dietary factors and practices may increase the risk of stone formation in susceptible individuals. In particular, inadequate fluid intake predisposes to dehydration, which is a major risk factor for stone formation. Other dietary practices that may increase an individual's risk of forming kidney stones include a high intake of animal protein, a high-salt diet, excessive sugar consumption, excessive vitamin D supplementation, and excessive intake of oxalate-containing foods such as raw spinach. Cooking spinach reduces oxalates by five to fifteen percent. Overcooking does not decrease oxalates further and destroys vitamins. Interestingly, low levels of dietary calcium intake may alter the calcium-oxalate balance and result in the increased excretion of oxalate and a propensity to form oxalate stones.
• Hyperoxaluria as an inherited condition is uncommon and is known as primary hyperoxaluria. Elevated oxalate levels in the urine increase the risk of stone formation. Primary hyperoxaluria is much less common than hyperoxaluria due to dietary factors as mentioned above.

Anyone may develop a kidney stone, but people with certain diseases and conditions (see below) or those who are taking certain medications are more susceptible to their development. Urinary tract stones are more common in men than in women. Most urinary stones develop in people 20 to 49 years of age, and those who are prone to multiple attacks of kidney stones usually develop their first stones during the second or third decade of life. People who have already had more than one kidney stone are prone to developing further stones.

In residents of industrialized countries, kidney stones are more common than stones in the bladder. The opposite is true for residents of developing areas of the world, where bladder stones are the most common. This difference is believed to be related to dietary factors. People who live in the southern or southwestern regions of the U.S. have a higher rate of kidney stone formation, possibly due to inadequate water intake leading to dehydration than those living in other areas. Over the last few decades, the percentage of people with kidney stones in the U.S. has been increasing, most likely related to the obesity epidemic.

Drinking a large amount of sugar-sweetened cola increases kidney stones. Conversely, you can lower your risk of kidney stones by drinking caffeinated coffee and decaffeinated coffee.

A family history of kidney stones is also a risk factor for developing kidney stones. Kidney stones are more common in Asians and Caucasians than in Native Americans, Africans, or African Americans.

Uric acid kidney stones are more common in people with chronically elevated uric acid levels in their blood (hyperuricemia).

A small number of pregnant women develop kidney stones, and there is some evidence that pregnancy-related changes may increase the risk of stone formation. Factors that may contribute to stone formation during pregnancy include a slowing of the passage of urine due to increased progesterone levels and diminished fluid intake due to a decreasing bladder capacity from the enlarging uterus. Healthy pregnant women also have a mild increase in their urinary calcium excretion. However, it remains unclear whether the changes in pregnancy are directly responsible for kidney stone formation or if these women have another underlying factor that predisposes them to kidney stone formation.

While some kidney stones may not produce symptoms (known as "silent" stones), people who have kidney stones often report the sudden onset of excruciating, cramping pain in their lower back and/or side, groin, or abdomen. Changes in body position do not relieve this pain.

The abdominal, groin, and/or back pain typically waxes and wanes in severity, characteristic of colicky pain (the pain is sometimes referred to as renal colic). It may be so severe that it is often accompanied by nausea and vomiting. The pain has been described by many as the worst pain of their lives, even worse than the pain of childbirth or broken bones.

Kidney stones also characteristically cause bloody urine. If the infection is present in the urinary tract along with the stones, there may be fever and chills. Sometimes, other symptoms may include the following:

• Difficulty urinating
• Urinary urgency
• Penile pain
• Testicular pain may occur due to kidney stones

Some kidney stones pass on their own without medical intervention. However, you should see a doctor if your pain is accompanied by:

• Fever or chills
• An inability to urinate
• Severe confusion and fatigue
• Severe nausea and vomiting

Additionally, if you have only one kidney, you should seek medical intervention for your kidney stone. Also, if you've been trying to pass your stone for close to six weeks, seek medical attention.

The diagnosis of kidney stones is suspected when the typical pattern of symptoms is noted and when other possible causes of abdominal or flank pain are excluded. Which is the ideal test to diagnose kidney stones is controversial. Imaging tests are usually done to confirm the diagnosis. Many patients who go to the emergency room will have a non-contrast CT scan done. This can be done rapidly and will help rule out other causes of flank or abdominal pain. However, a CT scan exposes patients to significant radiation, and recently, ultrasound in combination with plain abdominal X-rays is effective in diagnosing kidney stones.

In pregnant women or those who should avoid radiation exposure, an ultrasound examination may be done to help establish the diagnosis.

Most kidney stones eventually pass through the urinary tract on their own within 48 hours, with ample fluid intake. Ketorolac (Toradol), an injectable anti-inflammatory drug, and narcotics may be used for pain control when over-the-counter pain control medications are not effective. Toradol, aspirin, and NSAIDs must be avoided if lithotripsy is to be done because of the increased risk of bleeding or if there is impaired kidney function. Intravenous pain medications can be given when nausea and vomiting are present.

Although there are no proven home remedies to dissolve kidney stones, home treatment may be considered for patients who have a known history of kidney stones. Since most kidney stones, given time, will pass through the ureter to the bladder on their own, treatment is directed toward the control of symptoms. Home care in this case includes the consumption of plenty of fluids. Acetaminophen (Tylenol) may be used as pain medication if there is no contraindication to its use. If further pain medication is needed, stronger narcotic pain medications may be recommended.

Several factors influence the ability to pass a stone. These include the size of the person, prior stone passage, prostate enlargement, pregnancy, and the size of the stone. A 4 mm stone has an 80% chance of passage while a 5 mm stone has a 20% chance. Stones larger than 9 mm to 10 mm rarely pass without specific treatment.

Some medications have been used to increase the passage rates of kidney stones. These include calcium channel blockers such as nifedipine (Adalat, Procardia, Afeditab, Nifediac) and alpha-blockers such as tamsulosin (Flomax). These drugs may be prescribed to some people who have stones that do not rapidly pass through the urinary tract.

For kidney stones that do not pass on their own, a procedure called lithotripsy is often used. In this procedure, shock waves are used to break up a large stone into smaller pieces that can then pass through the urinary system.

Surgical techniques have also been developed to remove kidney stones when other treatment methods are not effective. This may be done through a small incision in the skin (percutaneous nephrolithotomy) or an instrument known as a ureteroscope passed through the urethra and bladder up into the ureter.

For some people who have had many kidney stones, home care may be appropriate. When passing a kidney stone, drinking lots of fluid is important. In fact, this is the most important home care measure. Medications may help control the pain (as described previously). However, if it is the first time one has had symptoms suggestive of a kidney stone, it is important to see a doctor right away.

Most kidney stones will pass on their own, and successful treatments have been developed to remove larger stones or stones that do not pass. People who have had a kidney stone remain at risk for future stones throughout their lives.

A kidney stone smaller than 4 millimeters may pass within 1-2 weeks, whereas a stone larger than 4 millimeters may take about 2-3 to pass completely.

Rather than having to undergo treatment, it is best to avoid kidney stones in the first place when possible. It can be especially helpful to drink more water since low fluid intake and dehydration are major risk factors for kidney stone formation.

Depending on the cause of the kidney stones and an individual's medical history, changes in the diet or medications are sometimes recommended to decrease the likelihood of developing further kidney stones. If one has passed a stone, it can be particularly helpful to have it analyzed in a laboratory to determine the precise type of stone so specific prevention measures can be considered.

People who tend to form calcium oxalate kidney stones may be advised to limit their consumption of foods high in oxalates, such as spinach, rhubarb, Swiss chard, beets, wheat germ, and peanuts. Also drinking lemon juice or lemonade may help prevent kidney stones.