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Renal stones
First steps and keys to
Key points
reducing recurrence
• In patients with a suspected ZAINUL A. QADRI MB BS
renal stone, history taking, MAUREEN LONERGAN BMedSc, MB BS, FRACP, PhD
examination and investigation KELLY LAMBERT BSc, MSc, GradCertMgmt
aim to confirm the diagnosis
and detect any complica In patients with a renal stone, management aims to detect complications,
tions, such as sepsis or renal triage to expectant observation or active intervention and identify any
damage, and underlying
predisposing factors. Referral for active urological intervention or detailed
factors that increase the
risk of recurrence. metabolic evaluation may be indicated. Dietary and lifestyle interventions
• Options for treatment of may help decrease the risk of recurrences.
renal stones include
R
expectant observation if the enal stones are common and are asso- recurrent stone disease, the risks associated
patient has good renal ciated with significant morbidity and, with repeated radiation exposure from imag-
function, well-controlled on rare occasions, mortality when the ing studies must also be considered.
pain and no evidence of stone obstructs the urinary tract in the Lifestyle factors can contribute to the risk
sepsis, or a need for active presence of infected urine. Common adverse of stone formation, and addressing these may
urological intervention. impacts of renal stones (calculi) include not reduce recurrences. Some patients, however,
• Urinary tract infection in the only pain but also the need for GP or emer- have more complex metabolic abnormalities
presence of obstruction is a gency department visits for pain relief or or underlying medical conditions that may
medical and surgical intervention, surgical procedures, follow-up require specific management by renal physi-
emergency, requiring reviews and time lost from work. Renal stones cians or urologists with a special interest in
immediate relief of the are associated with an increased risk of this area. This article discusses the approach
obstruction. chronic renal disease. In addition, people who to evaluation, treatment and referral of
• Factors that contribute to develop renal stones are at increased risk of patients with renal stones in general practice.
renal stone formation cardiovascular events, hypertension, diabetes It will not address surgical management in
should be addressed to and the m etabolic syndrome. For those with detail.
© KEVIN A. SOMERVILLE
also involves a dietitian taking a detailed one cup (240 mL) of coffee (caffeinated or recommended amounts – not more than
diet history, estimating intake of protein, decaffeinated) or tea daily may help pro- two standard drinks per day for men and
sodium, oxalate, calcium and other d ietary tect against renal stones in healthy one for women, with at least two alcohol-
components, and providing specific individuals.12,13 free days a week. Avoiding alcohol intake
dietary advice onCopyright
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4 against stone for- may be of benefit to people who develop
minimise. mation by inhibiting secretion of ADH, uric acid stones.
Practice tip
• Ensure a high fluid intake to maintain a urine output of at least 2L/day (ideally
aiming for 2.5 to 3.0 L/day)
• People in situations where they
sweating profusely require a higher
• Avoid dehydration by increasing water intake if sweating profusely; spread water
water intake (more than 2.5 L/day) to
intake over the day and night if awake.
avoid d
ehydration and maintain a
• Reduce dietary sodium intake high output of dilute urine.
• Maintain a normal calcium intake via dietary sources • Encourage patients to spread out
• In general, reduce total protein intake and increase fruit and vegetable consumption their water intake over the day and
during the night if awake.
• For patients with uric acid stones, maintain a high fluid intake, moderate protein
intake and no alcohol
Sodium intake
• For patients with oxalate stones, we recommend avoiding foods high in oxalate A high sodium intake (more than 100 mmol
and vitamin C, and consuming calcium-rich foods to bind oxalate and reduce its urinary sodium excretion in 24 hours)
absorption increases urinary calcium excretion. Reduc-
• For patients with stones caused by impaired absorption of calcium due to small ing sodium intake reduces urinary calcium
bowel disease, supplementation with magnesium citrate may be helpful excretion and the risk of stone formation
• Note that vitamin D supplementation may be a risk factor for renal stone disease and also increases the efficacy of thiazide
diuretics. Higher sodium excretion
• For patients taking a fish oil product, check the label carefully as some of these
increases uric acid excretion and decreases
products contain vitamin D, which may contribute to stone formation
urinary citrate concentrations.
• For patients who have a recurrence of renal stones while taking any herbal or other
botanical-based products, we consider it prudent to cease taking these products Practice tip
• Remember that obesity increases the risk of renal stones, as does weight loss • Suggestions for patients to reduce
achieved with laxatives or extreme dieting dietary sodium intake include
choosing low-salt packaged p roducts
(less than 120 mg sodium per 100 g)
Practice tips cranberry juice decreases urinary and avoiding adding salt to food in
• The most effective and simple pH and increases urine calcium cooking and at the table.
intervention to prevent recurrent oxalate concentration, leading to
renal stones is to ensure patients uric acid stone formation16 Calcium intake
have a high intake of fluid (ideally –– apple juice Calcium binds with oxalate in the normal
water) that m aintains a urine output –– grapefruit juice, which increases gastrointestinal tract. A low oral calcium
of at least 2 L/day (ideally aiming for the risk of recurrence via an intake increases the absorption of oxalate
2.5 to 3.0 L/day).14 unknown mechanism.17 and the risk of calcium oxalate stone
• Failure of patients to increase their • Fluids that may exert a protective formation. However, an excessive calcium
urine output has been found to be a effect include: intake can also increase the risk of stone
strong predictor for recurrent stone –– lemon juice (120 mL/day, mixed formation. Therefore maintenance of a
formation in patients followed up in with water), which is rich in citrate 18 normal calcium intake as per the dietary
a dedicated stone clinic. –– milk, which exerts a protective guidelines is recommended. The minimum
• Fluids that appear from observational effect by binding oxalate in the daily requirement for calcium is 840 mg,
studies to increase the risk of stone gastrointestinal tract.19 and the general recommendation for adults
recurrence include: is 1000 to 1300 mg/day.
–– soft drinks rich in phosphoric acid, Work environment and exercise If calcium supplements are used then
such as cola drinks; phosphoric People who work in hot conditions or they are best taken with food. Calcium
acid reduces urinary citrate and undertake heavy physical activity that citrate provides additional citrate, which
thus binding of oxalate15 results in profuse sweating and decreased is a key inhibitor of stone formation. It acts
–– cranberry juice, more _Layout
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urine
1:43production
PM Page 4have an increased risk by lowering urinary saturation and inhib-
1000 mL/day; this volume of of dehydration and concentrated urine. iting crystallisation of calcium salts.
absorption of calcium caused by small dieting can increase their risk of that in adults with increased water intake.
bowel disease. renal stones. Dietary modifications are similar to adults
except for calcium intake, which should be
Fish oil supplements SPECIAL SITUATIONS increased via dietary intake of high calcium
Intake of omega-3 fatty acids such as Bladder stones foods rather than supplementation.
eicosapentaenoic acid (EPA) and docos Bladder stones are usually composed of
ahexaenoic acid (DHA) may reduce the uric acid in non-infected urine or struvite Pregnant women
urinary excretion of calcium and oxalate. in infected urine. Most patients with these Pregnant women with renal stones should
Thus, it has been suggested that a higher types of stones have obstruction, which be imaged by ultrasound examination or
intake of EPA and DHA (from either causes them to reduce their fluid intake, MRI. Metabolic evaluation is not under-
dietary sources or fish oil supplementa- resulting in concentrated acidic urine. taken during pregnancy. Management
tion) may reduce the risk of renal stones; Calcium oxalate or cystine stones form in during pregnancy is generally surgical.
however, no clinical trials have evaluated the kidneys, pass down the ureter and are Stents are inserted via cystoscopy with
the effect of omega-3 fatty acids on the trapped in the bladder. m
inimal radiation.
development of renal stones. Patients Typical symptoms of bladder stones are
intending to take a fish oil product should intermittent, painful voiding and terminal CONCLUSION
check the labels carefully as some of these haematuria. The pain may be dull, aching Renal stones are common. Stone recurrence
products contain vitamin D and may or sharp suprapubic pain, which is exacer- can be avoided or reduced by addressing
contribute to stone formation. bated by exercise and sudden movement. lifestyle and dietary factors. Referral for
Severe pain typically occurs near the end more detailed and specialised management
Herbal and other botanical products of micturition when the stone becomes to a specialised renal stone clinic is neces-
Specific advice about herbal products and impacted at the bladder neck. This is sary for some patients. MT
risk of stone formation is difficult because relieved when the patient lies flat. Pain may
of a lack of information. However, if be referred to the tip of the penis, scrotum, REFERENCES
patients develop recurrent stones while perineum and occasionally the back or hip.
using herbal or other botanical-based prod- Impaction of the stone in the bladder neck A list of references is included in the website version
ucts, particularly herbal teas, the prudent interrupts the urinary stream. (www.medicinetoday.com.au) and the iPad app
advice is to cease taking these products. The main intervention for the preven- version of this article.
tion of recurrent bladder stones is relief of
Obesity bladder outlet obstruction. COMPETING INTERESTS: Professor Lonergan
Obesity is a risk factor for renal stone and Dr Qadri: None. Ms Lambert has previously
formation, particularly in women. Obese Infants received an honorarium from Shire.
patients have a higher incidence of uric Neonates with frusemide-induced neph-
acid stones. The metabolic syndrome is rolithiasis present with haematuria,
associated with a lower urinary pH. worsening renal function and calcific
Online CPD Journal Program
Bariatric surgery and certain types of densities on renal ultrasound or plain film What are the
weight loss diets may also increase the risk radiography. Nephrocalcinosis is often minimum
of renal stone formation. For example, a present. Similar findings have been seen investigations
small study found that a low-carbohydrate, in neonates with severe low birth weight suggested
© KARLSTURY/SHUTTERSTOCK
high-protein diet lowered urinary pH and and/or prematurity and no history of loop after a first
citrate levels and increased urinary uric diuretic usage. renal stone?
acid levels and acid and calcium excretion
in healthy subjects. All of these changes Children and adolescents
increase the risk of stone formation and The presence of stones in children and
may increase the risk of bone loss. Excess adolescents suggests the possibility of an
sucrose intake is also linked with higher inherited genetic disease such as cystinuria, Review your knowledge of this topic
calcium excretion. renal tubular acidosis or primary oxaluria. and earn CPD points by taking part in
With increasing obesity in childhood there MedicineToday’s Online CPD Journal Program.
Practice tip is also an increase in the incidence of renal Log in to
• Patients must beCopyright
informed_Layout
that losing stones.
1 17/01/12 1:43 PM Page 4
www.medicinetoday.com.au/cpd
weight with laxatives or extreme The medical management is similar to
Renal stones
First steps and keys to
reducing recurrence
ZAINUL A. QADRI MB BS; MAUREEN LONERGAN BMedSc, MB BS, FRACP, PhD; KELLY LAMBERT BSc, MSc, GradCertMgmt
REFERENCES
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