Renal Calculi

Epidemiology
The lifetime prevalence of kidney stone disease is estimated at 1% to 15%, with the
probability of having a stone varying according to age, gender, race, and geographic
location. In the United States, the prevalence of stone disease has been estimated
at 10% to 15% (Norlin et al, 1976; Sierakowski et al, 1978; Johnson et al, 1979).
Risk Factors
Gender
Stone disease typically affects adult men more commonly than adult women. By a
variety of indicators including inpatient admissions, outpatient office visits,
and emergency department visits, men are affected two to three times more often
than women (Hiatt et al, 1982; Soucie et al, 1994; Pearle et al, 2005).
Race/Ethnicity
Racial/ethnic differences in the incidence of stone disease have been observed.
Among U.S. men, Soucie and colleagues (1994) found the highest prevalence of
stone disease in whites, followed by Hispanics, Asians, and African-Americans,
who had prevalences of 70%, 63%, and 44% of whites, respectively. Among U.S.
women, the prevalence was highest among whites but lowest among Asian women
(about half that of whites).

Age
Stone occurrence is relatively uncommon before age 20 but peaks in incidence in the
fourth to sixth decades of life (Marshall et al, 1975; Johnson et al, 1979; Hiatt et al,
1982).
It has been observed that women show a bimodal distribution of stone disease,
demonstrating a second peak in incidence in the sixth decade of life, corresponding to
the onset of menopause (Marshall et al, 1975; Johnson et al, 1979). This finding and
the lower incidence of stone disease in women compared with men have been
attributed to the protective effect of estrogen against stone formation in
premenopausal women, owing to enhanced renal calcium absorption and reduced
bone resorption (McKaneet al, 1995; Nordin et al, 1999).
Geography
The geographic distribution of stone disease tends to roughly follow environmental
risk factors; a higher prevalence of stone disease is found in hot, arid, or dry climates
such as the mountains, desert, or tropical areas.

Climate
Seasonal variation in stone disease is likely related to temperature by way of fluid
losses from perspiration and perhaps by sunlight induced increases in vitamin D.
Prince and Scardino (1960) noted the highest incidence of stone disease in the
summer months, July through September, with the peak occurring within 1 to 2
months of maximal mean temperatures (Prince et al, 1956).

Body Mass Index and Weight

The association of body size and incidence of stone disease has been investigated. In
two large prospective cohort studies of men and women, the prevalence and incident
risk of stone disease were directly correlated with weight and body mass index (BMI)
in both sexes, although the magnitude of the association was greater in women than
men (Curhan et al, 1998; Taylor et al, 2005).
Water
The beneficial effect of a high fluid intake on stone prevention has long been
recognized. In two large observational studies, fluid intake was found to be inversely
related to the risk of incident kidney stone formation (Curhan et al, 1993, 1997).
Furthermore, in a prospective, randomized trial assessing the effect of fluid intake on
stone recurrence among first-time idiopathic calcium stone formers, urine volume was
significantly higher in the group assigned to a high fluid intake compared with the
control group receiving no recommendations, and, accordingly, stone recurrence rates
were significantly lower (12% vs. 27%, respectively) (Borghi et al, 1996).
Etiology
The Etiology of urinary stone formation is complex. It is thought to encompass a
number of factors, including increases in blood and urinary levels of stone
components and interactions among the component, anatomy changes in urinary
tract structures, metabolic and endocrine influences, dietary and intestinal absorption
factors, and UTIs.
Pathogenesis
Kidney stone formation requires a supersaturated urine and an environment that
allows the stone to grow. The risk for stone formation is increased when the urine is
supersaturated with stone components (e.g., calcium salts, uric acid, magnesium
ammonium phosphate, cystine). Supersaturation depensd on urinary pH, solute
concentration, ionic strength, and complexation. The greater the concentration of two
ions, the more likeliy they are to precipate. Complexation influences the availability of
specific ions.

In supersaturated urine, stone formation begins with small clusters of crystals such as
calcium oxalate. Most small clusters tend to disperse because the internal forces that
hold them together are too weak to overcome the random tendency of ions to move
apart. Larger ion clusters form nuclei and remain stable because the attraction forces
balance surface losses. Once they are stable, nuclei can grow at levels of
supersaturation below that needed for their creation.
Types of Stones
There are four types of kidney stones
Calcium stones (i.e., oxalate or phosphate)
Magnesium ammonium phosphate stones
Uric acid stones
Cystine stones
Clinical Manifestations
One of major manifestations of kidney stones is pain.
Renal Colic and noncolickly renal pain
Renal colic is the term used to describe the colickly pain that accompanies stretching
of the collcting system or ureter. The symptoms of renal colic are caused by stones 1 to
5 mm in diameter that can move into the ureter and obstruct flow.
Classic ureteral colic is manifsted by acute, intermitten, and excruciating pain in the
flank and upper outer quadrant of the abdomen on the affected side.

Noncolickly pain is caused by stones that produce distention of renal calyces or renal
pelvis. The pain usually is a dull, deep ache in the flank or back that can vary in
intensity from mild to severe.
Diagnosis
The Diagnosis based on symptomatology and diagnostic test, which include urinalysis,
plain film radiography, intravenous pyelography (IVP), and abdominal ultrasonography.

Urinalysis provides information related to hematuria, infection, the presence of stone-

forming crystals, and urine pH.
Most stone are radiopaque and readily visible on plain radiograph of the abdomen.
IVP used to visualize the collecting system of the kidneys and ureters
Abdominal ultrasonography is highly sensitive to hydronephrosis, which may be a
manifestations of ureteral obstruction.
Treatment
Treatment of acute renal colic usually is suportive. Pain relief may be needed during
acute phases of obstruction, and antibiotic therapy may be necessary to treat UTIs.
Most stones that are less than 5 mm in diameter pass spontaneously. All urine should
be strained during an attack in the hope of retrieving the stone for chemical analysis
and determination of type.