NEPHROLITHIASIS

• Nephrolithiasis generally refers to stones within the renal tubules or colleting system. Stones can however be seen in various sites of the urinary tract like renal parenchyma, ureters, bladder and urethra
• Urine stones are most commonly composed of calcium oxalates. Less common stones are made up of uric acid, struvite (due to infection with urease-producing bacteria), calcium phosphate, or cystine
• While nephrolithiasis can be asymptomatic, they occasionally present with excruciating pain and can even be cause of renal failure. Nephrolithiasis manifests as sudden onset colicky flank pain that may radiate to the groin, testes, or labia (renal/ureteric colic) and is usually associated with haematuria

Super saturation of urine with substances like calcium, oxalate, uric acid can result in stone formation

Risk factors

Hypercalciuria, Hypercitrauria, Hyperoxaluria, Low calcium intake, High Oxalate intake, High animal protein intake, High sodium intake, low fluid intake, Family history, Bariatric surgery, UTI with urease splitting organisms, Drugs like acyclovir, sulphonamides etc.

Calcium stones

• Majority (80%) are calcium stones (mainly calcium oxalate and occasionally calcium phosphate)
• Causes : Hypercalciuria , Hyperoxaluria, Hypocitraturia, increased intake of Vitamin C , ↓ Urine pH (acidic)

Uric acid stones

• Accounts for 10% stones , associated with persistently acidic urine (pH <5.5)
• Causes: Gout, hyperuricemia, and hyperuricosuria, High cell turnover (e.g., leukemia,

Struvite stones

• Less common ( 5% of all calculi), ↑ Urine pH (alkaline)
• Causes: UTI with urease-producing bacteria (e.g., Proteus mirabilis, S. saprophyticus, Klebsiella)

Calcium phosphate stones

• < 5%, ↑ Urine pH (alkaline)
• Causes : Hyperparathyroidism, Type 1 renal tubular acidosis

Cystine stones : Seen in a genetic disorder where there is a tubal defect, ↓ Urine pH (acidic)

Xanthine stones : Generally independent of urine pH

Stones usually form in the collecting ducts of the kidneys but may be deposited along the entire urogenital tract from the renal pelvis to the urethra. Their localization and size determine the specific symptoms.

• Asymptomatic - Small kidney stones, detected on routine imaging
• Haematuria – macroscopic or detected only on microscopy of urinary deposits
• Severe unilateral and colicky flank pain (renal colic) 
• Graveluria / Lithuria ( passing gravel or stones in urine)
• Abdominal/ loin pain
• Loin to Groin pain ( Uretric colic)
• Nausea/ vomiting ( with Uretric colic)
• Dysuria/ urgency / stangury
• Acute kidney injury ( obstruction to a single functioning kidney or bilateral obstruction)
• Chronic kidney disease ( staghorn calculi / bilateral renal calculi / oxalosis / chronic tubulointerstitial nephritis)
• Uretric colic – waxes and wanes with typical radiation

Location and characteristics of pain

Depends on the level of obstruction and its degree:

UPJ (Ureteropelvic junction) stone:

• Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral stone:

• According to site of obstruction
• Intense nausea, with or without vomiting, usually is present.
• With radiation to the testicles or the vulval area
• Cause abrupt, severe, colicky pain in the flank and ipsilateral lower abdomen
  • Upper ureter:- Tends to radiate to the flank and lumbar areas
  • Mid Ureter: - Cause pain that radiates anteriorly and caudally. Can easily mimic appendicitis on the right or acute diverticulitis on the left
  • Distal Ureter :- Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

UVJ (Ureterovesical junction) stones:

• Pain similar to distal ureteral stone
• may cause irritative voiding symptoms mimicking cystitis, such as- urinary frequency, dysuria

Bladder stone:

• Usually asymptomatic and are passed relatively easily during urination
• Rarely, a patient reports positional urinary retention (obstruction precipitated by standing, relieved by recumbency)

Urine analysis - Gross or microscopic haematuria 

Urine pH: > 7 suggests urea-splitting organisms and struvite stones, < 5 indicates uric acid stones

Urine microscopy: to detect crystals

• Calcium oxalate stones : dumbbell-shaped or octahedron-shaped crystals 
• Uric acid stones: rhomboid/needle-shaped crystals 
• Struvite stones : rectangular prisms (coffin lid-appearance)
• Calcium phosphate stones : wedge-shaped crystals
• Cystine stones :hexagonal crystals 
• Xanthine stones : amorphous crystals

Urine culture: in patients with s/s of UTI

24-hour urine profile

↑ WBC: suggests concomitant UTI

↑ Serum urea nitrogen and creatinine: suggests acute kidney injury

Abdomino pelvic CT : Non enhanced CT scan is the gold standard.

Ultrasound

X-ray (KUB) - Not useful for evaluating calcium stones < 3 mm, radiolucent stones, or to identify urinary tract obstruction

• Calcium oxalate stones: radio opaque
• Uric acid stones :radiolucent
• Struvite stones :Weakly radio opaque
• Calcium phosphate stones: radio opaque
• Cystine stones : Weakly radio opaque

Intravenous pyelogram (IVP): rarely used

• Asymptomtic stones- increase fluid intake to at least 2 litres per day
• Citrate supplementation – in hyocitraturia , not good in calcium phosphate stones
• Low oxalate diet – (Restrict intake of spinach, potatoes, almonds etc.) – in Oxalate stones
• Low purine diet with minimal animal protein – Uric acid stones

Treatment depends on the size of the stone

• < 5 mm: often pass spontaneously
• < 10 mm: likelihood of spontaneous passage
• > 10 mm: often require shock wave lithotripsy or ureterorenoscopy
• > 20 mm: percutaneous nephrolithotomy

Internal Medicines

• Veerataradi kashaya
• Varanadi kashaya
• Bruhatyadi kashaya
• Chandraprabha gutika
• Saptasara Kashaya
• Dashamoola hareetaki
• Sukumara lehya
• Kalyanaka kshara
• Aviltholadi bhasma
• Punarnavasava
• Abhayarishta
• Gokshura paneeya kalpana
• Sweta parpati

Procedures

• Avagaha – Dhanyamla