Nephrolithiasis

Aka: Nephrolithiasis, Urolithiasis, Ureterolithiasis, Kidney Stone, Renal Calculi, Ureteral Calculus, Renal Colic, Ureteral Colic, Medical Expulsive Therapy, Ureteral Stone

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II. Epidemiology

  1. Nephrolithiasis prevelance is increasing in U.S.
    1. Prevalence 1994: 5%
    2. Prevalence 2010: 9%
  2. Ureterolithiasis Incidence
    1. Accounts for 2% of U.S. Emergency Department visits
  3. Life-time risk
    1. Males: 10-13%
    2. Females: 3-7%
  4. Recurrence of Nephrolithiasis
    1. One recurrence in 50% of patients
    2. More than 3 recurrences in 10% of patients
  5. Peak age 20-50 years
    1. Peak Incidence in midlife
    2. However childhood stone Incidence is increasing (pediatric diabetes, Obesity, Hypertension)
  6. Gender associations: Overall Male:Female ratio 4:1
    1. Males: Calcium oxalate
    2. Females: Struvite
    3. Both: Urate Stones and Cystine Stones
    4. Pregnancy: Calcium Phosphate (75% of cases)

III. Pathophysiology

  1. Stone formation is inhibited by Citrate
  2. Women have much higher levels of citrate than men
  3. Low citrate levels are related to most stone forms

IV. Risk Factors

  1. See Nephrolithiasis Risk Factors

V. Types: Stones

  1. Calcium Nephrolithiasis (75%)
    1. Calcium oxalate (70%)
    2. Calcium Phosphate (5-10%)
      1. Approaches 75% in pregnant women
      2. Also more common in children
  2. Struvite Nephrolithiasis (15-20%)
    1. Chronic infection (e.g. Proteus, Pseudomonas) that forms staghorn calculi
  3. Uric Acid Nephrolithiasis (10-15%)
    1. Radiolucent stones that may be associated with gout and low Urine pH
  4. Cysteine Nephrolithiasis (1%)
    1. Typically due to inborn error of metabolism
    2. Like Struvute, forms staghorn calculi
  5. Drug-Induced (1%)
    1. Indinavir (Protease Inhibitor in HIV)
    2. Triamterene

VI. Symptoms: Renal Colic

  1. Severe Abdominal Pain of sudden onset
    1. Onset is often at night
    2. Severe pain, with difficulty finding a comfortable position
    3. Episodic pain, each lasting 20 to 60 minutes
    4. Distribution (see Stone Location related pain below)
      1. Unilateral Flank Pain
      2. Lower, unilateral Abdominal Pain
      3. Ipsilateral inguinal or Groin Pain
  2. Associated symptoms
    1. Nausea and Vomiting
      1. Renal capsule related pain via splanchnic innervation (shared with intestinal innervation), triggers Vomiting
    2. Gross Hematuria (30%)
      1. Most common on the first day of Ureteral Colic
      2. Gross Hematuria is neither sensitive nor specific for Ureteral Stones
    3. Dysuria, urine frequency and fever may be present
      1. Exclude Urinary Tract Infection and Pyelonephritis associated with stone (requires emergent management)
      2. Fever is atypical in Ureterolithiasis outside of infection

VII. Symptoms: By stone location

  1. Kidney Calyx (typically asymptomatic other than Hematuria)
    1. Vague Flank Pain
    2. Hematuria
  2. Ureteropelvic junction or UPJ (Proximal ureter where ureter meets renal Pelvis)
    1. Flank Pain
    2. Upper Abdominal Pain
    3. Renal Colic
  3. Pelvic Brim (Low-Mid Ureter, where ureter crosses over iliac crest and iliac artery, iliac vein)
    1. Flank Pain
    2. Anterior Abdominal Pain
    3. Renal Colic
  4. Distal ureter: Ureterovesicular junction or UVJ (most common impaction site)
    1. Dysuria
    2. Urinary Frequency
    3. Anterior Abdominal Pain
    4. Flank Pain
    5. Renal Colic

VIII. Differential Diagnosis

  1. See Flank Pain
  2. See Hematuria
  3. See Dysuria
  4. See Urinary Frequency
  5. See Acute Abdominal Pain Causes in Adults
  6. See Acute Pelvic Pain Causes
  7. Acute onset of symptoms
    1. Urinary Tract Infection (esp. Pyelonephritis)
    2. Acute Prostatitis
    3. Musculoskeletal spasm
    4. Acute Constipation or other acute bowel disorder
    5. Ectopic Pregnancy
    6. Ovarian Torsion
    7. Testicular Torsion
    8. Appendicitis
    9. Incarcerated Hernia
    10. Biliary Colic
    11. Diverticulitis
    12. Acute Bowel Ischemia
    13. Aortic Dissection
    14. Abdominal Aortic Aneurysm rupture
      1. Consider in new onset Ureterolithiasis symptoms in age over 50 years old (especially if Tobacco use)
      2. May present with Flank Pain and Hematuria
      3. Ureterolithaisis is the most common mis-diagnosis of Abdominal Aortic Aneurysm presentations
  8. Chronic intermittent or insidious onset of symptoms
    1. Bowel disease
    2. Interstitial Cystitis
    3. Inguinal Hernia
    4. Testicular Mass
    5. Urothelial or Renal Mass
    6. Benign prostatitic hyperplasia

IX. Imaging: General

  1. Indications
    1. Stone size and location
    2. Exclude alternative diagnosis
  2. Imaging Selection
    1. See Nephrolithiasis Imaging

X. Imaging: Sample approach for suspected uncomplicated Nephrolithiasis (emergency department)

  1. Background
    1. Intention
      1. Reduce ionizing radiation exposure in the evaluation of Nephrolithiasis
      2. Avoid delaying intervention (when indicated)
    2. Bedside renal Ultrasound can reliably identify stones >5mm based on Hydronephrosis
      1. Goertz (2010) Am J Emerg Med 28(7):813-6 [PubMed]
      2. Edmonds (2010) CJEM 12(3): 201-6 [PubMed]
    3. Bedside Ultrasound is a safe evaluation strategy without serious missed conditions
      1. Relies on appropriate patient selection (Ureteral Colic most likely, no significant comorbidity)
      2. Moore (2019) Ann Emerg Med 74(3): 391-9 [PubMed]
      3. Smith-Bindman (2014) N Engl J Med 371(12):1100-10 +PMID:25229916 [PubMed]
    4. Consider scoring system (e.g. STONE Score) approach to imaging
      1. See STONE Score
      2. Bedside Ultrasound with Hydronephrosis present after hydration increases STONE Score Specificity
      3. High risk STONE Score (10-13) is associated with a 87% Test Specificity for Ureteral Stone
        1. Consider expectant management in otherwise healthy patients at low risk for alternative diagnosis
        2. Consider low dose CT if needed for stone localization or size
      4. Moderate risk STONE Score (6-9) is associated with a 51% Test Specificity for Ureteral Stone
        1. Bedside Ultrasound with Hydronephrosis increases likelihood of Ureteral Stone and may be sufficient for diagnosis
      5. Low risk STONE Score (0 to 5) suggests alternative diagnosis
  2. Step 1: Suspicion for uncomplicated Ureterolithiasis
    1. Hematuria and abdominal, pelvic or Flank Pain AND
    2. No Urinary Tract Infection AND
    3. No serious comorbidity (e.g. cancer, AAA risk) or other confounding factor (e.g. single Kidney)
  3. Step 2: Bedside renal Ultrasound (bilateral for comparison) and Bladder (for obstruction, distal stone shadowing at UVJ)
    1. Ultrasound offers best accuracy for Hydronephrosis
    2. Hydronephrosis on side of pain
      1. Consider empiric treatment of Ureterolithiasis with expectant management
      2. Consider other causes of Hydronephrosis (e.g. Abdominal Aortic Aneurysm)
      3. Consider non-contrast CT as indicated (see Step 3 below)
    3. No Hydronephrosis
      1. Extend Bedside Ultrasound to explore other diagnoses (e.g. AAA, Urinary Retention, Cholecystitis)
      2. Consider imaging with discussion of risks (e.g. CT-associated Radiation Exposure)
        1. Strongly consider CT if UTI by Urinalysis (exclude infected stone)
        2. False NegativeUltrasound for Hydronephrosis
        3. Alternative intraabdominal diagnosis (e.g. Appendicitis, Diverticulitis)
      3. May treat empirically as small, non-obstructing stone (likely to pass without intervention)
      4. Close interval follow-up
      5. Consider alternative diagnoses
  4. Step 3: Consider Helical, Non-Contrast CT Abdomen and Pelvis for Ureterolithiasis
    1. Non-Contrast CT indications
      1. First stone suspected (no prior imaging or Ureterolithiasis history), esp. if over age 50 years old
      2. Persistent Ureterolithiasis symptoms at 14 weeks without prior imaging
      3. Infected stone suspected
      4. Urology consulted for intervention (see indications as below)
    2. IV Contrast Enhanced CT Indications
      1. Alternative intraabdominal diagnosis (e.g. Appendicitis, Diverticulitis, Abdominal Aortic Aneurysm)
      2. Intravenous Contrast does not significantly reduce Test Sensitivity for Ureterolithiasis
        1. Lei (2021) Am J Emerg Med 47:70-3 [PubMed]
    3. Consider KUB Abdominal XRay if CT positive for Ureteral Stone of 5 mm or greater
      1. Helical CT will localize the stone and ease simultaneous identification on KUB XRay
      2. KUB XRay allows for serial XRays for monitoring progression without significant radiation exposure
      3. KUB XRay is preferred over CT scout film due to better resolution and for easier comparison on future films

XI. Labs: Initial Diagnostics

  1. Precautions
    1. Absent gross and Microscopic Hematuria does not exclude Nephrolithiasis (may miss up 10-40% of cases)
    2. Infected Ureteral Stone is a urologic emergency
  2. Urinalysis with reflex to Urine Culture
    1. Microscopic or Gross Hematuria in 90% of Nephrolithiasis cases
    2. Evaluate for Urinary Tract Infection
      1. Send urine for Urine Culture in all cases of suspected UTI and Ureteral Stone
      2. Nephrolithiasis with Urinary Tract Infection is high risk and requires immediate urologic Consultation (and urgent intervention)
      3. Factors most suggestive or higher risk of Urinary Tract Infection complicating Nephrolithiasis
        1. Fever (associated Likelihood Ratio of 10)
        2. Female (associated Likelihood Ratio of 27)
        3. Positive Urine Nitrite (associated Likelihood Ratio of 36)
        4. White Blood Cells in urine has Test Specificity of 25%
          1. However, risk of infection increases with WBC concentration
        5. Abrahamian (2013) Ann Emerg Med 62(5): 526-33 [PubMed]

XII. Labs: Evaluation of single stone former without risk (labs to consider)

  1. Chemistry panel
    1. Serum Electrolytes
    2. Serum Calcium
  2. Renal Function tests
    1. Blood Urea Nitrogen
    2. Serum Creatinine
  3. Serum Uric Acid
  4. Stone Analysis (nidus and outer layer)
    1. Stone analysis is important to direct preventive strategies, esp. if Ureterolithiasis Risk Factors
      1. However, stone analysis is often not performed for the initial stone
    2. Microscopic Crystal Analysis
      1. Envelope shape crystal: Calcium oxalate
      2. Diamond shape crystal: Uric Acid
      3. Coffin-lid shape crystal: Struvite
      4. Hexagon shape crystal: Cystine

XIII. Labs: Evaluation of recurrent stone formation

  1. See those labs listed above
  2. Parathyroid Hormone level
    1. Obtain if Urine Calcium >10 mg/dl
  3. 24 hour Urine Collection
    1. Urine pH
      1. Acidic urine predisposes to Uric Acid stones, Cystine Stones and Calcium Oxalate Stones
      2. Alkaline urine predisposes to Struvite Stones and Calcium Phosphate Stones
    2. Urine Sodium
    3. Urine Creatinine
    4. Urine Calcium (Hypercalciuria >300 mg/day)
    5. Urine Uric Acid (Hyperuricosuria >750 mg/day)
    6. Urine Oxalate (Hyperoxaluria >40 mg/day)
    7. Urine Citrate (Hypocitraturia <320 mg/day)
    8. Urine Magnesium (Hypomagnesuria <50 mg/day)
    9. Other urine labs to consider
      1. Urine Phosphorus
      2. Urine Calcium Oxalate (Supersaturation)
      3. Urine Calcium Phosphate

XIV. Precautions

  1. Do not miss concurrent Urinary Tract Infection and Ureterolithiasis (requires emergent stone management)
  2. Do not miss Abdominal Aortic Aneurysm (which may also cause Hydronephrosis or otherwise mimic Renal Colic)
  3. Post-Renal Transplant obstructive uropathy
    1. Struvite Stones are more common with Corynebacterium urealyticum infections (seen in transplant patients)
    2. Consult urology
    3. CorynebacteriumAntibiotic coverage
      1. Vancomycin
    4. References
      1. Cappuccino (2014) J Nephrol 27(2):117-25 +PMID:24563271 [PubMed]

XV. Management: Indications for Urology Consultation

  1. Failure to pass stone
    1. Unpassed stone after 14 days (may be followed without intervention up to 4-6 weeks)
    2. Overall, 86% of Kidney Stones pass spontaneously
      1. Tchey (2011) Korean J Urol 52(12): 847-51 [PubMed]
    3. Large calculus >5 mm (esp. >10 mm)
      1. Calculi <5 mm pass spontaneously in 90% of cases within 2 to 4 weeks
      2. Calculi 5-7 mm pass spontaneously in 50-60% of cases
      3. Calculi >7 mm pass spontaneously in 10-30% of cases
      4. Calculi 10 mm rarely pass spontaneously
      5. Prior history of passing stones increases the chance of passing larger stones
    4. Persistent proximal stones
      1. Stones distal to the sacroiliac joint pass in 84% of cases
      2. Stones proximal to the sacroiliac joint pass in 52% of cases
      3. Jendeberg (2017) Eur Radiol 27(11): 4775-85 [PubMed]
  2. Ureterolithiasis and Urinary Tract Infection
    1. Emergent management for stone removal required
    2. May quickly progress to Sepsis
    3. Struvite Stones or Staghorn calculi (Magnesium ammonium phosphate stones) are high risk for infection
  3. Significant Hydronephrosis or renal dysfunction
    1. Even significant Hydronephrosis alone does not drive urgent management
      1. In otherwise healthy patient with normal Renal Function (and 2 Kidneys) and no Urinary Tract Infection
      2. However significant persistent Hydronephrosis may result in permanent renal damage
    2. Urgent management indications for significant Hydronephrosis
      1. Persistent severe Hydronephrosis
      2. Single Kidney with obstruction
      3. Impaired Renal Function
  4. Intractable pain and Vomiting
  5. High grade ureteral obstruction
  6. Severe pain requiring Opioids >2 days
  7. Multiple stones (esp. bilateral obstruction)
  8. Recurrent stone formation
  9. Struvite Stones or Staghorn calculi (Magnesium ammonium phosphate stones)
    1. High risk of infection and typically do not pass without intervention
  10. High risk comorbidity
    1. Pregnancy with failed expectant management
    2. Immunosuppression
    3. Solitary Kidney
    4. Renal dysfunction
  11. Occupation (unable to return to work until clear)
    1. Police officer
    2. Firefighter
    3. Train engineer
    4. Airline pilot

XVI. Management: Indications for Hospitalization and Urgent Urology Evaluation

  1. Ureterolithiasis with Urinary Tract Infection (infected stone)
  2. Acute Renal Failure
  3. Solitary Kidney with complete obstruction
  4. Intractable pain and Vomiting

XVII. Management: Emergency Department

  1. Exclude Urinary Tract Infection complicating Ureterolithiasis
    1. Obstructive uropathy with a Urinary Tract Infection requires emergent urologic management
    2. Empiric Antibiotics in suspected concurrent Urinary Tract Infection (for Escherichia coli, Klebsiella, Proteus)
      1. Antibiotic selection is influenced by local Antibiotic Resistance rates
      2. Fluoroquinolones (Ciprofloxacin, Levofloxacin) IV
      3. Ceftriaxone IV
      4. Oral agents in inconclusive cases in non-toxic, afebrile patients (consider with one dose Ceftriaxone before discharge)
        1. Fluoroquinolones (Ciprofloxacin, Levofloxacin) orally
        2. Trimethoprim-Sulfamethoxazole (Septra, Bactrim)
        3. Amoxicillin-Clavulanate (Augmentin)
        4. Cefpodoxime (Vantin)
        5. Cefdinir (Omnicef)
    3. Empiric Antibiotics in suspected Urinary Tract Infection after urologic instrumentation (Pseudomonas coverage)
      1. Ciprofloxacin
      2. Carbapenem IV
  2. Consider crystalloid (NS, LR) in emergency department (consider D5 1/2NS if calciuria)
    1. IV fluid hydration as of 2012 is limited to those patients with signs, symptoms of Dehydration
      1. May worsen pain, and does not offer significant benefit in a well-hydrated patient
      2. May allow for Emergency Department Nephrolithiasis management without Intravenous Access
      3. Patient could be discharged after Urinary Tract Infection was excluded and analgesia administered
    2. No evidence that high volume IV fluids improves stone passage, pain control or avoids intervention
      1. Worster (2012) Cochrane Database Syst Rev 2: CD004926 [PubMed]
  3. Analgesics
    1. Ketorolac (Toradol) 15-30 mg IV
    2. Hydromorphone (Dilaudid) or Morphine Sulfate IV
    3. Ketamine 0.15 mg/kg IV (as adjunct to Ketorolac and Opioids)
      1. Abbasi (2017) Am J Emerg Med +PMID:28821365 [PubMed]
  4. Antiemetics
    1. Ondansetron
  5. Disposition
    1. See below for Outpatient Management including Medical Expulsive Therapy

XVIII. Management: Outpatient

  1. See Prevention below
    1. Fluid and dietary measures apply to both acute management and prevention
    2. Maintain >2-2.5 liters of oral fluid daily
  2. See Specific Types
    1. Calcium Nephrolithiasis
    2. Uric Acid Nephrolithiasis
    3. Struvite Nephrolithiasis
    4. Cystine Nephrolithiasis
  3. Adequate Analgesics
    1. Example Protocol
      1. Ibuprofen 600 mg every 6 hours scheduled AND
      2. Acetaminophen 1000 mg orally every 6 hours scheduled AND
      3. Oxycodone 5 mg orally every 4-6 hours for breakthrough pain esp. at night (avoid use if possible)
    2. NSAIDs
      1. Avoid NSAIDS in significant renal disease (e.g. congenital cysteine Ureterolithiasis) or otherwise containdicated
      2. Highly effective in Renal Colic (which is in part Prostaglandin mediated)
        1. Decrease ureteral spasm
        2. Cordell (1994) Ann Emerg Med 23(2):262 [PubMed]
        3. Cordell (1996) Ann Emerg Med 28:151-8 [PubMed]
      3. NSAIDs compared with Opioids
        1. Equal to or more effective than Opioids
        2. Less Vomiting than with Opioids
        3. Holdgate (2004) BMJ 328:1401-4 [PubMed]
      4. ParenteralNSAIDs given intramuscularly
        1. Ketorolac (Toradol) 30-60 mg IM (or 15-30 mg IV) or
        2. Diclofenac (Voltaren) 75 mg IM
          1. Pathan (2016) Lancet 387(10032): 1999-2007 [PubMed]
    3. Opioids may be required as adjuncts to NSAIDs and Acetaminophen for adequate analgesia
      1. If Morphine or Oxycodone are used, then Acetaminophen may be used separately
  4. Medical Expulsive Therapy
    1. Efficacy - mixed data (may be allow moderate stones >=5 mm to pass without intervention)
      1. Some studies have shown benefit in stone expulsion with alpha Antagonists
        1. Singh (2007) Ann Emerg Med 50(5): 552-63 [PubMed]
        2. Al-Ansari (2010) Urology 75(1): 4-7 [PubMed]
      2. Tamsulosin may facilitate more distal stones >5 mm to pass spontaneously without intervention
        1. Furyk (2015) Ann Emerg Med +PMID: 26194935 [PubMed]
      3. Tamsulosin increased chance of passing Ureteral Stone to >80%
        1. Porpiglia (2004) J Urol 172:568-71 [PubMed]
      4. Most studies have shown no benefit (particularly for small stones <5 mm)
        1. Vincendeau (2010) Arch Intern Med 170(22): 2021-7 [PubMed]
        2. Ferre (2009) Ann Emerg Med 54(3): 432-9 [PubMed]
        3. Hermanns (2009) Eur Urol 56(3): 407-12 [PubMed]
      5. Tamsulosin and Nifedipine are ineffective at four weeks to facilitate stone passage
        1. Pickard (2015) Lancet 386: 341-9 [PubMed]
    2. Preparations
      1. Tamsulosin (Flomax)
        1. Preferred over Nifedipine or Doxazosin (Tamsulosin has no effect on Blood Pressure)
        2. Dose: 0.4 mg orally daily for 14 days
        3. Other alpha blockers are probably effective
      2. Doxazosin (Cardura)
        1. Dose: 4 mg orally daily for 14 days
      3. Nifedipine (Procardia)
        1. Not recommended, as may be no better than Placebo
        2. Less effective than Tamsulosin and Doxazosin
        3. Dose: 30 mg orally daily for 14 days
        4. Hollingsworth (2006) Lancet 368:1171-9 [PubMed]
        5. Wang (2016) Drug Des Devel Ther 10:1257-65 [PubMed]
  5. Disposition
    1. Re-evaluation and repeat imaging (e.g. renal Ultrasound) every 2 weeks
      1. May continue to observe if only partial obstruction, pain controlled and no Urinary Tract Infection
    2. Refer to Urology if indicated (see indications above)
    3. Consider non-contrast CT Abdomen by 2 weeks for persistent pain (if not already obtained)
    4. Return precautions
      1. Intractable pain or Vomiting
      2. Fever

XIX. Management: Specific Stone Therapy

  1. See Urate Stones
  2. See Calcium Stones
  3. See Struvite Stones
  4. See Cystine Stones (Cystinuria)

XX. Management: Interventions

  1. Anatomic directed stone therapy
    1. Stone above Illiac crest
      1. Extracorporeal Shock Wave Lithotripsy (ESWL)
      2. Pushback and Extracorporeal Shock Wave Lithotripsy
      3. Antegrade or retrograde Ureteroscopy
      4. Percutaneous Nephrostomy tube
      5. Open surgery (See Below)
    2. Stone below Illiac Crest
      1. Pushback and Extracorporeal Shock Wave Lithotripsy
      2. Cystoscopy and stent placement
      3. Ureteroscopy and Stone Manipulation (Loop, basket)
      4. Open surgery (See Below)
  2. Available Interventions
    1. Ureteroscopy
      1. Ureteral Stone
    2. Ureterorenoscopy
      1. Renal stones <2 cm
    3. Extracorporeal Shock Wave Lithotripsy (ESWL)
      1. Radiolucent calculi
      2. Renal stones <2 cm
      3. Ureteral Stones <1 cm
    4. Percutaneous Nephrolithotomy
      1. Renal stones >2 cm
      2. Proximal Ureteral Stones >1 cm
    5. Open Surgery Procedures in refractory cases
      1. Anatomic nephrolithotomy
      2. Partial nephrectomy
      3. Illeal ureter

XXI. Management: Asymptomatic Renal Stones

  1. Incidental asymptomatic Kidney Stones are commonly found on abdominal imaging (10-25% annual risk of symptoms)
  2. Repeat imaging in 6 months, then each year
  3. Intervention indications for stone removal
    1. Symptomatic stone
    2. Obstruction
    3. Recurrent Urinary Tract Infection
    4. Increasing stone size
    5. Future conception desired
    6. Calyceal Diverticular stones
    7. Stones >10 mm
    8. Renal pathology

XXII. Prevention

  1. See stone types for specific prevention
  2. Eliminate modifiable predisposing factors (responsible for 50% of Ureteral Stones)
    1. See Nephrolithiasis Risk Factors
    2. See Medication Causes of Nephrolithiasis
  3. Prevention can be more finely directed by stone type
    1. See Calcium Oxalate Nephrolithiasis for prevention of the most common type
  4. Maintain fluid intake >2.5 to 3 Liters per day
    1. Most important single measure
    2. Ingest 8 to 12 ounces fluid on awakening and at bedtime
    3. Avoid soft drinks (esp. colas which contain phosphoric acid, predisposing to stone formation)
    4. Recommended fluids
      1. Water
      2. Citrus juice
  5. Maintain Urine Volume > 2 Liters per day
    1. Periodically measure Urine Output in a 2 liter bottle
    2. Urine should be clear in appearance with minimal color
  6. Dietary restrictions
    1. Limit animal Protein to 8 ounces per day (or <1 gram/kg/day)
      1. Animal Protein increases urinary Calcium and Uric Acid excretion
      2. Animal Protein decreases urinary pH and urinary citrate excretion
    2. Limit Sodium intake to <4 grams per day (target 2.3 grams)
      1. Increases renal Calcium absorption and lower urinary Calcium excretion
    3. Limit Oxalate Containing Foods (e.g. tea, tomatoes, cashews, almonds, potatoes, spinach)
      1. Decreases urinary oxalate excretion
    4. Limit high sugar or fat content (Obesity predisposes to stone formation)
    5. Avoid excessive Vitamin C (target <1 g/day)
  7. Lifestyle
    1. Move toward target BMI, Ideal Weight
    2. Encourage daily physical Exercise
  8. Dietary increases or no restriction
    1. Consider DASH Diet
      1. Diet high in vegetables and fruits, low animal Protein, moderate no-fat dairy
    2. Increase vegetable Dietary Fiber
    3. Maintain Calcium intake at at least 1000 to 1200 mg/day (if Calcium Oxalate Stone)
      1. No Dietary Calcium restriction (unless absorptive Hypercalciuria)
      2. Calcium binds oxalate in the Intestine and decreases oxalate absorption
      3. Take Calcium with meals

XXIII. Complications

  1. Renal Scarring
  2. Urinary Tract Infection (emergent intervention required)
    1. Pyelovenous backflow from Hydronephrosis increases risk for bacteremia and Sepsis
  3. Renal Forniceal Rupture or Calyceal Rupture (emergent Ureteral Stenting required)
    1. Rare complication of ureteral obstruction and increased renal Pelvis pressure
    2. Results in urine leakage into the Retroperitoneum

XXIV. References

  1. Mobley (Feb 1999) Hospital Medicine, p. 21-38
  2. Herbert (2012) EM:Rap 2(8): 7-8
  3. Spangler and Varghese (2022) Crit Dec Emerg Med 36(11): 4-10
  4. Swaminathan in Herbert (2014) EM:Rap 14(12): 11-2
  5. Goldfarb (1999) Am Fam Physician 60(8): 2269-76 [PubMed]
  6. Houshiar (1996) Postgrad Med 100(4): 131-8 [PubMed]
  7. Fontenelle (2019) Am Fam Physician 99(8): 490-6 [PubMed]
  8. Frassetto (2011) Am Fam Physician 84(11): 1234-42 [PubMed]
  9. Pietrow (2006) Am fam Physician 74(1): 86-94 [PubMed]
  10. Preminger (2007) J Urol 178(6): 2418-34 [PubMed]
  11. Portis (2001) Am Fam Physician 63(7):1329-38 [PubMed]
  12. Segura (1997) J Urol 158:1915-21 [PubMed]
  13. Teichman (2004) N Engl J Med 350:684-93 [PubMed]
  14. Trivedi (1996) Postgrad Med, 100(6): 63-78 [PubMed]

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Related Studies

Ontology: Kidney Calculi (C0022650)

Definition (MEDLINEPLUS)

A kidney stone is a solid piece of material that forms in the kidney from substances in the urine. It may be as small as a grain of sand or as large as a pearl. Most kidney stones pass out of the body without help from a doctor. But sometimes a stone will not go away. It may get stuck in the urinary tract, block the flow of urine and cause great pain.

The following may be signs of kidney stones that need a doctor's help:

  • Extreme pain in your back or side that will not go away
  • Blood in your urine
  • Fever and chills
  • Vomiting
  • Urine that smells bad or looks cloudy
  • A burning feeling when you urinate

Your doctor will diagnose a kidney stone with urine, blood, and imaging tests.

If you have a stone that won't pass on its own, you may need treatment. It can be done with shock waves; with a scope inserted through the tube that carries urine out of the body, called the urethra; or with surgery.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases
Definition (NCI_CTCAE) A disorder characterized by the formation of crystals in the pelvis of the kidney.
Definition (NCI) Crystals in the pelvis of the kidney.
Definition (MSH) Stones in the KIDNEY, usually formed in the urine-collecting area of the kidney (KIDNEY PELVIS). Their sizes vary and most contains CALCIUM OXALATE.
Concepts Disease or Syndrome (T047)
MSH D007669
ICD9 592.0
ICD10 N20.0
SnomedCT 197795009, 155867005, 155868000, 266622009, 197793002, 197792007, 266623004, 95570007, 56491003
LNC LA14297-8
English KIDNEY STONE, Kidney Calculi, Kidney Stones, Renal Calculi, Calculi, Kidney, Calculi, Renal, Calculus, Kidney, Calculus, Renal, RENAL CALCULUS, Stone, Kidney, Stones, Kidney, Renal calculus NOS, Renal Calculus, nephrolith, Renal stones, renal calculi, Calculus kidney, Calculus renal, Calculus renal NOS, Kidney stones, Stone in kidney, Kidney Calculi [Disease/Finding], kidney calculus, renal stones, Calculus;kidney, calculus of kidney, kidney stones, nephroliths, Stone;kidney, Stone;renal, kidney stone, kidney calculi, Nephrolith, Renal calculus NOS (disorder), Renal calculi, Kidneys--Calculi, Renal calculus, Calculus of kidney, Kidney stone, Kidney calculus, Renal stone, Kidney stone (disorder), renal calculus, calculus; kidney, calculus; nephritic, Kidney Calculus, Kidney Stone, Renal Stone, Renal calculus or stone, renal stone
French LITHIASE RENALE, CALCUL RENAL, Calcul rénal SAI, Calcul néphrétique, Pierres au rein, Calcul du rein, Néphrolithes, Calculs du rein, Calcul rénal, Calculs rénaux
Dutch nierstenen, niersteen, nierstenen NAO, niersteen NAO, steen van nier, calculus; nefritisch, calculus; nier, Calculi renali, Niersteen, Nierstenen, Renale calculi
German Nierenstein, Nierenstein NNB, Niernstein, NIERENKONKREMENT, NIERENSTEIN, Nierenkonkremente, Calculi renales, Nierensteine
Italian Calcolo del rene, Calcolosi renale, Calcolo renale NAS, Calcolo renale, Calcoli renali
Portuguese Cálculo do rim, Cálculo renal NE, Pedra no rim, Cáculo renal, Pedras nos rins, Cálculos renais, Cálculo renal, CALCULO RENAL, LITIASE RENAL, Pedras no Rim, Pedra no Rim, Cálculos Renais, Pedras nos Rins
Spanish Cálculo en el riñón, Cálculo renal NEOM, Cálculo renal, Cálculo de riñón, Cálculos renales, Piedra renal, Piedras en el riñón, Piedra en riñón, CALCULO RENAL, LITIASIS RENAL, cálculo renal, SAI, cálculo renal, SAI (trastorno), Piedras en el Riñón, Piedra en el Riñón, cálculo renal (trastorno), cálculo renal, nefrolito, piedra renal, Cálculos Renales, Piedras en los Riñones
Japanese 腎結石ＮＯＳ, ｼﾞﾝｹｯｾｷ, ｼﾞﾝｹｯｾｷNOS, 腎結石, 腎臓結石
Swedish Njurstenar
Finnish Munuaiskivet
Russian POCHEK KAMNI, POCHECHNOKAMENNAIA BOLEZN', ПОЧЕК КАМНИ, ПОЧЕЧНОКАМЕННАЯ БОЛЕЗНЬ
Czech ledvinové kaménky, Konkrement ledviny, Konkrement ledviny NOS, Konkrementy ledviny, Renální konkrement, ledviny - kameny, ledvinové kameny
Korean 콩팥(신장)의 결석
Croatian BUBREŽNI KAMENCI
Polish Kamienie nerkowe
Hungarian Vesekő, vesekő k.m.n., vesekő, vesekő, k.m.n., Vesekövek, vesekövesség, Vese calculus
Norwegian Nyresteiner, Calculi renales, Nyresten, Konkrementer i nyre, Nyrestener, Nyrestein
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Ureterolithiasis (C0041952)

Definition (MSH) Formation of stones in the URETER.
Concepts Disease or Syndrome (T047)
MSH D053039
ICD9 592.1
SnomedCT 31054009, 95573009
English Ureterolithiases, calculus of ureter (diagnosis), calculus of ureter, ureteral stone, Ureterolithiasis [Disease/Finding], stones ureteral, ureteral calculus, ureteric calculus, stone ureteral, stones ureter, ureteric stone, stone ureteric, ureter stone, ureterolithiasis, stone ureter, ureter calculus, calculus ureteral, calculus ureteric, stones ureteric, ureteral calculi, Ureterolithiasis (disorder), Ureteral calculus, Ureteral stone, Calculus of ureter, Ureteric stone, Ureteric calculus, Ureteric stone (disorder), Ureterolithiasis
Portuguese Ureterolitíase, Litíase do Ureter, Litíase Ureteral, Calculose do Ureter
Spanish Ureterolitiasis, ureterolitiasis, ureterolitiasis (trastorno), Litiasis del Uréter, Litiasis Ureteral, cálculo ureteral, litiasis ureteral (trastorno), litiasis ureteral, piedra ureteral, ureterolitiasis (concepto no activo)
Russian УРЕТЕРОЛИТИАЗ, URETEROLITIAZ
Italian Ureterolitiasi
German Ureterolithiasis
French Lithiase urétérale, Urétérolithiase, Lithiase de l'uretère
Finnish Virtsanjohdinkivitauti
Czech ureterolitiáza
Swedish Ureterolitiasis
Croatian Not Translated[Ureterolithiasis]
Polish Kamica moczowodowa
Norwegian Ureterolitiasis, Ureterolithiasis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Renal Colic (C0152169)

Definition (MSH) A severe pain in the lower back radiating to the groin, scrotum, and labia which is most commonly caused by a kidney stone (RENAL CALCULUS) passing through the URETER or by other urinary track blockage. It is often associated with nausea, vomiting, fever, restlessness, dull pain, frequent urination, and HEMATURIA.
Definition (NCI) Paroxysmal and severe flank pain radiating to the inguinal area. It is caused by the passage of a kidney stone through the ureter.
Definition (NCI_CTCAE) A disorder characterized by paroxysmal and severe flank marked discomfort radiating to the inguinal area. Often, the cause is the passage of kidney stones.
Concepts Sign or Symptom (T184)
MSH D056844
ICD9 788.0
ICD10 N23
SnomedCT 207155001, 207158004, 207156000, 207157009, 17329003, 139420002, 162140006, 267170005, 139422005, 271844003, 158458000, 162142003, 158457005, 158459008, 7093002
English RENAL COLIC, Renal colic NOS, Renal colic, unspecified, [D]Renal colic (context-dependent category), [D]Renal colic NOS (context-dependent category), [D]Renal colic, unspecified (context-dependent category), [D]Ureteric colic (context-dependent category), Unspecified renal colic, [D]Renal colic, [D]Renal colic NOS, [D]Renal colic, unspecified, [D]Ureteric colic, Ureteral colic, renal colic, renal colic (diagnosis), Colic renal, Colic, Renal, Renal Colic, Acute, Colics, Ureteral, Ureteral Colics, Colics, Renal, Ureteral Colic, Acute Renal Colics, Renal Colics, Colic, Acute Renal, Renal Colic, Acute Renal Colic, Colics, Acute Renal, Renal Colics, Acute, Colic, Ureteral, Renal Colic [Disease/Finding], Colic;renal, ureteric colic, kidney colic, colic kidneys, ureter colic, colic renal, colics renal, ureteral colic, Renal colic (& symptom), Renal colic (& symptom) (finding), Colic - ureteric, [D]Renal colic (situation), Renal colic, unspecified (finding), [D]Ureteric colic (situation), [D]Renal colic, unspecified (situation), [D]Renal colic NOS (situation), Colic - renal, symptom, Renal colic, symptom, Renal colic, Ureteric colic, Renal colic (finding), Ureteric colic (finding), colic; kidney, colic; ureter, kidney; colic, pain; ureter, ureter; colic, ureter; pain, Colic of kidney, Colic of ureter
Dutch koliek nier, ureterkoliek, koliek; nier, koliek; ureter, nier; koliek, pijn; ureter, ureter; koliek, ureter; pijn, Niet gespecificeerde nierkoliek, nierkoliek
German Kolik der Niere, NIERENKOLIK, Nicht naeher bezeichnete Nierenkolik, Nierenkolik, Akute Nierenkolik, Harnleiterkolik
Italian Colica dell'uretere, Colica renale, Colica renale acuta
Portuguese Cólica ureteral, COLICA RENAL, Cólica Renal Aguda, Cólica Ureteral, Cólica Renal, Cólica renal
Spanish Cólico ureteral, [D]cólico ureteral (categoría dependiente del contexto), [D]cólico renal, SAI (categoría dependiente del contexto), [D]cólico renal (categoría dependiente del contexto), [D]cólico renal no especificado (categoría dependiente del contexto), COLICO RENAL, Cólico Ureteral, Cólico Renal, Cólico Renal Agudo, cólico renal, no especificado, [D]cólico ureteral, cólico renal, no especificado (hallazgo), [D]cólico renal (situación), [D]cólico renal no especificado (situación), [D]cólico renal, SAI, [D]cólico renal, SAI (situación), [D]cólico ureteral (situación), [D]cólico renal, [D]cólico renal no especificado, cólico renal (hallazgo), cólico renal, cólico ureteral (hallazgo), cólico ureteral, Cólico renal
Japanese 尿管仙痛, 腎仙痛, ｼﾞﾝｾﾝﾂｳ, ﾆｮｳｶﾝｾﾝﾂｳ, 腎疝痛, 急性腎疝痛, 疝痛-腎
French COLIQUES NEPHRETIQUES, Colique rénale, Colique urétérique, Colique néphrétique, Colique urétérale, Colique rénale aiguë
Czech Renální kolika, Kolika močovodu, ledviny - kolika, renální kolika, akutní renální kolika, ledvinová kolika
Korean 상세불명의 콩팥(신장) 산통
Russian ОСТРАЯ ПОЧЕЧНАЯ КОЛИКА, УРЕТРАЛЬНАЯ КОЛИКА, ПОЧЕЧНАЯ КОЛИКА, POCHECHNAIA KOLIKA, OSTRAIA POCHECHNAIA KOLIKA, URETRAL'NAIA KOLIKA
Swedish Njurkolik
Polish Kolka nerkowa, Kolka moczowodowa
Hungarian renalis colica, vesegörcs, Ureter colica
Norwegian Nyresteinskolikk, Nyrekolikk, Ureterkolikk, Akutt nyrekolikk
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Nephrolithiasis (C0392525)

Definition (CSP) condition marked by the presence of renal calculi, abnormal concretions within the kidney, usually of mineral salts.
Definition (MSH) Formation of stones in the KIDNEY.
Concepts Disease or Syndrome (T047)
MSH D053040
ICD10 N20.0
SnomedCT 197793002, 56491003, 236707002, 155868000, 266623004, 95570007
English Nephrolithiasis, NEPHROLITHIASIS, nephrolithiasis, nephrolithiasis (diagnosis), Renal lithiasis, Nephrolithiasis NOS, kidney stone, calculus of kidney, Nephrolithiasis [Disease/Finding], renal lithiasis, lithiasis renal, (Calculus of kidney) or (nephrolithiasis NOS), Nephrolithiasis NOS (disorder), (Calculus of kidney) or (nephrolithiasis NOS) (disorder), Nephrolithiasis (disorder), Nephrolithiasis, NOS
French LITHIASE RENALE, Néphrolithiase, Lithiase rénale, Lithiase du rein, Lithiases rénales
Italian Litiasi renale, Nefrolitiasi
Portuguese Nefrolitíase, NEFROLITIASE, Litíase Renal, Litíase renal
Spanish Nefrolitiasis, NEFROLITIASIS, nefrolitiasis, nefrolitiasis (concepto no activo), nefrolitiasis, SAI (trastorno), nefrolitiasis, SAI, Litiasis Renal, Litiasis renal
Russian НЕФРОЛИТИАЗ, NEFROLITIAZ
German Nephrolithiasis, NEPHROLITHIASIS, Nierensteinerkrankungen
Japanese 腎結石症, ｼﾞﾝｹｯｾｷｼｮｳ
Swedish Nefrolitias
Finnish Munuaiskivitauti
Czech nefrolitiáza, Renální litiáza, Nefrolitiáza
Polish Kamica nerkowa
Hungarian nephrolithiasis, Renális lithiasis
Croatian NEFROLITIJAZA
Norwegian Nefrolithiasis, Nyresteinsykdom, Nefrolitiatis
Dutch nefrolithiase, nefrolithiasis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Urolithiasis (C0451641)

Definition (MSH) Formation of stones in any part of the URINARY TRACT, usually in the KIDNEY; URINARY BLADDER; or the URETER.
Concepts Disease or Syndrome (T047)
MSH D052878
ICD10 N20-N23.9 , N20-N23
SnomedCT 198527007, 95566004, 52950009
English Urolithiases, Lithiasis, Urinary, Urinary Lithiasis, Urolithiasis [Disease/Finding], urolithiasis, Urolithiasis (N20-N23), Urolithiasis (disorder), Urolithiasis, NOS, Urolithiasis
Dutch urolithiase, urolithiasen
Portuguese Urolitíase, Urolitíases
Spanish Urolitiasis, Litiasis Urinaria, litiasis urinaria (trastorno), litiasis urinaria, urolitiasis, Litiasis urinaria
Russian УРОЛИТИАЗ, МОЧЕКАМЕННАЯ БОЛЕЗНЬ, MOCHEKAMENNAIA BOLEZN', UROLITIAZ
Italian Urolitiasi, Litiasi urinaria
German Urolithiasis, Urolithiasen
French Lithiase urinaire, Lithiase des voies urinaires, Urolithiase, Urolithiases
Japanese 尿石症, ﾆｮｳﾛｹｯｾｷｼｮｳ, ﾆｮｳｾｷｼｮｳ, 尿路結石症, 結石症-尿路
Swedish Urolitiasis
Czech urolitiáza, Urolitiáza, Urolitiázy
Finnish Virtsatiekivitauti
Polish Kamica układu moczowego, Kamica moczowa, Kamica dróg moczowych
Hungarian Urolithiasisok, Urolithiasis
Croatian UROLITIJAZA
Norwegian Urolitiasis, Urolithiasis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Ureteral Calculi (C1456865)

Definition (MSH) Stones in the URETER that are formed in the KIDNEY. They are rarely more than 5 mm in diameter for larger renal stones cannot enter ureters. They are often lodged at the ureteral narrowing and can cause excruciating renal colic.
Concepts Disease or Syndrome (T047)
MSH D014514
ICD10 N20.1
SnomedCT 155869008
English Ureteral calculus, Calculi, Ureteral, Calculus, Ureteral, Calculus of ureter, URETERAL CALCULUS, Ureteric calculus, Ureteral Calculus, Calculus ureteral, Calculus ureteric, Ureteric stone, Ureteral Calculi [Disease/Finding], Calculus;ureter, Stone;ureter, Ureteric calculus (disorder), calculus; ureter, ureter; calculus, Ureteral Calculi, Ureteric Calculus, Ureteric Stone, ureteric calculus, ureteric stone
Italian Calcolo ureterale, Calcolosi ureterale, Calcolo dell'uretere, Calcoli dell'uretere
Dutch steen van ureter, calculus; ureter, ureter; steen, uretersteen, Calculus ureteris, Ureterolithiasis, Uretersteen
French Calcul de l'uretère, Calcul urétérique, CALCUL URETRAL, Calcul urétéral, Calcul dans l'uretère, Calculs de l'uretère, Calculs urétéraux, Urétérolithes
German Stein im Harnleiter, Ureterstein, Harnleiterstein, URETERSTEIN, Harnleitersteine, Uretersteine
Portuguese Cálculo ureteral, CALCULO URETRAL, Cálculos no Ureter, Cálculo do uréter, Cálculos Ureterais
Spanish Cálculo en uréter, Cálculo de uréter, LITIASIS URETERAL, Piedras Uretéricas, Cálculos en el Uréter, Cálculo ureteral, Cálculos Ureterales
Swedish Uretärstenar
Japanese ﾆｮｳｶﾝｹｯｾｷ, 尿管結石, 結石-尿管
Czech ureter - kameny, Konkrement močovodu
Finnish Virtsanjohtimen kivet
Russian MOCHETOCHNIKA KAMNI, МОЧЕТОЧНИКА КАМНИ
Korean 요관의 결석
Croatian URETERNI KAMENCI
Polish Kamienie moczowodowe
Hungarian Húgyvezetékkő, ureter-kövesség, Calculus ureteri, ureterkő, Ureteralis calculus
Norwegian Uretersteiner, Konkrementer i urinleder, Stein i urinleder, Sten i urinleder, Ureterstener
Derived from the NIH UMLS (Unified Medical Language System)

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