Kidney Stones

Original Editors - Suzanne Shelburne from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Top Contributors - Suzanne Shelburne, Admin, Lucinda hampton, Kim Jackson, 127.0.0.1, Elaine Lonnemann, Wendy Walker and WikiSysop  

Introduction

Kidney Stones

Kidney stones (also termed urolithiasis, nephrolithiasis) are hardened deposits of minerals that form in the kidneys and can cause pain as they pass through the urinary tract. Kidney stones do not usually cause permanent damage if recognized early and treated appropriately.

Depending on the size of the stone, treatment may involve drinking a lot of water and letting the stone pass naturally or taking active measures to break up and remove the stone.

Epidemiolgy

Most patients tend to present between 30-60 years of age. Lifetime incidence of renal stones is high: approx. 5% of women and 12% of males.

• By far the most common stone is calcium oxalate, however, the exact distribution of stones depends on the population and associated metabolic abnormalities.
• 17% of all the population will have kidney stones in his or her life.
• People who have had kidney stones previously are at an increased risk to have a second episode of kidney stones.

Clinical Presentation

Kidney Stones can be one of the most painful urologic disorders and kidney stone have been increasing in the population over the past 30 years. This fact is attributed to the increasing incidence of obesity due to poor dietary habits and lack of physical activity.

Although some renal stones remain asymptomatic, most will result in pain.

• The common symptoms associated with kidney stones, including acute pain radiating to the groin, occurs once the stone begins descending the ureters from the kidneys. Described as dull, colicky, sharp, and severe pain.  The pain is often associated with nausea and vomiting due to the severity of pain.
• Hematuria, although common, may be absent in approximately 15% of patients.
• If the stone becomes infected, patients may develop fever, chills, or other signs of worsening systemic signs of infection (i.e., shock).

Risk Factors

Kidney stones often have no single, definable cause. Multiple factors can contribute, some of which are controllable and others of which are not

• Personal history of prior kidney stones increases the risk of kidney stones by 15% within the first year, and 50% within the next ten years.
• A family history of kidney stones increases the risk by 2.5 times.
• Hyperoxaluria: high dietary oxalate (vegetarians); low gut absorption of calcium, leading to increased absorption of oxalate; low dietary intake of calcium; malabsorption / ileal disease (e.g. Crohn disease)
• Urinary tract infections altering urinary pH in the setting of urease-producing bacteria, producing struvite crystals
• Dehydration is a major contributing factor to all types of kidney stones. Inadequate fluids increase the concentration of compounds in the urine, some of which can crystallize and form into hardened masses.
• Diet can also play a part, including the high intake of animal proteins, sodium, and sugars.
• Others are caused by genetic conditions passed from parent to child. Diabetes and obesity can also contribute.

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Associated Co-morbidities

As of now, not enough research has been completed on kidney stones to link any co-morbidity to this disorder. Research is currently being analysis to see if there is a connection between a history of kidney stones and Chronic Kidney Disease. 

Risk Factors for Kidney Stones

• Family History/personal history
• Being over the age of 30 years old
• Male
• Dehydration
• Diet
• Obesity 
• Digestive disease
• History of digestive surgeries
• Rental Tubular Acidosis
• Cystinuria
• Hyperparathyroidism
• Urinary Tract Infections

Diagnostic Tests/Lab Tests/Lab Values

Blood Tests

Blood tests are one of the first lab tests that will be performed if kidney stones are thought to be present. Blood tests can help the doctor to check the function of the kidneys, check for infection, calcium or uric acid levels and can also check for other medical conditions. , 

Urine Tests

Urine can be sent for a urinalysis and culture to check for infection within the urinary tract.

Imaging Tests

X-rays are often performed of the abdomen to see if a calcification in the area of the kidneys or ureters can be seen to be as an obstructing stone. This is very simple, painless, cost effective way to diagnosis kidney stones. 

Analysis of Stone

When people are thought to have kidney stones, often they will be given a strainer to catch stones that may pass with urine. This is a good way to analysis what kind of stone was formed and maybe what caused the stone to form in the first place. Since there is an increased risk for people that have had stone before knowing what caused their formation of their first stone is the primary way of preventing future stones from forming. 

Causes 

There are many different factors that may cause kidney stones to form. Doctors do not always know why a person may get a kidney stone until the stone is sent to the lab for further testing. Doctors believe that life-style, family history, and certain diseases play a big role in people suffering from kidney stones. Diet (life-style) is thought to have a role in the formation of kidney stones. Foods and drinks containing oxalate are thought to make people more prone to forming calcium oxalate stones. Foods that are high in oxalate are spinach, beets, Swiss cheese, soybean crackers, chocolate and sweet potatoes. People that are trying to prevent a second episode of kidneys stones may be asked to monitor their in-take of these foods. As stated earlier, family history/personal history of kidney stones may have an increased risk to develop this disorder. People with the past family history/personal history are thought to have a 30 percent more likely chance to develop kidney stones and are often put on a preventive program. Lastly, doctors believe that certain disease put people more at risk for developing kidney stones. Urinary tract infections, cystic kidney disease, and certain metabolic disorders all make people more susceptible. "In addition, more than 70 percent of people with a rare hereditary disease called renal tubular acidosis develop kidney stones." Many of these patients that do have this disease will be put on a preventive plan to help decrease the risk of development of kidney stones.

Systemic Involvement

Kidney Stones are usually not a medical emergency and will pass with normal flow of the urine, therefore does not have major systemic involvement with the rest of the body.  However, kidney stone have been linked to several disorders such as connective tissue disorders, gastric disorders, metabolic syndrome disorder, immunologic disorders and eating disorders.

• Connective Tissue Disorder: Sarcoidosis
• "Raised serum calcium level in 2-63% of sarcoidosis patients due to overproduction of vitamin D by sarcoid granulomas, which can lead to kidney stones as a result of abnormal calcium metabolism."
  

• Gastric Disorder: Inflammatory Bowel Disease
• "The incidence of kidney stones is increased in Crohn's disease because of malabsorption of fat and bile salts. Patients who have Crohn's disease are likely to form calcium oxalate stones due to the unabsorbed long-chain fatty acids that bind calcium in the kidney.  
  

• Metabolic Syndrome:
• Patients with metabolic syndrome have a highly acidic urine, which can cause formation of uric acid kidney stones, which can be hard to detect because these kind of stones will not shoe up on a regular abdominal x-ray, often leading to increased growth of the stone.  
  

• Eating Disorder: Anorexia & Bulimia
• Patients that have a eating disorder such as anorexia or bulimia usually will develop kidney stones during their life. "Fasting, repeated cycle of vomiting and the use of laxative will result in a loss of fluid and crucial electrolytes from the body. Chronic dehydration and low potassium level can lead to kidney stones and even kidney failure."   

Medical Management

If the stones are too large to pass naturally or is blocking the flow of urine then other methods need to be explored. The first option is usually medication but if this proves unsuccessful then surgery may be considered.

Medication

Medication is often not needed when dealing with a kidney stone. Doctors will commonly prescribe pain medication for a kidney stone because passing a small stone can be very painful. The doctor usually orders the patient to drink "2 to 3 quarts of water a day" to help pass the stone through the urinary system.  If the patient is unable to pass the stone surgical intervention may be needed. The most common medications for kidney stones are:

• Citrate 
• Topamax 
• Topiramate Capsules 
  

Surgical Intervention

Things to consider before Surgery:

1. The stone does not pass after a considerable amount of time

2. The stone is too large to pass

3. Does the stone block urine flow?

4. Is the stone causing an ongoing infection in the urinary tract?

5. Is the stone causing damage to the tissue or constant bleeding

6. Has the stone grown larger?

Surgical options include:

• Extracorporeal Shock Wave Lithotripsy
• Percutaneous Nephrolithotomy
• Ureteroscopic Stone Removal
• Open Surgery

Extracorporeal Shock Wave Lithotrispy

Extracorporeal shock wave lithotrispy (ESWL) is a sugerical medical management of kidney stones that is most commonly used and the best current evidence for the removal kidney stones. "In ESWL, shock waves that are created outside the body travel through the skin and body tissues until they hit the denser stones. The stones break down into small particles and are easily passed through the urinary tract in the urine. Several types of ESWL devices exist. Most devices use either x rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of ESWL procedures, anesthesia is needed."                                            

Physical Therapy Management

Kidney Stones are managed medically but physical therapist can play an important role in screening patients for kidney stones and helping these patient seek proper medically attention. However, kidney stones can present as a musculoskeletal problem therefore therapist should be aware of some of the key questions and evaluation techniques to screen for kidney stones.

Key Questions

1. Was the onset of pain immediate or gradual? 

2.What activities increase or decrease your symptoms? 

• Eating.drinking
• Bowl/bladder function
• Exercise
• Sleeping
• Position 

3.Do your symptoms vary or remain constant? 

4. How long have you been experiencing fever, sweats, fatigue and nausea/vomiting? 

5. Can you describe your pain? 

6. Do you have pain with urination or noticed a change in the color of your urine? 

Key Evaluation Techniques

1. Kidney Percussion 

Differential Diagnosis 

• Cholecystitis
• Appendicitis
• Diverticulitis
• Abdominal Aortic Aneurysm
• Pancreatitis 
• Pelvic Inflammatory Disease
• Urinary Tract Infection 
• Kidney Cancer
• Overactive bladder/Urinary incontinence
• Peptic Ulcer
• Ectopic Pregnancy 

Resources

• National Kidney Foundation
• National Institute of Diabetes and Digestive and Kidney Diseases