Evaluation of the adult patient with established nephrolithiasis and treatment if stone composition is unknown
- Glenn M Preminger, MD
Glenn M Preminger, MD
- Section Editor — Renal Ureteral Stones
- Professor of Urologic Surgery
- Duke University Medical Center
- Director of Education
- Endourological Society
- Gary C Curhan, MD, ScD
Gary C Curhan, MD, ScD
- Section Editor — Chronic Kidney Disease
- Professor of Medicine
- Harvard Medical School
Once it has been documented that a patient has symptomatic nephrolithiasis, determining the type of stone and the possible presence of either biochemical abnormalities or underlying conditions that predispose to stone formation are essential for guiding therapy to prevent recurrent disease.
TYPE OF STONE
Patients should be encouraged to retrieve stones they pass or have removed for analysis, although novel computerized tomography (CT) imaging techniques may permit noninvasive discrimination among the main subtypes of urinary calculi (see "Diagnosis and acute management of suspected nephrolithiasis in adults", section on 'Determination of stone composition'). Analysis of the stone is an essential part of the evaluation [1,2]. (See "Interpretation of kidney stone analysis".)
Approximately 80 percent of patients with urolithiasis form calcium stones, most of which are composed primarily of calcium oxalate or, less often, calcium phosphate [3-6]. The other main types include uric acid, struvite (magnesium ammonium phosphate), and cystine stones. The same patient may have a mixed stone (eg, calcium oxalate and uric acid). (See "Interpretation of kidney stone analysis".)
Calcium stones — Stones composed purely or predominantly of calcium oxalate can occur in various disorders. In general, calcium phosphate stones are associated with similar risk factors as calcium oxalate stones (except that calcium phosphate stones are associated with urine pH but not hyperoxaluria) . (See "Risk factors for calcium stones in adults".)
Biochemical risk factors — A number of biochemical urinary risk factors are associated with calcium stone formation [3,5,8]:
- Kourambas J, Aslan P, Teh CL, et al. Role of stone analysis in metabolic evaluation and medical treatment of nephrolithiasis. J Endourol 2001; 15:181.
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- Gault MH, Chafe LL, Morgan JM, et al. Comparison of patients with idiopathic calcium phosphate and calcium oxalate stones. Medicine (Baltimore) 1991; 70:345.
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- Curhan GC, Willett WC, Speizer FE, et al. Comparison of dietary calcium with supplemental calcium and other nutrients as factors affecting the risk for kidney stones in women. Ann Intern Med 1997; 126:497.
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- Parks JH, Goldfisher E, Asplin JR, Coe FL. A single 24-hour urine collection is inadequate for the medical evaluation of nephrolithiasis. J Urol 2002; 167:1607.
- Bao Y, Wei Q. Water for preventing urinary stones. Cochrane Database Syst Rev 2012; 6:CD004292.
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- Ferrandino MN, Bagrodia A, Pierre SA, et al. Radiation exposure in the acute and short-term management of urolithiasis at 2 academic centers. J Urol 2009; 181:668.
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- TYPE OF STONE
- Calcium stones
- - Biochemical risk factors
- - Predisposing conditions
- Uric acid stones
- Struvite stones
- Cystine stones
- Focused history
- Radiologic testing
- Laboratory testing
- - Limited evaluation
- - Complete metabolic evaluation
- - Targeted approach
- THE COMPLETE METABOLIC EVALUATION
- Blood tests
- - Urine calcium-creatinine ratio
- 24-hour urine collections
- - Number of collections
- - Timing of collections
- TREATMENT IF STONE COMPOSITION IS UNKNOWN
- High urine calcium
- Low urine citrate
- High urine oxalate
- High urine uric acid
- Low urine volume
- No obvious metabolic abnormality
- Use of calculated supersaturations
- RADIOLOGIC MONITORING
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS