The first kidney stone and asymptomatic nephrolithiasis in adults
- 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
- Section Editors
- Stanley Goldfarb, MD
Stanley Goldfarb, MD
- Editor-in-Chief — Nephrology
- Section Editor — Mineral and Bone Metabolism; Renal Ureteral Stones
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Michael P O'Leary, MD, MPH
Michael P O'Leary, MD, MPH
- Section Editor — Urology
- Professor of Surgery, Harvard Medical School
- Senior Urologic Surgeon, Brigham and Women's Hospital
Renal stones (nephrolithiasis) are a relatively common problem [1-5]. In the United States, almost 2 million outpatient visits for a primary diagnosis of urolithiasis were recorded in 2000 . Up to 16 percent of men and 8 percent of women will have at least one symptomatic stone by the age of 70 years ; over 80 percent of these stones will contain calcium, usually as calcium oxalate.
The prevalence of kidney stones appears to be increasing in the United States. In a report from the National Health and Nutritional Examination Survey, the prevalence increased from 3.8 percent in the period 1976 to 1980 to 8.4 percent in the period from 2007 to 2010 [1,3]. Furthermore, the male-to-female ratio has changed over the past 25 years, from 3:1 (male:female) to now less than 2:1 [1,6,7]. Whether this represents an actual increase in incidence or an increase in detection is uncertain . If true, some have speculated that it is due to changes in lifestyle factors, such as increasing obesity among women .
The prevalence of nephrolithiasis varies regionally. In one study of over 40,000 men between the ages of 45 and 70 years, the risk of having a history of kidney stones was 13 and 31 percent lower in the mid-Atlantic and northwestern regions, respectively, compared with the southeastern United States . A second study confirmed this regional variation, but found that differences were greatly reduced after adjustment for temperature, sunlight, and beverage consumption .
The prevalence of nephrolithiasis increases with age, is slightly higher in men compared with women, and in whites compared with blacks, Asians, and those of Hispanic ethnicity [1,3,11,12]. Although urinary calcium excretion tends to be lower in blacks [13,14], other urinary factors are similar among patients of different races and ethnicities.
The goal of a diagnostic evaluation of nephrolithiasis is to identify, as efficiently and economically as possible, the particular physiologic defect present in a given patient so that effective therapy can be established and the prognosis can be better defined. Therefore, the type and extent of evaluation depends in part upon the following :
- Scales CD Jr, Smith AC, Hanley JM, et al. Prevalence of kidney stones in the United States. Eur Urol 2012; 62:160.
- Johnson CM, Wilson DM, O'Fallon WM, et al. Renal stone epidemiology: a 25-year study in Rochester, Minnesota. Kidney Int 1979; 16:624.
- Stamatelou KK, Francis ME, Jones CA, et al. Time trends in reported prevalence of kidney stones in the United States: 1976-1994. Kidney Int 2003; 63:1817.
- Parmar MS. Kidney stones. BMJ 2004; 328:1420.
- Bansal AD, Hui J, Goldfarb DS. Asymptomatic nephrolithiasis detected by ultrasound. Clin J Am Soc Nephrol 2009; 4:680.
- Pearle MS, Calhoun EA, Curhan GC, Urologic Diseases of America Project. Urologic diseases in America project: urolithiasis. J Urol 2005; 173:848.
- Scales CD Jr, Curtis LH, Norris RD, et al. Changing gender prevalence of stone disease. J Urol 2007; 177:979.
- Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006; 295:1549.
- Curhan GC, Rimm EB, Willett WC, Stampfer MJ. Regional variation in nephrolithiasis incidence and prevalence among United States men. J Urol 1994; 151:838.
- Soucie JM, Coates RJ, McClellan W, et al. Relation between geographic variability in kidney stones prevalence and risk factors for stones. Am J Epidemiol 1996; 143:487.
- Soucie JM, Thun MJ, Coates RJ, et al. Demographic and geographic variability of kidney stones in the United States. Kidney Int 1994; 46:893.
- Lieske JC, Peña de la Vega LS, Slezak JM, et al. Renal stone epidemiology in Rochester, Minnesota: an update. Kidney Int 2006; 69:760.
- Maloney ME, Springhart WP, Ekeruo WO, et al. Ethnic background has minimal impact on the etiology of nephrolithiasis. J Urol 2005; 173:2001.
- Taylor EN, Curhan GC. Differences in 24-hour urine composition between black and white women. J Am Soc Nephrol 2007; 18:654.
- Pak CY, Britton F, Peterson R, et al. Ambulatory evaluation of nephrolithiasis. Classification, clinical presentation and diagnostic criteria. Am J Med 1980; 69:19.
- Uribarri J, Oh MS, Carroll HJ. The first kidney stone. Ann Intern Med 1989; 111:1006.
- Sutherland JW, Parks JH, Coe FL. Recurrence after a single renal stone in a community practice. Miner Electrolyte Metab 1985; 11:267.
- Borghi L, Meschi T, Amato F, et al. Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized prospective study. J Urol 1996; 155:839.
- Pak CY. Should patients with single renal stone occurrence undergo diagnostic evaluation? J Urol 1982; 127:855.
- Strauss AL, Coe FL, Parks JH. Formation of a single calcium stone of renal origin. Clinical and laboratory characteristics of patients. Arch Intern Med 1982; 142:504.
- 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.
- Pak CY, Poindexter JR, Adams-Huet B, Pearle MS. Predictive value of kidney stone composition in the detection of metabolic abnormalities. Am J Med 2003; 115:26.
- Lotan Y, Cadeddu JA, Roerhborn CG, et al. Cost-effectiveness of medical management strategies for nephrolithiasis. J Urol 2004; 172:2275.
- Preminger GM. The metabolic evaluation of patients with recurrent nephrolithiasis: a review of comprehensive and simplified approaches. J Urol 1989; 141:760.
- Sarmina I, Spirnak JP, Resnick MI. Urinary lithiasis in the black population: an epidemiological study and review of the literature. J Urol 1987; 138:14.
- Pak CY, Sakhaee K, Moe O, et al. Biochemical profile of stone-forming patients with diabetes mellitus. Urology 2003; 61:523.
- Ekeruo WO, Tan YH, Young MD, et al. Metabolic risk factors and the impact of medical therapy on the management of nephrolithiasis in obese patients. J Urol 2004; 172:159.
- Hess B, Hasler-Strub U, Ackermann D, Jaeger P. Metabolic evaluation of patients with recurrent idiopathic calcium nephrolithiasis. Nephrol Dial Transplant 1997; 12:1362.
- 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.
- Dropkin BM, Moses RA, Sharma D, Pais VM Jr. The natural history of nonobstructing asymptomatic renal stones managed with active surveillance. J Urol 2015; 193:1265.
- Glowacki LS, Beecroft ML, Cook RJ, et al. The natural history of asymptomatic urolithiasis. J Urol 1992; 147:319.
- Fine JK, Pak CY, Preminger GM. Effect of medical management and residual fragments on recurrent stone formation following shock wave lithotripsy. J Urol 1995; 153:27.
- Springhart WP, Maloney ME, Marguet CG, et al. Appropriate medical treatment after percutaneous nephrolithotomy can control active stone disease in the presence of residual calculi. J Urol 2004; 171:302.
- Osman MM, Alfano Y, Kamp S, et al. 5-year-follow-up of patients with clinically insignificant residual fragments after extracorporeal shockwave lithotripsy. Eur Urol 2005; 47:860.
- THE FIRST KIDNEY STONE
- CONSERVATIVE APPROACH
- Focused history for stone risk factors
- Stone analysis
- APPROACH BASED UPON RISK ASSESSMENT
- Abbreviated protocol
- - Laboratory tests
- - Radiography
- Urine stone risk profile
- ASYMPTOMATIC NEPHROLITHIASIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS