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
- Editor-in-Chief emeritus
- Harvard Medical School
Once it has been documented that a patient has 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 higher 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.
- Teichman JM. Clinical practice. Acute renal colic from ureteral calculus. N Engl J Med 2004; 350:684.
- Coe FL, Parks JH, Asplin JR. The pathogenesis and treatment of kidney stones. N Engl J Med 1992; 327:1141.
- Levy FL, Adams-Huet B, Pak CY. Ambulatory evaluation of nephrolithiasis: an update of a 1980 protocol. Am J Med 1995; 98:50.
- 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.
- Curhan GC. Epidemiology of stone disease. Urol Clin North Am 2007; 34:287.
- Gault MH, Chafe LL, Morgan JM, et al. Comparison of patients with idiopathic calcium phosphate and calcium oxalate stones. Medicine (Baltimore) 1991; 70:345.
- Parks JH, Coe FL. A urinary calcium-citrate index for the evaluation of nephrolithiasis. Kidney Int 1986; 30:85.
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- Yendt ER, Gagne RJ. Detection of primary hyperparathyroidism, with special reference to its occurrence in hypercalciuric females with "normal" or borderline serum calcium. Can Med Assoc J 1968; 98:331.
- Yagisawa T, Kobayashi C, Hayashi T, et al. Contributory metabolic factors in the development of nephrolithiasis in patients with medullary sponge kidney. Am J Kidney Dis 2001; 37:1140.
- Parks JH, Coe FL, Strauss AL. Calcium nephrolithiasis and medullary sponge kidney in women. N Engl J Med 1982; 306:1088.
- 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.
- von Unruh GE, Voss S, Sauerbruch T, Hesse A. Dependence of oxalate absorption on the daily calcium intake. J Am Soc Nephrol 2004; 15:1567.
- 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.
- Pak CY. Should patients with single renal stone occurrence undergo diagnostic evaluation? J Urol 1982; 127:855.
- Preminger GM. The metabolic evaluation of patients with recurrent nephrolithiasis: a review of comprehensive and simplified approaches. J Urol 1989; 141:760.
- Mardis HK, Parks JH, Muller G, et al. Outcome of metabolic evaluation and medical treatment for calcium nephrolithiasis in a private urological practice. J Urol 2004; 171:85.
- Chandhoke PS. When is medical prophylaxis cost-effective for recurrent calcium stones? J Urol 2002; 168:937.
- 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.
- Parmar MS. Kidney stones. BMJ 2004; 328:1420.
- Parks JH, Coe FL. An increasing number of calcium oxalate stone events worsens treatment outcome. Kidney Int 1994; 45:1722.
- 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.
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- Candau C, Saussine C, Lang H, et al. Natural history of residual renal stone fragments after ESWL. Eur Urol 2000; 37:18.
- Kang DE, Maloney MM, Haleblian GE, et al. Effect of medical management on recurrent stone formation following percutaneous nephrolithotomy. J Urol 2007; 177:1785.
- Coe FL, Keck J, Norton ER. The natural history of calcium urolithiasis. JAMA 1977; 238:1519.
- Kopp JB, Miller KD, Mican JA, et al. Crystalluria and urinary tract abnormalities associated with indinavir. Ann Intern Med 1997; 127:119.
- Stankus N, Worcester E, Hammes M, Coe FL. Evidence against a contribution of conventional urine risk factors to de novo ESRD renal stones. Nephrol Dial Transplant 2006; 21:701.
- Curhan GC, Taylor EN. 24-h uric acid excretion and the risk of kidney stones. Kidney Int 2008; 73:489.
- Pak CY, Skurla C, Harvey J. Graphic display of urinary risk factors for renal stone formation. J Urol 1985; 134:867.
- Nicar MJ, Hsu MC, Johnson T, Pak CY. The preservation of urine samples for determination of renal stone risk factors. Lab Med 1987; 18:382.
- 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.
- Bao Y, Wei Q. Water for preventing urinary stones. Cochrane Database Syst Rev 2012; :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.
- Zilberman DE, Tsivian M, Lipkin ME, et al. Low dose computerized tomography for detection of urolithiasis--its effectiveness in the setting of the urology clinic. J Urol 2011; 185:910.
- 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
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS