Management of Kidney Stone

Introduction

The functions of human body are regulated by various organs. One pair of such organ located inside on the Right and left side the abdomen is called kidney. It filters the dissolved waste products from the blood and excreted in the form of urine.  Kidneys also make substances that help control  to blood pressure. Daily about 1 litre to 3 litres of urine is excreted by an adult person. The amount of urine varies with water intake, nature of diet, physical activity, body temperature, climate and environment.

When the urine becomes concentrated, sometimes the waste products crystallises inside the kidney. Over the time, these crystals may build up as hard lumpy deposits. These are called kidney stones. In medical term this is called Nephrolithiasis or Renal calculi or Urolithiasis.  In the recent times, kidney stone is emerging as a common disease.

Kidney stones are made of mineral and acid salts. The common mineral constituent of the kidney stone is calcium combined with oxalate, phosphate or carbonate.  Another constituent is uric acid that makes up about 10% of all stones and is more common in men. Certain diseases of the small intestine increase the tendency to form calcium oxalate stones. Most stones form due to a combination of genetics and environmental factors. Overweight, certain food items, some medications  and not drinking enough fluids are the common risk factors.

A small stone may pass without causing symptoms. If stones grow to sufficient size (usually at least 3 millimetres they can cause blockage of the ureter. This may lead to pain, most commonly beginning in the flank or lower back and often radiating to the groin. This pain is often known as renal colic and typically comes in waves lasting 20 to 60 minutes. Other associated symptoms include nausea, vomiting, fever, blood in the urine, pus in the urine and painful urination. Blockage of the ureter can cause decreased function and dilation of the kidney.

References
Qaseem, A; Dallas, P; Forciea, MA; Starkey, M et al. (4 November 2014). "Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: A clinical practice guideline from the American College of Physicians". Annals of Internal Medicine161 (9): 659

Bladder Stones General Overview, Retrieved on 2010-01-19.
www.mayoclinic.org 
www.channel4embarrassingillnesses.com

Causes

The main cause for stone formation in kidney is drinking inadequate water or due to an excess of stone-forming substances in the urine. Those who do strenuous exercise without drinking sufficient water, increase the risk of kidney stones.  Urinary tract obstruction may also lead to this problem.

Living in hot and dry areas, repeated urinary tract infections, certain metabolic abnormalities, increased amount of uric acid in the blood or urine and people with high calcium in blood are susceptible to kidney stones.

Diseases like diabetes, hypertension and ulcerative colitis increase the risk of stone formation. Medications like diuretics, calcium-containing antacids are also possible promoting factors of kidney stones.

People who take less water and eating more animal proteins and a high-salt diet      have more chance to get kidney stones. Excessive use of sugar, vitamin D supplements and oxalate-containing foods such as spinach are also found to promote stone formation in kidney. 

Kidney stones are usually formed following a build-up of  substances like calcium, ammonia, uric acid, cystine  in the body. Certain medical conditions can lead to an unusually high level of these substances in your urine.

References
Chauhan Dr V. K.; and Gupta Dr Meeta,  Homeopathic Principles and Practice, A text Book  for Medical Students and Homeopathic practitioners
www.nhs.uk

Symptoms

The hallmark of a stone that obstructs the ureter or renal pelvis is excruciating, intermittent pain that radiates from the flank to the groin or to the inner thigh. This pain, known as renal colic, is often described as one of the strongest pain sensations known. Pain caused by kidney stones is commonly accompanied by  urgency for urination, restlessness,  blood in the urine (hematuria), sweating, nausea, and vomiting. It typically comes in waves lasting 20 to 60 minutes caused by peristaltic contractions of the ureter as it attempts to expel the stone.   

Stone in the kidney may not produce symptoms until they begin to move down the ureter. The pain may be sudden and severe colicky, often radiating from the back, down the sides, and into the groin. It may not get relieved even by changes in position. It may be either on one side or on both the sides.

At times there may be blood in the urine, pain in the groin or testis. Fever, chills and abnormal colour in the urine may be present in some cases.  The embryological link between the urinary tract, the genital system, and the gastrointestinal tract is the basis of the radiation of pain to the gonads, as well as the nausea and vomiting.

Some kidney stones may not produce symptoms. This is known as "silent" stone. Kidney stone that is very small is unlikely to cause many symptoms. It may even go undetected and pass out painlessly with urine.

Symptoms usually occur if the kidney stone gets stuck in the kidney or starts to travel down the ureter  which progressively narrow down from above down. As it tries to pass through  the ureter or when it causes an infection, the pain become severe.  When the stone cannot pass down, it blocks the ureter. As the waste products cannot pass out, it may cause building up of bacteria and  lead to kidney infection. Symptoms of a kidney infection are similar to symptoms of kidney stones, but may also include a high temperature (fever) of 38°C (100.4°F) or over, shivering, chills, feeling very weak or tired, diarrhoea, cloudy and bad-smelling urine

Reference: www.nhs.uk

Diagonosis

Diagnosis of kidney stone is made on the basis of information obtained from the history, physical examination, urine analysis and radiographic studies. Clinical diagnosis is usually made on the basis of the location and severity of the pain, which is typically colicky in nature (comes and goes in spasmodic waves). Pain in the back occurs when calculi produce an obstruction in the kidney.  Physical examination may reveal fever and tenderness at the costo-vertebral angle on the affected side.

Typical laboratory investigations carried out  are microscopic examination of the urine, which may show red blood cells, bacteria, leukocytesurinary casts and crystals. Urine culture is advised to identify any infecting organisms present in the urinary tract and sensitivity to determine the susceptibility of these organisms to specific antibiotics.

Complete blood count may be done when there is a suspected infection. An  increased   neutrophil  count  is suggestive of bacterial infection.

Renal function tests  is necessary to look for abnormally high blood calcium blood levels hypercalcemia.  24 hour urine collection is done to measure total daily urinary volume, magnesium, sodium, uric acid, calcium, citrate, oxalate and phosphate.

Collection of stones by urinating through a kidney stone collection cup or a simple tea strainer is useful. Chemical analysis of collected stones can establish their composition, which in turn can help to guide future preventive and therapeutic management.

All stones are detectable on CT scans except very rare stones composed of certain drug residues in the urine. Some 60% of all renal stones are radio opaque.  Where a CT scan is unavailable, an intravenous pyelogram may be performed to help confirm the diagnosis of urolithiasis. This involves intravenous injection of a contrast agent followed by a Kidney Ureter Bladder (KUB) X- ray. Uroliths present in the kidneys, ureters or bladder may be better seen by the use of this contrast agent. Stones can also be detected by a retrograde pyelogram.

Ultrasound examination is preferred in pregnant women or those who should avoid radiation exposure like children to establish the diagnosis. This is  sometimes useful, as it gives details about the presence of hydronephrosis, suggesting the stone is blocking the outflow of urine. Radiolucent stones, which do not appear on KUB, may show up on ultrasound imaging studies.  Renal ultra sonography includes its low cost and absence of radiation exposure

Management

Most kidney stones pass from the kidney on their own. Drinking more fluids helps facilitate the passage of kidney stones, but most people require some medications for pain control.

Treatment is often directed toward control of symptoms. Patients with kidney stone are advised to drink plenty of fluids.  The size of the stone, previous history of stone passage, prostate enlargement and pregnancy are the contributing factors which influence passage of a stone.  If the stone is 4 mm or less, there is an 80% chance of passage while a 5 mm stone has a 20% chance. Stones larger than 9 mm-10 mm rarely pass without a specific treatment.

When a stone causes no symptoms, no treatment is needed. For stones which are causing symptoms, pain control is usually the first measure. Successful treatments have been developed to remove larger stones or stones that do not pass. A procedure called “lithotripsy” is used where in shock waves are used to break up a large stone into smaller pieces that can then pass through the urinary system.

Surgery is resorted to remove kidney stones when other treatment is not effective or in more severe cases. People who have had a kidney stone remain at risk for future stones throughout their lives.

Homeopathic remedies like Berberis vulgaris, Hydrangea, Pareira brava, Solidago, Uva ursi, and Ocimum canum are used to control the pain due to renal stone.  Some of these medicines also have property to expel stones. Constitutional medicines like Lycopodium, Calcarae carb, Sarasaparilla are used to control the stone formation. Always take the advice of an expert Homeopath for medication.

Precaution to avoid stone formation is the best course in kidney stone. Drinking more water is first and foremost step. Changes in the diet or medications are sometimes recommended to decrease the likelihood of developing further kidney stones. People who have a tendency to form calcium oxalate stones may limit their consumption of foods high in oxalate, such as spinach, beets, wheat germ and peanuts. Drinking lemon juice or lemonade may be helpful in preventing kidney stones.

If you have had a history of stones, it is recommended to drink 6 to 8 glasses of water per day. Depending on the type of stone, medications or other measures may be recommended to prevent recurrence.

In the case of uric acid stone, reduce the intake of meat and meat products, shell fish, whole grain cereals, oats meals, dried peas, beans, spinach and dal. 

If the stone is of oxalate, avoid green plantain, spinach, sweet potato, beet, currents, figs, almonds, cashew nuts and grapes.

Preventative measures depend on the type of stones. In those with calcium stones, drinking lots of fluids.

Dietary measures

Specific therapy should be tailored to the type of stones involved. Diet can have a profound influence on the development of kidney stones. Preventive strategies include some combination of dietary modifications and medications with the goal of reducing the excretory load of calculogenic compounds on the kidneys. Current dietary recommendations to minimize the formation of kidney stones include:

  • Increasing total fluid intake to more than two litres per day of urine output.
  • Increasing citric acid intake; lemon/lime juice is the richest natural source.
  • Moderate calcium intake
  • Limiting sodium intake
  • Avoidance of large doses of supplemental vitamin C
  • Limiting animal protein intake to no more than two meals daily (an association between animal protein consumption and recurrence of kidney stones has been shown in men.
  • Limiting consumption of cola soft drinks, which contain phosphoric acid, to less than one litre of soft drink per week.
  • Magnesium has also been shown to inhibit crystal formation thus reducing the risk for forming kidney stones. When 24-hour kidney stone risk profiles are performed, magnesium levels are a key indicator as to the potential stability of the urinary environment.
  • Maintenance of dilute urine by means of vigorous fluid therapy is beneficial in all forms of nephrolithiasis, so increasing urine volume is a key principle for the prevention of kidney stones. Fluid intake should be sufficient to maintain a urine output of at least 2 litres (68 US fl oz) per day. A high fluid intake has been associated with a 40% reduction in recurrence risk. The quality of the evidence for this, however, is not very good.

References
Coe, FL; Evan, A; Worcester, E (2005). "Kidney stone disease"The Journal of Clinical Investigation 115 (10): 2598–608. doi:10.1172/JCI26662PMC 1236703.PMID 16200192

del Valle, EE; Spivacow, FR; Negri, AL (2013). "[Citrate and renal stones]". Medicina (B Aires) 73 (4): 363–8. PMID 23924538.

Anoia, EJ; Paik, ML; Resnick, MI (2009). "Ch. 7: Anatrophic Nephrolithomy". In Graham, SD; Keane, TE. Glenn's Urologic Surgery (7th ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 45–50. ISBN 978-0-7817-9141-0.

Weaver, SH; Jenkins, P (2002). "Ch. 14: Renal and Urological Care". Illustrated Manual of Nursing Practice (3rd ed.). Lippincott Williams & Wilkins. ISBN 1-58255-082-4.

American College of Emergency Physicians (October 27, 2014). "Ten Things Physicians and Patients Should Question"http://www.choosingwisely.org/. Retrieved 14 January2015

Smith, RC; Varanelli, M (2000). "Diagnosis and management of acute ureterolithiasis: CT is truth". American Journal of Roentgenology 175 (1): 3–6. Fang, LST (2009). "Chapter 135: Approach to the Paient with Nephrolithiasis". In Goroll, AH; Mulley, AG. Primary care medicine: office evaluation and management of the adult patient (6th ed.). Philadelphia: Lippincott Williams & Wilkins. pp. 962–7.ISBN 978-0-7817-7513-7.

  • PUBLISHED DATE : Sep 24, 2015
  • PUBLISHED BY : NHP CC DC
  • CREATED / VALIDATED BY : NHP Admin
  • LAST UPDATED ON : Feb 09, 2016

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