What Are The Main Causes Of Kidney Stones – Nephrolithiasis, also known as Kidney Stones or kidney calculi, refers to the presence of stones in the kidneys. It is one of the most common kidney diseases in adults. Stone formation occurs when there is an excess of crystal-forming substances that cannot be dissolved in the urine. High urinary excretion of certain substances – for example calcium, oxalate, uric acid and cysteine ​​- can promote stone formation, while the excretion of others, such as citrate, has a protective effect. Disturbances in urinary pH, low urine volume, and a lack of protective substances that prevent crystals from sticking together can contribute to stone formation. In addition, environmental factors such as reduced fluid intake, hot climate, and dietary factors play an important role in the development of nephrolithiasis.

The word nephrolithiasis comes from “nephro”, which is the Latin word for kidney, and “lithiasis”, which is the medical term used to refer to stones.

What Are The Main Causes Of Kidney Stones

Nephrolithiasis refers specifically to Kidney Stones, although it is commonly used to refer to stones in the urinary tract. Ureterolithiasis, on the other hand, refers to stones in the ureter, and urolithiasis refers to stones in any part of the urinary tract (kidneys, ureters, bladder and urethra).

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The vast majority of kidney stones are composed of calcium salts. Calcium oxalate stones are the most common type, followed by calcium phosphate stones. The main risk factor for developing calcium stones is an increased excretion of calcium (hypercalciuria) and oxalate (hyperoxaluria). These abnormalities may be idiopathic, meaning their cause is unknown, or may result from other systemic diseases, such as hyperparathyroidism, renal tubular acidosis, and malabsorption.

Citrate has a protective role in stone formation by forming complexes with calcium and inhibiting further aggregation and growth of crystals. For this reason, a low excretion of citrate (hypocitraturia) is associated with an increased risk of developing stones. In most cases, the cause of hypocitraturia is not known. However, it is associated with the presence of acid imbalance, low levels of potassium in the blood, high-protein diets and chronic diarrhea.

Other less common types of stones found in the urinary tract may be struvite stones, uric acid stones, cystine stones, or drug-induced stones.

Struvite stones are sometimes referred to as infectious stones because they may be associated with urinary tract infections, especially those caused by urea-splitting organisms (

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, thereby increasing the pH of the urine to neutral or alkaline values, and ultimately leading to the precipitation of solutions to which the bacteria adhere.

In addition, other types of stones can be infected by urea-splitting organisms, leading to secondary struvite stone formation. Struvite stones are more common in biologically-female individuals; they tend to grow large, fill part of the renal pelvis and calyces, and assume a staghorn shape. In the urine they can be seen as “coffin lid” shaped crystals. After their removal, if infected fragments of the stone are left in the kidney, they can often grow back, causing persistent urinary tract infection and decreased kidney function.

Uric acid stones generally develop due to increased excretion of uric acid (hyperuricosuria) and low urine pH. Risk factors include high-protein diets, gout, inflammatory bowel disease, genetic diseases and diabetes. Uric acid stones are one of the few kidney stones that can be successfully managed by medical treatment, which consists of adequate hydration and supplements to increase the pH of the urine.

Cystine stones are commonly caused by cystinuria, a hereditary disease that causes increased excretion of cystine in the urine, as well as low urinary pH. Cystine stones are very hard and can be seen as thin hexagonal crystals in a urinalysis.

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Finally, drug-induced stones can develop through two mechanisms. In some cases, excessive use of laxatives or diuretics can contribute to metabolic abnormalities, which ultimately lead to stone formation. On the other hand, certain drugs, such as indinavir or ciprofloxacin, can crystallize in the urine and create stones.

The symptoms of nephrolithiasis depend on their size, shape and location in the urinary tract. Initially, the stones are deposited in the renal pelvis, where they can be asymptomatic and do not cause pain or obstruction of the flow of urine.

Kidney stones can move from the kidney to the ureter, which is a narrow tube that connects the kidney to the bladder. The passage of the ureteral stone causes increased pressure in the ureter, followed by spasms of the smooth muscle lining and stretching of the walls. This typically presents as renal colic, with severe flank pain of sudden onset that may radiate to the inner thigh or groin. Because of the intense pain, people may feel restless or unable to find a comfortable position. Some individuals may even show signs of sweating, or have nausea and vomiting as a physiological response to the intense pain. In addition, as the stone moves down, it can damage the ureter, causing bloody urine (hematuria).

When stones reach the bladder, they can irritate and clog the bladder, leading to frequent or painful urination. Finally, small stones can be spontaneously eliminated through urine, relieving the pain. If the obstruction is not resolved, it can lead to severe complications, including chronic bladder discomfort, hydronephrosis, and a decrease in kidney function due to urine build-up. In addition, the obstructed kidney can become infected, causing obstructive pyelonephritis, a life-threatening condition that requires urgent surgery to drain the kidney, as well as intravenous antibiotics.

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On the other hand, symptomatic individuals are first evaluated by physical examination. A common sign in people with kidney infection or kidney stones is Giordano’s sign, which refers to tenderness on percussion at the costovertebral angle, formed by the angle between the 12th rib and the lumbar spine.

Next, kidney stones can be identified through imaging techniques, such as X-rays and non-contrast CT scans. The majority of calcium stones are visible on an abdominal X-ray, while some stones such as uric acid and cystine stones are radiolucent, meaning they cannot be seen on an X-ray due to their composition. A non-contrast CT scan, however, is able to detect most stones, regardless of their size and composition, and can also help determine the type of stone by looking at its density.

An ultrasound is an alternative imaging technique that does not require radiation, and therefore can be used to assess nephrolithiasis in vulnerable individuals such as children or pregnant people. The presence of stones can be seen directly as a dense line with distal shadows on the kidney or ureter, as well as indirectly by evaluating the dilatation of the kidneys (hydronephrosis). For pregnant women with a high clinical suspicion and a negative ultrasound, an MRI can be used to identify kidney stones.

Once an acute episode has subsided, a metabolic evaluation may be recommended, especially for people with recurrent episodes of nephrolithiasis. A metabolic evaluation generally includes the assessment of the characteristics of a 24-hour urine sample and, if possible, the analysis of stone crystals in the urine. In addition, blood tests may be done to detect metabolic abnormalities, such as high calcium and uric acid levels in the blood.

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To treat nephrolithiasis, the first step is pain control. This may include nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and ureteral spasms, intravenous fluids, and medications to help with nausea and vomiting. Individuals with persistent pain despite treatment may be given opioid medications.

The subsequent treatment depends on the size, composition and location of the stone, as well as the presence of complications.

For small stones (

Larger stones or those that cannot be passed despite MET should be considered for lithotripsy or surgical intervention, while urgent surgery may be required if there is severe obstruction or infection of the urinary tract, decreased kidney function, uncontrollable pain, or kidney obstruction. a single kidney.

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Lithotripsy, also known as extracorporeal shock wave lithotripsy (ESWL), is a non-invasive procedure that uses shock waves to fragment the stone, breaking it into smaller pieces that are excreted in the urine. Shock waves can only fragment stones with low density, so hard stones such as cystine or calcium oxalate cannot be treated with lithotripsy.

If lithotripsy is not possible, surgical removal of the stones is the preferred treatment. Stones can be removed either by ureteral endoscopy or by minimally invasive surgery, as in percutaneous nephrolithotomy (PCNL). PCNL may be necessary for large stones (> 2 cm) or those that cannot be removed endoscopically due to their shape, such as staghorn stones.

In rare cases where stones cannot be removed by endoscopy or minimally invasive surgery, open surgery such as ureterolithotomy or nephrolithotomy may be necessary.

Finally, many people who develop nephrolithiasis are at risk for future recurrence. Therefore, general dietary modifications such as increased fluid intake and reduced sodium and protein intake may be recommended to prevent future stone formation. In addition, individuals who develop

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