[Guideline] Turk C, Neisius A, Petrik A, Seitz C, Skolarikos A, Thomas K. Guidelines on urolithiasis. Rare extraspinal cause of acute lumbar radiculopathy. [QxMD MEDLINE Link]. This relieves patients of their renal colic pain even if the stone remains. The main symptom is pain, either in the side and back (known as flank pain), abdomen or groin. 2005 Mar. American Urological Association. 2011 Jan. 185(1):192-7. Obstructive Nephropathy Without Hydronephrosis: Suspicion Is the Key Obstructive Nephropathy Without Hydronephrosis: Suspicion Is the Key Urology. In these patients, retrograde endourological procedures such as retrograde pyelography and stent placement may exacerbate infection by pushing infected urinary material into the obstructed renal unit. Forced versus minimal intravenous hydration in the management of acute renal colic: a randomized trial. Methylene blue is then give intravenously, which allows the surgeon to find the avascular plane of Brodel and then mark it using electrocautery. The most common adverse effects are gastrointestinal symptoms. Elsevier 2020. https://www.clinicalkey.com. June 4, 2015; Accessed: September 15, 2021. They recommend considering a course of an alpha-blocker for patients with ureteral colic, unless it is medically contraindicated. Middleton WD, Dodds WJ, Lawson TL, Foley WD. Uric acid and cystine calculi can be dissolved with medical therapy. Obstructive Uropathy - Merck Manuals Professional Edition I would recommend that you see a urologist to get an evaluation to determine yo. Urologia. [98], Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine with potassium citrate. MRI would be a second line choice and low dose CT scans should be saved as a last resort. For patients in whom desmopressin therapy failed, suitable analgesics were administered. Bilateral nephrolithiasis: simultaneous operative management Thomas A, Woodard C, Rovner ES, Wein AJ. Meltzer AC, Burrows PK, Wolfson AB, Hollander JE, Kurz M, Kirkali Z, et al. Patients with uric acid stones who do not require urgent surgical intervention for reasons of pain, obstruction, or infection can often have their stones dissolved with alkalization of the urine. 26th ed. [45], The clinical presentation of infected hydronephrosis is variable. [55, 56] The dosage is 30-60 mg IM or 30 mg IV initially followed by 30 mg IV or IM every 6-8 hours. Urology. Stone disease in pregnancy poses a particular challenge. Kidney stones in adults: Surgical management of kidney and - UpToDate The patient, under varying degrees of anesthesia (depending on the type of lithotriptor used), is placed on a table or in a gantry that is then brought into contact with the shock head. Urinary calcium levels are normal in many patients with calcium stones. The former includes measures to dissolve the stone (possible only with noncalcium stones) or to facilitate stone passage, and the latter includes treatment to prevent further stone formation. In addition, immediately consult with a urologist for patients whose pain fails to respond to ED management. May 10, 2018. 2017. 2017 Nov. 35 (11):1637-1649. However, a 2002 evidence-based consensus review from the United Kingdom recommended that ultrasonography be performed within one week of symptom onset.13 Referral to a urologist for active stone removal is warranted when the stone is larger than 10 mm or if significant hydronephrosis is present.5,13. [Guideline] Assimos DG, Krambeck A, Miller NL, et al. Complete staghorn calculus that fills the collecting system of the kidney (no intravenous contrast material in this patient). Often, a ureteral stent must be placed after ureteroscopy in order to prevent obstruction from ureteral spasm and edema. CT urograms in pediatric patients with ureteral calculi: do adult criteria work?. Kidney stones are a common cause of blood in the urine and pain in the abdomen, flank, or groin. } Other medications commonly used as antiemetics include ondansetron, promethazine, prochlorperazine, and hydroxyzine. In: Principles and Practice of Hospital Medicine. Nephrolithiasis refers to the presence of crystalline stones (calculi) within the urinary system (kidneys and ureter). *Many urologists find CT scans inadequate to help plan surgery, predict stone passage, or monitor patients. This causes a delay, which may be significant in some institutions, and adds additional patient radiograph exposure and cost. These include significant allergic responses and renal failure. Pr-AKI: Acute Kidney Injury in Pregnancy - Etiology, Diagnostic Workup, Management. doi: 10.1016/j.urology.2016.11.041. 2007 Dec. 178 (6):2418-34. If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones (present in only a relative minority), allopurinol (300 mg qd) is recommended because it reduces uric acid excretion. This is the American ICD-10-CM version of N13.2 - other international versions of ICD-10 N13.2 may differ. Obstructive nephropathy secondary to sulfasalazine calculi. [78] Nevertheless, a shift seems to be occurring from the use of ESWL to that of ureteroscopy, due to the latters greater efficacy. Renal calculi without hydronephrosis refers to calculi in the pelvis or in one or more kidney calices or stag horn calculi without significant obstruction of the renal collective system. Obstruction in the absence of infection can be initially managed with analgesics and with other medical measures to facilitate passage of the stone. This is likely the single most important aspect of stone prophylaxis. Ultimately when dealing with seriously ill patients requiring urologic decompression, discussion between urology, anesthesia and interventional radiology is key to determine the best course of treatment based on positioning and comorbid conditions. To decrease the risk of those complications, hypothermia of the renal bed is initiated to prevent ischemic injury and intravenous mannitol is given to limit reperfusion injury, due to its ability to attenuate free radical scavengers. [80] A meta-analysis comparing the two approaches showed that although ESWL was just as effective for the management of stones less than 1 cm in the proximal ureter, ureteroscopy otherwise had the following advantages{ref77): Although data have been somewhat conflicting, the EAU and urologic community recommend that MET be used as an adjunct to ESWL to expedite stone passage, increase stone-free rates, and potentially reduce analgesic requirements. Long-term Adverse Effects of Extracorporeal Shock-wave Lithotripsy for Nephrolithiasis and Ureterolithiasis: A Systematic Review. Nephrolithiasis: acute renal colic. Animal studies have demonstrated a significant reduction in mean intraureteral pressure after an acute obstruction in subjects administered desmopressin compared with controls. 28 (3):748-759. [QxMD MEDLINE Link]. No adverse effects from the antidiuretic medication occurred. [Guideline] Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, Wolf JS Jr. Chapter 1: AUA guideline on management of staghorn calculi: diagnosis and treatment recommendations. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. Generally, hospitalization for an acute renal colic attack is now officially termed an observation because most patients recover sufficiently to go home within 24 hours. Yilmaz E, Batislam E, Basar MM, Tuglu D, Ferhat M, Basar H. The comparison and efficacy of 3 different alpha1-adrenergic blockers for distal ureteral stones. Urol Res. Distal ureteral stone observed through a small, rigid ureteroscope prior to ballistic lithotripsy and extraction. Adequate intravenous (IV) hydration is essential to minimize the nephrotoxic effects of IV contrast agents. Kidney swelling happens when urine can't drain from a kidney and builds up in the kidney as a result. If the kidney is not working at all, kidney removal is not usually required unless there is an ongoing problem such as repeated infection. The primary indications for surgical treatment include pain, infection, and obstruction. J Am Soc Nephrol. Obstructive uropathy refers to. Retroperitoneal fibrosis: a rare cause of acute renal failure. Above and beyond this, additional imaging is often unnecessary in a patient with a previous radiopaque stone who has no further symptoms. } ACR Appropriateness Criteria acute onset flank pain--suspicion of stone disease. Note that the image provided by fiberoptics, although still acceptable, is inferior to that provided by the rod-lens optics of the rigid ureteroscope in the previous picture. J Am Soc Nephrol. [58, 59, 60] The best studied of these is tamsulosin, 0.4 mg administered daily. Calcium stones. [1]. [QxMD MEDLINE Link]. King SA, Klaassen Z, Madi R. Robot-assisted anatrophic nephrolithotomy: description of technique and early results. Distribution of renal and ureteral pain. Cooper JT, Stack GM, Cooper TP. 2003 Feb. 30(1):123-31. Parenteral narcotics are another mainstay of analgesia for patients with acute renal colic. Renal calculi. Kidney stone preventive therapy consists of dietary adjustments, nutritional supplements, medications, or combinations of these. Gdor Y, Faddegon S, Krambeck AE, et al. While case numbers are not high, such an infection can dramatically complicate the clinical outcome for that patient. [Full Text]. Most common findings are hypercalciuria, hyperuricosuria, hyperoxaluria, hypocitraturia, and low urinary volume. POC renal US for the diagnosis of nephrolithiasis has a reported sensitivity and specificity of 70% and 75%, respectively using the gold standard of CT . HHS Vulnerability Disclosure, Help Bilateral hydronephrosis occurs when urine is unable to drain from the kidney into the bladder. 2012 Mar. 2000 Aug. 164(2):308-10. Click here for an email preview. In these cases, consider percutaneous nephrostomy drainage rather than retrograde endoscopy, especially in very ill patients. It occurs as a result of a problem that prevents urine from draining out of the kidneys, ureters, and bladder. Before It is potentiated by probenecid and should be avoided in patients with peptic ulcer disease, renal failure, or recent gastrointestinal (GI) bleeding. Although the role of supranormal hydration in the management of renal (ureteral) colic is controversial (see below), patients who are dehydrated or ill need adequate restoration of circulating volume. Percutaneous management. 2015 Apr 28. In general, however, patients who are acutely ill, who have significant medical comorbidities, or who harbor stones that probably cannot be bypassed with ureteral stents undergo percutaneous nephrostomy, whereas others receive ureteral stent placement. Ureteral calculi almost always originate in the kidneys, although they may continue to grow once they lodge in the ureter. The shock head delivers shockwaves developed from an electrohydraulic, electromagnetic, or piezoelectric source. Pyonephrosis in childhood--is ultrasound sufficient for diagnosis?. Hydronephrosis Treatments - Urologists [QxMD MEDLINE Link]. Overuse of the more effective agents leaves only highly resistant bacteria, but failure to adequately treat a UTI complicated by an obstructing calculus can result in potentially life-threatening urosepsis and pyonephrosis. Share cases and questions with Physicians on Medscape consult. Worcester EM, Coe FL. St Lezin M, Hofmann R, Stoller ML. 2001 Jan. 57 (1):161-5. [44]. Accessed Jan. 20, 2020. For example, do not perform ESWL if a ureteral obstruction is distal to the calculus or the patient is pregnant. 167(3):1235-8. However, any strongly motivated patients can benefit from a prevention analysis and prophylactic treatment if they are willing to pursue long-term therapy. Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, National Association of EMS Physicians, Society for Academic Emergency MedicineDisclosure: Nothing to disclose. Because nausea and vomiting frequently accompany acute renal colic, antiemetics often play a role in renal colic therapy. National Institute of Diabetes and Digestive and Kidney Diseases. The guidelines state that observation with or without medical expulsive therapy (MET) should be offered to patients with uncomplicated distal ureteral stones that are 10 mm or less in diameter. Idiopathic bilateral ureteral stenosis presenting as bilateral If outpatient treatment fails, promptly consult a urologist. J Urol. 2006 Jul-Aug. 40(7-8):1361-8. In one small series of 23 patients with infected hydronephrosis, the temperature was higher than 38C in 15 patients, the peripheral WBC count was more than 10 109/L in 13 patients, and the creatinine level was greater than 1.3 mg/dL in 12 patients. Kellerman RD, et al. Therapy should also include long-term urinary alkalinization and aggressive fluid intake. 2008 Nov-Dec. 103(6):665-8. Chirag N Dave, MD Physician in Sexual and Male Reproductive Medicine and Urology, Advanced Urology Institute of Georgia Kingo PS, Ryhammer AM, Fuglsig S. Clinical experience with the Swiss lithoclast master in treatment of bladder calculi. Dai JC, Nicholson TM, Chang HC, Desai AC, Sweet RM, Harper JD, et al. MET with 0.4 mg tamsulosin once daily or 4 mg of terazosin once daily is recommended dosing. The plural is calculi or stones.) Accessed Jan. 20, 2020. Ureteral stenosis is typically seen in the setting of genitourinary tract manipulation or nephrolithiasis. Elsevier; 2020. https://www.clinicalkey.com. Acute bilateral obstructive uropathy - sudden blockage of the kidneys. Mini Rev Med Chem. 2012;2012:645407. doi: 10.1155/2012/645407. [QxMD MEDLINE Link]. UpToDate [97]. [54], Hollingsworth et al found that overall, passage of larger stones was 57% more likely in patients treated with an alpha-blocker compared with controls (risk ratio 1.57); the likelihood of stone passage increased by 9.8% with every 1 mm increase in stone size. [QxMD MEDLINE Link]. N13.2 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Percutaneous procedures have higher morbidity than ESWL and ureteroscopy and so are generally reserved for large and/or complex renal stones and cases in which the other two modalities have failed. [QxMD MEDLINE Link]. 2014 Mar 26. 2001 Jan. 176(1):105-12. Hydronephrosis may result in decreased kidney function. The role of C-reactive protein and erythrocyte sedimentation rate in the diagnosis of infected hydronephrosis and pyonephrosis. Clipboard, Search History, and several other advanced features are temporarily unavailable. 2003 Oct. 62(4):748. Evidence of a possible UTI includes an abnormal finding upon microscopic urinalysis, showing pyuria of 10 WBCs/hpf (or more WBCs than RBCs), bacteriuria, fever, or unexplained leukocytosis. clip-path: url(#SVGID_2_); 1994 Jun 27. [QxMD MEDLINE Link]. During this procedure the renal artery is clamped, which raises the risk for ischemic injury, as well as reperfusion injury once the procedure is complete. 1999 Jan. 17(1):6-10. Somani BK, Dellis A, Liatsikos E, Skolarikos A. Prim Care. Diagnosis and Initial Management of Kidney Stones | AAFP Factors affecting stone-free rate and complications of percutaneous nephrolithotomy for treatment of staghorn stone. Kidney Atrophy - Symptoms, causes, treatment - National Kidney Foundation 1, 2 Worldwide, it is also increasing in Europe and . Staghorn Calculus: Causes, Symptoms & Treatment - Cleveland Clinic [Acute obstructive renal failure secondary to retroperitoneal mass]. Preminger GM. Opioids can cause respiratory depression in the fetus; therefore, they should not be used near delivery or when other medications are adequate. Nifedipine versus tamsulosin for the management of lower ureteral stones. Many randomized trials have confirmed the efficacy of MET in reducing the pain of stone passage, increasing the frequency of stone passage, and reducing the need for surgery. More serious cases with intractable pain may require drainage with a stent or percutaneous nephrostomy. A KUB radiograph can be used to determine stent position, while infection is easily diagnosed by urinalysis. Porpiglia F, Destefanis P, Fiori C, Scarpa RM, Fontana D. Role of adjunctive medical therapy with nifedipine and deflazacort after extracorporeal shock wave lithotripsy of ureteral stones. 1996 Nov. 167(5):1109-13. Hydronephrosis Causes. Ann Vasc Surg. Wu TT, Lee YH, Tzeng WS, Chen WC, Yu CC, Huang JK. No IV contrast necessary, so no risk of nephrotoxicity or acute allergic reactions, With only rare exceptions, shows all stones clearly, Can be performed in patients with significant azotemia and severe contrast allergies who cannot tolerate IV contrast studies, Shows perinephric stranding or streaking not visible on IVP and can be used as an indirect or secondary sign of ureteral obstruction, No radiologist needs to be physically present, Preferred imaging modality for acute renal colic in most EDs, Without hydronephrosis, cannot reliably distinguish between distal ureteral stones and pelvic calcifications or phleboliths, No nephrogram effect study to help identify obstruction, Unable to identify ureteral kinks, strictures, or tortuousities, May be hard to differentiate an extrarenal pelvis from true hydronephrosis, Gonadal vein sometimes can be confused with the ureter, Does not indicate likelihood of fluoroscopic visualization of the stone, which is essential information in planning possible surgical interventions, Cannot be performed during pregnancy because of high dose of ionizing radiation exposure, Usually more costly than an IVP in most institutions, Clear outline of complete urinary system without any gaps, Clearly shows all stones either directly or indirectly as an obstruction, Nephrogram effect film indicates obstruction and ureteral blockage in most cases, even if the stone itself might not be visible, Ureteral kinks, strictures, and tortuousities often visible, Can modify study with extra views (eg, posterior oblique positions, prone views) to better visualize questionable areas, Stone size, shape, surgical orientation, and relative position more clearly defined, Orientation similar to urologists surgical approach, Limited IVP study can be considered in selected cases during pregnancy, although plain ultrasonography is preferred initially, Lower cost than CT scan in most institutions, Relatively slow; may need multiple delay films, which can take hours, Cannot be used in azotemia, pregnancy, or known significant allergy to intravenous contrast agents, Risk of potentially dangerous reactions to IV contrast material, Cannot detect perinephric stranding or streaking, which is visible only on CT scans, Harder to visualize radiolucent stones (eg, uric acid), although indirect signs of obstruction are apparent, Presence of a radiologist generally necessary, which can cause extra delay, Cannot be used to reliably evaluate other potential pathologies. You will also receive Demirci D, Sofikerim M, Yalin E, Ekmekiolu O, Glmez I, Karacagil M. Comparison of conventional and step-wise shockwave lithotripsy in management of urinary calculi. Table. J Urol. Referral to a urologist is necessary for all stones that prove refractory to outpatient management or that fail to pass spontaneously. This is roughly equivalent to a single high-calcium or dairy meal per day. Intravenous mannitol is given prior to the induction of hypothermia. for: Medscape. [1] During pregnancy, radiation may cause teratogenesis or carcinogenesis effects. {ref73) In some cases, a combination of ESWL and a percutaneous technique is necessary to completely remove all stone material from a kidney. Nephrolithiasis often is incidentally identified in asymptomatic patients who undergo plain radiographs or computed tomographic imaging for another indication. Oral Antibiotic Exposure and Kidney Stone Disease. Urology. Kidney stones are a common disorder, with an annual incidence of eight cases per 1,000 adults. Although many staghorn calculi are struvite (related to infection with urease-splitting bacteria), the density of this stone suggests that it may be metabolic in origin and is likely composed of calcium oxalate. 173(6):1991-2000. Larkin GL, Peacock WF 4th, Pearl SM, Blair GA, D'Amico F. Efficacy of ketorolac tromethamine versus meperidine in the ED treatment of acute renal colic. el-Nahas AR, Eraky I, Shokeir AA, Shoma AM, el-Assmy AM, el-Tabey NA, et al. The StoneBreaker has been shown to be more effective than the Swiss LIthoclast in the management of staghorn calculi. Urol Clin North Am. In: Conn's Current Therapy 2020. [QxMD MEDLINE Link]. ESWL, the least invasive of the surgical methods of stone removal, utilizes high-energy sound waves focused on the stone to shatter it into passable fragments. [65, 1, 66]. 2013 Nov. 27 (11):1393-8. Nephrolithiasis: The process of forming a kidney stone, a stone in the kidney (or lower down in the urinary tract). It has been proven in multiple studies to be as effective as opioid analgesics, with fewer adverse effects. 2012 Spring. They can become blocked, kinked, dislodged, or infected. [QxMD MEDLINE Link]. Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial. Kidney stones (also called renal calculi, nephrolithiasis or urolithiasis) are hard deposits made of minerals and salts that form inside your kidneys. [Full Text]. Seema Mehta, DO, MSc Resident Physician, Department of Family Medicine, University of Michigan Medical SchoolDisclosure: Nothing to disclose. Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases. In 2 double-blinded studies, it apparently provided pain relief equivalent to narcotic analgesics in addition to relieving nausea. [Guideline] Trk C, Knoll T, Seitz C, Skolarikos A, Chapple C, McClinton S, et al. Antibiotic use in patients with kidney stones remains controversial. Kishore TA, Pedro RN, Hinck B, Monga M. Estimation of size of distal ureteral stones: noncontrast CT scan versus actual size. [44], In the case of pediatric patients with uncomplicated ureteral stones 10 mm or asymptomatic non-obstructing renal stones, active surveillance with periodic ultrasonography can be offered. A Cochrane review of seven randomized controlled trials comparing ESWL with ureteroscopy concluded that achievement of a stone-free state occurs more often with ureteroscopy, but ureteroscopy has a higher complication rate and involves a longer hospital stay. The outcome of open renal stone surgery calls for limitation of its use: A single institution experience. If possible, try to save your kidney stone if you pass one so that you can bring it to your doctor for analysis. All rights reserved. Schneider K, Helmig FJ, Eife R, Belohradsky BH, Kohn MM, Devens K, et al. Dellabella M, Milanese G, Muzzonigro G. Randomized trial of the efficacy of tamsulosin, nifedipine and phloroglucinol in medical expulsive therapy for distal ureteral calculi. For symptomatic patients with or without hydronephrosis or asymptomatic patients with hydronephrosis noted on kidney ultrasound, computed tomography (CT) of the abdomen and pelvis . The alpha-blockers, such as terazosin, and the alpha-1 selective blockers, such as tamsulosin, also relax the musculature of the ureter and lower urinary tract, markedly facilitating passage of ureteral stones. However, if the condition persists in both kidneys (bilateral hydronephrosis), a more serious complication can arise: kidney failure. Ketorolac works at the peripheral site of pain production rather than on the CNS. Stones can then be retrieved by stone basket and/or allowed to pass spontaneously. Accessed Jan. 20, 2020. The Canadian StoneBreaker trial: a randomized, multicenter trial comparing the LMA StoneBreaker and the Swiss LithoClast during percutaneous nephrolithotripsy. JAMA Intern Med. Ganpule AP, Prashant J, Desai MR. Laparoscopic and robot-assisted surgery in the management of urinary lithiasis. The size of the stone is an important predictor of spontaneous passage. An empiric restriction of dietary calcium may also adversely affect bone mineralization and may have osteoporosis implications, especially in women. [Full Text]. Patients with complete obstruction, perinephric urine extravasation, a solitary kidney, or pregnancy, and those with a poor social support system, also should be considered for admission, especially if rapid urologic follow-up is not reliably available. The renal artery is then clamped and hypothermia is achieved. 154(12):1381-7. One had extracorporeal shock wave lithotripsy for removal of residual calculi. Ureteral stone with hydronephrosis and urolithiasis alone are - Nature [QxMD MEDLINE Link]. Springhart WP, Marguet CG, Sur RL, Norris RD, Delvecchio FC, Young MD, et al. The postoperative course of minimally invasive stone-removal modalities is generally characterized by short-lived discomfort easily managed with oral medications. Causes. 2008 Jun. Knowing when a stone is going to pass is impossible regardless of its size or location. Unable to load your collection due to an error, Unable to load your delegates due to an error. [QxMD MEDLINE Link]. The patient is placed into the flank position and once port access is obtained, the colon is reflected and the hilum is exposed. Guidelines are now available to assist the urologist in selecting surgical treatments. Ureteric stones almost always originate in the kidney but then pass down into the ureter. [Full Text]. Kidney stone disease (nephrolithiasis) is a common problem in primary care practice. [QxMD MEDLINE Link]. health information, we will treat all of that information as protected health 2004 May 19. Mechanism of formation of human calcium oxalate renal stones on Randall's plaque. It may also be associated with certain medications used to treat migraines or seizures, such as topiramate (Topamax, Trokendi XR, Qudexy XR). Learn how we can help. Jeffrey RB, Laing FC, Wing VW, Hoddick W. Sensitivity of sonography in pyonephrosis: a reevaluation. Once a stable regimen has been established, annual 24-hour urinalyses are adequate. Several studies have now demonstrated that desmopressin (DDAVP), a potent antidiuretic that is essentially an antidiuretic hormone, can dramatically reduce the pain of acute renal colic in many patients. Ureteral obstruction from a stone occurs in the presence of a urinary tract infection (UTI), fever, sepsis, or pyonephrosis. Wang CJ, Huang SW, Chang CH. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvNDM3MDk2LXRyZWF0bWVudA==. [44]. the unsubscribe link in the e-mail. 2004 Aug. 172(2):568-71. J Urol. Lancet. Noncontrast-enhanced CT should be considered if residual stone is suspected; this modality may help identify stone composition.31, Basic laboratory evaluations include creatinine (for renal function), ionized calcium (for hyperparathyroidism), and uric acid (for hyperuricemia); parathyroid hormone should be measured only if the serum calcium level is high.15,31 If a stone was not retrieved for analysis, additional tests should be considered: urine pH (for nephrocalcinosis and other metabolic abnormalities), microscopy of sediment from morning urine (for urine crystals that may suggest stone composition), and a test for cystinuria (especially in children because it is an inherited metabolic disorder).31, Many kidney stones are asymptomatic and found on imaging; each year, 10% to 25% become symptomatic or require intervention.5 Conservative management is an option for adults who are healthy, unfit for surgery, or pregnant, and who have access to health care and can adhere to active surveillance (imaging after six months, then annually).5,36 The patient should be referred for stone removal if symptoms, obstruction, or recurrent infection develops, or if the stone grows larger.5,36 Stone removal should be considered if the patient prefers removal to conservative management; plans to conceive in the near future; has calyceal diverticular stones, stones larger than 10 mm (possibly larger than 4 mm), or renal pathology; or is unsuited for conservative management.36, Kidney stones are becoming more prevalent in children because of increasing rates of diabetes mellitus, obesity, and hypertension in this population.24,9 Increasing age is a risk factor for kidney stones; therefore, adolescents are more likely to form stones than younger children.2 Children with kidney stones are more likely to have a metabolic, neurologic, or congenital urinary system structural abnormality; to have concomitant urinary infection; and to have recurrent stones.2,3,9,31, Urinary stasis, increased glomerular filtration rate, and elevated urine pH affect kidney stone formation in pregnant women.
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