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    Kidney stonesadults Kidney stonesadults Document Transcript

    • Kidney Stonesin Adults National Kidney and Urologic Diseases Information Clearinghouse Kidney stones, one of the most painful of Introduction to the the urologic disorders, have beset humans for centuries. Scientists have found evi­ Urinary Tract dence of kidney stones in a 7,000-year-old The urinary tract, or system, consists ofNationalInstitute of Egyptian mummy. Unfortunately, kidney the kidneys, ureters, bladder, and urethra.Diabetes and stones are one of the most common disor­ The kidneys are two bean-shaped organsDigestiveand Kidney ders of the urinary tract. Each year, people located below the ribs toward the middleDiseases make almost 3 million visits to health care of the back, one on each side of the spine.NATIONAL providers and more than half a million The kidneys remove extra water and wastesINSTITUTES people go to emergency rooms for kidney from the blood, producing urine. They alsoOF HEALTH stone problems. keep a stable balance of salts and other sub­ stances in the blood. The kidneys produce Most kidney stones pass out of the body hormones that help build strong bones and without any intervention by a physician. form red blood cells. Stones that cause lasting symptoms or other complications may be treated by various techniques, most of which do not involve major surgery. Also, research advances Kidneys have led to a better understanding of the many factors that promote stone formation and thus better treatments for preventing stones. Ureter Bladder UrethraU.S. Departmentof Health and The urinary tract.Human Services
    • Narrow tubes called ureters carry urinefrom the kidneys to the bladder, an oval-shaped chamber in the lower abdomen.Like a balloon, the bladder’s elastic wallsstretch and expand to store urine. Theyflatten together when urine is emptiedthrough the urethra to outside the body.What is a kidney stone?A kidney stone is a hard mass developedfrom crystals that separate from the urinewithin the urinary tract. Normally, urinecontains chemicals that prevent or inhibitthe crystals from forming. These inhibi­tors do not seem to work for everyone,however, so some people form stones. Ifthe crystals remain tiny enough, they willtravel through the urinary tract and passout of the body in the urine without beingnoticed.Kidney stones may contain various combi­ Kidney stones in the kidney, ureter, and bladder.nations of chemicals. The most commontype of stone contains calcium in combi­nation with either oxalate or phosphate. Urolithiasis is the medical term used toThese chemicals are part of a person’s describe stones occurring in the urinarynormal diet and make up important parts tract. Other frequently used terms are uri­of the body, such as bones and muscles. nary tract stone disease and nephrolithiasis.A less common type of stone is caused by Doctors also use terms that describe theinfection in the urinary tract. This type of location of the stone in the urinary tract.stone is called a struvite or infection stone. For example, a ureteral stone—or uretero­Another type of stone, uric acid stones, lithiasis—is a kidney stone found in theare a bit less common, and cystine stones ureter. To keep things simple, the generalare rare. term kidney stones is used throughout this fact sheet. Gallstones and kidney stones are not related. They form in different areas of the body. Someone with a gallstone is not necessarily more likely to develop kidney stones. Kidney Stones in Adults
    • Who gets kidney stones?For unknown reasons, the number ofpeople in the United States with kidneystones has been increasing over the past 30 Jaggedyears. In the late 1970s, less than 4 percentof the population had stone-forming dis­ease. By the early 1990s, the portion of thepopulation with the disease had increasedto more than 5 percent. Caucasians aremore prone to develop kidney stones thanAfrican Americans. Stones occur more Staghornfrequently in men. The prevalence of kid­ney stones rises dramatically as men entertheir 40s and continues to rise into their70s. For women, the prevalence of kidneystones peaks in their 50s. Once a persongets more than one stone, other stones are Smoothlikely to develop.What causes kidney stones? Shapes of various stones. Sizes are usually smaller than shown here.Doctors do not always know what causesa stone to form. While certain foods maypromote stone formation in people who Cystinuria and hyperoxaluria are two otherare susceptible, scientists do not believe rare, inherited metabolic disorders thatthat eating any specific food causes stones often cause kidney stones. In cystinuria,to form in people who are not susceptible. too much of the amino acid cystine, whichA person with a family history of kidney does not dissolve in urine, is voided, leadingstones may be more likely to develop to the formation of stones made of cystine.stones. Urinary tract infections, kidney In patients with hyperoxaluria, the bodydisorders such as cystic kidney diseases, produces too much oxalate, a salt. Whenand certain metabolic disorders such as the urine contains more oxalate than can behyperparathyroidism are also linked to dissolved, the crystals settle out and formstone formation. stones.In addition, more than 70 percent of Hypercalciuria is inherited, and it may bepeople with a rare hereditary disease called the cause of stones in more than half ofrenal tubular acidosis develop kidney patients. Calcium is absorbed from food instones. excess and is lost into the urine. This high level of calcium in the urine causes crystals of calcium oxalate or calcium phosphate to form in the kidneys or elsewhere in the urinary tract.3 Kidney Stones in Adults
    • Other causes of kidney stones are hyper­ If the stone is too large to pass easily, painuricosuria, which is a disorder of uric acid continues as the muscles in the wall of themetabolism; gout; excess intake of vitamin narrow ureter try to squeeze the stone intoD; urinary tract infections; and blockage of the bladder. As the stone moves and thethe urinary tract. Certain diuretics, com­ body tries to push it out, blood may appearmonly called water pills, and calcium-based in the urine, making the urine pink. As theantacids may increase the risk of forming stone moves down the ureter, closer to thekidney stones by increasing the amount of bladder, a person may feel the need to uri­calcium in the urine. nate more often or feel a burning sensation during urination.Calcium oxalate stones may also form inpeople who have chronic inflammation of If fever and chills accompany any of thesethe bowel or who have had an intestinal symptoms, an infection may be present. Inbypass operation, or ostomy surgery. As this case, a person should contact a doctormentioned earlier, struvite stones can form immediately.in people who have had a urinary tractinfection. People who take the protease How are kidney stonesinhibitor indinavir, a medicine used to treatHIV infection, may also be at increased risk diagnosed?of developing kidney stones. Sometimes “silent” stones—those that do not cause symptoms—are found on x raysWhat are the symptoms of taken during a general health exam. If the stones are small, they will often pass out ofkidney stones? the body unnoticed. Often, kidney stonesKidney stones often do not cause any are found on an x ray or ultrasound takensymptoms. Usually, the first symptom of a of someone who complains of blood in thekidney stone is extreme pain, which begins urine or sudden pain. These diagnosticsuddenly when a stone moves in the urinary images give the doctor valuable informationtract and blocks the flow of urine. Typically, about the stone’s size and location. Blooda person feels a sharp, cramping pain in the and urine tests help detect any abnor­back and side in the area of the kidney or in mal substance that might promote stonethe lower abdomen. Sometimes nausea and formation.vomiting occur. Later, pain may spread to The doctor may decide to scan the urinarythe groin. system using a special test called a com­ puterized tomography (CT) scan or an intravenous pyelogram (IVP). The results of all these tests help determine the proper treatment.4 Kidney Stones in Adults
    • Preventing Kidney Stones How are kidney stonesA person who has had more than one kid­ treated?ney stone may be likely to form another; so, Fortunately, surgery is not usually neces­if possible, prevention is important. To help sary. Most kidney stones can pass throughdetermine their cause, the doctor will order the urinary system with plenty of water—laboratory tests, including urine and blood to 3 quarts a day—to help move the stonetests. The doctor will also ask about the along. Often, the patient can stay homepatient’s medical history, occupation, and during this process, drinking fluids andeating habits. If a stone has been removed, taking pain medication as needed. Theor if the patient has passed a stone and doctor usually asks the patient to save thesaved it, a stone analysis by the laboratory passed stone(s) for testing. It can be caughtmay help the doctor in planning treatment. in a cup or tea strainer used only for thisThe doctor may ask the patient to collect purpose.urine for 4 hours after a stone has passedor been removed. For a 4-hour urine col­ Lifestyle Changeslection, the patient is given a large con­ A simple and most important lifestyletainer, which is to be refrigerated between change to prevent stones is to drink moretrips to the bathroom. The collection is liquids—water is best. Someone who tendsused to measure urine volume and levels of to form stones should try to drink enoughacidity, calcium, sodium, uric acid, oxalate, liquids throughout the day to produce atcitrate, and creatinine—a product of muscle least  quarts of urine in every 4-hourmetabolism. The doctor will use this period.information to determine the cause of the In the past, people who form calcium stonesstone. A second 4-hour urine collection were told to avoid dairy products and othermay be needed to determine whether the foods with high calcium content. Recentprescribed treatment is working. studies have shown that foods high in calcium, including dairy products, may help prevent calcium stones. Taking calcium in pill form, however, may increase the risk of developing stones. Patients may be told to avoid food with added vitamin D and certain types of ant­ acids that have a calcium base. Someone who has highly acidic urine may need to eat less meat, fish, and poultry. These foods increase the amount of acid in the urine.5 Kidney Stones in Adults
    • To prevent cystine stones, a person should drink enough water each day to dilute the Foods and Drinks concentration of cystine that escapes into Containing Oxalate the urine, which may be difficult. More People prone to forming calcium oxa­ than a gallon of water may be needed every late stones may be asked by their doctor 4 hours, and a third of that must be drunk to limit or avoid certain foods if their during the night. urine contains an excess of oxalate. Medical Therapy High-oxalate foods—higher to lower A doctor may prescribe certain medica­ • rhubarb tions to help prevent calcium and uric • spinach acid stones. These medicines control the amount of acid or alkali in the urine, key • beets factors in crystal formation. The medicine • swiss chard allopurinol may also be useful in some cases of hyperuricosuria. • wheat germ Doctors usually try to control hypercalci­ • soybean crackers uria, and thus prevent calcium stones, by • peanuts prescribing certain diuretics, such as hydro­ chlorothiazide. These medicines decrease • okra the amount of calcium released by the • chocolate kidneys into the urine by favoring calcium • black Indian tea retention in bone. They work best when sodium intake is low. • sweet potatoes Rarely, patients with hypercalciuria are Foods that have medium amounts given the medicine sodium cellulose phos­ of oxalate may be eaten in limited phate, which binds calcium in the intestines amounts. and prevents it from leaking into the urine. Medium-oxalate foods—higher to lower If cystine stones cannot be controlled by • grits drinking more fluids, a doctor may pre­ scribe medicines such as Thiola and Cupri­ • grapes mine, which help reduce the amount of • celery cystine in the urine. • green pepper For struvite stones that have been totally removed, the first line of prevention is to • red raspberries keep the urine free of bacteria that can • fruit cake cause infection. A patient’s urine will be • strawberries tested regularly to ensure no bacteria are present. • marmalade • liver Source: The Oxalosis and Hyperoxaluria Foundation. (www.ohf.org/diet.html) Kidney Stones in Adults
    • If struvite stones cannot be removed, a doc­tor may prescribe a medicine called aceto­hydroxamic acid (AHA). AHA is used withlong-term antibiotic medicines to preventthe infection that leads to stone growth.People with hyperparathyroidism some­times develop calcium stones. Treatment inthese cases is usually surgery to remove theparathyroid glands, which are located in theneck. In most cases, only one of the glandsis enlarged. Removing the glands cures thepatient’s problem with hyperparathyroidismand kidney stones.Surgical Treatment ShockwavesSurgery may be needed to remove a kidney Ellipsoidal reflectorstone if it • does not pass after a reasonable period Shockwave of time and causes constant pain generator • is too large to pass on its own or is caught in a difficult place • blocks the flow of urine • causes an ongoing urinary tract Extracorporeal shock wave lithotripsy. infection • damages kidney tissue or causes con­ Extracorporeal Shock Wave stant bleeding Lithotripsy Extracorporeal shock wave lithotripsy • has grown larger, as seen on follow-up (ESWL) is the most frequently used proce­ x rays dure for the treatment of kidney stones. InUntil 0 years ago, open surgery was ESWL, shock waves that are created out­necessary to remove a stone. The surgery side the body travel through the skin andrequired a recovery time of 4 to  weeks. body tissues until they hit the denser stones.Today, treatment for these stones is greatly The stones break down into small particlesimproved, and many options do not require and are easily passed through the urinarymajor open surgery and can be performed tract in the urine.in an outpatient setting. Several types of ESWL devices exist. Most devices use either x rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of ESWL proce­ dures, anesthesia is needed.7 Kidney Stones in Adults
    • In many cases, ESWL may be done on an Percutaneous Nephrolithotomyoutpatient basis. Recovery time is rela­ Sometimes a procedure called percutane­tively short, and most people can resume ous nephrolithotomy is recommended tonormal activities in a few days. remove a stone. This treatment is often used when the stone is quite large or in aComplications may occur with ESWL. location that does not allow effective use ofSome patients have blood in their urine ESWL.for a few days after treatment. Bruis­ing and minor discomfort in the back or In this procedure, the surgeon makes a tinyabdomen from the shock waves can occur. incision in the back and creates a tunnelTo reduce the risk of complications, doc­ directly into the kidney. Using an instru­tors usually tell patients to avoid taking ment called a nephroscope, the surgeonaspirin and other medicines that affect locates and removes the stone. For largeblood clotting for several weeks before stones, some type of energy probe—ultra­treatment. sonic or electrohydraulic—may be needed to break the stone into small pieces. Often,Sometimes, the shattered stone par­ patients stay in the hospital for several daysticles cause minor blockage as they pass and may have a small tube called a neph­through the urinary tract and cause rostomy tube left in the kidney during thediscomfort. In some cases, the doctor will healing process.insert a small tube called a stent throughthe bladder into the ureter to help the One advantage of percutaneous nephro­fragments pass. Sometimes the stone is lithotomy is that the surgeon can removenot completely shattered with one treat­ some of the stone fragments directly insteadment, and additional treatments may be of relying solely on their natural passageneeded. from the kidney.As with any interventional, surgicalprocedure, potential risks and complica­tions should be discussed with the doctorbefore making a treatment decision. Nephroscope Ultrasonic probe Percutaneous nephrolithotomy. Kidney Stones in Adults
    • Ureteroscopic Stone Removal KidneyAlthough some stones in the ureters canbe treated with ESWL, ureteroscopymay be needed for mid- and lower-ureter Ureterstones. No incision is made in this proce­ Ureterdure. Instead, the surgeon passes a small Stonefiberoptic instrument called a ureteroscopethrough the urethra and bladder into theureter. The surgeon then locates the stone Ureteroscopeand either removes it with a cage-likedevice or shatters it with a special instru­ Stonement that produces a form of shock wave.A small tube or stent may be left in the ure­ter for a few days to help urine flow. Beforefiber optics made ureteroscopy possible, Bladderphysicians used a similar “blind basket”extraction method. But this technique israrely used now because of the higher risks Eye pieceof damage to the ureters. Ureteroscope Ureteroscopic stone removal.9 Kidney Stones in Adults
    • Hope Through ResearchThe Division of Kidney, Urologic, and Points to RememberHematologic Diseases of the National Insti­ • A person with a family history oftute of Diabetes and Digestive and Kidney stones or a personal history ofDiseases (NIDDK) funds research on the more than one stone may be morecauses, treatments, and prevention of kidney likely to develop more stones.stones. The NIDDK is part of the NationalInstitutes of Health in Bethesda, MD. • A good first step to prevent the formation of any type of stone isNew medicines and the growing field to drink plenty of liquids—water isof lithotripsy have greatly improved the best.treatment of kidney stones. Still, NIDDKresearchers and grantees seek to answer • Someone who is at risk for devel­questions such as oping stones may need certain blood and urine tests to determine • Why do some people continue to have which factors can best be altered to painful stones? reduce that risk. • How can doctors predict, or screen, • Some people will need medicines those at risk for getting stones? to prevent stones from forming. • What are the long-term effects of • People with chronic urinary tract lithotripsy? infections and stones will often • Do genes play a role in stone need a stone removed if the doctor formation? determines that the stone is causing the infection. Patients must receive • What is the natural substance(s) found careful follow-up to be sure that in urine that blocks stone formation? the infection has cleared.Researchers are also developing new medi­cines with fewer side effects.10 Kidney Stones in Adults
    • For More Information For Information About Gout:American Urological Association National Institute of Arthritis andFoundation Musculoskeletal and Skin Diseases1000 Corporate Boulevard Information ClearinghouseLinthicum, MD 21090 National Institutes of HealthPhone: 1–866–RING–AUA (746–4282) or 1 AMS Circle 410–689–3700 Bethesda, MD 20892–3675Email: patienteducation@auafoundation.org Phone: 1–877–22–NIAMS (226–4267) orInternet: www.auafoundation.org 301–495–4484 www.UrologyHealth.org TTY: 301–565–2966 Fax: 301–718–6366National Kidney Foundation Email: niamsinfo@mail.nih.gov30 East 33rd Street Internet: www.niams.nih.govNew York, NY 10016Phone: 1–800–622–9010 or 212–889–2210Internet: www.kidney.org You may also find additional information about this topic by visiting MedlinePlus at www.medlineplus.gov.Oxalosis and Hyperoxaluria Foundation201 East 19th Street, Suite 12E This publication may contain information about medications used to treat a health condition. WhenNew York, NY 10003 this publication was prepared, the NIDDK includedPhone: 1–800–OHF–8699 (643–8699) or the most current information available. Occasion­ ally, new information about medication is released. 212–777–0470 For updates or for questions about any medications,Fax: 212–777–0471 please contact the U.S. Food and Drug Administra­Email: execdirector@ohf.org tion at 1–888–INFO–FDA (463–6332), a toll-free call, or visit their website at www.fda.gov. Consult yourInternet: www.ohf.org doctor for more information.For Information AboutHyperparathyroidism:National Endocrine and MetabolicDiseases Information ServiceNational Institute of Diabetes andDigestive and Kidney DiseasesNational Institutes of Health6 Information WayBethesda, MD 20892–3569Phone: 1–888–828–0904Fax: 703–738–4929Email: endoandmeta@info.niddk.nih.gov11 Kidney Stones in Adults
    • The U.S. Government does not endorse or favor any National Kidney andspecific commercial product or company. Trade,proprietary, or company names appearing in this Urologic Diseasesdocument are used only because they are considered Information Clearinghousenecessary in the context of the information provided.If a product is not mentioned, the omission does not 3 Information Waymean or imply that the product is unsatisfactory. Bethesda, MD 20892–3580 Phone: 1–800–891–5390 Fax: 703–738–4929 Email: nkudic@info.niddk.nih.govThis publication is not copyrighted. The Clearing- Internet: www.kidney.niddk.nih.govhouse encourages users of this publication to dupli-cate and distribute as many copies as desired. The National Kidney and Urologic DiseasesThis fact sheet is also available at Information Clearinghouse (NKUDIC) is awww.kidney.niddk.nih.gov. service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). The NIDDK is part of the National Institutes of Health of the U.S. Department of Health and Human Services. Established in 1987, the Clearinghouse provides information about diseases of the kidneys and urologic system to people with kidney and urologic disorders and to their families, health care professionals, and the public. The NKUDIC answers inquiries, develops and distributes publications, and works closely with professional and patient organiza- tions and Government agencies to coordinate resources about kidney and urologic diseases. Publications produced by the Clearinghouse are carefully reviewed by both NIDDK scien- tists and outside experts. This publication was reviewed by Frederic L. Coe., M.D., University of Chicago. U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health NIH Publication No. 08–2495 October 2007