Kidney stones

A kidney stone is a hard mass developed from crystals that separate from the urine and build up on the inner surfaces of the kidney. Kidney stones may be as small as a grain of sand or as large as a pearl. Some stones are even as big as golf balls. Stones may be smooth or jagged. They are usually yellow or brown. Urolithiasis is the medical term used to describe stones occurring in the urinary tract. Gallstones and kidney stones are not related. They form in different areas of the body.

Types
There are four major types of kidney stones. Calcium stone. This is the most common type of kidney stones. It contains calcium in combination with either oxalate or phosphate. These chemicals are part of a person's normal diet and make up important parts of the body, such as bones and muscles. Struvite stone. This type of stone is caused by a bacterial infection in the urinary system. The stone contains ammonia resulting from specific enzymes produced by the bacteria. Uric acid stone. It may form when there is too much acid in the urine. Cystine stone. This type of stone is rare. Cystine is one of the building blocks that make up muscles, nerves, and other parts of the body. Cystine can build up in the urine to form a stone. The disease that causes cystine stones runs in families.

Symptoms
Kidney stones often do not cause any symptoms. Usually, the first symptom of a kidney stone is extreme pain, which occurs when a stone acutely blocks the flow of urine. The pain often begins suddenly when a stone moves in the urinary tract, causing irritation or blockage. Typically, a person feels a sharp, cramping pain in the back and side in the area of the kidney or in the lower abdomen. Sometimes nausea and vomiting occur. Later, pain may spread to the groin. If the stone is too large to pass easily, pain continues as the muscles in the wall of the tiny ureter try to squeeze the stone along into the bladder. As a stone grows or moves, blood may appear in the urine. As the stone moves down the ureter closer to the bladder, you may feel the need to urinate more often or feel a burning sensation during urination. If fever and chills accompany any of these symptoms, an infection may be present. In this case, you should contact a doctor immediately.

Diagnosis
Sometimes "silent" stonesthose that do not cause symptomsare found on x rays taken during a general health exam. If they are small, these stones would likely pass out of the body unnoticed. More often, kidney stones are found on an x ray or sonogram taken on someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone's size and location. Blood and urine tests help detect any abnormal substance that might promote stone formation. The doctor may decide to scan the urinary system using a special test called a CT (computed tomography) scan or an IVP (intravenous pyelogram). The results of all these tests help determine the proper treatment.

Causes
Normally, urine contains chemicals that prevent or inhibit the crystal formation from the substances that constitute a kidney stone. If the level of inhibiting chemicals is too low, or the concentration of stone constituents (calcium, oxalate, phosphate, ammonia, uric acid, or cystine) is too high, a kidney stone may develop. The concentrations of chemicals in the urine depend on heredity, drugs, diet, and certain medical conditions. Hypercalciuria (elevated calcium level) is inherited. It is the cause of stones in more than half of patients. Calcium is absorbed from food in 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 urinary tract. Other causes of kidney stones are hyperuricosuria which is a disorder of uric acid metabolism, gout, excess intake of vitamin D, urinary tract infections, and blockage of the urinary tract. Certain diuretics which are commonly called water pills or calciumbased antacids may increase the risk of forming kidney stones by increasing the amount of calcium in the urine. Calcium oxalate stones may also form in people who have a chronic inflammation of the bowel or who have had an intestinal bypass operation, or ostomy surgery. As mentioned above, struvite stones can form in people who have had a urinary tract infection. People who take the protease inhibitor indinavir, a drug used to treat HIV infection, are at risk of developing kidney stones. Cystinuria and hyperoxaluria are two other rare, inherited metabolic disorders that often cause kidney stones. In cystinuria, too much of the amino acid cystine, which does not dissolve in urine, is voided. This can lead to the formation of stones made of cystine. In patients with hyperoxaluria, the body produces too much of the salt oxalate. When there is more oxalate than can be dissolved in the urine, the crystals settle out and form stones. In addition, more than 70 percent of people with a rare hereditary disease called renal

tubular acidosis develop kidney stones. If you've had more than one kidney stone, you are likely to form another; so prevention is very important. In most cases, kidney stones can be avoided by making a few lifestyle changes. In some cases, the doctor may prescribe certain medications. Lifestyle Changes A simple and most important lifestyle change to prevent stones is to drink more liquids water is best. If you tend to form stones, you should try to drink enough liquids throughout the day to produce at least 2 quarts of urine in every 24-hour period. People who form calcium stones used to be told to avoid dairy products and other foods with high calcium content. But recent 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. You may be told to avoid food with added vitamin D and certain types of antacids that have a calcium base. If you have very acidic urine, you may need to eat less meat, fish, and poultry. These foods increase the amount of acid in the urine. To prevent cystine stones, you should drink enough water each day to dilute the concentration of cystine that escapes into the urine, which may be difficult. More than a gallon of water may be needed every 24 hours, and a third of that must be drunk during the night.

Foods and Drinks Containing Oxalate People prone to forming calcium oxalate stones may be asked by their doctor to cut back on certain foods if their urine contains an excess of oxalate: beets chocolate coffee cola nuts rhubarb spinach strawberries tea wheat bran People should not give up or avoid eating these foods without talking to their doctor first. In most cases, these foods can be eaten in limited amounts. Medical Therapy The doctor may prescribe certain medications to prevent calcium and uric acid stones. These drugs control the amount of acid or alkali in the urine, key factors in crystal formation. The drug allopurinol may also be useful in some cases of hyperuricosuria. Doctors usually try to control hypercalciuria, and thus prevent calcium stones, by prescribing certain diuretics, such as hydrochlorothiazide. These drugs decrease the amount of calcium released by the kidneys into the urine by favoring calcium retention in bone. They work best when sodium intake is low. Very rarely, patients with hypercalciuria may be given the drug sodium cellulose phosphate, which binds calcium in the intestines and prevents it from leaking into the urine. If cystine stones cannot be controlled by drinking more fluids, your doctor may prescribe drugs such as Thiola and Cuprimine, which help reduce the amount of cystine in the urine. For struvite stones that have been totally removed, the first line of prevention is to keep

the urine free of bacteria that can cause infection. Your urine will be tested regularly to be sure that no bacteria are present. If struvite stones cannot be removed, your doctor may prescribe a drug called acetohydroxamic acid (AHA). AHA is used with long-term antibiotic drugs to prevent the infection that leads to stone growth. Most kidney stones can pass through the urinary system with plenty of water (2 to 3 quarts a day) to help move the stone along. Often, you can stay home during this process, drinking fluids and taking pain medication as needed. The doctor usually asks you to save the passed stone(s) for testing. If the kidney stone does not pass after a reasonable period of time and causes constant pain is too large to pass on its own or is caught in a difficult place blocks the flow of urine causes ongoing urinary tract infection damages kidney tissue or causes constant bleeding has grown larger (as seen on followup x ray studies). then you may need one of the following procedures. Extracorporeal Shockwave Lithotripsy Extracorporeal shockwave lithotripsy (ESWL) is the most frequently used procedure for the treatment of kidney stones. In ESWL, shock waves that are created outside the body travel through the skin and body tissues until they hit the denser stones. The stones break down into sand-like particles and are easily passed through the urinary tract in the urine.

There are several types of ESWL devices. In one device, the patient reclines in a water bath while the shock waves are transmitted. Other devices have a soft cushion on which the patient lies. Most devices use either x rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of ESWL procedures, anesthesia is needed. In most cases, ESWL may be done on an outpatient basis. Recovery time is short, and most people can resume normal activities in a few days. Complications may occur with ESWL. Most patients have blood in their urine for a few days after treatment. Bruising and minor discomfort in the back or abdomen from the shock waves are also common. To reduce the risk of complications, doctors usually tell patients to avoid taking aspirin and other drugs that affect blood clotting for several weeks before treatment. Another complication may occur if the shattered stone particles cause discomfort as they pass through the urinary tract. In some cases, the doctor will insert a small tube called a stent through the bladder into the ureter to help the fragments pass. Sometimes the stone is not completely shattered with one treatment, and additional treatments may be needed. ESWL is not ideal for very large stones. Percutaneous Nephrolithotomy Sometimes a procedure called percutaneous nephrolithotomy is recommended to remove a stone. This treatment is often used when the stone is quite large or in a location that does not allow effective use of ESWL.

In this procedure, the surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney. Using an instrument called a nephroscope, the surgeon locates and removes the stone. For large stones, some type of energy probe (ultrasonic or electrohydraulic) may be needed to break the stone into small pieces. Generally, patients stay in the hospital for several days and may have a small tube called a nephrostomy tube left in the kidney during the healing process. One advantage of percutaneous nephrolithotomy over ESWL is that the surgeon removes the stone fragments instead of relying on their natural passage from the kidney. Ureteroscopic Stone Removal

Although some kidney stones in the ureters can be treated with ESWL, ureteroscopy may be needed for mid- and lower-ureter stones. No incision is made in this procedure. Instead, the surgeon passes a small fiberoptic instrument called a ureteroscope through the urethra and bladder into the ureter. The surgeon then locates the stone and either removes it with a cage-like device or shatters it with a special instrument that produces a form of shock wave. A small tube or stent may be left in the ureter for a few days to help the lining of the ureter heal. Before fiber optics made ureteroscopy possible, physicians used a similar "blind basket" extraction method. But this outdated technique should not be used because it may damage the ureters.

Gallstones
Gallstones form when liquid stored in the gallbladder hardens into pieces of stone-like 7

material. The liquid, called bile, is used to help the body digest fats. Bile is made in the liver, then stored in the gallbladder until the body needs to digest fat. At that time, the gallbladder contracts and pushes the bile into a tubecalled the common bile ductthat carries it to the small intestine, where it helps with digestion. Bile contains water, cholesterol, fats, bile salts, proteins, and bilirubin. Bile salts break up fat, and bilirubin gives bile and stool a yellowish color. If the liquid bile contains too much cholesterol, bile salts, or bilirubin, under certain conditions it can harden into stones. The two types of gallstones are cholesterol stones and pigment stones. Cholesterol stones are usually yellow-green and are made primarily of hardened cholesterol. They account for about 80 percent of gallstones. Pigment stones are small, dark stones made of bilirubin. Gallstones can be as small as a grain of sand or as large as a golf ball. The gallbladder can develop just one large stone, hundreds of tiny stones, or almost any combination.

The gallbladder and the ducts that carry bile and other digestive enzymes from the liver, gallbladder, and pancreas to the small intestine are called the biliary system.

Gallstones can block the normal flow of bile if they lodge in any of the ducts that carry bile from the liver to the small intestine. That includes the hepatic ducts, which carry bile out of the liver; the cystic duct, which takes bile to and from the gallbladder; and the common bile duct, which takes bile from the cystic and hepatic ducts to the small intestine. Bile trapped in these ducts can cause inflammation in the gallbladder, the ducts, or, rarely, the liver. Other ducts open into the common bile duct, including the pancreatic duct, which carries digestive enzymes out of the pancreas. If a gallstone blocks the opening to that duct, digestive enzymes can become trapped in the pancreas and cause an extremely painful inflammation called gallstone pancreatitis. If any of these ducts remain blocked for a significant period of time, severepossibly fataldamage or infections affecting the gallbladder, liver, or pancreas can occur. Warning signs of a serious problem are fever, jaundice, and persistent pain.

Symptoms
Symptoms of gallstones are often called a gallstone "attack" because they occur suddenly. A typical attack can cause steady pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours pain in the back between the shoulder blades pain under the right shoulder nausea or vomiting Gallstone attacks often follow fatty meals, and they may occur during the night. Other gallstone symptoms include abdominal bloating recurring intolerance of fatty foods colic belching gas indigestion People who also have the above and any of following symptoms should see a doctor right away: chills low-grade fever yellowish color of the skin or whites of the eyes clay-colored stools Many people with gallstones have no symptoms. These patients are said to be asymptomatic, and these stones are called "silent stones." They do not interfere with gallbladder, liver, or pancreas function, and do not need treatment.

Diagnosis
Many gallstones, especially silent stones, are discovered by accident during tests for other problems. But when gallstones are suspected to be the cause of symptoms, the doctor is likely to do an ultrasound exam. Ultrasound uses sound waves to create images of organs. Sound waves are sent toward the gallbladder through a handheld device that a technician

glides over the abdomen. The sound waves bounce off the gallbladder, liver, and other organs such as a pregnant uterus, and their echoes make electrical impulses that create a picture of the organ on a video monitor. If stones are present, the sound waves will bounce off them, too, showing their location. Ultrasound is the most sensitive and specific test for gallstones. Other tests may also be used. Computed tomography (CT) scan may show the gallstones or complications. Magnetic resonance cholangiogram may diagnose blocked bile ducts. Cholescintigraphy (HIDA scan) is used to diagnose abnormal contraction of the gallbladder or obstruction. The patient is injected with a radioactive material that is taken up in the gallbladder, which is then stimulated to contract. Endoscopic retrograde cholangiopancreatography (ERCP). The patient swallows an endoscopea long, flexible, lighted tube connected to a computer and TV monitor. The doctor guides the endoscope through the stomach and into the small intestine. The doctor then injects a special dye that temporarily stains the ducts in the biliary system. ERCP is used to locate and remove stones in the ducts. Blood tests. Blood tests may be used to look for signs of infection, obstruction, pancreatitis, or jaundice. Gallstone symptoms are similar to those of heart attack, appendicitis, ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. So accurate diagnosis is important.

Causes
Cholesterol Stones Scientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty as it should for some other reason. Pigment Stones The cause of pigment stones is uncertain. They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders, such as sickle cell anemia, in which too much bilirubin is formed. Surgery Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones. (Asymptomatic gallstones usually do not need treatment.) Each year more than 500,000 Americans have gallbladder surgery. The surgery is called cholecystectomy.

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The most common operation is called laparoscopic cholecystectomy. For this operation, the surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a closeup view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures. Then the cystic duct is cut and the gallbladder removed through one of the small incisions. Because the abdominal muscles are not cut during laparoscopic surgery, patients have less pain and fewer complications than they would have had after surgery using a large incision across the abdomen. Recovery usually involves only one night in the hospital, followed by several days of restricted activity at home. If the surgeon discovers any obstacles to the laparoscopic procedure, such as infection or scarring from other operations, the operating team may have to switch to open surgery. In some cases the obstacles are known before surgery, and an open surgery is planned. It is called "open" surgery because the surgeon has to make a 5- to 8-inch incision in the abdomen to remove the gallbladder. This is a major surgery and may require about a 2- to 7-day stay in the hospital and several more weeks at home to recover. Open surgery is required in about 5 percent of gallbladder operations. The most common complication in gallbladder surgery is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and potentially dangerous infection. Mild injuries can sometimes be treated nonsurgically. Major injury, however, is more serious and requires additional surgery. If gallstones are in the bile ducts, the physician (usually a gastroenterologist) may use endoscopic retrograde cholangiopancreatography (ERCP) to locate and remove them before or during the gallbladder surgery. In ERCP, the patient swallows an endoscopea long, flexible, lighted tube connected to a computer and TV monitor. The doctor guides the endoscope through the stomach and into the small intestine. The doctor then injects a special dye that temporarily stains the ducts in the biliary system. Then the affected bile duct is located and an instrument on the endoscope is used to cut the duct. The stone is captured in a tiny basket and removed with the endoscope. Occasionally, a person who has had a cholecystectomy is diagnosed with a gallstone in the bile ducts weeks, months, or even years after the surgery. The two-step ERCP procedure is usually successful in removing the stone. Nonsurgical Treatment Nonsurgical approaches are used only in special situationssuch as when a patient has a serious medical condition preventing surgeryand only for cholesterol stones. Stones usually recur after nonsurgical treatment. Oral dissolution therapy. Drugs made from bile acid are used to dissolve the stones. The drugs, ursodiol (Actigall) and chenodiol (Chenix), work best for small cholesterol stones. Months or years of treatment may be necessary before all the stones dissolve. Both drugs cause mild diarrhea, and chenodiol may temporarily 11

raise levels of blood cholesterol and the liver enzyme transaminase. Contact dissolution therapy. This experimental procedure involves injecting a drug directly into the gallbladder to dissolve stones. The drugmethyl tertbutyl ether can dissolve some stones in 1 to 3 days, but it must be used very carefully because it is a flammable anesthetic that can be toxic. The procedure is being tested in patients with symptomatic, noncalcified cholesterol stones.

Don't people need their gallbladder?

Fortunately, the gallbladder is an organ that people can live without. Losing it won't even require a change in diet. Once the gallbladder is removed, bile flows out of the liver through the hepatic ducts into the common bile duct and goes directly into the small intestine, instead of being stored in the gallbladder. However, because the bile isn't stored in the gallbladder, it flows into the small intestine more frequently, causing diarrhea in about 1 percent of people.

Proteinuria
Proteinuria describes a condition in which urine contains an abnormal amount of protein. A major protein in the blood is called albumin, which acts like a sponge, drawing extra fluid from the body into the bloodstream, where it remains until the kidneys remove it. But when albumin leaks into the urine, the blood loses its capacity to absorb extra fluid from the body. Fluid can accumulate outside the circulatory system in the face, hands, feet, or ankles and cause swelling.

Symptoms and Diagnosis

Large amounts of protein in your urine may cause it to look foamy in the toilet. Also, because the protein albumin has left your body, your blood can no longer soak up enough fluid and you may notice swelling in your hands, feet, abdomen, or face. These are signs of very large protein loss. More commonly, you may have proteinuria without noticing any signs or symptoms. Testing is the only way to find out how much protein you have in your urine. To test for proteinuria, you will need to give a urine sample. A strip of chemically treated paper will change color when dipped in urine that has too much protein. Laboratory tests that measure exact amounts of protein or albumin in the urine are recommended for people at risk for kidney disease, especially those with diabetes. The protein-to-creatinine or albumin-to-creatinine ratio can be measured on a sample of urine to detect smaller amounts of protein, which can indicate kidney disease. If the laboratory test shows high levels of protein, another test should be done 1 to 2 weeks later. If the second test also shows high levels of protein, you have persistent proteinuria and should have additional

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tests to evaluate your kidney function. Your doctor will also test a sample of your blood for creatinine and urea nitrogen. These are waste products that healthy kidneys remove from the blood. High levels of creatinine and urea nitrogen in your blood indicate that kidney function is impaired.

Causes
As blood passes through healthy kidneys, they filter the waste products out and leave in the things the body needs, like proteins. Most proteins are too big to pass through the kidneys' filters (called glomeruli) into the urine unless the filters are damaged. Inflammation in the glomeruli is called glomerulonephritis, or simply nephritis. Many diseases can cause this inflammation, which leads to proteinuria. Additional processes that can damage the glomeruli and cause proteinuria include diabetes, hypertension, and other forms of kidney diseases.

Treatment
If you have diabetes, hypertension, or both, the first goal of treatment will be to control your blood glucose and blood pressure. If you have diabetes, you should test your blood glucose often, follow a healthy eating plan, take your medicines, and get plenty of exercise. If you have diabetes and high blood pressure, your doctor may prescribe a medicine from a class of drugs called ACE (angiotensin-converting enzyme) inhibitors or a similar class called ARBs (angiotensin receptor blockers). These drugs have been found to protect kidney function even more than other drugs that provide the same level of blood pressure control. The American Diabetes Association recommends that people with diabetes keep their blood pressure below 130/80. People who have high blood pressure and proteinuria but not diabetes also benefit from taking an ACE inhibitor or ARB. Their blood pressure should be maintained below 130/80. To maintain this target, you may need to take a combination of two or more blood pressure medicines. Your doctor may also prescribe a diuretic in addition to your ACE inhibitor or ARB. Diuretics are also called "water pills" because they help you urinate and get rid of excess fluid in your body. In addition to blood glucose and blood pressure control, the National Kidney Foundation recommends restricting dietary salt and protein. Your doctor may refer you to a dietitian to help you develop and follow a healthy eating plan.

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