A 22 year old male was admitted with severe abdominal pain. The pain was in his left flank area goingdown into his groin. It was constant and he was not able to lie still with the pain. With the pain he feltnauseous. He did not notice any urinary symptoms. He had a similar episode six months ago whichresolved with conservative management. He stated since the episode he increased his fluid intake andinstituted a trial of dietary change. He was otherwise fit and well, except for a past medical history ofasthma for which he used clenil modulate 200mcg BD and salmeterol 100mcg BD. He smoked 20cigarettes per day and consumed 20 units of alcohol per week mainly at the weekends.

On examination he was in obvious discomfort and restless. His blood pressure was 118/72 mmHg, hisheart rate was 88 and his temperature was 36.9 degrees celcius. Examination of the cardiovascularsystem revealed the presence of normal heart sounds with warm well perfused peripheries. Other thantachypnoea, examination of his respiratory system was unremarkable. Examination of his gastrointestinalsystem revealed the presence of left renal angle tenderness but otherwise a soft non tender abdomen withno evidence of guarding or rigidity. Examination of his neurological system was unremarkable.

A number of investigations were performed:

Na 142 mmol/l

K 4.0 mmol/l

Urea 4.2 mmol/l

Creatinine 77 µmol/l

CRP 12 mg/l

Adjusted calcium 2.40 mmol/l

Urinalysis: blood +++, nil else

KUB x-ray: single solitary area of calcification within left kidney

The patient was treated conservatively with an intravenous fluid infusion, non steroidal anti-inflammatorydrugs and opioid analgesia and within 48 hours recovered fully.

He was subsequently seen in the renal clinic where he underwent a number of investigations:

Urea and electrolytes normal

Urate 0.39 (NR 0.12-0.42 mmol/l)

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Vitamin D 62 (NR 30 100 ng/ml)

Parathyroid hormone 48 (NR 11-54 pg/ml)

Urine 24 hr collection

Calcium 525 (NR 25 - 300mg/24hrs)Oxalate 21 (NR 7 - 44 mg/24hrs)Citrate 588 (NR 320 1240mg/24hrs)Sodium 137 (NR 40 220mg/24hrs)

Which therapeutic option will most likely be of benefit in the prevention of future episodes?

Calcium carbonate

Bendroflumethiazide

Allopurinol

Captopril

Furosemide

This patient has had two episodes of renal colic secondary to renal stones (note that a normal urinalysisdoes not exclude renal calculi). His abdominal xray shows calcification, hence indicating that the stonecomposition most likely contains a significant quantity of calcium. The most common types of stonecontain either calcium phosphate or calcium oxalate. Thiazide diuretics are useful in the prevention ofstones due to hypercalcuria (such as eg calcium phosphate stones); potassium citrate may be of use ofuse for calcium oxalate stones. Allopurinol is of use for uric acid stones, which tend to be radiolucent onplain xray investigations.

Renal stones: management

Acute management of renal colic

Medicationthe British Association of Urological Surgeons (BAUS) recommend diclofenac (intramuscular/oral)as the analgesia of choice for renal colic*BAUS also endorse the widespread use of alpha-adrenergic blockers to aid ureteric stone passage

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Imagingpatients presenting to the Emergency Department usually have a KUB x-ray (shows 60% of stones)the imaging of choice is a non-contrast CT (NCCT). 99% of stones are identifiable on NCCT. ManyGPs now have direct access to NCCT

Stones < 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases.

Prevention of renal stones

Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population. high fluid intakelow animal protein, low salt diet (a low calcium diet has not been shown to be superior to anormocalcaemic diet)thiazides diuretics (increase distal tubular calcium resorption)

Oxalate stonescholestyramine reduces urinary oxalate secretionpyridoxine reduces urinary oxalate secretion

Uric acid stonesallopurinolurinary alkalinization e.g. oral bicarbonate

*Diclofenac use is now less common following the MHRA warnings about cardiovascular risk. It istherefore likely the guidelines will change soon to an alternative NSAID such as naproxen

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Open MRCP Part 2 Written textbook (../review/textbook.php)

External links

European Urology Association(http://www.baus.org.uk/_userfiles/pages/files/professionals/sections/EAU2015-Urolithiasis.pdf)2015 Urolithiasis guidelines

Royal College of Physicians(http://www.clinmed.rcpjournal.org/content/12/5/467.full.pdf)2012 Kidney stone disease: pathophysiology, investigation and medical treatment

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