Nephrolithiasis

Last reviewed: 28 Feb 2023

Last updated: 28 Oct 2020

Nephrolithiasis (kidney stones) is a common condition, typically affecting adult men more commonly than adult women, although this difference is narrowing.

Patients typically present with acute renal colic, although some patients are asymptomatic.

Multiple risk factors include chronic dehydration, diet, obesity, positive family history, specific medications, and various metabolic abnormalities.

Non-contrast computed tomography scan of the abdomen/pelvis is the imaging modality with the highest sensitivity and specificity to diagnose stones. Plain x-ray (KUB) and renal ultrasound can be utilized for diagnosis in some cases, such as a desire to reduce or eliminate radiation exposure.

Treatment consists of both medical and surgical therapies.

24-hour urine tests are recommended for most stone formers to determine the cause of stone formation and optimal treatment to help prevent future stone episodes.

Definition

Nephrolithiasis refers to the presence of crystalline stones (calculi) within the urinary system (kidneys and ureter). Such renal stones are composed of varying amounts of crystalloid and organic matrix. Ureteric stones almost always originate in the kidney but then pass down into the ureter.[1] BMJ talk medicine: nephrolithiasis Opens in new window

History and exam

Key diagnostic factors

acute, severe flank pain

More key diagnostic factors

Other diagnostic factors

previous episodes of nephrolithiasis
nausea and vomiting
urinary frequency/urgency
hematuria
testicular pain
obesity
family history of nephrolithiasis
precipitant medications
groin pain
fever
tachycardia
hypotension
costovertebral angle and ipsilateral flank tenderness

Other diagnostic factors

Risk factors

high protein intake
high salt intake
white ancestry
male sex
dehydration
obesity
crystalluria
occupational exposure to dehydration
warm climate
family history of nephrolithiasis
precipitant medications

More risk factors

Diagnostic investigations

1st investigations to order

urinalysis
CBC and differential
serum electrolytes, BUN, and creatinine
urine pregnancy test
noncontrast helical CT scan
stone analysis

More 1st investigations to order

Investigations to consider

plain abdominal radiograph (KUB)
renal ultrasound
intravenous pyelogram (IVP)
magnetic resonance imaging (MRI)
24-hour urine monitoring
spot urine for cystine

More investigations to consider

Treatment algorithm

INITIAL

acute renal colic nonpregnant

ACUTE

confirmed stone: no evidence of obstruction nonpregnant

confirmed stone: with evidence of obstruction nonpregnant

pregnant

ONGOING

following an acute episode nonpregnant

Contributors

Authors

Jodi Antonelli, MD

Assistant Professor

Department of Urology

University of Texas Southwestern Medical Center

Dallas

Disclosures

JA has received a grant for being a member of the Scientific Advisory Board for Boston Scientific, a company that manufactures products for kidney stone surgery. JA has received a research grant from the US National Institutes of Health to study strategies to reduce recurrence of nephrolithiasis and reduce stent-associated pain.

Naim Maalouf, MD

Associate Program Director

Associate Professor

University of Texas Southwestern Medical Center

Dallas

Disclosures

NM has received a research grant from the US National Institutes of Health to study strategies to reduce recurrence of nephrolithiasis and reduce stent-associated pain.

Acknowledgements

Dr Jodi Antonelli and Dr Naim Maalouf would like to gratefully acknowledge Dr Brian Eisner, Dr Michael E. Lipkin, Dr Muhammad Iqbal, Dr Keith Xavier, and Dr Mantu Gupta, previous contributors to this monograph. BE has received fees for consulting from Boston Scientific, Olympus/Gyrus ACMI, PercSys, and The Ravine Group. MEL declares that he is a consultant for Boston Scientific Corporation. MI, KX, and MG declare that they have no competing interests.

Peer reviewers

Robert Tompkins, MD

Associate Professor

Department of Family Medicine

University of Texas Health Science Center

Tyler

Disclosures

RT declares that he has no competing interests.

Lynda Frassetto, MD

Associate Professor of Medicine

Division of Nephrology

University of California at San Francisco

Disclosures

LF declares that she has no competing interests.

Irfan Moinuddin, MD

Assistant Professor

Chicago Medical School

Rosalind Franklin University

Lombard

Disclosures

IM declares that he has no competing interests.

Nagaraja Rao, MBBS, ChM, FRCS

Consultant Urological Surgeon

Spire Manchester Hospital

Manchester

Disclosures

NR declares no competing interests.

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Nephrolithiasis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

acute renal colic nonpregnant

confirmed stone: no evidence of obstruction nonpregnant

confirmed stone: with evidence of obstruction nonpregnant

pregnant

following an acute episode nonpregnant

Contributors

Authors

Jodi Antonelli, MD

Disclosures

Naim Maalouf, MD

Disclosures

Acknowledgements

Peer reviewers

Robert Tompkins, MD

Disclosures

Lynda Frassetto, MD

Disclosures

Irfan Moinuddin, MD

Disclosures

Nagaraja Rao, MBBS, ChM, FRCS

Disclosures

Differentials

Guidelines

Patient leaflets

Log in or subscribe to access all of BMJ Best Practice

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