Kidney stones

KIDNEY STONES

Kidney stones are small, hard deposits that form in the urine and are made up of minerals and acid salts.

Kidney stones are composed of organic and inorganic crystals amalgamated with proteins. Calcium stones are the most frequent type, accounting for up to 80% of cases. Some risk factors for stone diseases are genetic causes like cystinuria, and anatomic abnormalities like horseshoe kidney, solitary kidney, etc.

Management of stone diseases needs individualization. Clinical presentation, proper history, and laboratory tests help identify whether one needs urgent surgical or medical treatment.

FORMATION

The nucleus for a stone can be formed by the presence of a small lesion. Crystals get deposited on the nucleus and continue to grow. These can sometimes adhere to renal papillae.

SUBSTANCES FOUND IN THE CALCULI

• Uric acid
• Triple phosphate
• Urate
• Calcium carbonate
• Calcium phosphate
• Calcium oxalate
• Cholesterol
• Cystine
• Xanthine

MECHANISM

Urine supersaturation → Nucleus Formation → Crystallization & aggregation → Matrix Formation → Kidney Stone

AETIOPATHOGENESIS

• Infection: Pseudomonas, Klebsiella, etc.
• Hot climate
• Dietary factors: Red meat, fish, tomatoes, milk, diet lacking in vitamin A
• Metabolic factors: Hypoparathyroidism, immobilization, decreased urinary citrate
• Inadequate urinary drainage
• Randall’s plaque

TYPES

COMMON STONES

1. Calcium Oxalate stones (Mulberry calculi – 75%):

   • Dumbbell or enveloped shape
   • Hard, single, and irregular
   • Sharp projections produce hematuria, resulting in blood deposition over the stone, giving it a dark brown color.

2. Uric acid stones (5%):

   • Occur in acidic urine
   • Multiple, small, hard, faceted, yellow-colored with varying size and shape
   • Pure uric acid stones are radiolucent.
   • Common in patients who consume red meat
   • Best responsive to lithotripsy

3. Phosphate stones (15%):

   • Triple phosphate: Calcium ammonium magnesium phosphate
   • Commonly occur in the renal pelvis and tend to grow in alkaline urine
   • Smooth, round, dirty white to yellow in color and attain a large size with a coffin lid shape

4. Cystine calculi (2%):

   • Occur in young girls at puberty
   • Commonly found in cystinuria (defective absorption of cystine from renal tubules)
   • Stones are yellow in color with a hexagonal shape and are radio-opaque due to sulfur.

UNCOMMON STONES

• Xanthine stones
• Dihydroxy adenine stones
• Silicate stones
• Matrix stones

URETERIC STONE SITES

• Pelviureteric junction
• Crossing of the iliac artery
• Crossing of the broad ligament
• Sites of entry into the bladder wall
• Ureteric orifice

CLINICAL FEATURES/SYMPTOMS

• Pain: Renal pain – renal angle, hypochondrium, lumbar region; Ureteric colic – radiating to groin and testis in males, with vomiting; Pain worsens on movement
• Hematuria
• Pyuria
• Fever
• Tenderness over the renal angle, often with a mass in the loin – moves with respiration, bimanually palpable, ballotable
• Urinary tract infection
• Guarding and rigidity

COMPLICATIONS

1. Calculous Hydronephrosis
2. Calculous Pyonephrosis
3. Renal Failure
4. Squamous cell carcinoma

INVESTIGATIONS

• Blood – Urea, Creatinine
• Plain x-ray KUB (Kidney, Ureter, Bladder)
• USG (Ultrasound)
• IVP (Intravenous Pyelogram)
• CT (Computed Tomography)
• Urine analysis

TREATMENT IN AYURVEDA

According to Ayurveda, kidney stones (Ashmari) are due to apathya sevana (unwholesome diet and lifestyle) and other etiological factors (viruddha vihara), leading to the vitiation of Kapha dosha in the urine. This results in the formation of Ama (toxins) and leads to mandagni (low digestive fire). Kapha accumulates in the kidneys (vrikka), and the action of ushma (heat) of Pitta, along with the drying effect of Vata dosha, dries up the urine. The vitiated Kapha dosha in the vrikka bhaga (kidney region) hardens the components lodged within. Mutra Ashmari is formed in the form of gravel and obstructs the mutravaha srotas (urinary tract).

Common symptoms: Sudden pain in the right or left lower abdomen (flanks) that radiates from back to front, pain during urination, burning sensation during urination, pain in the bladder and urethra, reduced urine output, yellow or reddish-yellow colored urine, lethargy, vomiting sensation, headache, body ache, etc.

The patient is advised to drink plenty of water and avoid a protein-rich diet (egg, meat, soybean, dairy products, etc.) and oxalate-rich food (spinach, tomatoes, ladyfinger, chocolates, cold drinks, etc.).

The use of calcium tablets, syrups, and vitamin C should be minimized, but milk and milk products containing natural calcium are beneficial. Diabetes and obesity should be controlled. Urine acidity should be controlled.

Regarding diet, increase consumption of the following vegetables, cereals, and fruits: Carrot, bitter gourd, potatoes, radish, pumpkin, banana, apple, apricot, lemon, almond, barley, horse gram, etc. Eat more fruits with high water content.

It is good to use barley water, buttermilk, coconut water, lemon water, pumpkin juice, etc. Drink boiled water of njerinjil, thazhuthama, etc.

Kalluruki, Kallurvanchi, root bark of moringa, and cardamom are useful as single herbs but use only as per medical prescription. Depending on the severity of the disease and the type of stone, use various kashaya (decoctions), arishtam (fermented preparations), gutika (tablets), and ghruta (medicated ghee) as prescribed by the doctor.

Some formulations include chandraprabha vati, varanadi kashayam, gokshuradi guggulu, etc.

Treatments like avagaha swedam (sitz bath) are also beneficial for pain relief and stone removal.