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Re-Recurrent Renal Stones : An Outcome of
Missed Metabolic Evaluation
Gaurang Shah*, Raseash Desai** |
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| With the success of PCNL and ESWL with less
morbidity in the treatment of symptomatic renal calculi, the
need for metabolic evaluation has been ignored by both the physician
and patient. We report a case of 45 years old female who developed
seven episodes of recurrent right multiple renal stones over
last 18 years. She underwent pyelolithotomy thrice, PCNL (percutaneous
nephrolithotomy) twice and eight sittings of ESWL for the same.
Metabolic evaluation was done for first time at her eight recurrent
renal stone by us and revealed primary hyperparathyroidism as
the missed metabolic disorder which was successfully managed
by parathyroidectomy. Levels of calcium and parathyroid hormone
became normal postoperatively. After a right D-J stenting all
right renal stones were fragmented with ESWL. Patient is now
asymptomatic, stone free with normal metabolic parameters and
has not developed recurrence at one year follow up. A simple,
effective and economical metabolic evaluation algorithm is suggested. |
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| Introduction |
The dramatic success of PCNL and ESWL for
treatment of symptomatic renal calculi has led both the physician
and patient to ignore the need for appropriate metabolic
evaluation of recurrent nephrolithiasis. Though these new
techniques have reduced the morbidity of conventional open
stone surgery, they are costly to perform and have certain
hazards and complications. Recurrent stone formation can
be prevented by identifying the underlying metabolic disorder.
The metabolic evaluation should be efficient and economical
and identify specific medical diseases like primary hyperparathyroidism,
distal renal tubular acidosis, hyperoxaluria, uric acid lithiasis
(with gout) causing recurrent urolithiasis.
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| Case Report |
| A 45 year old female patient presented with right
loin pain, vomiting and fever for 2 weeks. She had past history
of seven episodes of right renal stone recurrences and had
underwent pyelolithotomy 3 times (1986, 1990, 1993), right
PCNL twice (1995 and 1998) and 8 sittings of ESWL on right
side (1998-2002). X-rays and ultrasound done after open surgery
or PCNL had confirmed complete clearance of stones. Not a single
time till now her metabolic evaluation was done. On examination,
she had right flank tenderness, fever and raised WBC counts,
X-ray (KUB), ultrasound and IVU showed 3 stones in right kidney
(1 in pelvis - 1 cm, 2 in lower calyces - 1 cm and 7 mm) with
an obstructing right upper third ureteric stone (6 mm x 5 mm)
with back pressure changes and absolutely normal left kidney.
After intravenous antibiotics and right D-J stenting, she underwent
a complete metabolic evaluation for the first time consisting
of serum calcium, phosphorus, uric acid, electrolytes and chemical
analysis of previously removed stones. 24 hrs urinary calcium
and uric acid was also done additionally. Her S Calcium was
12.47 mg% (Normal : 8.4-11.0 mg%) and 24 hr urinary calcium
was 500 mg/24 hrs (Normal < 300 mg/24 hrs). Rest of metabolic
evaluation was normal and stones were of calcium oxalate and
phosphate. A repeat S Calcium was also high (12.52 mg%). Hence
a serum parathyroid hormone level was done which was also high
at 340 pg/ml (Normal : 10-70 pg/ml) 99mTc MIBI radio isotope
scan revealed all four parathyroid glands to be enlarged with
increased uptake. Thus with primary hyperparathyroidism as
the metabolic causative factor of her multiple renal stone
recurrences she underwent surgical removal of 3 and half parathyroid
glands. Histopathology revealed hyperplasia. After a month
of parathyroidectomy all the biochemical parameters became
normal. After two sittings of ESWL all stones were fragmented
and right kidney became stone free at 3 months and D/J stent
was removed. Patient is now asymptomatic, stone free, asymptomatic
with no recurrences and normal metabolic parameters at one
year follow up. |
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Fig. 1 : Initial X-ray (KUB). It shows three abnormal radio-opacities
opposite L2-L3 vertebra in the right renal region with no abnormal
opacity seen in the left renal region or in the pelvis. |
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Fig. 2 : 5th Recurrence X-ray (KUB). It shows four abnormal
radio-opacities opposite L2-L3 vertebra in the right renal
region with no abnormal opacity seen in the left renal region
or in the pelvis. |
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Fig. 3 : 8th Latest recurrence X-ray (KUB). It shows three
large abnormal radio-opacities opposite L2-L3 disc space in
the right renal region with no abnormal opacity seen in the
left renal region or in the pelvis. |
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Fig. 4 : 8th Latest recurrence IVU (Release Film). It shows
3 stones in right kidney (1 in pelvis-1cm, 2 in lower calyces
- 1 cm and 7 mm) with an obstructing right upper third ureteric
stone (6 mm x 5 mm) with back pressure changes and absolutely
normal left kidney. |
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| Discussion |
Urolithiasis is the third most common affliction
of the urinary tract, exceeded only by urinary tract infections
and pathological conditions of the prostate. Recurrent stone
formation has been eported within 7 years in more than 50%
of men with a single stone episode. Every first time stone
former is a potential metabolically active stone former. Hence
an efficient and economical practical metabolic stone evaluation
is recommended in all first time stone formers if morbidity
from recurrent stone disease is to be prevented and enable
rational therapy of stone disease. Common causes of metabolically
active stone diseases are primary hyperparathyroidism causing
calcium oxalate and phosphate lithiasis, gout causing uric
acid lithiasis, distal renal tubular acidosis, enteric hyperoxaluria
and infection lithiais. In our case the patient suffered from
seven episodes of stone recurrences and underwent multiple
operations before a metabolic evaluation was done.
| Table 1 : Practical metabolic work-up for
recurrent renal stone disease |
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| Urinalysis |
Microscopic
pH
Culture and Sensitivity |
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| Blood Chemistries |
Calcium
Phosphate
Uric Acid
Creatinine
Electrolytes |
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| 24 HR |
Urine chemistries Calcium
Creatinine
Phosphate
Uric Acid
Oxalate
Total Volume |
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| Stone analysis |
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Metabolic evaluation is mandatory to diagnose primary aetiology in recurrent
renal stone formers, paediatric patients, patients with nephrocalcinosis
and patients with positive family history. A practical and cost-effective
metabolic work up is shown in Primary hyperparathyroidism is the commonest
cause of hypercalcaemia causing recurrent stones. It occurs in females
between 20 and 60 years of life. The most common presentation is the detection
of unsuspected and asymptomatic hypercalcaemia (serum calcium close to
the upper limit of normal, or over 10.1 mg/dl) during routine biochemical
screening.2 “Bones, stones, abdominal goans and psychic moans” only
50% of the patients suffer from any of these.3 Primary hyperparathyroidism
occurs due to hyperplasia, adenoma or rarely carcinoma and is confirmed
by a raised plasma parathyroid (PTH) level. Thallium 101 and MIBI technetium
isotope scan is superior to ultrasound, CT scan and MRI of neck for pre-operative
localization of gland and differentiating between hyperplasia, adenoma
and carcinoma.3 Patients with calcium phosphate stones, women with recurrent
calcium stones and those with both nephrocalcinosis and nephrolithiasis
should be suspected of having hyperparathyroidism. This group represents
5-10% of all patients with urolithiasis.1 Treatment includes removal of
both, the stone by PCNL, ESWL or pyelolithotomy and parathyroidectomy.
In parathyroid adenoma removal of the adenoma suffices and in hyperplasia
removal of three and half parathyroid is recommended. Hypercalcaemia reverts
to normal postoperatively in all. One controlled retrospective study done
by Charlotte L Mollerup et al showed that the parathyroid surgery reduces
the recurrence of renal stones by 8.3% but after 10 years of surgery the
risk returns to the same as in normal persons.4 This suggests that idiopathic
hypercalcaemia may play an important role in recurrent stone formation. |
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| Conclusion |
| Thus, this case emphasizes importance of metabolic
evaluation along with expedient diagnosis and efficient treatment
in recurrent stone formers due to metabolic disorder. An efficient,
practical and cost-effective metabolic workup goes a long way
in preventing patient morbidity due to repeated surgeries for
same illness. This also helps in directing appropriate medical
therapy and lifestyle changes to reduce recurrence rate. |
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| References |
| 1. |
Marshall L, Stoller, Damien
M Bolton. Urinary stone disease : In Smith’s General
Urology, 15th edition, chapter 17; The McGraw Hill Companies,
USA; 2000; 291-321. |
| 2. |
Mani Menon, Martin I Resnick. Urinary
lithiasis : Etiology, Diagnosis, and Medical Management;
In Campbell’s Urology, 8th edition, chapter 96,
Saunders, Philadelphia-Pennsylvania; 2002; 4 : 3243-48.. |
| 3. |
Anthony W Goode. The parathyroid and
adrenal glands; In Bailey and Love’s Short Practice
of Surgery, 23rd edition, chapter 38; Arnold, London;
2000; 734-39. |
| 4. |
Charlotte L Mollerup, Peter Vestergaad,
Vibe Gedso Frokjaer, Leif Mosekilde, et al. Risk of renal
stone events in primary hyperparathyroidism before and
after parathyroid surgery: controlled retrospective followup
study. BMJ 2002; 325 (7368) : 807. |
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Use NSAIDs for renal colic
In patients with acute renal colic, non-steroidal
anti-inflammatory drugs (NSAIDs) should be the drug treatment
of choice. Reviewing 20 trials including 1613 patients
with renal colic, Holdgate and Pollock found that patients
taking non-steroidal anti-inflammatory drugs had slightly
less pain and were less likely to need additional analgesia
than those taking opioids. Those taking opioids were more
likely to have vomiting or other adverse events..
BMJ, 2004; 328 : 1401.
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