PREVENTION AND TREATMENT OF KIDNEY STONES

Kidney stones are hard deposits of minerals that form inside the kidneys due to a lack of fluids to dissolve them. In the general course, our kidneys function effectively to filter the waste and fluid out of our bodies through urine; however, when the natural process is disturbed and there is excessive waste and simultaneous lack of fluids to dissolve it, it leads to the creation of hard mass that appear like stones in kidneys. A kidney stone is formed when excessive minerals build up in the urine because of a lack of hydration. These stones can vary greatly in size – these could be the size of a kernel, corn or grain of salt and are often very painful. However, in several cases, the stone might go unnoticed for a long period of time until it starts to stir inside the kidney and move towards the ureter. These stones are brown, yellowish in colour and are soft and hard in texture.

Kidney stones are created when the levels of minerals such as calcium, oxalate and uric acid are very high in the urine and they tend to accumulate over time due to lack of fluids to dissolve them properly.

That said, some of the factors that cause kidney stones or increase the risk of kidney stones are:

  • Lack of water
  • Excessively rich diet of protein, sugar or sodium
  • Obesity
  • History of kidney stones
  • Family history of kidney stones
  • Past record of gastric bypass or intestinal surgery
  • Kidney disease such as polycystic or cystic
  • Irritation in bowel or joints
  • Diarrhoea
  • Digestive problems
  • Medications
  • Medical conditions

A small stone might pass through the urinary tract, sometimes on its own or through little medical help. However, in cases where the stone size is relatively big, surgery may be the only solution. Kidney stones in general cases are extremely painful and cause a lot of discomfort.

Thus, the best way to manage this problem is to avoid the problem on the whole – prevent the formation of kidney stones.

Prevention of Kidney Stones

It is easy to prevent the formation of kidney stones by making some adjustments in the diet, as well as everyday living. 

Staying hydrated: The formation of kidney stones happens basically because of lack of fluids to dissolve the accumulated minerals. Hence, the core to prevent the problem is to drink a lot of water to ensure there is proper dissolution of the minerals in the body. On a general level, a normal person should consume 8 litres of water on a daily basis. Moreover, for people who sweat a lot, additional intake of water needs to be included. Lack of water results in low urine output, causing accumulation of urine salts, leading to the formation of stones. 

Eating a calcium-rich diet: Excess calcium does not cause the formation of stones, instead, a calcium-rich dietincluding items such as low-fat milk, cheese, and yogurt is known to prevent the formation of stones. 

Reducing sodium intake: Excess salt prevents the calcium from being reabsorbed from the urine to the blood, leading to a heavy concentration of calcium in the urine and the formation of kidney stones. Avoid food such as processed items, canned soups, canned vegetables, and condiments.

Reduce oxalate-rich foods: Foods such as spinach, chocolate, sweet potatoes, coffee, peanuts, wheat bran, etc. are naturally rich in oxalate. A large intake of these foods can cause excessive oxalate to combine with calcium in the urine to form stones

Avoid animal protein: Animal protein such as beef, poultry, fish and pork might get acidic in the body, thereby increasing the concentration of urine acid that causes uric acid and calcium oxalate kidney stones.

Avoiding vitamin C supplements: Only vitamin C naturally present in the food is permitted for the body. Other than that vitamin c supplements can cause kidney stones.

Moreover, on the advice of the doctor, you can also take some preventive medications for stones.

Treatment for Kidney Stones

The treatment for kidney stones depends on factors – the size of the stone, the composition of stone, and whether or not it is causing pain or blocking the urinary tract. To know the accurate answer to these questions, the doctor will ask you to get some tests including urine test, blood test, CT scan or X-ray. Once, the results of the tests are clear, the doctor will suggest any of the following options as a course of treatment:

  • If the stone is small and has negligible symptoms, the doctor will ask you to wait for a period of at least 2-4 weeks for the kidney stone to pass on its own by drinking excess water.
  • The doctor might suggest pain killers and would ask you to allow the stone to pass through on their own.
  • The last resort is surgery, provided the intensity of the pain is too much and there seems to be a possible infection due to the kidney stones. That said, the doctor might recommend any of the following procedures:
  • Shock wave lithotripsy (SWL): In this treatment, high-energy sound waves are used to break the stones into small particles to enable the kidney stones to pass through easily on their own.
  • Ureteroscopy: In this course, a thin, flexible tube is inserted through the urethra, bladder and into the ureter to reach the stone and break it through laser (if it is too big) or remove the stone (if it is small or medium in size).
  • Percutaneous Nephrolithotomy or Percutaneous Nephrolithotripsy: This course of treatment is opted when the other treatments fail to break the stone. In this surgery, a thin tube is inserted through the skin to reach the stone, which is then removed or broken.
  • Open Surgery: The last resort of treatment, if the kidney stone is overtly big or cannot be removed through any other course. In this method, the doctor will make an incision on your side to reach the kidney stone and take it out through the opening.

Each case is different and so accordingly, the course of treatment varies. Hence, it is very critical to identify symptoms and consult your doctor well before deciding on a treatment method. Moreover, it is important to know ways to prevent kidney stones in the future.

PCNL VS RIRS

Percutaneous nephrolithotomy (PCNL) is a procedure to remove kidney stones when they are unable to pass on their own. This involves making a small incision on the back to remove the kidney stone that is too large (more than two cms), too many, or too dense to be treated by other stone removal methods such as extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy. PCNL is a non-invasive method and an innovation on the previous open surgeries used to remove kidney stones which were far more complicated and invasive than PCNL. 

Why is PCNL done?

A doctor will recommend Percutaneous Nephrolithotomy in following cases:

  • Kidney stones larger in diameter than two cms
  • Large kidney stones are causing increasing complications such as blocking more than one collecting branch of the kidney
  • Presence of large stones in the ureter
  • When other therapies have failed

Before recommending a PCNL for kidney stones, the doctor will conduct several tests, including blood and urine tests, to assess the present health condition of the patient. A CT scan can also be conducted to know the problem in-depth.

Risks of PCNL

The surgery has the following risks:

  • Bleeding
  • Infection at the site of incision
  • Damage or injury to the surrounding organs and tissues
  • Injury to the kidney
  • Incomplete removal of kidney stones
  • Risk of conversion to open surgery (when reaching the stone become complicated due to unforeseen circumstances)

The procedure of the Surgery

The surgery is performed after influencing the patient with anaesthesia. The doctor makes a small incision on the back and inserts a tube through the incision into the kidney through X-ray guidance. Once the tube is in place, a telescope is passed through the tube to get a clear picture of the stone/stones, break the stone and then remove it from the body. In case, the stone is very large, a device called – lithotripter can be used to first break the stone before removing it. The surgery lasts for about three to four hours and has less postoperative complications, shorter recovery time and a shorter stay in hospital as compared to open stone surgery. The surgery has more success rates of clearing all stones as compared to an extracorporeal shock wave lithotripsy (ESWL).

That said, the techniques of kidney stone removal have seen immense advancement over time, from open surgery to more feasible and less invasive options such as percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), extracorporeal shock wave lithotripsy (ESWL), and laparoscopic surgery. Doctors increasingly relied on percutaneous nephrolithotomy (PCNL) and extracorporeal shock wave lithotripsy (ESWL) to remove large kidney stones and small kidney stones, respectively. However, with further progress in the field and the new generation of even more flexible surgical instruments, including ureteroscopes and lithotripters – Retrograde Intrarenal Surgery has increasingly been adopted to treat large kidney stones.

RIRS or Retrograde Intrarenal Surgery is an endoscopic surgery performed to remove renal stones by reaching the kidney from the ureter. RIRS procedure uses a viewing tube called fibre optic endoscope and a laser fibre – Holmium – to treat the renal stones. Once the large stone is removed, small fragments of the stones are taken off through stone baskets. In some cases, a stent may be pushed in the kidney to improve drainage. Post the procedure, the endoscope is crushed, blasted or evaporated by using a laser probe or can also be manually removed through forceps. The surgery is performed by a urologist who has specialized expertise in RIRS. During the procedure, the patient is given local, spinal or general anaesthesia and the endoscope is inserted in the body through the urethra then onto the kidney; the surgery does not involve any incisions and hence, has a very fast recovery time. With RIRS, a vast majority of renal stones can be cleared without open surgery.

Moreover, with the recent technological developments in the management of renal stones, RIRS has emerged as a very reliable, safe and efficient method. The main purpose of a renal stone treatment is to clear the stones completely with minimum morbidity – RIRS clears renal stones through flexible ureterorenoscopes and lithotripters including holmium laser, ensuring no trace of stones are left. Moreover, advancement in related types of equipment such as guide-wires, urethral access sheath and stone baskets have enhanced the effectiveness of the RIRS procedure. As of today, RIRS is a prime method of treatment for renal stones that are less than 2 cm and cannot be successfully treated via other methods. 

RIRS procedure is best suited for cases where:

  • Earlier attempts to remove renal stones have failed
  • Stones are too large in size
  • There is a tumour in the kidney
  • There are strictures in the kidney
  • The patient involved is a child
  • The patient has bleeding disorders
  • The patient is obese
  • The patient has complex anatomical kidneys
  • Patient is on anticoagulants

Risks of the Surgery

Complications or risks associated with RIRS are fairly uncommon and occur only in very cases.

  • Fever
  • Flank pain
  • Urinary infection
  • Transient hematuria
  • Acute urinary retention
  • Ureteral pelvicalyceal abrasion
  • Fornix rupture
  • Ureter avulsion
  • Bleeding
  • Sepsis
  • Trauma to kidneys

PCNL vs RIRS

That said, RIRS has increasingly become the first choice of doctors to treat patients that have kidney stones and considerable health conditions. Some basic points of difference between PCNL and RIRS are:

  • Recovery time is more in PCNL than RIRS
  • PCNL has more chances of post-operative complications than RIRS, including blood transfusion, multi-follow ups, etc.
  • Stone free rate is higher in PCNL than RIRS after one session
  • PCNL useful for stones larger than 2 cm; however, single or multi-session RIRS may be required to break stone larger than 2 cm
  • RIRS is a longer procedure than PCNL
  • Haemoglobin levels are less likely to drop after RIRS as compared to PCNL
  • RIRS is best to use for stones lesser than 2 cm in size in morbidly obese patients, patients with musculoskeletal deformities, bleeding diatheses, and in cases of unsuccessful ESWL treatment previously. Thus, RIRS can be alternative in patients who need stone treatment (stone ranging 2-4 cm in diameter) but have health conditions.

That said, PCNL and RIRS need to be evaluated per case basis to decide which method is the best suited as per need of the patient.

URINARY STONE MANAGEMENT – ESWL, PCNL, MINIPERC AND RIRS

Urinary stones are solid masses made of crystals which usually develop in the kidneys, though they can develop anywhere along the urinary tract – kidney, ureter, bladder and urethra. Depending on the location of the stone, the stones are referred to kidney stone, ureteral stone or bladder stone. Also, varying by the location of the stone, the process of stone formation is called urolithiasis, renal lithiasis or nephrolithiasis. These stones are formed due to excessive accumulation of certain minerals in the body and the lack of fluids to dissolve the accumulated minerals that can include calcium, oxalate and uric acid. Moreover, other factors such as poor diet, severe diarrhoea, excessive weight, family history or certain medications can also lead to formation of stones along the urinary tract.

Urinary stones especially, kidney stones are one of the most painful medical conditions and are very common in middle-aged and older men and women. Stones vary in size from too small (not visible through naked eye) to big approximately of 2.5 centimetres in diameter or more. While tiny stones often do not cause any symptoms and can pass on their own, whereas large stones can cause intense pain in the area between the ribs and hips in the back. Some stones can be passed by the help of medications, while others would need to be treated medically depending on the size, location and the severity of symptoms.

Some methods for management/treatment of urinary stones include:

Extracorporeal Shock Wave Lithotripsy (ESWL): This is a form of lithotripsy procedure that uses high-frequency shock waves to break down the stones in the urinary tract. In this method of treatment, an instrument known as lithotripter is used to direct high-energy sound waves to focused ultrasonic energy directly at the stones, causing them to break into smaller pieces. The basic advantage of this type of treatment of urinary stone is that it does not cause any damage or harm to the surrounding organs and tissues since the energy is aimed directly at the stone, through shock waves which travel into the body from the skin and tissue. Post the treatment, the smaller pieces of stones are eventually passed through urine over several days or weeks. ESWL procedure is approximately and hour-long procedure and has a shorter hospital stay and faster recovery time. This method or urinary stone management is non invasive and is preferred over invasive procedure; however, certain conditions must be met to perform the medical procedure.

Percutaneous Nephrolithotomy (PCNL): This method of urinary stone management is used when the stone are large enough and cannot pass on their own. The method involves making a small incision on the back to remove the stone; the surgery is performed majorly in case of kidney stones that are too large – more than 2 cms in diameter or are too dense to be treated with any other method such as an ESWL. PCNL is a minimally invasive method in which a tube is inserted into the kidney (via guidance from X-rays) through the incision made on the back. Once the tube is in place, a telescope is passed through the tube to get a clear picture of the stone/stones and then break the stone and remove it from the body. In case, the stone is too large, a lithotripter can be used to break the stone first before removing it through a PCNL procedure. A PCNL procedure is safe and has minimum post-operative complications, shorter recovery time and shorter stay in the hospital as compared to an open stone surgery. This form of treatment has more success rates as compared to an ESWL. Moreover, it is also very effective when large kidney stones cause a lot of complications such as blocking more than one collecting branch of the kidney; or there is presence of large stone in the ureter and other therapies have failed to provide results.

Miniaturized Percutaneous Nephrolithotomy (PCNL) (MINI-PERC): This is a minimally-invasive form of PCNL method that has lesser disadvantages as compared to a PCNL technique of stone removal. This method is an improvised version of stone removal in which a percutaneous nephrolithotomy is performed in one step by using a 16 G micro-puncture needle. In more advancement, a mini-microperc uses a 8 Fr sheath to insert ultrasonic energy to treat urinary tract stones, especially kidney stones. This method has more advantages as compared to a PCNL, such as low risk of haemorrhage, low post-operative pain, faster recovery and shorter hospital stay.

Retrograde Intrarenal Surgery (RIRS): RIRS is an endoscopic surgery performed to remove renal stones by reaching the kidney from the ureter. RIRS procedure uses a viewing tube called fibre optic endoscope and a laser fibre – Holmium – to treat the renal stones. Once the large stone is removed, small fragments of the stones are taken off through stone baskets. In some cases, a stent may be pushed in the kidney to improve drainage. Post the procedure, the endoscope is crushed, blasted or evaporated by using laser probe or can also be manually removed though forceps. The surgery is performed by an urologist who has specialized expertise in RIRS. During the procedure the patient is given local, spinal or general anaesthesia and the endoscope is inserted in the body through the urethra then onto the kidney; the surgery does not involve any incisions and hence, has a very fast recovery time. With RIRS a vast majority of renal stones can be cleared without an open surgery. Also, with recent medical advancements, RIRS has become none of the most reliable, safe and efficient method to treat urinary tract stones. This method aims to clear the stones with minimum morbidity, RIRS clears renal stones through flexible ureterorenoscopes and lithotripters including holmium laser, ensuring no trace of stones are left. Moreover, advancement in related equipments such as guide-wires, urethral access sheath and stone baskets have enhanced the effectiveness of the RIRS procedure. As of today, RIRS is a prime method of treatment for renal stones that are less than 2 cm and cannot been successfully treated via other methods.

These methods of urinary stone management are minimally invasive and very effective in removing stones along the urinary tract.

SUSTAINED LOW-EFFICIENCY DAILY DIALYSIS (SLEDD)

Sustained low-efficiency daily dialysis (SLEDD) is a very widely accepted renal replacement therapy for patients in the intensive care unit suffering from critically ill severe renal failure. This method is a therapeutic improvement of the continuous renal replacement therapy (CRRT) and intermittent haemodialysis (IHD) methods; this method combines the desirable properties of both methods including:

  • Reduced rate of ultra filtration to ensure optimized flow of blood through the cardiovascular system
  • Minimises chances of solute misbalance by removing solute through low-efficiency method
  • Maximises daily dose of dialysis that helps in sustaining treatment
  • Easy access to patient for various out-of-unit diagnostic and therapeutic procedures

SLEDD mainly aims to minimize hemodynamic perturbations that occur during intermittent hemodialysis for patients suffering from acute kidney injury and hemodynamic instability. This procedure uses normal hemodialysis machines to provide extended duration of renal replacement therapy. This method was introduced in 2007 as an alternative treatment to Continuous Renal Replacement Therapies (CRRT) that involves dialysis treatment on a continuous 24-hour per day. The latter therapy proved very expensive and also has problems with anticoagulation, which are all not present in SLEDD. SLEDD is a reasonable treatment that can be readily performed with no anticoagulation. This new form of treatment has been increasingly adopted by doctors across the world to treat patients with acute kidney injury and hemodynamic instability.

Some of the basic advantages of SLEDD over other similar treatment methods include:

  • Effective clearance of small solutes
  • Enhanced hemodynamic tolerability
  • Flexible treatment schedules
  • Flexibility of intensity
  • Reduced treatment costs

Over the years, SLEDD has emerged as a better hybrid of Continuous Renal Replacement Therapies (CRRT) and Intermittent Hemodialysis (IHD). This treatment method combines the desirable properties of both methods to provide the best results. Moreover, with recent advancements, SLEDD is preferred as an efficient and convenient renal replacement therapy for patients that are not considered appropriate for IHD. SLEDD has made it possible to achieve ultra filtration goals in patients that are hypotensive or inotrope dependent. However, for a patient being treated by SLEDD treatment, electrolytes should be closely monitored to avoid any complications.

That said, for a patient to be considered for SLEDD, he/she must be unsuitable for other standard therapies. Some conditions in which SLEDD is highly recommended are:

  • Patients with a risk of disequilibrium, such as people with urea levels of more than 50mmol/l, etc.
  • Patients that are beyond a certain age
  • Patients with pre-existing CNS disease
  • Patients that have cardiovascular problems or are on the borderline for cardiovascular stability
  • Patients that have excessive fluid or are nephrotic
  • Patients that need inotropic support

In all, SLEDD is a very effective method as compared to other treatment methods of acute kidney disease, such as Continuous Renal Replacement Therapies (CRRT) and Intermittent Hemodialysis (IHD). Over the years, SLEDD has proven to be very advantageous in treating patients that have high instability and are hypeotensive. The SLEDD method is an ultimate combination of the best of both therapies that aims to save more lives. It is been increasing adopted for sever case patients who do not qualify for other treatment methods.

WHAT IS A NEPHROLOGIST? UNDERSTAND WHEN TO SEE A NEPHROLOGIST

A Nephrologist is a specialized doctor that treats diseases and problems related to the kidneys. A Nephrologist is also trained to understand how kidney issues and diseases can affect vital human body organs. Each human has bean-shaped kidneys that are located below the ribcage on each side of the spine; these kidneys perform very vital body functions including:

  • Filtering waste and excess fluid from the blood through urination
  • Maintaining the electrolyte balance in the body
  • Regulating blood pressure
  • Monitoring production of red blood cells
  • Producing a form of Vitamin D that helps in the absorption of calcium in the body

Kidneys are a very critical organ of the body and thus, it is important to ensure their health and protect them from common diseases. Kidney diseases are very common among people of all ages and are typically defined by a condition where the kidneys are unable to perform their set functions efficiently.

It is important to treat kidney problems since it can lead to further serious complications such as nerve damage, malnutrition, weakening of bones, etc. A doctor who specialises in diagnosing and treating kidney diseases is called a Nephrologist. Nephrologists also tend to help manage the impact of kidney dysfunction on other body organs. Hence, it is very important to understand when to see a Nephrologist.

When to see a Nephrologist?

Anyone with signs or symptoms of kidney problems, diseases or dysfunction must see a Nephrologist, irrespective of the condition of the problem – chronic, moderate or severe. Some common signs of kidney problems that help with this are:

  • Swollen legs, ankles or feet
  • Frequent, chronic headaches
  • Nausea
  • Itchiness
  • Lack of appetite
  • Unexplained and sudden weight loss
  • Change in taste buds
  • Reduction in urine output
  • Confusion, memory issues and trouble in concentration
  • Stiffness or fluid in joints
  • Pain in joints
  • Muscle cramps
  • Numbness or weakness
  • Feeling exhausted during the day
  • Sleep problems at night
  • Blood pressure problems
  • Blood in urine

That said, these symptoms indicate the beginning or a mediocre kidney problem. The below symptoms signify that the kidney diseases are resulting in kidney failure and hence, the patient must immediately see a Nephrologist.

  • Vomiting and Nausea
  • Complete loss of appetite
  • Fluid retention
  • Changes in urine
  • Decrease in red blood cells – anaemia
  • Reduced sexual desires
  • Unexplained hike in potassium
  • Inflammation of the fluid-filled sac surrounding the heart

In many cases, the doctor will refer a patient to a Nephrologist in case they have existing medical conditions that are likely to increase the risk of kidney problems. These conditions include but are not limited to:

  • Diabetes and other metabolic conditions
  • High blood pressure
  • Heart problems

Additionally, some people are at more risk of experiencing kidney problems than others. These people should consult a Nephrologist regularly. These conditions include:

  • High blood pressure
  • Diabetes
  • Family history of chronic kidney problems
  • Old age
  • Race – African, Asian, Hispanic or American Indian

What medical conditions does a Nephrologist treat?

Nephrologists treat all conditions that can or have impacted the kidneys either directly or indirectly.

Some of the common kidney issues treated by Nephrologists include:

  • Chronic kidney diseases
  • Glomerulonephritis
  • Kidney Infections
  • Tubular Defects
  • Nephrotic Syndrome
  • Tubulointerstitial kidney problems
  • High blood pressure
  • Vasculitis
  • Auto-immune disorders affecting the kidneys
  • Diabetes and other metabolic disorders
  • Structural abnormalities of kidneys
  • Congenital problems of kidneys
  • Functional abnormalities of kidneys, bladder, etc.
  • Imbalance of electrolyte, fluid, acid-base, etc.
  • Abnormal growth in kidney
  • Renal artery stenosis
  • Kidney stones
  • Polycystic Kidney Disease
  • Urinary Tract Infections (UTI)

What procedures does a Nephrologist perform?

Nephrologists perform a variety of tests and diagnostic procedures to monitor and detect any kidney problems. These tests help the Nephrologists to undertake the required medical procedure.

Some of the common tests used to detect kidney issues and conditions include:

  • Blood Tests such as serum creatinine, glomerular filtration rate (GFR), Blood urea nitrogen
  • Urine Tests such as Urinalysis, 24-hour urine test, Creatinine clearance, Microalbuminuria, etc.

Common medical procedures that help to detect, monitor and treat kidney conditions include:

  • Ultrasound: This technique uses high-energy sound waves to produce inside picture of the kidneys, helping the Nephrologist detect any abnormalities in size, the position of kidneys and obstructions such as cysts, tumours, etc.
  • CT Scan: A CT Scan is used in combination with a special dye to provide a picture of the kidneys via X-Ray images. This helps to diagnose any problems in the structure of kidneys.
  • Biopsy: A Nephrologist performs a biopsy to analyse various conditions such as the extent of kidney damage, identify the disease and decide the treatment course, and understand any other complications. In a biopsy, the nephrologists collect a small slice of kidney tissue by inserting a thin needle.
  • Haemodialysis: This procedure is used to support patients with chronic kidney problems or kidney failure. In this procedure, an artificial kidney known as hemodialyser is used to run the blood and remove excess fluid, toxins, waste, etc. The purified is blood is then returned to the body through a port or catheter.
  • Kidney Transplant: In this procedure, a portion of the entire damaged kidney is removed and replaced with a matching donor kidney to save the life of the patient.

Kidneys are extremely vital organs of the human body and it is very important to ensure their health for a good, healthy life. Hence, one should be aware of the symptoms of kidney problems and know when to see a Nephrologist.

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