Fred, a fit and healthy 44-year-old, was working outside one warm summer afternoon. When he returned home by the end of the day, his lower back felt sore and he felt nauseated. His wife made him dinner, but he was not hungry and chose to go to bed instead
Fred's symptoms progressed, and soon he was rolling on the bed with excruciating pain. He said his back hurt as well as his stomach and groin area. The pain would ease off only to return a short while later, and when it did, Fred would begin to sweat and run to the bathroom to vomit. His wife became concerned and started the car. When his symptoms abated, she helped him into the car and rushed him to the hospital.
At the hospital, an abdominal radiograph showed the presence of renal calculi in Fred's right ureter (urolithiasis). What is the mechanism of stone formation in the kidney? What is the role of citrate in the kidneys?
Why would the administration of calcium supplements be useful for a patient with calcium oxalate stones?
Hydronephrosis can be a complication of renal calculi. What is hydronephrosis? How does back pressure occur in a kidney, and what physiological mechanism is responsible for nephron damage when back pressure is present?
The formation of renal calculi relies on supersaturated urine, a nidus, and a deficit in stone inhibitors. Calculi are formed from particular crystals that are not unbound and highly concentrated in the urine. These components aggregate around a small nucleus of organic or inorganic material that acts as an attracting force for stone formation. The presence of a nidus lowers the level of supersaturation normally needed for the development of calculi. Citrate, along with magnesium and the Tamm-Horsfall mucoprotein, acts to inhibit stone formation. Citrate is administered clinically as a means to prevent the formation of hypocitraturic calculi.
Calcium supplementation encourages the binding of oxalate to calcium in the gut. The oxalate fails to be absorbed into the bloodstream and is subsequently excreted.
Hydronephrosis occurs when an obstruction causes urine to accumulate in and dilate the renal pelvis and calices. Back pressure occurs in the kidney when glomerular filtration is still occurring, yet formed urine is unable to leave the kidney due to an obstruction. Nephrons suffer mechanical damage from the increased intrapelvic pressure and ischemic damage from alterations in blood flow.
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