Nephrolithiasis: Causes, Symptoms, and Treatment Options with a Focus on Staghorn Calculi

Introduction

Nephrolithiasis, or renal stone disease, is a common urological condition that presents with symptoms such as abdominal pain, flank or groin pain (radiating or non-radiating), and sometimes hematuria (blood in urine). It may also be associated with urinary tract infections (UTIs). The common causes include decreased urine volume, acidic urine pH, high concentrations of stone-forming substances, and infections. Treatment depends on the size and location of the stone. While smaller stones can often pass spontaneously with medical expulsive therapy (MET), larger stones—especially staghorn calculi—typically require surgical intervention.

Overview

Nephrolithiasis is a frequent reason for emergency department visits worldwide. Patients commonly report abdominal or flank pain, pubic discomfort, hematuria, and symptoms of urinary tract infection. Renal and ureteric stones can lead to complicated UTIs and may be life-threatening in individuals with comorbidities such as diabetes, hypertension, or immunosuppressed states (e.g., elderly patients, those with HIV, or chronic alcoholics). If left untreated, complications such as pyelonephritis, sepsis, multi-organ dysfunction syndrome (MODS), or even death may occur.

Epidemiologically, the prevalence of nephrolithiasis varies globally. In India, studies suggest that individuals in Northern regions have a higher incidence. The etiology is multifactorial, including dietary, environmental, metabolic, and genetic factors.

Causes of Nephrolithiasis

1.     Decreased Urine Volume: Leads to concentrated urine, promoting crystal formation.

2.     Acidic Urine pH: Reduces uric acid solubility, favoring crystallization.

3.     Dietary Factors: High intake of oxalate-rich foods (spinach, nuts, chocolate), excessive sodium or animal protein, low calcium, dehydration, and excessive vitamin C intake.

4.     Medical Conditions: Hyperparathyroidism, obesity, metabolic syndrome, gout, Crohn’s disease, ulcerative colitis, recurrent UTIs, family history of renal stones.

5.     Lifestyle and Environmental Factors: Sedentary lifestyle and living in hot climates increase the risk.

Types of Renal Stones

1.     Calcium Oxalate Stones: The most common type; associated with oxalate-rich foods such as spinach, almonds, rhubarb, tea, and soy.

2.     Calcium Phosphate Stones: Often linked to structural abnormalities in the urinary tract.

3.     Uric Acid Stones: Frequently occur in patients with gout or high protein intake (meat, nuts, soy).

4.     Struvite Stones: Also known as "infection stones" or "triple phosphate stones" (composed of calcium, ammonium, and magnesium phosphate). Caused by infections from urease-producing organisms such as Proteus, Klebsiella, Providencia, and Corynebacterium.

5.     Cystine Stones: Result from a genetic disorder called cystinuria, which causes excessive urinary cystine excretion.

Staghorn Calculus

Staghorn calculi are large renal stones with branching projections that occupy two or more parts of the renal collecting system. They develop gradually and, if left untreated, can cause significant renal dysfunction. These stones carry higher morbidity and mortality risks compared to smaller stones. Management often requires frequent urology consultations and surgical interventions to achieve a stone-free status.

Image 1: Axial non-contrast CT KUB scan showing a large staghorn calculus (highlighted with red arrows) occupying the infundibulo-calyceal and renal pelvis regions of the right kidney.

Symptoms of Nephrolithiasis

1.     Renal Colic: Sudden, severe flank or abdominal pain that may radiate and occur in waves.

2.     Hematuria: Presence of blood in the urine.

3.     Urinary Tract Infection: May present with fever, dysuria, or foul-smelling urine.

4.     Burning Micturition: A burning sensation during urination.

5.     Urinary Retention: Caused by obstruction from the stone in the urinary tract.

Diagnosis and Work-Up

1.     Urinalysis: Checks for red blood cells, urine pH, crystals, and pus cells. Urine culture is done when infection is suspected.

2.     X-ray KUB (Kidney-Ureter-Bladder): Useful in detecting radiopaque stones.

3.     Ultrasound KUB: Sensitive for renal stones but less accurate for ureteric/bladder stones.

4.     Non-Contrast CT KUB: The gold standard diagnostic tool. It can detect most stones due to their high radiodensity.

5.     24-hour Urine Analysis: Recommended for recurrent or complex stone formers to assess excretion of stone-forming substances.

6.     Blood Tests: Include calcium, parathyroid hormone (PTH), renal function tests, uric acid, electrolytes, blood glucose, and complete blood count.

Management of Nephrolithiasis

1.     Medical Expulsive Therapy (MET): For small or uncomplicated stones. Uses alpha-blockers, calcium channel blockers, alkalizers, steroids, and NSAIDs.

2.     Shock Wave Lithotripsy (SWL/ESWL): A non-invasive method that uses focused shock waves to fragment stones.

3.     Percutaneous Nephrolithotomy (PCNL): A minimally invasive surgical procedure involving tract dilation and stone removal.

4.     Ureteroscopy (URS): A scope is passed through the urethra to retrieve stones using laser or mechanical fragmentation.

5.     Open Surgery: Reserved for complex or very large stones when less invasive methods fail.

6.     Role of Ayurveda

7.     Ayurvedic medicine can be effective for smaller stones and for post-surgical maintenance in staghorn calculus cases. Although staghorn calculi often require surgical intervention, Ayurveda can assist in achieving stone-free status postoperatively. Maintenance therapy—usually given monthly or quarterly—is especially useful in recurrent stone formers, those with cystinuria, or strong family history. It eliminates the need for daily medication and improves long-term outcomes.

Case Presentation

A 53-year-old female presented with recurrent flank pain and UTIs over the last three months. She had a history of diabetes, hypertension, dyslipidemia, and central obesity (metabolic syndrome). General physical examination was unremarkable.

·        Imaging: Non-contrast CT KUB revealed a large staghorn calculus (36 x 37 x 37 mm) occupying the infundibulo-calyceal and renal pelvis region of the right kidney.

Image 2: Non-contrast CT KUB showing a large staghorn calculus (36 × 37 × 37 mm) occupying the infundibulo-calyceal and renal pelvis regions of the right kidney.

·        Treatment: She was referred for urology consultation and advised Percutaneous Nephrolithotomy (PCNL).

·        Conclusion

·        Nephrolithiasis is a widespread condition with diverse etiologies ranging from metabolic and dietary factors to infections and genetic predisposition. Early diagnosis and appropriate treatment—whether conservative or surgical—are crucial to prevent complications. Staghorn calculi represent a particularly challenging form of nephrolithiasis due to their size and impact on kidney function, often necessitating specialized surgical approaches. Complementary therapies like Ayurveda can play a supportive role, particularly in recurrence prevention and postoperative care. A multidisciplinary, patient-tailored approach is essential for optimal outcomes.