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Signs and symptoms[ edit ] Diagram showing the typical location of renal colic , below the rib cage to just above the pelvis The hallmark of a stone that obstructs the ureter or renal pelvis is excruciating, intermittent pain that radiates from the flank to the groin or to the inner thigh. It typically comes in waves lasting 20 to 60 minutes caused by peristaltic contractions of the ureter as it attempts to expel the stone. Risk factors[ edit ] Dehydration from low fluid intake is a major factor in stone formation. High dietary intake of animal protein ,  sodium , sugars including honey, refined sugars , fructose and high fructose corn syrup ,  oxalate ,  grapefruit juice , and apple juice may increase the risk of kidney stone formation. This is typically done with a hour urine collection. The urine is analyzed for features that promote stone formation. In the United States, kidney stone formation was used as an indicator of excess calcium intake by the Reference Daily Intake committee for calcium in adults. As the amount of calcium intake decreases, the amount of oxalate available for absorption into the bloodstream increases; this oxalate is then excreted in greater amounts into the urine by the kidneys. In the urine, oxalate is a very strong promoter of calcium oxalate precipitation—about 15 times stronger than calcium. A study found that diets low in calcium are associated with a higher overall risk for kidney stone formation. For example, by increasing urinary calcium excretion, high dietary sodium may increase the risk of stone formation. Magnesium inhibits stone formation. Consumption of animal protein creates an acid load that increases urinary excretion of calcium and uric acid and reduced citrate. Urinary excretion of excess sulfurous amino acids e. Excessive vitamin D supplementation may increase the risk of stone formation by increasing the intestinal absorption of calcium; correction of a deficiency does not. However, some people have theorized that certain behaviors associated with frequent and binge drinking can lead to dehydration, which can, in turn, lead to the development of kidney stones. Staghorn kidney stones are considerably larger. Calcium and oxalate come together to make the crystal nucleus. Supersaturation promotes their combination as does inhibition. Continued deposition at the renal papillae leads to the growth of the kidney stones. Kidney stones grow and collect debris. In the case where the kidney stones block all routes to the renal papillae, this can cause severe discomfort. The complete staghorn stone forms and retention occurs. Smaller solids that break off can become trapped in the urinary glands causing discomfort. Displaced stones travel through the ureter. If they cannot be broken down, they must be physically removed by a surgeon. The protective role of citrate is linked to several mechanisms; in fact, citrate reduces urinary supersaturation of calcium salts by forming soluble complexes with calcium ions and by inhibiting crystal growth and aggregation. The therapy with potassium citrate, or magnesium potassium citrate, is commonly prescribed in clinical practice in order to increase urinary citrate and to reduce stone formation rates. Adhering to cells on the surface of a renal papilla , a seed crystal can grow and aggregate into an organized mass. Depending on the chemical composition of the crystal, the stone-forming process may proceed more rapidly when the urine pH is unusually high or low. For example, at a pH of 7. Reducing the pH to 5. The formation of uric-acid stones requires a combination of hyperuricosuria high urine uric-acid levels and low urine pH; hyperuricosuria alone is not associated with uric-acid stone formation if the urine pH is alkaline. Other endogenous inhibitors include calgranulin an S calcium-binding protein , Tamm—Horsfall protein , glycosaminoglycans , uropontin a form of osteopontin , nephrocalcin an acidic glycoprotein , pro thrombin F1 peptide, and bikunin uronic acid-rich protein. The biochemical mechanisms of action of these substances have not yet been thoroughly elucidated. However, when these substances fall below their normal proportions, stones can form from an aggregation of crystals. Magnesium's efficacy in subduing stone formation and growth is dose-dependent. Pain in the back occurs when calculi produce an obstruction in the kidney. Calcium-containing stones are relatively radiodense , and they can often be detected by a traditional radiograph of the abdomen that includes the kidneys, ureters, and bladder KUB film. Cystine calculi are only faintly radiodense , while uric acid stones are usually entirely radiolucent. This involves intravenous injection of a contrast agent followed by a KUB film. Uroliths present in the kidneys, ureters, or bladder may be better defined by the use of this contrast agent. Stones can also be detected by a retrograde pyelogram , where a similar contrast agent is injected directly into the distal ostium of the ureter where the ureter terminates as it enters the bladder. Other advantages of renal ultrasonography include its low cost and absence of radiation exposure. Ultrasound imaging is useful for detecting stones in situations where X-rays or CT scans are discouraged, such as in children or pregnant women. There are phleboliths in the pelvis, which can be misinterpreted as bladder stones. Axial CT scan of abdomen without contrast, showing a 3-mm stone marked by an arrow in the left proximal ureter Renal ultrasonograph of a stone located at the pyeloureteric junction with accompanying hydronephrosis. Measurement of a 5.
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