Kidney stones: Pathology review

10,490views

test

00:00 / 00:00

Kidney stones: Pathology review

Watch later

Watch later

Abdominal hernias
Small bowel ischemia and infarction
Familial adenomatous polyposis
Peutz-Jeghers syndrome
Juvenile polyposis syndrome
Colorectal polyps
Colorectal cancer
Irritable bowel syndrome
Diverticulosis and diverticulitis
Appendicitis
Biliary atresia
Jaundice
Cirrhosis
Portal hypertension
Hemochromatosis
Wilson disease
Non-alcoholic fatty liver disease
Cholestatic liver disease
Autoimmune hepatitis
Alcohol-induced liver disease
Alpha 1-antitrypsin deficiency
Primary biliary cirrhosis
Primary sclerosing cholangitis
Hepatitis
Neonatal hepatitis
Reye syndrome
Benign liver tumors
Hepatocellular carcinoma
Gallstones
Biliary colic
Acute cholecystitis
Ascending cholangitis
Chronic cholecystitis
Gallbladder cancer
Acute pancreatitis
Chronic pancreatitis
Pancreatic cancer
Congenital gastrointestinal disorders: Pathology review
Esophageal disorders: Pathology review
GERD, peptic ulcers, gastritis, and stomach cancer: Pathology review
Inflammatory bowel disease: Pathology review
Malabsorption syndromes: Pathology review
Diverticular disease: Pathology review
Appendicitis: Pathology review
Gastrointestinal bleeding: Pathology review
Colorectal polyps and cancer: Pathology review
Pancreatitis: Pathology review
Jaundice: Pathology review
Viral hepatitis: Pathology review
Cirrhosis: Pathology review
Iron deficiency anemia
Beta-thalassemia
Alpha-thalassemia
Sideroblastic anemia
Anemia of chronic disease
Glucose-6-phosphate dehydrogenase (G6PD) deficiency
Autoimmune hemolytic anemia
Sickle cell disease (NORD)
Aplastic anemia
Folate (Vitamin B9) deficiency
Vitamin B12 deficiency
Acute intermittent porphyria
Hemophilia
Hemolytic-uremic syndrome
Von Willebrand disease
Disseminated intravascular coagulation
Heparin-induced thrombocytopenia
Antithrombin III deficiency
Factor V Leiden
Protein C deficiency
Protein S deficiency
Antiphospholipid syndrome
Hodgkin lymphoma
Non-Hodgkin lymphoma
Chronic leukemia
Acute leukemia
Myelodysplastic syndromes
Polycythemia vera (NORD)
Myelofibrosis (NORD)
Essential thrombocythemia (NORD)
Waldenstrom macroglobulinemia
Microcytic anemia: Pathology review
Non-hemolytic normocytic anemia: Pathology review
Intrinsic hemolytic normocytic anemia: Pathology review
Extrinsic hemolytic normocytic anemia: Pathology review
Macrocytic anemia: Pathology review
Heme synthesis disorders: Pathology review
Coagulation disorders: Pathology review
Platelet disorders: Pathology review
Mixed platelet and coagulation disorders: Pathology review
Thrombosis syndromes (hypercoagulability): Pathology review
Lymphomas: Pathology review
Leukemias: Pathology review
Plasma cell disorders: Pathology review
Myeloproliferative disorders: Pathology review
Abscesses
Type I hypersensitivity
Food allergy
Anaphylaxis
Asthma
Type II hypersensitivity
Myasthenia gravis
Pemphigus vulgaris
Type III hypersensitivity
Serum sickness
Systemic lupus erythematosus
Poststreptococcal glomerulonephritis
Type IV hypersensitivity
Graft-versus-host disease
Contact dermatitis
Transplant rejection
Cytomegalovirus infection after transplant (NORD)
Post-transplant lymphoproliferative disorders (NORD)
X-linked agammaglobulinemia
Selective immunoglobulin A deficiency
Common variable immunodeficiency
IgG subclass deficiency
Hyperimmunoglobulin E syndrome
Isolated primary immunoglobulin M deficiency
Thymic aplasia
DiGeorge syndrome
Severe combined immunodeficiency
Adenosine deaminase deficiency
Ataxia-telangiectasia
Hyper IgM syndrome
Wiskott-Aldrich syndrome
Leukocyte adhesion deficiency
Chediak-Higashi syndrome
Chronic granulomatous disease
Complement deficiency
Hereditary angioedema
Asplenia
Thymoma
Ruptured spleen
Immunodeficiencies: T-cell and B-cell disorders: Pathology review
Immunodeficiencies: Combined T-cell and B-cell disorders: Pathology review
Immunodeficiencies: Phagocyte and complement dysfunction: Pathology review
Vitiligo
Albinism
Acne vulgaris
Folliculitis
Rosacea
Hidradenitis suppurativa
Atopic dermatitis
Lichen planus
Pityriasis rosea
Psoriasis
Seborrhoeic dermatitis
Urticaria
Actinic keratosis
Epidermolysis bullosa
Bullous pemphigoid
Erythema multiforme
Stevens-Johnson syndrome
Pressure ulcer
Sunburn
Burns
Frostbite
Cellulitis
Erysipelas
Impetigo
Necrotizing fasciitis
Human papillomavirus
Varicella zoster virus
Poxvirus (Smallpox and Molluscum contagiosum)
Coxsackievirus
Herpes simplex virus
Candida
Malassezia (Tinea versicolor and Seborrhoeic dermatitis)
Pediculus humanus and Phthirus pubis (Lice)
Sarcoptes scabiei (Scabies)
Human herpesvirus 6 (Roseola)
Parvovirus B19
Measles virus
Rubella virus
Skin cancer
Alopecia areata
Telogen effluvium
Onychomycosis
Pigmentation skin disorders: Pathology review
Acneiform skin disorders: Pathology review
Papulosquamous and inflammatory skin disorders: Pathology review
Vesiculobullous and desquamating skin disorders: Pathology review
Skin cancer: Pathology review
Radial head subluxation (Nursemaid elbow)
Developmental dysplasia of the hip
Legg-Calve-Perthes disease
Slipped capital femoral epiphysis
Transient synovitis
Osgood-Schlatter disease (traction apophysitis)
Rotator cuff tear
Dislocated shoulder
Winged scapula
Thoracic outlet syndrome
Carpal tunnel syndrome
Ulnar claw
Erb-Duchenne palsy
Klumpke paralysis
Iliotibial band syndrome
Unhappy triad
Anterior cruciate ligament injury
Patellar tendon rupture
Meniscus tear
Patellofemoral pain syndrome
Sprained ankle
Achilles tendon rupture
Spondylolysis
Spondylolisthesis
Degenerative disc disease
Spinal disc herniation
Sciatica
Compartment syndrome
Rhabdomyolysis
Osteogenesis imperfecta
Craniosynostosis
Pectus excavatum
Arthrogryposis
Genu valgum
Genu varum
Pigeon toe
Flat feet
Club foot
Cleidocranial dysplasia
Achondroplasia
Osteomyelitis
Bone tumors
Osteochondroma
Chondrosarcoma
Osteoporosis
Osteomalacia and rickets
Osteopetrosis
Paget disease of bone
Osteosclerosis
Lordosis, kyphosis, and scoliosis
Osteoarthritis
Spondylosis
Spinal stenosis
Rheumatoid arthritis
Juvenile idiopathic arthritis
Gout
Calcium pyrophosphate deposition disease (pseudogout)
Psoriatic arthritis
Ankylosing spondylitis
Reactive arthritis
Spondylitis
Septic arthritis
Bursitis
Baker cyst
Muscular dystrophy
Polymyositis
Dermatomyositis
Inclusion body myopathy
Polymyalgia rheumatica
Fibromyalgia
Rhabdomyosarcoma
Lambert-Eaton myasthenic syndrome
Sjogren syndrome
Mixed connective tissue disease
Raynaud phenomenon
Scleroderma
Back pain: Pathology review
Rheumatoid arthritis and osteoarthritis: Pathology review
Seronegative and septic arthritis: Pathology review
Gout and pseudogout: Pathology review
Systemic lupus erythematosus (SLE): Pathology review
Scleroderma: Pathology review
Sjogren syndrome: Pathology review
Bone disorders: Pathology review
Bone tumors: Pathology review
Myalgias and myositis: Pathology review
Neuromuscular junction disorders: Pathology review
Muscular dystrophies and mitochondrial myopathies: Pathology review
Spina bifida
Chiari malformation
Dandy-Walker malformation
Syringomyelia
Tethered spinal cord syndrome
Aqueductal stenosis
Septo-optic dysplasia
Cerebral palsy
Spinocerebellar ataxia (NORD)
Transient ischemic attack
Ischemic stroke
Intracerebral hemorrhage
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Saccular aneurysm
Arteriovenous malformation
Broca aphasia
Wernicke aphasia
Wernicke-Korsakoff syndrome
Kluver-Bucy syndrome
Concussion and traumatic brain injury
Shaken baby syndrome
Epilepsy
Febrile seizure
Early infantile epileptic encephalopathy (NORD)
Tension headache
Cluster headache
Migraine
Idiopathic intracranial hypertension
Trigeminal neuralgia
Cavernous sinus thrombosis
Alzheimer disease
Vascular dementia
Frontotemporal dementia
Lewy body dementia
Creutzfeldt-Jakob disease
Normal pressure hydrocephalus
Torticollis
Essential tremor
Restless legs syndrome
Parkinson disease
Huntington disease
Multiple sclerosis
Central pontine myelinolysis
Acute disseminated encephalomyelitis
Transverse myelitis
JC virus (Progressive multifocal leukoencephalopathy)
Adult brain tumors
Pediatric brain tumors
Brain herniation
Brown-Sequard Syndrome
Cauda equina syndrome
Treponema pallidum (Syphilis)
Friedreich ataxia
Neurogenic bladder
Meningitis
Neonatal meningitis
Encephalitis
Brain abscess
Epidural abscess
Sturge-Weber syndrome
Tuberous sclerosis
Neurofibromatosis
von Hippel-Lindau disease
Amyotrophic lateral sclerosis
Spinal muscular atrophy
Poliovirus
Guillain-Barre syndrome
Charcot-Marie-Tooth disease
Bell palsy
Horner syndrome
Congenital neurological disorders: Pathology review
Headaches: Pathology review
Seizures: Pathology review
Cerebral vascular disease: Pathology review
Traumatic brain injury: Pathology review
Spinal cord disorders: Pathology review
Dementia: Pathology review
Central nervous system infections: Pathology review
Movement disorders: Pathology review
Demyelinating disorders: Pathology review
Adult brain tumors: Pathology review
Pediatric brain tumors: Pathology review
Neurocutaneous disorders: Pathology review
Renal agenesis
Horseshoe kidney
Potter sequence
Hyperphosphatemia
Hypophosphatemia
Hypernatremia
Hyponatremia
Hypermagnesemia
Hypomagnesemia
Hyperkalemia
Hypokalemia
Renal tubular acidosis
Minimal change disease
Amyloidosis
Membranous nephropathy
Lupus nephritis
Rapidly progressive glomerulonephritis
IgA nephropathy (NORD)
Alport syndrome
Kidney stones
Hydronephrosis
Acute pyelonephritis
Chronic pyelonephritis
Prerenal azotemia
Renal azotemia
Postrenal azotemia
Renal cortical necrosis
Chronic kidney disease
Multicystic dysplastic kidney
Medullary cystic kidney disease
Medullary sponge kidney
Renal cell carcinoma
Angiomyolipoma
Nephroblastoma (Wilms tumor)
WAGR syndrome
Posterior urethral valves
Hypospadias and epispadias
Vesicoureteral reflux
Bladder exstrophy
Urinary incontinence
Lower urinary tract infection
Transitional cell carcinoma
Non-urothelial bladder cancers
Congenital renal disorders: Pathology review
Renal tubular defects: Pathology review
Renal tubular acidosis: Pathology review
Acid-base disturbances: Pathology review
Electrolyte disturbances: Pathology review
Renal failure: Pathology review
Nephrotic syndromes: Pathology review
Nephritic syndromes: Pathology review
Urinary incontinence: Pathology review
Urinary tract infections: Pathology review
Kidney stones: Pathology review
Renal and urinary tract masses: Pathology review
Klinefelter syndrome
Turner syndrome
Benign prostatic hyperplasia
Prostate cancer
Testicular cancer
Erectile dysfunction
Amenorrhea
Ovarian cyst
Sex cord-gonadal stromal tumor
Surface epithelial-stromal tumor
Germ cell ovarian tumor
Uterine fibroid
Endometriosis
Endometritis
Endometrial hyperplasia
Endometrial cancer
Cervical cancer
Pelvic inflammatory disease
Breast cancer
Preeclampsia & eclampsia
Placenta previa
Placental abruption
Postpartum hemorrhage
Congenital cytomegalovirus (NORD)
Miscarriage
Ectopic pregnancy
Fetal alcohol syndrome
Disorders of sex chromosomes: Pathology review
Prostate disorders and cancer: Pathology review
Testicular tumors: Pathology review
Uterine disorders: Pathology review
Ovarian cysts and tumors: Pathology review
Cervical cancer: Pathology review
Vaginal and vulvar disorders: Pathology review
Benign breast conditions: Pathology review
Breast cancer: Pathology review
Complications during pregnancy: Pathology review
Congenital TORCH infections: Pathology review
Upper respiratory tract infection
Sinusitis
Congenital pulmonary airway malformation
Sudden infant death syndrome
Acute respiratory distress syndrome
Methemoglobinemia
Emphysema
Chronic bronchitis
Cystic fibrosis
Bronchiectasis
Restrictive lung diseases
Sarcoidosis
Idiopathic pulmonary fibrosis
Pneumonia
Lung cancer
Pancoast tumor
Superior vena cava syndrome
Pneumothorax
Pleural effusion
Mesothelioma
Pulmonary embolism
Pulmonary edema
Pulmonary hypertension
Respiratory distress syndrome: Pathology review
Cystic fibrosis: Pathology review
Pneumonia: Pathology review
Tuberculosis: Pathology review
Deep vein thrombosis and pulmonary embolism: Pathology review
Pleural effusion, pneumothorax, hemothorax and atelectasis: Pathology review
Obstructive lung diseases: Pathology review
Restrictive lung diseases: Pathology review
Apnea, hypoventilation and pulmonary hypertension: Pathology review
Lung cancer and mesothelioma: Pathology review

Assessments

USMLE® Step 1 questions

0 / 5 complete

Questions

USMLE® Step 1 style questions USMLE

0 of 5 complete

A 45-year-old woman comes to the outpatient clinic because of intermittent left flank pain that has been ongoing for the past two weeks. She has noticed blood in her urine on a few occasions. Moreover, the pain has become more severe. She works as a personal trainer. Family and medical history are unremarkable. Temperature is 39.0°C (102.2°F), pulse is 80/minute, respiratory rate is 16/minute, and blood pressure is 130/95 mm Hg. An x-ray is ordered and shown below:

Retrieved from:

Which of the following best describes the composition of this pathological structure?

Transcript

Watch video only

In the Emergency Department, two people with similar symptoms came in.

One of them is 35 year old Conrad who has a terrible left flank pain, along with nausea and vomiting and the other one is 40 year old Sam who has left flank pain, but also has dysuria.

An electrolyte panel and urinalysis was done in both individuals.

Results showed that Conrad had normal levels of calcium in the blood, but urinalysis showed hypercalciuria and hematuria.

Sam’s urinalysis showed positive leukocyte esterase, as well as positive nitrites and hematuria. Abdominal CT showed radiopaque masses in their ureters.

Now, the suspicion is that both individuals have kidney stones, but there are actually several types of kidney stones and we need to know what we’re dealing with in order to give the right treatment.

Okay, let’s first talk about how kidney stones form.

Urine’s a combination of water, which acts as a solvent, and all sorts of particles, or solutes.

In general, when certain solutes become too concentrated in the solvent, they become supersaturated.

Urinary supersaturation of certain solutes results in precipitation out of the solution and formation of crystals.

Those crystals then act as a nidus, or place where more solutes can deposit and over time it builds up a crystalline structure.

This can happen if there’s an increase in the solute, or a decrease in the solvent, as would be the case with dehydration.

This means that dehydration leads to a low urine volume which can further put a person at risk for kidney stones.

Okay, let’s now talk about the different types of stones.

There are four main types of stones.

Calcium stones are present in about 80 percent of the cases, while struvite stones are present in about 15 percent of the cases and uric acid stones are present in about 5 percent of the cases.

Finally, a super rare type of stone is a cysteine stone.

Let’s start with calcium stones.

With calcium stones, in most cases, the inorganic precipitate is calcium oxalate, formed by a positively charged calcium ion binding to a negatively charged oxalate ion, which results in a black or dark brown colored stone that’s shaped like an envelope or a dumbbell.

Calcium oxalate stones appear radiopaque on X-ray, as well as on a CT-scan.

Now, there are some risk factors for developing calcium stones, such as idiopathic hypercalciuria or hypercalcemia.

Another very important risk factor is hypocitraturia, which means that less citrate is eliminated in the urine.

This is because normally, citrate prevents stone formation by inhibiting crystal growth and aggregation.

Other risk factors include fat malabsorption, which can happen with Crohn’s disease or in individuals that have had a gastric bypass operation.

This happens because since fat won’t be absorbed in the intestine, it will bind to calcium and this leaves a lot of oxalate free to be absorbed in the intestine, which raises oxalate levels in the blood and can further promote calcium oxalate stone formation.

Another risk factor is the ingestion of ethylene glycol or antifreeze, because ethylene glycol forms oxalate once ingested.

Finally, there’s vitamin C abuse, because one product of vitamin C metabolism is oxalate.

Now, treatment of calcium-oxalate stones involves giving thiazide diuretics.

Thiazides inhibit the sodium-chloride transporter in the distal convoluted tubule, meaning that more sodium and chloride get in the urine.

Okay, the distal convoluted tubule also has a calcium channel which allows calcium from the lumen to diffuse into the cell.

Once in the cell, calcium is transported out into the interstitium through a sodium-calcium exchanger, that pumps a sodium in, and a calcium out.

Now, since thiazides decrease sodium reabsorption, there’s less sodium in the cell, so the sodium-calcium exchanger works overtime to pump more sodium in, and more calcium out.

The decrease in intracellular calcium, in turn, leads to more calcium reabsorption from the urine. Another treatment is giving potassium citrate which binds to the calcium in urine, preventing reabsorption.

Finally, another treatment involves a low-sodium diet.

That’s because when a person has a high sodium diet, more water is retained.

This means that the extracellular volume expands.

Since there’s so much water and sodium, the renin-angiotensin-aldosterone system has nothing to respond to, so its activity is dialed down.

This means that not that much sodium will be reabsorbed in the proximal convoluted tubule.

Now, calcium and sodium reabsorption are tied together in the proximal convoluted tubule, so when there’s less sodium reabsorption, there’s also less calcium reabsorption and there will be hypercalciuria.

Sometimes, instead of oxalate, the calcium bind to negatively charged phosphate groups to form calcium phosphate stones.

These are dirty white in color and shaped like a wedge prism which appears radiopaque on a X-ray.

A risk factor is highly alkaline urine which could be caused by renal tubular acidosis where there’s a decreased secretion of hydrogen or increased secretion of bicarbonate into the urine. Treatment includes a low-sodium diet, as well as thiazide diuretics.

Another type are struvite stones, sometimes called infection stones, which are a composite mix of magnesium, ammonium, and phosphate.

Since they are infections stones, this means that the individual can present with signs of a urinary tract infection, like dysuria.

For your tests, remember that these form when there’s an overabundance of urease-positive bugs like Proteus mirabilis, Staphylococcus saprophyticus, and Klebsiella species.

They use the enzyme urease to split urea into ammonia and carbon dioxide.

The ammonia makes the urine more alkaline and favors precipitation of magnesium, ammonium, and phosphate into jagged crystals called “staghorn” because they often branch into the several of the renal calyces and look like the horns of a staghorn deer.

On an X-ray or on a CT-scan, such stones are radiopaque,, but are less dense than calcium stones.

Sources

  1. "Robbins Basic Pathology" Elsevier (2017)
  2. "Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2)" McGraw-Hill Education / Medical (2018)
  3. "Practical Renal Pathology, A Diagnostic Approach E-Book" Elsevier Health Sciences (2012)
  4. "An Update and Practical Guide to Renal Stone Management" Nephron Clinical Practice (2010)
  5. "Kidney stone disease" Journal of Clinical Investigation (2005)
  6. "HELICAL CT OF URINARY TRACT STONES" Radiologic Clinics of North America (1999)