Nephrolithiasis resident survival guide: Difference between revisions

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{{CMG}}
{{CMG}} {{AE}} {{ATS}}
 
==Definition==


==Overview==
Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances.  The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.


==Causes==
==Causes==


===Life Threatening Causes===
===Life Threatening Causes===
===Common Causes===
* Renal Obstruction
* Renal Isquaemia
* Renal Impairment
 
===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458  }} </ref>===
*[[Hypercalciuria]]
*[[Hyperoxaluria]]
*Hypernatruria
*[[Hypocitraturia]]
*[[Hyperuricosuria]]
*[[Cystinuria]]
*[[Gout]]
*[[Metabolic acidosis]]
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]]
*Urine Infection
*Drug related stones
**[[Allopurinol]]
**[[Triamterene]]
**[[Indinavir]]


==Management==
==Management==
===Diagnostic Approach===
Shown below is an algorithm depicting the diagnostic approach to [[Kidney stone|Nephrolithiasis]]  based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656  }} </ref>
{{familytree/start}}
{{familytree | | | | | | A01 | | | | | A01='''Characterize the symptoms:'''<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586  }} </ref> <br>
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;">
❑ [[Abdominal Pain]] <br>
:❑ [[Colic]] pain <br>
:❑ Irradiated to the lower abdomen and groin <br>
:❑ Acute, moderate to severe pain
❑ [[Urinary urgency]] <br>
❑ [[Dysuria]] <br>
❑ [[Polyuria]] <br>
❑ [[Vomit]]s <br>
❑ [[Nausea]]<br>
❑ [[Malaise]] <br>
❑ [[Fever]] and [[Rigor|chills]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | B01 | | | | | B01= '''Obtain a detailed history:''' <br>
<div style="float: left; text-align: left; height: 45em; width: 30em; padding:1em;">
❑ History of [[kidney stones]]
:❑ Personal and Family  <br>
::❑ Treatment <br>
::❑ Stone analysis <br>
❑ History of [[UTI]] or [[pyelonephritis]]  <br>
❑ Anatomic Features <br>
:❑ Horse shoe kidney <br>
:❑ Solitary kidney <br>
:❑ Obstruction of uteropelvic junction <br>
:❑ Previous Kidney or ureteral surgery <br>
❑ Diseases such as: <br>
:❑ [[Hyperparathyroidism]] <br>
:❑ [[Renal tubular acidosis]] <br>
:❑ [[Cystinuria]]<br>
:❑ [[Gout]] <br>
:❑ [[Diabetes mellitus type 2]] or [[Insulin resistance]] <br>
:❑ [[Inflammatory bowel disease]] <br>
:❑ [[Renal insufficiency]]<br>
:❑ [[Sarcoidosis]] <br>
:❑ [[Gastro-intestinal]] pathology <br>
❑ Drug treatments and regular intake: <br>
:❑ Carbonic anhydrase inhibitor <br>
:❑ [[Ephedrine]]<br>
:❑ [[Sulfadiazine]] <br>
:❑ [[Calcium]] and [[Vitamin D]]<br></div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | C01 | | | | | C01= '''Examine the patient:''' <br>
<div style="float: left; text-align: left; height: 14em; width: 30em; padding:1em;">
❑ Measure the [[blood pressure]] <br>
❑ Measure the [[heart rate]] <br>
❑ Measure the [[temperature]] <br>
❑ Abdomen <br>
:❑ Tender <br>
:❑ Painful<br>
❑ [[Obesity]]</div>}}
{{familytree | | | | | | |!| | | | | | }}
{{familytree | | | | | | D01 | | | | |  D01= '''Order labs and tests:''' <br>
<div style="float: left; text-align: left; height: 32em; width: 30em; padding:1em;">
❑ [[Urinalysis]] <br>
:❑ [[Microscopic hematuria]]<br>
:❑ Nitrates <br>
:❑ [[Leucocyte]]s<br>
:❑ [[Crystalluria]]<br>
❑ [[Hemogram]] <br>
:❑ [[Complete blood count]]<br>
:❑ Serum [[electrolytes]]<br>
:❑ [[Urea]]
:❑ [[Creatinine]]
❑ [[CT]] <br>
❑ [[Ultrasound]] if pregnant <br>
❑ [[Intravenous]] [[Pyelography]] <br>
❑ 24 hour urine collection analysis <br>
:❑ [[Calcium]]
:❑ [[Phosphorus]]
:❑ [[Magnesium]]
:❑ [[Uric acid]]
:❑ [[Oxalate]]</div>}}
{{familytree/end}}
===Therapeutic Approach===
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656  }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586  }} </ref>:
{{familytree/start}}
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br>
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;">
❑ Hydration <br>
:❑ [[Water]] (2L/24h)<br>
:❑ 0.9% [[Saline|Normal saline]]
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]]
❑ [[Analgesics]]
:❑ Opioid Narcotics <br>
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]]))
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours) 
:❑ [[NSAID]]s
::❑ [[Diclofenac]]
::❑ [[Ibuprofen]]
::❑ [[Ketorolac]]
❑ [[Antispasmodic]]s
:❑ [[Alpha blocker|Alpha-blockers]]
::❑ [[Doxazosin]] (4mg/day)
::❑ [[Tamsulosin]] (0.4mg/day)
:❑ Calcium channel blockers
::❑ [[Nifedipine]] (30mg/day)
:❑ [[Steroids]]
::❑ [[Corticosteroid]] </div>  }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications?  }}
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }}
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }}
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }}
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }}
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }}
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01=
<div style="float: left; text-align: left; padding:1em;"> <5mm
</div>
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm
</div>
| E03= <div style="float: left; text-align: left;  padding:1em;">❑ Broad spectrum antibiotics include coverage for:
*[[Gram-negative bacteria|Gram (-)]] bacili
*[[Gram-positive|Gram(+)]] cocci
❑ Antibacterial treatment should be administer to the results of the urine culture
</div>
| E04= <div style="float: left; text-align: left;  padding:1em;">❑ Ureter Obstruction: <br>
*decresed glomerular filtration
*decresed renal blood flow
*Acute intervention is needed  </div> }}
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }}
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention if the has not passed after 2 - 4 weeks| F03=Intervention }}
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }}
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }}
{{familytree/end}}
Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458  }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656  }} </ref>
{|Class="wikitable"
|-
| '''Kidney Stone'''
| '''Treatment and future prevention'''
|-
|Calcium Oxalate stones
|❑[[Thiazide]] [[Diuretics]] <br>
❑[[Sodium]] restriction <br>
❑[[Calcium]] supplements <br>
❑[[Protein]] intake <30% of [[TCI]]<br>
❑[[Vitamin D]] (if <30ng/ml)
|-
|Calcium Phosphate stones
|❑Acidify urine<br>
❑Perform a pregnancy test on women<br>
❑Decrease dietary intake of [[phosphate]]
|-
|Cystine stones
|❑Alkalize urine<br>
❑Cystine-binding agents<br>
❑Decrease [[methionine]] intake <br>
❑If measures fail:
:❑D-penicillamine OR
:❑[[Tiopronin]] OR
:❑[[Captopril]]
|-
|Struvite stones
|❑Acidify urine<br>
❑Avoid supplementary [[magnesium]]<br>
❑[[Acetohydroxamic acid]]<br>
|-
|Uric acid stones
|❑Alkalize urine<br>
❑[[Allopurinol]]<br>
❑Reduce [[protein]] intake <30% of TCI<br>
❑Reduce or eliminate [[alcohol]] intake<br>
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake
|}
{| Class="wikitable"
|-
|
| '''Indications'''
|-
|Acidify urine
|❑[[Betaine]] (650mg three times/day with meals) <br>
❑Cranberry juice (16oz/day)
|-
|Alkalinize urine
|❑[[Potassium citrate]] (10-20mEq with meals<br>
❑[[Calcium citrate]] (1g/day with meals)
|}
Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648  }} </ref>
{| Class="wikitable"
|-
| '''Treatment'''
| '''Indications'''
|-
|Extracorporeal shock wave lithotripsy
|❑Renal stones <2cm <br>
❑Ureteral stones <1cm
|-
|Uteroscopy
|❑Ureteral stones
|-
| Ureterorenoscopy
|❑Renal stones <2cm <br>
|-
| Percutaneous nephrolithotomy
|❑Renal Stones >2cm <br>
❑Proximal ureteral stones >1cm
|}
==Do´s<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586  }} </ref>==
*Perform a metabolic evaluation in patients with risk factors for stone recurrence
**Family history of nephrolithiasis
**Presence of biliary stone disease
**[[Nephrocalcinosis]]
**Stones are formed from cysteine, uric acid or calcium phosphate
**The patient is a child
*Administer [[tamsulosin]] and [[corticosteroids]] to help stones pass quicker and with less analgesics.
*Proceed intravenously in patients who are unable to take oral fluids or oral medications and with [[hypotension]].
*Perform
==Don´ts<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586  }} </ref><ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648  }} </ref>==
*Do not recommend [[calcium]] restrictions, as the may increase the urinary oxalate excretion.
*Do not administer [[NSAID]]s when extracorporeal shock lithotripsy is planned, as it may increase the risk of perinephric bleeding.
*Do not perform extracorporeal shock lithotripsy in women who want to have children, percutaneous nephrolithotomy is a safer option.


==References==
==References==

Latest revision as of 00:24, 13 March 2014

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Andrea Tamayo Soto [2]

Overview

Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.

Causes

Life Threatening Causes

  • Renal Obstruction
  • Renal Isquaemia
  • Renal Impairment

Common Causes[1]

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic approach to Nephrolithiasis based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.[2]

 
 
 
 
 
Characterize the symptoms:[3]

Abdominal Pain

Colic pain
❑ Irradiated to the lower abdomen and groin
❑ Acute, moderate to severe pain

Urinary urgency
Dysuria
Polyuria
Vomits
Nausea
Malaise

Fever and chills
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history:

❑ History of kidney stones

❑ Personal and Family
❑ Treatment
❑ Stone analysis

❑ History of UTI or pyelonephritis
❑ Anatomic Features

❑ Horse shoe kidney
❑ Solitary kidney
❑ Obstruction of uteropelvic junction
❑ Previous Kidney or ureteral surgery

❑ Diseases such as:

Hyperparathyroidism
Renal tubular acidosis
Cystinuria
Gout
Diabetes mellitus type 2 or Insulin resistance
Inflammatory bowel disease
Renal insufficiency
Sarcoidosis
Gastro-intestinal pathology

❑ Drug treatments and regular intake:

❑ Carbonic anhydrase inhibitor
Ephedrine
Sulfadiazine
Calcium and Vitamin D
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

❑ Measure the blood pressure
❑ Measure the heart rate
❑ Measure the temperature
❑ Abdomen

❑ Tender
❑ Painful
Obesity
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order labs and tests:

Urinalysis

Microscopic hematuria
❑ Nitrates
Leucocytes
Crystalluria

Hemogram

Complete blood count
❑ Serum electrolytes
Urea
Creatinine

CT
Ultrasound if pregnant
Intravenous Pyelography
❑ 24 hour urine collection analysis

Calcium
Phosphorus
Magnesium
Uric acid
Oxalate
 
 
 
 


Therapeutic Approach

Shown below is an algorithm depicting the therapeutic approach to Nephrolithiasis[2][3]:

 
 
 
 
 
 
 
 
 
 
Initial Management

❑ Hydration

Water (2L/24h)
❑ 0.9% Normal saline
❑ 5% dextrose in water and 0.45% Normal saline

Analgesics

❑ Opioid Narcotics
Codeine / acetaminophen (1 or 2 tablets(5-10mg codeine / 325-500mg acetaminophen))
❑ Hydrocodone / acetaminophen (5-10mg/4-6hours)
NSAIDs
Diclofenac
Ibuprofen
Ketorolac

Antispasmodics

Alpha-blockers
Doxazosin (4mg/day)
Tamsulosin (0.4mg/day)
❑ Calcium channel blockers
Nifedipine (30mg/day)
Steroids
Corticosteroid
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Complications?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Size
 
 
 
 
Infection
 
Obstruction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<5mm
 
 
 
>5mm
 
 
❑ Broad spectrum antibiotics include coverage for:

❑ Antibacterial treatment should be administer to the results of the urine culture

 
❑ Ureter Obstruction:
  • decresed glomerular filtration
  • decresed renal blood flow
  • Acute intervention is needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Spontaneous passage
 
Elective intervention if the has not passed after 2 - 4 weeks
 
Intervention
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Spontaneous passage[1][2]

Kidney Stone Treatment and future prevention
Calcium Oxalate stones Thiazide Diuretics

Sodium restriction
Calcium supplements
Protein intake <30% of TCI
Vitamin D (if <30ng/ml)

Calcium Phosphate stones ❑Acidify urine

❑Perform a pregnancy test on women
❑Decrease dietary intake of phosphate

Cystine stones ❑Alkalize urine

❑Cystine-binding agents
❑Decrease methionine intake
❑If measures fail:

❑D-penicillamine OR
Tiopronin OR
Captopril
Struvite stones ❑Acidify urine

❑Avoid supplementary magnesium
Acetohydroxamic acid

Uric acid stones ❑Alkalize urine

Allopurinol
❑Reduce protein intake <30% of TCI
❑Reduce or eliminate alcohol intake
❑In patients with diabetes - increase tea and coffee intake

Indications
Acidify urine Betaine (650mg three times/day with meals)

❑Cranberry juice (16oz/day)

Alkalinize urine Potassium citrate (10-20mEq with meals

Calcium citrate (1g/day with meals)


Intervention[4]

Treatment Indications
Extracorporeal shock wave lithotripsy ❑Renal stones <2cm

❑Ureteral stones <1cm

Uteroscopy ❑Ureteral stones
Ureterorenoscopy ❑Renal stones <2cm
Percutaneous nephrolithotomy ❑Renal Stones >2cm

❑Proximal ureteral stones >1cm


Do´s[3]

  • Perform a metabolic evaluation in patients with risk factors for stone recurrence
    • Family history of nephrolithiasis
    • Presence of biliary stone disease
    • Nephrocalcinosis
    • Stones are formed from cysteine, uric acid or calcium phosphate
    • The patient is a child
  • Administer tamsulosin and corticosteroids to help stones pass quicker and with less analgesics.
  • Proceed intravenously in patients who are unable to take oral fluids or oral medications and with hypotension.
  • Perform


Don´ts[3][4]

  • Do not recommend calcium restrictions, as the may increase the urinary oxalate excretion.
  • Do not administer NSAIDs when extracorporeal shock lithotripsy is planned, as it may increase the risk of perinephric bleeding.
  • Do not perform extracorporeal shock lithotripsy in women who want to have children, percutaneous nephrolithotomy is a safer option.

References

  1. 1.0 1.1 Hall PM (2009). "Nephrolithiasis: treatment, causes, and prevention". Cleve Clin J Med. 76 (10): 583–91. doi:10.3949/ccjm.76a.09043. PMID 19797458.
  2. 2.0 2.1 2.2 Frassetto L, Kohlstadt I (2011). "Treatment and prevention of kidney stones: an update". Am Fam Physician. 84 (11): 1234–42. PMID 22150656.
  3. 3.0 3.1 3.2 3.3 Miller NL, Lingeman JE (2007). "Management of kidney stones". BMJ. 334 (7591): 468–72. doi:10.1136/bmj.39113.480185.80. PMC 1808123. PMID 17332586.
  4. 4.0 4.1 Portis AJ, Sundaram CP (2001). "Diagnosis and initial management of kidney stones". Am Fam Physician. 63 (7): 1329–38. PMID 11310648.


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