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Pathological Case Report: Nephrolithiasis (Renal Calculi)
COVER PAGE
Title: Nephrolithiasis with Acute Obstructive Uropathy: A Pathological Case Report
Date: July 13, 2026
Speciality: Nephrology / Urology / Pathology
1. PATIENT DEMOGRAPHICS
| Parameter | Details |
|---|---|
| Name | Mr. R.K. (identity anonymized) |
| Age | 38 years |
| Sex | Male |
| Occupation | Office worker (sedentary) |
| Nationality | Indian |
| Date of Admission | July 13, 2026 |
| Presenting Hospital | General Hospital, Urology Department |
Background Note: Nephrolithiasis is more common in men than women by a 2:1 ratio, with a peak age at the third to fourth decade. Predisposing medical conditions include diabetes mellitus, hypertension, metabolic syndrome, distal renal tubular acidosis, gout, and autosomal dominant polycystic kidney disease (ADPKD). - Washington Manual of Medical Therapeutics, p. 495
2. CHIEF COMPLAINT
"Severe left-sided flank pain since this morning, radiating to the groin, associated with blood in my urine and repeated vomiting."
Duration: Acute onset, 8 hours prior to admission
Character: Colicky, severe (patient rated 9/10 on pain scale), intermittent waves
Radiation: Left costovertebral angle → left flank → left groin → left testicle
Associated symptoms: Nausea and vomiting (x3 episodes), gross hematuria, urinary urgency, dysuria
3. HISTORY OF PRESENTING ILLNESS
Mr. R.K. was a 38-year-old male with a 2-year history of recurrent episodes of left flank pain. He presented with an acute, severe onset of left flank pain that woke him from sleep at 5:00 AM. The pain was colicky in nature, rated 9/10 in severity, and radiated from the left costovertebral angle (CVA) to the left groin and left scrotum. He noted dark, reddish urine when attempting to void, with associated urinary urgency and a burning sensation on urination. He had two prior similar episodes in the past 2 years, one of which resolved spontaneously with the passage of what he described as a "small gravel-like stone." He reported no fever, no chills, no dysuria beyond the current episode, and no prior urological procedures.
Dietary History: High dietary intake of animal protein, oxalate-rich foods (spinach, nuts), low daily water intake (~1 L/day), high sodium diet.
Family History: Father had kidney stones.
Past Medical History: Hypertension (on amlodipine), BMI 29.4 kg/m² (overweight), no diabetes mellitus.
Medications: Amlodipine 5 mg once daily.
Allergies: No known drug allergies.
Social History: Minimal physical activity; desk job; lives in a hot, humid climate (known to concentrate urine).
4. PHYSICAL EXAMINATION
4.1 General Appearance
- Patient in significant distress, writhing in pain, unable to find a comfortable position (classic "restless" appearance of renal colic, distinguishing it from peritonitis where the patient lies still)
- Pale, diaphoretic
- Not jaundiced, not cyanosed
4.2 Vital Signs
| Parameter | Value | Reference |
|---|---|---|
| Temperature | 37.2°C | Normal |
| Blood Pressure | 148/90 mmHg | Elevated (pain-related) |
| Heart Rate | 102 bpm | Tachycardia |
| Respiratory Rate | 18/min | Normal |
| SpO₂ | 98% on room air | Normal |
| Pain Score | 9/10 | Severe |
4.3 Systemic Examination
Abdomen:
- Soft, non-rigid (no peritonism)
- Left flank tenderness +++, especially over the left costovertebral angle
- Murphy's punch test (renal punch sign) - Positive on the left - sharp pain elicited on percussion of the left CVA
- No palpable abdominal mass
- Bowel sounds present and normal
Renal / Urological:
- No suprapubic tenderness
- No palpable bladder distension
- External genitalia: normal, no scrotal swelling or tenderness
Cardiovascular: S1 S2 regular, no murmurs; no peripheral edema
Respiratory: Bilateral air entry equal, no adventitious sounds
Neurological: Alert and oriented x3; no focal deficit
5. INVESTIGATIONS
5.1 Urinalysis
| Test | Result | Significance |
|---|---|---|
| Color | Red/smoky | Hematuria |
| Clarity | Turbid | Crystals/blood |
| pH | 5.5 (acidic) | Favors calcium oxalate / uric acid stones |
| Specific Gravity | 1.032 | Concentrated urine |
| Blood (dipstick) | 3+ | Significant hematuria |
| Protein | Trace | Mild, non-nephrotic |
| Leucocytes | 2+ | Mild pyuria |
| Nitrites | Negative | No active infection |
| Glucose | Negative | - |
Urine Microscopy:
- RBCs: 50-100/HPF, non-dysmorphic (indicating non-glomerular source - stones vs. lower urinary tract)
- WBCs: 10-15/HPF
- Calcium oxalate crystals: Present - dumbbell-shaped / envelope-shaped crystals (paired pyramids viewed on end)
- No RBC casts (excludes glomerulonephritis)
Urine Culture: Pending (no growth at 48 hours - excludes active infection)
Note: Approximately 95% of patients with acute renal colic have hematuria. - Grainger & Allison's Diagnostic Radiology, p. 719
5.2 Serum Biochemistry
| Test | Result | Reference Range |
|---|---|---|
| Serum Creatinine | 1.3 mg/dL | 0.7-1.2 mg/dL (mildly elevated) |
| BUN (Urea Nitrogen) | 22 mg/dL | 7-20 mg/dL |
| eGFR | 68 mL/min/1.73 m² | Stage G2 mild reduction |
| Serum Calcium | 10.8 mg/dL | 8.5-10.5 mg/dL (mildly elevated) |
| Serum Phosphate | 3.1 mg/dL | 2.5-4.5 mg/dL (normal) |
| Serum Uric Acid | 7.4 mg/dL | 3.5-7.2 mg/dL (elevated) |
| Serum PTH (iPTH) | 52 pg/mL | 15-65 pg/mL (upper normal) |
| Serum Magnesium | 1.8 mg/dL | 1.7-2.2 mg/dL (normal) |
| Serum Sodium | 140 mEq/L | 136-145 (normal) |
| Serum Potassium | 4.1 mEq/L | 3.5-5.0 (normal) |
| Venous bicarbonate | 22 mEq/L | 22-26 (normal) |
| Serum Albumin | 4.1 g/dL | Normal |
| CBC | WBC 9,800/mm³ | Normal; no leucocytosis |
Note: Mild hypercalcemia warrants further evaluation for primary hyperparathyroidism as a causative factor. PTH in the upper range in setting of high-normal calcium is "inappropriately normal" and suggests primary hyperparathyroidism may be contributing.
5.3 Imaging Studies
Plain Abdominal X-Ray (KUB - Kidneys, Ureters, Bladder):
- A radio-opaque density noted at the left ureteropelvic junction (UPJ), approximately 6 mm in diameter
- Mild soft tissue haziness in the left renal fossa
- Limitation: Plain radiography has a sensitivity of only 60% for renal stones. - Grainger & Allison's Diagnostic Radiology, p. 719
Renal Ultrasound:
- Left kidney: Mild hydronephrosis (Grade II), increased echogenicity at the renal pelvis
- Left ureteral stone identified at UPJ with posterior acoustic shadowing (~6 mm)
- Right kidney: Normal echogenicity, no hydronephrosis
- Bladder: Normal wall, no intraluminal mass
- Limitation: May miss stones <3 mm. Safe and readily available. - Washington Manual, p. 496
Non-Contrast CT Abdomen/Pelvis (Stone Protocol CT) - Gold Standard:
- Left UPJ stone: 6 mm, hyperdense, 550 HU - consistent with calcium oxalate stone (most calcium-containing stones: 150-1000 HU)
- Mild left hydroureter proximal to the stone
- Grade II left hydronephrosis
- Periureteral fat stranding (sign of edema and obstruction)
- Right kidney and ureter: Normal
- No secondary signs of perforation or rupture
- Conclusion: Non-contrast CT is the one-stop imaging study of choice for renal and ureteric stone evaluation. - Grainger & Allison's Diagnostic Radiology, p. 719
5.4 24-Hour Urine Collection (Outpatient, 3 Weeks Later - Patient on Usual Diet)
| Parameter | Result | Target |
|---|---|---|
| Urine Volume | 1.2 L/24h | >2.0 L/24h (low - major risk factor) |
| Urinary Calcium | 320 mg/24h | <250 mg/24h (hypercalciuria) |
| Urinary Oxalate | 48 mg/24h | <40 mg/24h (mild hyperoxaluria) |
| Urinary Citrate | 280 mg/24h | >320 mg/24h (hypocitraturia) |
| Urinary Sodium | 210 mEq/24h | <100 mEq/24h (high - drives calcium excretion) |
| Urinary Uric Acid | 750 mg/24h | <750 mg/24h (borderline hyperuricosuria) |
| Urinary pH | 5.4 | - |
This collection is reserved for when the patient is on their usual outpatient diet, not during an acute episode. - Washington Manual, p. 496
5.5 Stone Analysis (Stone Passed Spontaneously)
- Composition: 85% Calcium Oxalate Monohydrate (whewellite), 15% Calcium Oxalate Dihydrate (weddellite)
- Size: 5 x 4 mm
- Shape: Rough, irregular, yellowish-brown
- Consistency: Hard
- Gross appearance: Irregular surface with spiky projections (characteristic of calcium oxalate monohydrate)
Pathological Findings on Passed Stone:
- Calcium oxalate monohydrate - the most common form in most populations
- Studies in India have shown >90% of calculi are calcium oxalate stones, predominantly calcium oxalate monohydrate (80%). - Brenner and Rector's The Kidney, p. 3769
6. DIAGNOSIS
Primary Diagnosis:
Nephrolithiasis - Left Ureteric Stone at UPJ (Calcium Oxalate Monohydrate, 6 mm) with Grade II Left Hydronephrosis
Contributing Metabolic Abnormalities:
- Idiopathic Hypercalciuria - urinary calcium 320 mg/24h
- Hypocitraturia - citrate 280 mg/24h (citrate is a natural inhibitor of calcium crystal growth)
- Mild Hyperoxaluria - oxalate 48 mg/24h
- Chronic Low Fluid Intake / Hypovolumic Concentrated Urine - volume 1.2 L/24h
- Possible borderline Primary Hyperparathyroidism - mildly elevated calcium + inappropriately normal PTH (further DEXA scan, sestamibi scan ordered as outpatient)
Differential Diagnoses Considered and Excluded:
| Diagnosis | Reason Excluded |
|---|---|
| Ureteric transitional cell carcinoma | CT showed only stone; no soft tissue mass; young patient |
| Pyelonephritis | No fever, negative culture, no WBC casts |
| Renal papillary necrosis | No analgesic abuse history; no ring shadow on CT |
| Abdominal aortic aneurysm | CT abdomen normal aorta; no pulsatile mass |
| Appendicitis | Right side, normal appendix on CT |
| Ovarian/adnexal pathology | Male patient |
| Acute glomerulonephritis | Non-dysmorphic RBCs, no casts, no proteinuria |
7. PATHOLOGICAL MECHANISM AND STONE FORMATION
7.1 Types of Renal Stones and Their Pathology
Calcium-Based Stones (80% of all kidney stones):
- Most common type: mixed calcium oxalate + calcium phosphate
- Second: calcium oxalate alone
- Third: calcium phosphate alone
- Calcium oxalate crystals: Dumbbell-shaped or appear as paired pyramids (envelope appearance on end); found in acidic or alkaline urine; radio-opaque
- Calcium phosphate crystals: Elongated, blunt crystals; form in alkaline urine
- Washington Manual, p. 495
Uric Acid Stones (10%):
- Develop in persistently acidic urine (pH <5.5)
- Associated with metabolic syndrome, gout, myeloproliferative disorders
- Radiolucent; crystal shapes - needles and rhomboid forms
- Hypouricosuric states promote precipitation more by acidic pH than hyperuricemia
Struvite Stones (10%) - "Infection Stones":
- Composed of magnesium ammonium phosphate ("triple phosphate")
- Require urease-producing organisms: Proteus, Klebsiella, Serratia, Haemophilus, Pseudomonas
- Form in alkaline urine (urea → NH₃ → alkalinizes urine)
- Radio-opaque; can fill entire renal pelvis = staghorn calculus
- Characteristic microscopy: coffin-lid shaped crystals
- Associated with anatomic abnormalities (VUR, PUJ obstruction, ureteral stricture)
Cystine Stones (<1%):
- Autosomal recessive disorder of renal tubular reabsorption
- Defective reabsorption of dibasic amino acids: Cystine, Ornithine, Lysine, Arginine (mnemonic: COLA)
- Only cystine is highly insoluble and precipitates in acidic urine
- Intermediate radiolucency; hexagonal crystals on microscopy
- Washington Manual, p. 496
7.2 Pathophysiology of Calcium Oxalate Stone Formation in This Patient
- Low urine volume → concentrated urine → supersaturation of calcium and oxalate
- Hypercalciuria (dietary/absorptive) → increased urinary calcium load
- Hypocitraturia → reduced chelation of urinary calcium → calcium available to bind oxalate
- Mild hyperoxaluria → dietary excess (spinach, nuts) → more substrate available
- Acidic urine → favors calcium oxalate monohydrate precipitation
- Net result: Crystal nucleation → crystal growth → aggregation → stone formation
- Stone migrates from renal pelvis → ureter → impaction at UPJ (narrowest point)
- Impaction → obstruction → ureteral smooth muscle spasm → renal colic
- Stone abrades urothelium → hematuria
- Persistent obstruction → hydronephrosis → risk of obstructive nephropathy
7.3 Nephrocalcinosis vs. Nephrolithiasis
| Feature | Nephrocalcinosis | Nephrolithiasis |
|---|---|---|
| Location | Renal parenchyma | Renal collecting system |
| Medullary causes | Hyperparathyroidism, medullary sponge kidney, RTA, Vit D toxicity, primary hyperoxaluria | As per stone type |
| Cortical causes | Acute cortical necrosis, chronic GN, primary hyperoxaluria | - |
| Prevalence | 95% medullary | - |
Grainger & Allison's Diagnostic Radiology, p. 719
8. MANAGEMENT
8.1 Acute Management (Emergency/Inpatient)
Step 1 - Analgesia:
- IV Ketorolac 30 mg (NSAID - first-line for renal colic)
- Oral/IV Morphine sulfate if NSAID contraindicated or pain uncontrolled
- IV Ondansetron 4 mg for nausea and vomiting
Step 2 - Hydration:
- IV Normal Saline 1 L over 2 hours (volume expansion to increase urine output)
- Goal: Urine output >0.5 mL/kg/hour
Step 3 - Alpha-1 Blocker (Medical Expulsive Therapy - MET):
- Tamsulosin 0.4 mg once daily (alpha-1 adrenergic blocker)
- Relaxes ureteral smooth muscle → facilitates stone passage
- Most effective for stones <10 mm in the distal ureter
Step 4 - Monitor:
- Serial urine straining (to capture passed stone for analysis)
- Repeat vital signs, pain assessment every 4-6 hours
- Monitor urine output and creatinine
Indications for Urgent Urological Intervention:
- Stone >10 mm (unlikely to pass spontaneously)
- Concurrent urinary tract infection with obstruction (sepsis risk - urological emergency)
- Bilateral obstruction or solitary kidney obstruction with AKI
- Intractable pain / vomiting despite medical therapy
- Washington Manual, p. 496
8.2 Surgical/Interventional Options
| Procedure | Indication | Details |
|---|---|---|
| Ureteroscopy + Laser Lithotripsy (URS) | Ureteric stones, failed conservative therapy | Flexible ureteroscope, holmium laser fragmentation |
| Extracorporeal Shock Wave Lithotripsy (ESWL) | Renal/upper ureteric stones <2 cm | External shockwaves fragment stone; non-invasive |
| Percutaneous Nephrolithotomy (PCNL) | Large stones >2 cm, staghorn calculi | Percutaneous access to renal pelvis |
| Ureteral Stenting (DJ Stent) | Obstruction with infection/AKI | Bypasses stone; allows drainage |
ESWL Complications to Monitor (post-procedure): Flank pain, nausea, vomiting (especially 48 hours after procedure), skin ecchymosis, gross hematuria (usually self-limited <24 hours), UTI, and rarely sepsis. - Tintinalli's Emergency Medicine, p. 194
8.3 Long-Term Prevention (Specific to This Patient - Calcium Oxalate Stone)
Foundation of therapy for ALL stone types:
- Maintain high urine output: 2-3 L/day (the single most effective measure)
- Low-sodium diet: 2-2.3 g/day (80-100 mmol/day) - excess sodium increases urinary calcium excretion
- Washington Manual, p. 496
Specific measures for Calcium Oxalate Stones:
| Metabolic Problem | Intervention |
|---|---|
| Hypercalciuria | Low-sodium diet + Thiazide diuretic (hydrochlorothiazide 25 mg/day) - reduces renal calcium excretion |
| Hypocitraturia | Potassium citrate 10-60 mEq/day in divided doses; OR lemon juice (4 oz in 1 L water daily) |
| Hyperoxaluria (dietary) | Avoid oxalate-rich foods: spinach, rhubarb, nuts, chocolate, tea |
| Calcium intake | Age-appropriate dietary calcium intake (do NOT restrict dietary calcium - it binds oxalate in gut reducing absorption); avoid supplemental calcium tablets |
Uric Acid Stone Prevention (if recurrence includes uric acid component):
- Urinary alkalinization with potassium citrate to target urine pH 6.0-6.5
- Low-protein diet
- Xanthine oxidase inhibitors (allopurinol/febuxostat) if unresponsive to alkalinization
- Washington Manual, p. 497
Dietary Counseling Summary for This Patient:
- Increase water intake to >2.5 L/day
- Reduce sodium to <2 g/day
- Reduce animal protein
- Maintain normal dietary calcium intake (1000 mg/day from food)
- Avoid spinach, rhubarb, nuts, strong tea (oxalate sources)
- Avoid vitamin C supplements >1 g/day (metabolized to oxalate)
8.4 Follow-Up Plan
| Timeline | Action |
|---|---|
| 2 weeks | Repeat renal ultrasound to confirm stone passage / resolution of hydronephrosis |
| 3 weeks | 24-hour urine collection on usual diet (as performed above) |
| 4 weeks | Endocrinology referral for evaluation of primary hyperparathyroidism (DEXA scan, sestamibi parathyroid scan) |
| 3 months | Repeat serum calcium, PTH, creatinine |
| 6 months | Reassess 24-hour urine while on treatment |
| Ongoing | Annual review; urine pH monitoring at home; maintain hydration diary |
9. DISEASE COMPLICATIONS (If Untreated)
| Complication | Mechanism |
|---|---|
| Hydronephrosis | Persistent obstruction → back-pressure dilation |
| Obstructive Nephropathy / AKI | Pressure-related nephron damage |
| Chronic Kidney Disease (CKD) | Repeated obstruction → irreversible tubular damage; nephrolithiasis responsible for 5% of all ESKD in northern India/Pakistan ("renal stone belt") - Brenner & Rector's, p. 3769 |
| Pyelonephritis / Urosepsis | Stasis of infected urine proximal to obstructing stone |
| Pyonephrosis | Infected hydronephrosis - urgent drainage required |
| Renal Papillary Necrosis | Recurrent obstruction + infection |
| Hypertension | Renal parenchymal damage |
10. SUMMARY TABLE
| Domain | Key Finding |
|---|---|
| Chief Complaint | Severe left flank pain radiating to groin + hematuria |
| Stone Type | Calcium oxalate monohydrate (85%) |
| Stone Location | Left UPJ, 6 mm |
| Key Investigation | Non-contrast CT (gold standard), urine microscopy (envelope-shaped crystals), 24-hr urine |
| Metabolic Diagnosis | Hypercalciuria + hypocitraturia + mild hyperoxaluria |
| Acute Treatment | IV analgesia + hydration + tamsulosin (MET) |
| Definitive Intervention | Ureteroscopy + laser lithotripsy (if no spontaneous passage) |
| Long-Term Prevention | High fluid intake, low-sodium diet, thiazide, potassium citrate |
| Complication Risk | CKD, urosepsis, recurrence (50% at 5 years without prevention) |
REFERENCES (Textbook Sources)
- Washington Manual of Medical Therapeutics - Nephrolithiasis section, pp. 495-497
- Grainger & Allison's Diagnostic Radiology - Renal Tract Calcifications, p. 719
- Brenner and Rector's The Kidney, 2-Volume Set - Chronic Kidney Disease Due to Renal Calculi, p. 3769
- Tintinalli's Emergency Medicine - Lithotripsy / Renal Colic section
- Recent Systematic Review: Ungerer GN et al. "Mobile and eHealth technologies in the management and prevention of nephrolithiasis." Actas Urol Esp, 2024 [PMID: 37364768]
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