Delhi-based Ankur Gupta, a bachelor of commerce student, suffered from severe pain in the left flank and a burning sensation in urine. Earlier this month, the 21-year-old was diagnosed with a stone lodged in his ureter.
Manuj Sharma, 31, suffered from lower abdomen pain and a constant feeling of nausea. In 2009, he consulted Aman Gupta, consultant, urology and kidney transplant section, Fortis Flt Lt Rajan Dhall Hospital, Vasant Kunj, Delhi. An ultrasound revealed multiple stones in both kidneys; two of them had slipped into the urinary tract. This was the third time stones were detected in his kidney; the first time was in 2003, when he was still a student in Chandigarh.
Both Ankur and Sharma are young, and neither has a family history. The two traits they shared were wrong eating habits and very little intake of water.
“I see on an average 50-60 patients of kidney stone every month, and many of them are in their 20s and 30s. The number is definitely increasing,” says Atul Goswami, senior consultant and head of department of urology, Max Super Speciality Hospital, Shalimar Bagh, Delhi.
“The basic reason for the formation of stones is higher concentration of certain salts in the kidney. Stones don’t usually form in the urinary bladder, but migrate from the kidney. A fragment of stone called nidus is formed first around which more salts keep depositing, which increases the size of the stone,” says Narasimhan Subramanian, senior consultant, urology, Indraprastha Apollo Hospitals, Delhi. “The gender difference is clear—men have twice the chances of developing stones as compared to women—and genetics too plays a role. Some people who produce some salts in excess or those who excrete larger amounts of some of these salts tend to form stones more frequently. Similarly, people with hypertension, gout, obesity, diabetes, hyperparathyroidism, and intestinal diseases like Crohn’s disease have a higher probability of frequent stone formation,” he adds.
Wrong eating habits also contribute to the formation of stones in the kidney. “Factors like obesity, reduced water intake and physical activity, high intake of processed foods and caffeine, and a higher proportion of animal protein in the diet are the other reasons that contribute,” adds Dr Goswami.
Explaining the importance of water, Dr Goswami says: “Dehydration leads to the formation of highly concentrated urine (darker in colour), which leads to the precipitation of calcium salts and increases the possibility of formation of crystals that lead to stone formation.”
Dr Gupta adds: “Processed foods are a big problem too. These are usually high in salt (sodium). High salt intake leads to higher calcium excretion (increased amount of sodium passing into the urine can also pull calcium along with it), which increases the probability of stone formation. High salt intake also decreases citrate excretion in urine (citrate is an inhibitor of stone formation). Secondly, these foods tend to be low in fibre, which creates havoc with the excretion of calcium oxalate and uric acid in urine, often leading to stone formation,” he explains.
Clarifying the calcium versus stones debate, Dr Subramanian says the daily required intake of dietary calcium and supplements in those with normal levels of blood and urinary calcium does not lead to an increase in stone formation. However, people with higher levels of calcium should consult a physician before taking any supplements.
“Similarly, aerated drinks might lead to higher levels of oxalates in urine, thus increasing the risk, and the high level of caffeine in most energy drinks also increases urinary calcium excretion. Excess weight tends to be a problem too, as the obese tend to excrete more acidic urine, leading to increased risk of stone formation,” adds Dr Gupta. “Excessive use of over-the-counter medicines like some laxatives, antacids containing magnesium trisilicate, and cough suppressants containing guaifenesin and ephedrine, can also increase the risk of stone formation,” he warns.
Watch out for
The common symptoms of kidney stones include sudden onset of pain in the lower abdomen or the flanks, blood in the urine and difficulty in passing urine. “Often there are no symptoms till the stone becomes large, or moves from the kidney to the ureter. About one-third of all small stones are picked up in routine investigations, wherein patients do not have any symptoms,” says Dr Subramanian.
He recalls the case of a 54-year-old from Assam who had no pain but a stone the size of a cricket ball was found in his bladder during a routine check-up; it was removed through surgery. The only symptoms he felt were a frequent urge to urinate and some discomfort at the end of urination. “When a stone is left undiagnosed for a long time, it can hinder proper functioning of the kidney. Patient may also get prone to urinary infections. In case a stone is present in the inner area of the kidney for long time, the inner lining (epithelium) may undergo changes; also there is an increased risk of predisposition to cancer,” warns Dr Subramanian.
Diagnosis and treatment
Diagnosis is based on the patient’s symptoms and confirmed by radiological investigations like X-ray, ultrasonography or computerized tomography (CT) scan. “Of these, CT scan is considered the gold standard,” says Dr Goswami.
“Treatment of kidney stones depends on size and location, along with the severity of the symptoms. Stones which are less than 4mm often pass on their own and are assisted by using medication called alpha blockers, like Urimax,” says Dr Subramanian. Other treatments include ureteroscopy for lower ureteric stones, extracorporeal shock-wave lithotripsy for renal and upper ureteric stones, and percutaneous nephrolithotomy for larger kidney and upper ureteric stones, says Dr Goswami.
“Retrograde intra-renal surgery can deal with all kinds of stones, in all locations, in a minimally invasive manner. In this, a flexible ureteroscope is introduced through the urethra and is then advanced up the ureter into the kidney. The stone is directly visualized and broken up into sand-like particles with laser. These particles pass out later spontaneously. The advantage of this procedure is the avoidance of any incision, minimal blood loss, no damage to the kidney, minimal pain, short hospitalization, early recovery and a high success rate,” says Dr Goswami.
Ankur Gupta undwerwent ureteroscopic stone removal in mid-January. Dr Goswami has asked him to increase his water intake (at least 3 litres), and reduce junk food and salt intake. Manuj Sharma underwent retrograde intra-renal surgery. A serial stone former, he now undergoes regular check-ups and is extremely careful about his diet and water intake.