Medical Stone Management: 35 Years of Advances

Elements of selective approach. Diagnostic separation into different causes is made using knowledge gained from pathophysiological exploration, physicochemical elucidation and dietary aberrations. Tailor-made treatment is then chosen for each cause.

Three forms of hypercalciuria. Absorptive hypercalciuria is believed to be due mainly to intestinal calcium hyperabsorption. Renal hypercalciuria results primarily from renal leak of calcium and secondarily from stimulation of 1,25-dihydroxyvitamin D (1,25-(OH)₂D) synthesis. Resorptive hypercalciuria is characterized by primary hyperparathyroidism (PHPT).

Working scheme for gouty diathesis. Low urinary pH develops from excessive dietary and endogenous acid (H⁺ A⁻) load to kidneys, and from decreased renal synthesis of ammonia (NH₄⁺ A⁻) and urinary excretion of ammonium (NH₄⁺) due to renal fat infiltration and insulin resistance. Ensuing precipitation of uric acid may lead to formation of uric acid stones when there is inhibitor deficiency or promoter excess.

Physicochemical effects of hypocitraturia. Hypocitraturia increases urinary saturation of calcium oxalate (CaOx) by impairing formation of calcium citrate complex (CaCit⁻). Hypocitraturia also promotes aggregation and nucleation of calcium oxalate, and crystal growth of calcium phosphate (CaP).

Change (Δ) in urinary pH and citrate produced by potassium-poor lemonade and cranberry juices, and by potassium-rich orange juice. Two bars for orange juice indicate 2 studies.

Effect of potassium citrate treatment vs placebo on recurrent stone formation showing proportion or fraction of patients remaining free of stones.