Management of urolithiasis with chronic renal failure
Ganesh Gopalakrishnan and Gaurabathini Siva Prasad
Purpose of review
Epidemiological trends of urolithiasis and the prevalence of
renal failure in patients with stones have changed. This is
the era of minimally invasive therapy for stone disease. We
review the impact of minimally invasive therapy on the
management of urolithiasis in patients with renal failure and
its outcome.
Recent findings
The prevalence of urolithiasis has reached its peak and
plateaued in Europe and North America while it is still rising
in the underdeveloped countries. The prevalence of renal
failure in patients with chronic renal failure has reduced by
half over the last decade. Minimally invasive therapy like
percutaneous nephrolithotripsy has fared better than open
stone surgery in all respects. Patients with kidney stones do
not have normal renal function. Recently, cystine stones,
and stones in patients with renal tubular acidosis and bowel
disease were shown to affect renal function significantly.
Summary
Management of stones in chronic renal failure is
challenging. Efforts should be made to minimize renal injury.
Once a ‘stone-free’ kidney is achieved, steps should be
taken to conserve renal function and address the issue of
recurrence.
Keywords
calculus nephropathy, renal failure, urolithiasis
Curr Opin Urol 17:132–135. ß 2007 Lippincott Williams & Wilkins.
Department of Urology, Christian Medical College, Vellore, Tamil Nadu, India
Correspondence to Dr Ganesh Gopalakrishnan, Professor and Head of Urology,
Christian Medical College, Vellore, Tamil Nadu 632004, India
Tel: +416 2282111; fax: +416 2232035;
e-mail: ganeshgopalakrishnan@yahoo.com
Current Opinion in Urology 2007, 17:132–135
Abbreviations
CRF chronic renal failure
PCN percutaneous nephrostomy
PNL percutaneous nephrolithotripsy
SWL shockwave lithotripsy
ß 2007 Lippincott Williams & Wilkins
0963-0643
132
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Introduction
Renal insufficiency in patients with urolithiasis could be
either due to calculus nephropathy or nephropathy of
medical renal disease. The exact prevalence of calculus
nephropathy alone is not known. The reported preva-
lence of renal failure with urolithiasis is 1.7–18% [1,2].
The definition of renal failure and its severity is different
in various studies. Management of stones in chronic renal
failure (CRF) is challenging. An appropriate approach to
their management has been shown to stabilize renal
function and delay the requirement of renal replacement
therapy. We focus on the topic of management of calculus
nephropathy.
Problems specifically related to stones and
chronic renal failure
Patients with CRF are anemic, and have leucopenia
(lymphopenia), a low platelet count and impaired platelet
function. There is an increased tendency for bleeding
during intervention for removal of stones. Compared to
patients with normal renal function, they are also more
susceptible to infection and sepsis. Their body homeo-
stasis is impaired, with resulting dyselecterolytemia, fluid
overload and pulmonary edema. They might require
temporary dialysis. Depending on the duration and sever-
ity of renal failure, secondary hyperparathyroidism, renal
osteodystrophy, altered lipid profile and cardiomyopathy
are added problems. Thus, patients with CRF are high-
risk candidates for any form of anesthesia and surgery.
Management of urolithiasis in chronic
renal failure
Minimally invasive therapy has replaced open stone
surgery in the last two decades. The ultimate goal of a
‘stone-free kidney’ remains. Advancements have occur-
red in intensive care monitoring and antibiotic therapy,
with resultant overall reduction in morbidity and
mortality.
Presentation of patients with CRF and urolithiasis can
vary from silent uremia to loin pain, fever, urosepsis,
anuria and pulmonary edema. Patients with a low socio-
economic status and those with a poor understanding of
the disease can present with neglected stones and ure-
mia. Alternative medicine for stone disease is popular in
some parts of the world and such patients can ultimately
present with renal failure.
The immediate goal is to stabilize the patient with
inotropic support, empirical antibiotics and dialysis

whenever required. Decompression of the pelvicalyceal
system is best done by placement of a percutaneous
nephrostomy (PCN) when obstruction and infection is
suspected. PCN is better than double-J stenting in
relieving obstruction and control of sepsis. Sometimes
more than one PCN may be required in different
calyces to adequately decompress the pelvicalyceal
system. The site of placement of the PCN should
be appropriate so that it also helps in percutaneous
retrieval of the stone in the future. Once sepsis is con-
trolled and the nadir level of serum creatinine is reached,
the function of individual renal units is assessed by
measuring either creatinine clearance from the PCN
tube or by extraction fraction using 99Tc-labelled
diethylenetriamine pentaacetate or L-ethyl cystine
dynamic renal scan.
Definitive management depends on the function of the
affected renal unit and presence of any associated
anatomical anomaly.
Nephrectomy
A nephrectomy may be indicated when the kidney
is either nonfunctioning or poorly functioning. It may
be appropriate to remove a poorly functioning kidney
when its estimated glomerular filtration rate is below
15 ml/min, daily PCN output is below 400 ml and renal
parenchymal thickness is below 5 mm. It is worthwhile
to remove such a kidney and place the patient on
renal replacement therapy rather than leave behind an
infective focus which could lead to life-threatening
sepsis. Nephrectomy could be performed either by a
transabdominal laparoscopic or by a retroperitoneo-
scopic approach. Ablative procedures in stone disease
are challenging and conversion rates to open surgery are
high.
Open stone surgery
Open stone surgery in whichever form, pyelolithotomy,
extended pyelolithotomy, anatrophic nephrolithotomy
or ureterolithotomy, improves renal function and delays
or prevents progression to end-stage renal disease
[3–5]. Open stone surgery in today’s world is, however,
recommended only for patients with complex stone
burden and those with associated anatomic anomalies
such as pelvi-ureteric junction obstruction or infundib-
ular stenosis [6]. Recently, a prospective randomized
study was published comparing open stone surgery
and percutaneous nephrolithotripsy (PNL) in the
management of staghorn calculi [7]. Seventy-eight
patients with 88 complete staghorn calculi were pros-
pectively randomized to undergo open stone surgery
(n ¼ 45) or PNL (n ¼ 43). Both the treatment groups
were comparable with regard to stone-free rates. During
follow-up, the renal function either improved or
remained stable in 86.7% in the open surgery and 91%
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Chronic renal failure Gopalakrishnan and Siva Prasad 133
in the PNL group. Intraoperative complications like
bleeding requiring transfusion, and ureteral and pleural
injury were significantly higher in open surgery (38%)
compared to PNL (16%; P < 0.05). Major postoperative
complications like massive hematuria, sepsis and urine
leakage were higher in the open surgery group (31%)
when compared to the PNL group (18.6%); the results
were not statistically significant. Furthermore, patients
undergoing PNL had a shorter operation time and
hospital stay.
Shockwave lithotripsy
The main concern in using shockwave lithotripsy
(SWL) in patients with renal failure is that there is
decreased fragmentation due to a deficient wet layer
over the stone. Even if stones fragment, complete clear-
ance of fragments is doubtful due to decreased urine
output from the affected kidney. There could also be
further loss of renal function. SWL is usually given after
relief of obstruction by double-J stenting or PCN and
control of sepsis. There are few reports of primary
SWL in the management of renal stones with renal
failure [8,9]. Clearance rates up to 40–85% at 6 months
are reported and the necessity for ancillary procedures is
as high as 60% to clear stone fragments. Accurate data in
this regard are lacking. In one study [8], the long-term
effect on renal function was retrospectively evaluated
in CRF patients who underwent SWL for renal and
ureteral calculi, and it was found that there was no
evidence of loss in renal function following SWL.
SWL is mostly used as an adjuvant to clear post open
surgery or PNL residual stones. Clearance rates are only
up to 60% [5].
Percutaneous nephrolithotripsy
The main modality of management in patients with
stones and CRF is PNL. There is significant evidence
to support this from the Indian subcontinent [10,11]. In
a retrospective analysis of PNL for the treatment of
calculus nephropathy [10], a total of 1002 patients
underwent PNL and 78 (7%) had calculus nephropathy.
PCN was placed in 64 prior to PNL, and 14 had primary
PNL as they had no sepsis and obvious obstruction;
85% had improvement in renal function, 14% had no
improvement and 1% required permanent maintenance
hemodialysis. Overall morbidity and mortality were 17.3
and 3.8%, compared to less than 1% and none in the
group with normal renal function. All deaths were due to
sepsis.
In another study [11], 4400 patients with urolithiasis
underwent treatment and 84 (1.9%) had renal insuffi-
ciency defined as serum creatinine above 1.5 mg/dl;
87 renal units underwent PNL and required almost
two stages per renal unit. At 2.2 years follow-up, 39%
showed improvement, 28.6% showed stabilization and
 134 Urolithiasis
32% had deterioration in renal function; 19% required
dialysis. The authors suggested that large stone bulk
(above 1500 mm3), age below 15 years, proteinuria (above
300 mg/day), thinned out renal cortex (below 5 mm) and
recurrent urinary tract infection are significant factors in
predicting deterioration of renal function independent of
stone-free status. PNL fared better over open stone
surgery in all respects [7].
PNL has its own sets of problems. There could be
hypothermia if the temperature of the irrigation fluid is
not maintained. PNL operates in an almost closed system
at a pressure of about 60 cm water, when irrigation fluid
absorption is likely to occur. The threshold for fluid
overload is low in patients with renal failure and they
can develop pulmonary edema easily. Irrespective of
urine culture status, the presence of stones and indwel-
ling tubes makes the pelvicalyceal system a site of
bacterial growth. Bacteremia could occur during PNL
even if adequately covered with antibiotics. Being immu-
nocompromised, patients with CRF can go into septice-
mia easily. Although the overall operation time was
shown to be shorter in PNL than open stone surgery,
these factors should be noted and one should attempt
to reduce complications even if this involves reducing
the operative time or even performing it as a staged
procedure.
There are some concerns that intracorporeal energy
sources could affect renal function. Laser lithotripsy
has not been shown to affect the glomerular filtration
rate of the kidney. Flexible ureteroscopy and retrograde
intrarenal surgery can be performed either in isolation or
as an adjuvant to PNL to achieve a complete stone-free
kidney. Flexible nephroscopy either at the initial setting
of PNL or as a second-look procedure has been shown to
enhance stone-free rates following PNL for staghorn
calculi [6].
Pediatric urolithiasis
Stones in the pediatric population are rarer than adults,
comprising 1–3% of all urolithiasis. Prevalence of CRF in
pediatric patients with urolithiasis in developing
countries is 14% [12]. The pattern of pediatric urolithiasis
is different in the developed and developing world.
Perhaps the burden is minimal in the developed world.
Miniaturization of equipment has enabled us to use
similar minimally invasive approach as in adults and
achieve identical clearance rates. The main concern in
children is that 80% of them have associated metabolic
abnormalities and infection is coexistent in 49% [13–15].
An active search should be made to identify metabolic
disorders and treat them aggressively. Risk of recurrence
is high and patients should be kept on active surveillance.
Specific issues like nutritional support and treatment of
infection must be addressed.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Ureteric stones
Improvement in renal function is probably better after
treatment of ureteric stones with renal failure. They tend
to present early with obvious obstruction. Once renal
function has stabilized by either PCN or double-J stent-
ing, management depends on the site and size of the
stone apart from renal function.
Ureteric stones up to 1–1.5 cm in the upper and
mid ureter are usually treated by SWL, while in the
lower ureter, ureteroscopy is preferred. Upper ureteric
stones larger than 1.5 cm can be approached via a percu-
taneous route. It is advantageous if PCN placement is
in an appropriate calyx if stabilization of the patient
is being planned. Ureteroscopy with laser lithotripsy is
the treatment of choice for ureteric stones as retro-
pulsion and stone migration are greatly minimized.
Ureterolithotomy can be performed for ureteric stones
larger than 2 cm by a laparoscopic approach or by open
surgery.
Once stones and stents are removed, the patient should
be kept on regular follow-up for not only stone recur-
rence, but also for strictures after surgery on the ureter. A
drainage study is advisable at 6 months to rule out
ureteric obstruction.
How aggressive should the approach be?
The history of stone disease as a possible risk factor for
CRF was studied in a case-control study [16]. The odds
ratios (adjusted for confounding variables) for chronic
kidney disease (overall), diabetic nephropathy and inter-
stitial nephritis for patients with kidney stones were 1.9
(95% confidence interval 1.1, 3.3), 2.5 (0.87, 7.0) and 3.4
(1.5, 7.4), respectively. The authors [16] concluded that
kidney stones play a significant role in the development
of chronic kidney disease and suggested that the pre-
vention of kidney stones may be a means of delaying
the onset of chronic kidney disease. Once the stones are
removed, by whatever means, there is improvement in
renal function as evidenced by a mean drop of serum
creatinine (1.2–2.0 mg%) [5,10] and, furthermore, there is
either prevention or delayed dialysis dependency in a
significant percentage of patients.
The approach should be aggressive enough to achieve
stone-free kidneys, but each procedure results in some
loss of renal function. Stone disease that recurs requires
multiple procedures over the years and this is also a
contributing factor towards chronic renal insufficiency.
Measures should be taken to minimize renal injury and to
this end minimally invasive techniques should be used as
far as possible. The approach should be planned in such a
way that it removes maximum stone burden with minimal
possible injury to the kidney. At times it may not be
advisable to chase a small residue in an inaccessible

position which could cause more harm than benefit to the
patient and at the same time one should remember its
chances of stone migration and obstruction. Small-
volume residues could be removed by flexible nephro-
scopy or retrograde intrarenal surgery. The balance
between an aggressive approach and leaving behind a
residue in favor of preserving renal function should
be individualized.
Recent developments in urolithiasis with
renal failure
Epidemiological trends in urolithiasis suggest that the
prevalence of urolithiasis has apparently reached its peak
and plateaued in North America and Europe, whereas it is
still rising in the developing world [17]. The prevalence
of renal failure in stone disease itself has been signifi-
cantly reduced in the developed world from 4.7% in 1990
to 2.2% in 2000 [18]. This is further evident from the fact
that there are no recent data on the issue of the manage-
ment of urolithiasis in chronic failure from the developed
world. All published data from the developed world were
during the time when minimally invasive modalities in
management of urolithiasis were not fully developed.
The available recent data are from the Indian subconti-
nent [10,11].
Creatinine clearance was found to decrease with age at a
higher rate in stone formers than in non-stone formers
[19]. In recent intraoperative biopsies, interstitial papil-
lary deposits were found in calcium oxalate stone formers
and apatite crystal plugging the terminal collecting duct
with obvious renal injury was revealed in brushite
stone formers [20,21]. Renal function with regard to type
of stone was recently addressed [22]. Creatinine clear-
ance was impaired in all types of stone. Cystine stones,
and stones in patients with renal tubular acidosis and
bowel diseases had significant impairment of creatinine
clearance.
Conclusion
In patients with stone disease and CRF, a minimally
invasive approach, especially PNL, is recommended for
renal stones. Ureteric stones are best managed by ure-
teroscopy and laser lithotripsy. Recurrent urinary tract
infection, age below 15 years, proteinuria above 300 mg%
and large stone bulk are poor prognostic factors, and cause
rapid progression of renal failure. Improvement in renal
function is not directly related to stone removal – it also
depends on the associated tubulo-interstitial pathology.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Chronic renal failure Gopalakrishnan and Siva Prasad 135
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
 of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 148).
1 Gupta M, Bolton DM, Gupta PN, Stoller ML. Improved renal function following
aggressive treatment of urolithiasis and concurrent mild to moderate renal
insufficiency. J Urol 1994; 152:1086–1090.
2 Marangella M, Tricerri A, Bruno M, et al. Nephrolithiasis due to infections.
Analysis of the mode and factors of progression toward renal failure [in Italian].
Minerva Urol Nefrol 1986; 38:103–106.
3 Witherow RO, Wickham JE. Nephrolithotomy in chronic renal failure: saved
from dialysis! Br J Urol 1980; 52:419–421.
4 Hussain M, Lal M, Ali B, et al. Management of urinary calculi associated with
renal failure. J Pak Med Assoc 1995; 45:205–208.
5 Singh I, Gupta NP, Hemal AK, et al. Efficacy and outcome of surgical
intervention in patients with nephrolithiasis and chronic renal failure. Int Urol
Nephrol 2001; 33:293–298.
6 Preminger GM, Assimos DG, Lingeman JE, et al. Chapter 1: AUA guideline on
management of staghorn calculi: diagnosis and treatment recommendations.
J Urol 2005; 173:1991–2000.
7 Al-Kohlany KM, Shokeir A, Mosbah A, et al. Treatment of complete staghorn
stones: a prospective randomized comparison of open surgery compared with
percutaneous nephrolithotomy. J Urol 2005; 173:469–473.
8 Bhatia V, Biyani CS, Al-Awadi K. Extracorporeal shockwave therapy for
urolithiasis with renal insufficiency. Urol Int 1995; 55:11–15.
9 Chandhoke PS, Albala DM, Clayman RV. Long-term comparison of renal
function in patients with solitary kidneys and/or moderate renal insufficiency
undergoing extracorporeal shock wave lithotripsy or percutaneous nephro-
lithotomy. J Urol 1992; 147:1226–1230.
10 Agrawal MS, Aron M, Asopa HS. Endourological renal salvage in patients with
calculus nephropathy and advanced uremia. BJU Int 1999; 84:252–256.
11 Kukreja R, Desai M, Patel SH, Desai MR. Nephrolithiasis associated with renal
insufficiency: factors predicting outcome. J Endourol 2003; 17:875–879.
12 Jamro S, Channa NA, Shaikh AH, Ramzan A. Chronic renal failure in children.
J Pak Med Assoc 2003; 53:140–142.
13 Milliner DS, Murphy ME. Urolithiasis in pediatric patients. Mayo Clin Proc
1993; 68:241–248.
14 Diamond DA, Rickwood AM, Lee PH, Johnston JH. Infection stones in
children: a twenty-seven-year review. Urology 1994; 43:525–527.
15 Coward RJ, Peters CJ, Duffy PG, et al. Epidemiology of pediatric stone
disease in the UK. Arch Dis Child 2003; 88:962–965.
16 Vupputuri S, Soucie JM, McClellan W, Sandler DP. History of kidney stones
as a possible risk factor for chronic kidney disease. Ann Epidemiol 2004;
14:222–228.
17 Trinchieri A. Epidemiological trends in urolithiasis: impact on our healthcare
 systems. Urol Res 2006; 34:151–156.
Detailed review on trends in urolithiasis in the developed and developing world.
18 Jungers P, Joly D, Barbey F, et al. ESRD caused by nephrolithiasis: pre-
valence, mechanisms, and prevention. Am J Kidney Dis 2004; 44:799–805.
19 Worcester E, Parks JH, Josephson MA, et al. Causes and consequences of
kidney loss in patients with nephrolithiasis. Kidney Int 2003; 64:2204–2213.
20 Evan AP, Lingeman JE, Coe FL, et al. Randall’s plaque of patients with
nephrolithiasis begins in basement membranes of thin loops of Henle. J Clin
Invest 2003; 111:607–616.
21 Evan AP, Lingeman JE, Coe FL, et al. Crystal-associated nephropathy in
patients with brushite nephrolithiasis. Kidney Int 2005; 67:576–591.
22 Worcester EM, Parks JH, Evan AP, Coe FL. Renal function in patients with
 nephrolithiasis. J Urol 2006; 176:600–603; discussion 603.
An excellent study on creatinine clearance in various types of stone.