Calculus, Kidney Stone Panel

Calculus, Kidney Stone Panel

Synonym/acronym: Kidney stone analysis, nephrolithiasis analysis.

Common use

To identify the presence of kidney stones.

Specimen

Kidney stones.

Normal findings

(Method: Infrared spectrometry) None detected.

Description

Renal calculi (kidney stones) are formed by the crystallization of calcium oxalate (most common), magnesium ammonium phosphate, calcium phosphate, uric acid, and cystine. Formation of stones may be hereditary, related to diet or poor hydration, urinary tract infections caused by urease-producing bacteria, conditions resulting in reduced urine flow, or excessive amounts of the previously mentioned insoluble substances due to other predisposing conditions. The presence of stones is confirmed by diagnostic visualization or passing of the stones in the urine. The chemical nature of the stones is confirmed qualitatively. Analysis also includes a description of color, size, and weight.

This procedure is contraindicated for

    N/A

Indications

  • Identify substances present in renal calculi

Potential diagnosis

Positive findings in:

    Presence of calcium calculi (75–85%)

  • Decreased levels of citric acid, which creates an imbalance of mineral salts (related to conditions such as enteric hyperoxaluria, enterocystoplasty, or small bowel resection)
  • Distal renal tubular acidosis (related to accumulation of calcium in the kidneys)
  • Etiology unknown
  • Increased levels of calcium with or without alkaline pH, which creates an imbalance of mineral salts (related to conditions such as Cushing’s disease, Dent’s disease, enterocystoplasty, ileostomy, immobilization, medullary sponge kidney, metabolic syndrome, milk alkali syndrome, primary biliary cirrhosis, primary hyperparathyroidism, sarcoidosis, Sjörgren’s syndrome, use of calcium carbonate–containing antacids, use of corticosteroids, or vitamin D intoxication)
  • Increased levels of oxalic acid, which creates an imbalance of mineral salts (related to conditions such as bariatric surgery, enteric hyperoxaluria, enterocystoplasty, hereditary hyperoxaluria, hypomagnesemia, jejunal-ileal bypass, metabolic syndrome, pancreatitis, or small bowel resection)
  • Increased levels of uric acid, which creates an imbalance of mineral salts (uric acid crystals sometimes provide the base upon which calcium oxalate crystals grow)
  • Presence of magnesium ammonium phosphate (struvite or triple phosphate) calculi (10–15%)

  • Urinary tract infection (related to chronic indwelling catheter, neurogenic bladder dysfunction, obstruction, or urinary diversion)
  • Gram-positive bacteria associated with development of struvite calculi include Bacillus species, Corynebacterium species, Peptococcus asaccharolyticus, Staphylococcus aureus, and Staphylococcus epidermidis
  • Gram-negative bacteria associated with development of struvite calculi include Bacteroides corrodens, Flavobacterium species, Klebsiella species, Pasteurella species, Proteus species, Providencia stuartii, Pseudomonas aeruginosa, Serratia marcescens, Ureaplasma urealyticum, and Yersinia enterocolitica
  • Yeast associated with development of struvite calculi include Candida humicola, Cryptococcus species, Rhodotorula species, Sporobolomyces species, and Trichosporon cutaneum
  • Presence of uric acid calculi (5–8%)

  • Increased levels of uric acid or increased urinary excretion of uric acid
  • Anemias (pernicious, lead poisoning) (related to cellular destruction and turnover)
  • Chemotherapy and radiation therapy (related to high cell turnover)
  • Gout (usually related to excess dietary intake)
  • Glycogen storage disease type I (von Gierke’s disease) (related to a genetic deficiency of the enzyme G-6–P-D, ultimately resulting in hyperuricemia, increased production of uric acid via the pentose phosphate pathway, and increased purine catabolism)
  • Hemoglobinopathies (sickle cell anemia, thalassemias) (related to cellular destruction and turnover)
  • Ileostomy (related to imbalances in mineral salts)
  • Lesch-Nyhan syndrome (related to a disorder of uric acid metabolism)
  • Metabolic syndrome (elevated uric acid levels are associated with metabolic syndrome; there is evidence that uric acidemia is a risk factor for cardiovascular and renal disease)
  • Polycythemia (related to increased cellular destruction)
  • Psoriasis (related to increased skin cell turnover)
  • Tumors (related to high cell turnover)
  • Presence of cystine calculi (approximately 1%)

  • Fanconi’s syndrome (hereditary hypercistinuria) (related to increased excretion of cystine)
N/A

Critical findings

    N/A

Interfering factors

  • Drugs and substances that may increase the formation of urine calculi include probenecid and vitamin D.
  • Adhesive tape should not be used to attach stones to any transportation or collection container, because the adhesive interferes with infrared spectrometry.

Nursing Implications and Procedure

Potential nursing problems

ProblemSigns & SymptomsInterventions
Pain (Related to obstruction of urinary flow by stone, presence of stone, movement of stone)Report of pain, restlessness, grimace, moan, sleeplessness, diaphoretic, nausea, vomiting; elevated blood pressure Administer prescribed medication for pain; assesses effectiveness of pain medication and trend outcome; assess characteristics of pain (location, duration); consider nonpharmacological pain interventions that have worked for the patient in the past
Infection (Related to stasis; interrupted urinary flow; gravel; urinary tract instrumentation)Temperature; elevated white blood cell (WBC) count; cloudy urine; sediment in urine; blood in urine Monitor urinary output; assess urine color, odor, presence of blood; monitor and trend temperature and WBC count; obtain urine for culture and sensitivity as required; encourage fluid intake in excess of 3000 mL/day; administer prescribed antibiotics
Knowledge (Related to unfamiliarity of factors related to the development of kidney stones; unfamiliarity with disease management; methods of disease prevention)Lack of interest or questions; multiple questions; anxiety in relation to disease process and management; renal stone reoccurrence Assess understanding of renal stone formation; assess for a family history of renal stones; assess patient's understanding of the relationship between fluid intake and stone formation; strain urine; limit protein intake to decrease risk of stone formation; add cranberry juice to dietary intake; administer prescribed medications to decrease stone formation (cholestyramine, thiazide, allopurinol)
Elevated temperature (Related to infection secondary to stone formation)Elevated temperature; flushed; warm skin; diaphoresis Assess the patient's temperature frequently; encourage the use of light bedding and lightweight clothing to prevent overheating; increase fluid intake to offset insensible fluid loss; encourage bathing with tepid water for comfort and promotion of cooling; administer prescribed medication for elevated temperature

Pretest

  • Positively identify the patient using at least two unique identifiers before providing care, treatment, or services.
  • Patient Teaching: Inform the patient this test can assist in identification of the presence of kidney stones.
  • Obtain a history of the patient’s complaints, especially hematuria, recurrent urinary tract infection, and abdominal pain. Also, obtain a list of known allergens.
  • Obtain a history of the patient’s genitourinary system and results of previously performed laboratory tests and diagnostic and surgical procedures.
  • Obtain a list of the patient’s current medications, including herbs, nutritional supplements, and nutraceuticals (see Effects of Natural Products on Laboratory Values online at DavisPlus).
  • Review the procedure with the patient. Address concerns about pain and explain that there may be some discomfort during the procedure.
  • Sensitivity to social and cultural issues, as well as concern for modesty, is important in providing psychological support before, during, and after the procedure.
  • Note that there are no food, fluid, or medication restrictions unless by medical direction.

Intratest

  • Potential complications: N/A
  • Instruct the patient to cooperate fully and to follow directions.
  • Observe standard precautions, and follow the general guidelines in Patient Preparation and Specimen Collection. Positively identify the patient, and label the appropriate specimen container with the corresponding patient demographics, initials of the person collecting the specimen, date, and time of collection.
  • The patient presenting with symptoms indicating the presence of kidney stones may be provided with a device to strain the urine. The patient should be informed to transfer any particulate matter remaining in the strainer into the specimen collection container provided. Stones removed by the health-care provider (HCP) should be placed in the appropriate collection container.
  • Promptly transport the specimen to the laboratory for processing and analysis.

Post-Test

  • Inform the patient that a report of the results will be made available to the requesting HCP, who will discuss the results with the patient.
  • Inform the patient with kidney stones that the likelihood of recurrence is high. Educate the patient regarding risk factors that contribute to the likelihood of kidney stone formation, including family history, osteoporosis, urinary tract infections, gout, magnesium deficiency, Crohn’s disease with prior resection, age, gender (males are two to three times more likely than females to develop stones), race (whites are three to four times more likely than African Americans to develop stones), and climate.
  • Nutritional Considerations: Nutritional therapy is indicated for individuals identified as being at high risk for developing kidney stones. Educate the patient that diets rich in protein, salt, and oxalates increase the risk of stone formation. Adequate fluid intake should be encouraged.
  • Recognize anxiety related to test results.
  • Follow-up testing of urine may be requested, but usually not for 1 mo after the stones have passed or been removed. Answer any questions or address any concerns voiced by the patient or family.
  • Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patient’s symptoms and other tests performed.
  • Patient Education

    • Discuss the implications of abnormal test results on the patient’s lifestyle.
    • Provide teaching and information regarding the clinical implications of the test results, as appropriate.
    • Reinforce information given by the patient’s HCP regarding further testing, treatment, or referral to another HCP.
    • Teach patient to report worsening symptoms of infection such as fever, chills, and pain.
  • Expected Patient Outcomes

    • Knowledge
    • States the process and importance of straining all urine
    • States the importance of increasing fluid intake and adding cranberry juice to their diet
    • Skills
    • Accurately self-administers prescribed medication
    • Demonstrates proficiency in straining urine to check for stones
    • Attitude
    • Complies with the recommendation to increase fluid intake to more than 3,000 mL/day
    • Discusses the importance in reporting changes in the characteristics of the urine in relation to infection risk

Related Monographs

  • Related tests include CT abdomen, calcium, creatinine clearance, culture bacterial urine, cystoscopy, IVP, KUB, magnesium, oxalate, phosphorus, potassium, renogram, retrograde ureteropyelography, US abdomen, US kidney, uric acid, and UA.
  • Refer to the Genitourinary System table at the end of the book for related tests by body system.
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