Evaluation and Management of Nephrolithiasis in the Aging Population With Chronic Kidney Disease

Anna L Zisman; Fredric L Coe; Elaine M Worcester

Disclosures

Aging Health. 2011;7(3):423-433. 

In This Article

Abstract and Introduction

Abstract

The evaluation and management of the geriatric stone former poses unique challenges to the practitioner. Treatment can be complicated by the presence of multiple comorbidities such as chronic kidney disease, which can limit therapeutic options and is linked to poorer treatment outcomes. The coexistence of diseases such as osteoporosis, which can complicate evaluation and treatment, is an additional challenge. Herein we review the epidemiology of geriatric stone disease, the metabolic characteristics of the geriatric stone former, the approach to the evaluation of the older patient with stone disease alone or stone disease and chronic kidney disease, and the interplay between bone and stone disease. The impact of aging on a variety of medical and surgical treatments of nephrolithiasis is also reviewed.

Introduction

Nephrolithiasis is a highly prevalent disorder with a lifetime incidence of approximately 13% for Caucasian men and 7% for Caucasian women.[1,2] Incidence for African–American patients is lower. Over the last several decades the prevalence of stone disease has been steadily rising in the general population in the industrialized world.[3–5] While the increase is present across all age groups, it is interesting to note that the majority of the attributable rise in prevalence of stone disease stems from the 60–74 years age group in both men and women.[6] The reason for the latter observation is not entirely clear; however, some postulate that this may be related to improved and more frequent imaging, in turn leading to increased diagnosis of asymptomatic disease.[6] Other potential explanations include increased life expectancy, which allows for the development of comorbid conditions such as diabetes, which can be associated with increasing uric acid stone incidence.[7]

The increasing prevalence of stone disease in the older population is a concern, as nephrolithiasis has been associated with multiple comorbidities including hypertension,[8,9] diabetes mellitus and metabolic syndrome[10,11] and coronary artery disease.[12] Nephrolithiasis has also been linked with the development of chronic kidney disease (CKD) on a population level;[13,14] likewise, Vupputuri et al. found that patients with CKD were significantly more likely to have a history of kidney stones than those without CKD.[15] Individuals with stone disease are more likely to have diabetes, hypertension and obesity than control subjects,[13,14] and in some cases CKD, and it is plausible that the association between nephrolithiasis and CKD in the routine stone former may be due to the concurrent presence of several common conditions. Nonetheless, the risk for CKD is still greater in stone formers than controls even after adjusting for these three factors.[13] However, it is important to note that currently there is little direct evidence to suggest a pathogenic mechanism by which stone formation itself accounts for diminished kidney function, except for those with struvite stones and possibly those with cystinuria. Patients with calcium oxalate, calcium phosphate and uric acid stones have a very modest decrease in creatinine clearance compared with controls.[16]

The impact of CKD on the likelihood of future stone formation has not been well studied. In a longitudinal follow-up of 115 stone formers with a single kidney whose creatinine clearance was approximately 15% lower than that of stone formers with two kidneys, we have previously noted a decreased risk of recurrent stone disease compared with patients with both kidneys intact.[17] This seems reasonable, particularly with the well-documented fall in urinary calcium excretion with reduced glomerular filtration rate (GFR),[17,18] which would lead to decreased supersaturation for calcium salts. However, an older study evaluating urinary excretion of inhibitors of crystallization found a decreased excretion of these crystallization inhibitors in the urine of patients with CKD, which would presumably increase stone risk.[19] However, the relative contribution of this decline to actual lithogenesis is unknown. In our clinical experience, we have found the stone risk, particularly for calcium-based stones, decreases markedly with evolution of CKD.

Stone formation may be a marker for increased risk of CKD and cardiovascular disease, and this is particularly important in older adults. In patients over 70 years of age, 26% have evidence of estimated GFR (eGFR) <60 ml/min.[20] In the following pages we review the available evidence regarding the evaluation and management of nephrolithiasis in the elderly, with particular attention to the frequently encountered older patient with nephrolithiasis and CKD.

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