Kidney stones
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7453.1420 (Published 10 June 2004) Cite this as: BMJ 2004;328:1420
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I thank Drs. Mehta, Manfredini et al, Trevithick, and Willetts for
their comments.
Dr Mehta raise an interesting but theoretical concern regarding the
use of nifedipine in the treatment of acute ureteric colic. Calcium
channel blockers (e.g. nifedipine) selectively inhibits the quick phasic
contractions [present during hyperstimulation] without influencing the
tonic [baseline] activity of the ureter.[1] . Therefore, nifedipine by
relaxing smooth muscles relieves the pain but doesn’t appear to inhibit
the ‘normal’ peristalsis. However, nifedipine alone was not found to be
better than placebo in relieving the pain of acute ureteric colic. [2]
I agree with Manfredini and colleagues about the circadian variation
in the incidence of acute renal colic, however, this review was on kidney
stones in general and circadian changes, I agree affect the incidence of
acute renal colic or crystalluria but not the incidence of kidney stones,
as stones takes weeks to months to develop. This circadian variation is
more so dependent on the human nature of poor oral intake during fasting
states – sleeping hours. I am not sure if we should classify it as a ‘real
circadian variation’ – as this pattern is affected by more so external
than internal factors. Academics aside, I agree that increasing fluid
intake, especially during fasting states [sleeping hours (night for day
time workers and day for night time workers)] is important to prevent
urinary concentration of solutes to prevent supersaturation and recurrent
stone formation.
In response to Dr. Trevithick’s question about the role of
intravenous pyelography - Although intravenous pyelography or urography
has been considered the standard for many years, non-contrast helical CT
scanning has replaced it and has significant advantages in the setting of
acute renal colic. Helical CT scans can be performed rapidly, without the
use of intravenous contrast [no risk of reaction to contrast agent], has
high accuracy for stone disease [99%], can confirm or exclude obstruction
and can identify other causes of acute abdomen masquerading as renal
colic.
I welcome Dr. Willetts addition to the list of anatomical
abnormalities that may predispose to urinary tract stone formation. This
is another example of a positive impact of rapid response(s).
References:
1. Hannappel J, Rohrmann D, Lutzeyer W. [Pharmacologic modification
of ureteral activity] Urologe A. 1986 Sep;25(5):246-51.
2. Caravati EM, Runge JW, Bossart PJ, Martinez JC, Hartsell SC, Williamson
SG. Nifedipine for the relief of renal colic: a double-blind, placebo-
controlled clinical trial. Ann Emerg Med. 1989 Apr;18(4):352-4.
Competing interests:
None declared
Competing interests: No competing interests
Just to correct an omission from the paper. We manage a large number
of children who undergo bladder augmentation procedures for various
pathologies. Subsequently a number develop bladder calculi probably
secondary to stasis and mucous production by the augment bowel segment.
These children are now becoming adults. An awareness of this diagnostic
possibility in the previously augmented child is necessary.
Mr I E Willetts BSc, DM, FRCS(Paed Surg)
Competing interests:
None declared
Competing interests: No competing interests
What about I.V.U's ( intravenous urography) in the management of
acute renal colic,is it not indicated in everybody to exclude acute
obstruction?
Competing interests:
None declared
Competing interests: No competing interests
We appreciated the exhaustive clinical review by dr Parmar (1).
Although the existence of a seasonal variation has been reported, no
mention was made on the circadian aspects of renal colic. Acute renal
colic, in fact, shows a circadian pattern in occurrence, with an early
morning peak and a minimum in the afternoon (2). The renal system is
organized according to a specific temporal order, that is oscillatory in
nature. Most renal functions, eg, glomerular filtration rate (GFR), urine
production, and renal excretion of solutes, show temporal variations with
higher values during daytime and lower ones at night (3). Circadian
changes are not negligible, since GFR day-night variation in amplitude is
33% (4). Low urinary volume increases urinary supersaturation (1), a risk
factor for nephrolithiasis, and night and early morning hours are
characterized by a higher lithogenic risk, at least for calcium oxalate
stones (5). An easy measure for prevention of recurrent stone formation is
increasing fluid intake. Thus, contrary to normal habits, fluid intake
should be particularly increased in the evening and prior to bedtime, with
the exclusion of those conditions, eg, congestive heart failure and
hypertension, in which volume increase is harmful.
1) Parmar MS. Kidney stones. Br Med J 2004;328:14020-4.
2) Manfredini R, Gallerani M, la Cecilia O, Boari B, Fersini C,
Portaluppi F. Circadian pattern in occurrence of renal colic in an
emergency department: analysis of patients’ notes. Br Med J 2002;324;767.
3) Cambar J, Cal JC, Tranchot J. Renal excretion: rhythms in
physiology and pathology. In: Touitou Y, Haus E, eds. Biologic Rhythm in
Clinical and Laboratory Medicine, Berlin, Germany: Springer
Verlag;1992:470-82.
4) Koopman MG, Koomen GC, Krediet RT, de Moor EA, Hoek FJ, Arisz L.
Circadian rhythm of glomerular filtration rate in normal individuals. Clin
Sci 1989;77:105-11.
5) Robert M, Roux JO, Bourelly F, Boularan AM, Guiter J, Monnier L.
Circadian variations in the risk of urinary calcium oxalate stone
formation. Br J Urol 1994;74:294-7.
Competing interests:
None declared
Competing interests: No competing interests
I thank Dr. Ellrodt for his comments and slanderous remarks. Dr.
Ellrodt, you have opened a pandora box by making such a statement that in
fact was discussed recently in ‘Joy of rapid responses[1].’ Let’s change
this negative energy to positive one.
First of all, I suggest that you cool down and review the paper again
and then you would realize that what you want to say is already mentioned
in the paper. We all make mistakes and at times a short statement goes
unnoticed. There is no need to be angry as someone has said, “Every minute
you are angry, you loose sixty seconds of happiness.”
You mentioned that non-steroidal anti-inflammatory agents have been
used for decades in the management of acute ureteric colic and I agree
with that and that is, in fact, what constitutes "conventional treatment"
and is already mentioned in this review [2]. It is understood that the
"conventional treatment" includes use of non-steroidal inflammatory agents
and opiates in the management of acute ureteric colic.
I should clarify that this is not a review on the management
strategies of acute ureteric colic; instead is focused on the causes and
prevention of recurrent kidney stones. The topic by itself is a large
topic and when one is trying to cover a vast topic and trying to maintain
a balance, one may at times unintentionally miss highlighting important
fact(s). I am sorry and accept responsibility if you feel that I fail to
highlight the use of anti-inflammatory agents that I felt was covered when
using the term "conventional treatment." This is the positive impact of
‘rapid responses’ that I like and enjoy[1].
In fact, in my first version of the paper, I included a table [see
below] containing the cocktail [3] that included various agents helpful in
the management of acute ureteric colic. However, this table was deleted at
the suggestion of the reviewer(s) and later to meet the space and table
requirements of the journal.
Cocktail for acute renal colic (reference [3])
Extended release nifedipine 30 mg a day for 7 days
Prednisone 20 mg twice a day for 5 days
Trimethoprim/sulphamethoxazole 160mg/800mg once daily for 7 days
Acetaminophen 325 mg every 6 hours for 7 days
Toradol 10 mg every 6-hours for 5 days
Oxycodone/acetaminophen as required for breakthrough pain
Prochlorperazine 25 mg as required - for nausea
In response to you comments about the diagnostic pitfall of leaking
aortic aneurysm I agree with you that this diagnosis should be considered
in a patient presenting with acute abdomen. Again as stated above that
this was not a review on the management of acute ureteric colic and the
differential diagnosis of acute ureteric colic was specifically not
included and the focus was more so on the prevention and management of
kidney stones in general. Your point is well taken!
In the end, it is atimes importan to know the history of paper and I
submitted my paper in late December 2003 and the Cochrane review [4] was
not published then and interestingly both papers [2,5] were accepted on
the same date and I was not aware of the metanalysis until its
publication.
References:
1. Parmar MS, Vasenwala M, Colquitt PJ, Wharfield L. Joy of rapid
responses. BMJ 2004; 328(7440):644-5.
2. Parmar MS. Kidney stones. BMJ 2004; 328(7453):1420-24
3. Cooper JT, Stack GM, Cooper TP. Intensive management of ureteral
calculi. Urology 2000; 56:575-578.
4. Holdgate A, Pollock T. Non-steroidal anti-inflammatory drugs
versus opioids for acute renal colic. Cochrane Database Sys Rev
2004;(1):CD004137
5. Holdgate A, Pollock T. Systematic review of the relative efficacy
of non-steroidal anti-inflammatory drugs and opioids in the treatment of
acute renal colic. BMJ, doi:10.1136/bmj.38119.581991.55 (published 3 June
2004)
Competing interests:
None declared
Competing interests: No competing interests
Nifedipine relaxes the ureteral smooth muscle.
Would'nt the resultant lack of peristalsis hinder the ureteral calculus
to be pushed downwards and thus allow the colic to be relieved. To my
mind, the appropriate treatment would be a non-spasmolytic NSAID.
Competing interests:
None declared
Competing interests: No competing interests
I thank Dr. Bhattarai for sharing his experience about the use of
nifedipine in the management of ureteric colic. Nifedipine - a calcium
channel blocker, by relaxing ureteral muscles, is found to be helpful in
the management of acute ureteric colic [1] and is mentioned in this review
on page 1423. In this study [1], a cocktail containing nifedipine and
other agents [prednisone, acetaminophen and antibiotics] were added to
conventional therapy [non-steroidal anti-inflammatory agents and opiates]
and the cocktail was found to more effective than conventional therapy,
and resulted in increased passage of stone rates; less lost work days,
emergency room visits and surgical interventions with similar side effect
profile. Whether addition of nifedipine alone would be as effective as
this cocktail, is not clear, and I agree requires further investigation.
References:
1. Cooper JT, Stack GM, Cooper TP. Intensive management of ureteral
calculi. Urology 2000; 56:575-578.
Competing interests:
None declared
Competing interests: No competing interests
I am angry.
Isn't it strange that the management of renal colic advocated in this
review disregards the "Use NSAIDs for renal colic" title (1) in the same
BMJ issue, and the metaanalysis (2) also included in that very issue ?
Maybe the author considers NSAIDs as analgesics among others, but the
message that has to be conveyed is that of the NSAID treament of renal
colic. Desmopressin maybe an elegant treatment, but renal colic has been
relieved on a more that daily basis at home, at the office and in the
emergency department by the use of NSAIDs in many countries for decades.
And not even a word on "the" diagnostic pitfall of the leaking aortic
aneurysm that any decent emergency medicine book emphasizes.
As this chapter of the review fails to reach the quality expected in
my dear BMJ, I have serious doubts about the quality of its other
chapters. This is a pity since those were the chapters I wanted to rely on
for an update on urolithiasis. And why should they be more seriously
written than the "emergency aspect" that I am familiar with ?
For once, the review and its reviewing process by the BMJ are
disappointing
1-http://bmj.bmjjournals.com/cgi/content/full/328/7453/0
2- http://bmj.bmjjournals.com/cgi/content/full/bmj;328/7453/1401
Competing interests:
None declared
Competing interests: No competing interests
Editor -- Parmar (1) has rightly summarized that conservative
management is preferred for ureteric stones. But ureteroscopic stone
extraction, various forms of lithotripsy, with or without ureteral stent
and even invasive surgeries like pyelolithotomy and ureterolithotomy are
frequently done, including in developing countries. I had noticed a
possible beneficial effect of nifedipine in the passage of a ureteric
stone 9 X 10 mm in size (2). Nifedipine has smooth muscle relaxant effect
throughout the body as seen by its usefulness in angina, hypertension,
Raynaud’s phenomenon, pulmonary hypertension, esophageal motility
disorders like achalasia and preterm labour. Thus, in this background, I
would like to add that the beneficial effect of nifedipine in the
management of the ureteric stones, particularly before submitting the
patients to any invasive interventions, also deserves scientific
investigation by well-equipped centres.
References
1. Parmar MS. Kidney stones. BMJ 2004; 328: 1420-1424.
2. Bhattarai MD. Use of nifedipine in the management of ureteric
stones. Case Rep Clin Prac Rev 2003; 4(4): 291-293.
Competing interests:
None declared
Competing interests: No competing interests
(Now cold) I apologise, Dr Parmar and BMJ
Thank you for this detailed reply. I agree my e-letter was close to
offensive both to Dr Parmar and the BMJ and I'd like to markedly soften
its tone. It is unfortunately too late, and as you stated, why lose 60
seconds of happiness in an unnecessary anger?
I think some emphasis should have been given to NSAID treatment, but
1- I understand why you did not; 2- The scope of the review was too wide
to allow for that ; 3- there is a misunderstanding about "conventional"
treatment. I do see many patients with renal colic who never received
NSAIDs for their previous episodes. This is why my feeling is that
"conventional" treatment may not be the same for all. Conversely, for some
physicians and sometimes authorities, conventional treatment has for long
excluded opiates, in fear of masking another diagnosis, or leading to
addiction.
Thanks again and I will end with a question I feel too lazy to try
and answer through a literature screen (well, I tried but gave up early):
do you know what in the pain of renal colic pertains to cavity distension
on the one hand and ureteral spasms, if any, on the other hand ? After
all, your answer might help me catch up the minute of "anger" I wasted.
Competing interests:
None declared
Competing interests: No competing interests