A comprehensive review of renal calculi (kidney stones). Etiology, diagnosis, and management

Nº de DOI: 10.34896/RSI.2025.82.40.001

AUTHORS

1. Thalia Cecilia Inga Sinaluisa. General Practitioner. Attached to the Arturo Yumbay Foundation. Independent Researcher at the Matilde Hidalgo of Procel Research and Teaching Department. Graduate of the National University of Chimborazo. (Guaranda-Ecuador). https://orcid.org/0009-0004-6878-7505
2. Maritza Irene Calle León. General Practitioner. Attached to Clínica San Gabriel. Graduated from the University of Guayaquil. (El Triunfo-Ecuador). https://orcid.org/0009-0000-3515-1683
3. Wilma Nataly Morejón Dávila. Bachelor’s Degree in Nursing and Master’s Degree in Higher University Teaching. Attached to the Carlos Andrade Marín Specialty Hospital. Graduate of the Central University of Ecuador. (Quito-Ecuador). https://orcid.org/0009-0003-8963-333X
4. Estefanny Geovanna Dávila Cuenca. General Practitioner. Attached to Núcleo Solca Machala. Graduated from the Technical University of Machala. (Machala-Ecuador). https://orcid.org/0009-0005-3727-9361
5. Viviana Jackeline Chávez Mejía. General Practitioner. Attached to Enrique Garcés Hospital. Graduated from the Regional Autonomous University of the Andes. (Quito -Ecuador). https://orcid.org/0009-0008-7918-5998

ABSTRACT

This comprehensive review aims to elucidate the etiological factors contributing to renal calculi, evaluate current diagnostic tools, and analyze the spectrum of management strategies, providing a detailed synthesis of current knowledge and future directions in the prevention and treatment of kidney stones.

KEY WORDS

Renal calculi, kidney stones, urolithiasis, etiology, risk factors, diagnosis, imaging, management, treatment and prevention.

RESUMEN

Esta revisión exhaustiva tiene como objetivo dilucidar los factores etiológicos que contribuyen a los cálculos renales, evaluar las herramientas diagnósticas actuales y analizar el espectro de estrategias de manejo, proporcionando una síntesis detallada del conocimiento actual y las futuras tendencias en la prevención y el tratamiento de los cálculos renales.

PALABRAS CLAVE

Cálculos renales, cálculos renales, urolitiasis, etiología, factores de riesgo, diagnóstico, imagenología, manejo, tratamiento y prevención.

INTRODUCTION

Renal calculi, commonly known as kidney stones, represent a prevalent urological disorder characterized by the formation of solid mineral and salt deposits within the renal system, often leading to significant morbidity and healthcare burdens worldwide. The etiology of kidney stones is multifactorial, encompassing a complex interplay of genetic predispositions, metabolic abnormalities, and environmental influences such as diet and lifestyle, which collectively contribute to supersaturation of urine and subsequent stone formation. Understanding these risk factors is crucial for effective prevention and management, yet the pathophysiological mechanisms remain incompletely elucidated. Accurate diagnosis relies on a combination of advanced imaging modalities—such as computed tomography and ultrasonography—and laboratory investigations that identify stone composition and metabolic abnormalities, thereby aiding in differentiating renal calculi from other urological conditions with similar clinical presentations. The therapeutic landscape for kidney stones has evolved significantly, encompassing conservative management, minimally invasive procedures like extracorporeal shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy, alongside pharmacological interventions aimed at stone dissolution and recurrence prevention. Despite these advances, recurrence remains a significant challenge, underscoring the importance of patient education, metabolic evaluation, and follow-up strategies. Emerging therapies and ongoing research continue to explore novel minimally invasive techniques, targeted pharmacotherapies, and personalized approaches to optimize outcomes and reduce the burden of this condition.

OBJECTIVE

To elucidate the aetiological factors contributing to kidney stones, evaluate current diagnostic tools, and analyse the spectrum of management strategies, providing a detailed synthesis of current knowledge and future directions in the prevention and treatment of kidney stones.

METHODOLOGY

The methodology for this scientific review article is designed to provide a comprehensive and evidence-based analysis of the etiology, diagnosis, and management of renal calculi (kidney stones). A structured literature search is conducted using electronic databases including PubMed, Scopus, Web of Science, and Embase. The search strategy employs a combination of Medical Subject Headings (MeSH) and relevant keywords such as “renal calculi”, “kidney stones”, “urolithiasis”, “etiology”, “risk factors”, “diagnosis”, “imaging”, “management”, “treatment” and “prevention.” Boolean operators (AND, OR) are used to refine the search, and filters are applied to include articles published in English within the last 15 years to ensure the relevance and recency of the evidence.

Articles meeting the eligibility criteria are screened through title and abstract review, followed by full-text evaluation. Relevant data are extracted systematically, including study design, sample size, geographic region, identified etiological factors (such as dietary, genetic, or metabolic contributors), diagnostic tools (e.g., ultrasound, CT scan, urinalysis), treatment strategies (e.g., medical expulsion therapy, lithotripsy, surgical intervention), and outcomes. Particular attention is paid to comparative effectiveness studies, emerging technologies, and preventive strategies.

The extracted data are synthesized in a narrative format, grouped thematically according to the main sections of the review: etiology, diagnosis, and management. This approach allows for a clear presentation of current understanding, highlights clinical implications, and identifies gaps in the literature that warrant further investigation.

RESULTS

Etiology of Renal Calculi:

What are the primary risk factors contributing to kidney stone formation?

A complex interplay of lifestyle, dietary, and genetic factors underpins the primary risk factors for kidney stone formation, with significant interconnections observed across these domains. Lifestyle choices such as sedentary behavior and obesity disrupt normal metabolic processes, directly affecting urinary composition and promoting the development of kidney stones¹. Diet further compounds this risk; high intake of sodium and sugar can elevate calcium levels in the urine—a condition known as hypercalciuria—which is a precursor for calcium-based stones, while consumption of oxalate-rich foods like spinach and chocolate similarly increases stone risk¹. Inadequate fluid intake stands out as a critical factor, as insufficient hydration leads to concentrated urine, which not only facilitates the crystallization of minerals but also links back to lifestyle factors such as strenuous activity without proper hydration and living in hot climates, both of which exacerbate dehydration¹. Moreover, genetic predisposition plays a pivotal role, with a family history of kidney stones and inherited traits influencing mineral metabolism and waste excretion, thereby increasing individual susceptibility^1,2. These risk factors often interact synergistically; for instance, unhealthy eating patterns and sedentary lifestyles can exacerbate metabolic imbalances, while genetic factors may amplify the impact of environmental and dietary exposures. Given this intricate web of influences, comprehensive strategies that target modifiable lifestyle and dietary behaviors, alongside greater awareness of familial risk, are essential to effectively mitigate the burden of kidney stone disease.

How do genetic and metabolic disorders influence the development of renal calculi?

Genetic and metabolic disorders significantly influence the development of renal calculi by disrupting the normal physiological processes that govern mineral handling within the kidneys and throughout the body. Mutations inherited within families may cause defects in renal tubular function, particularly in the handling of calcium and other substrates, thereby creating an environment conducive to stone formation³. These genetic abnormalities not only affect the risk of stone production but also manifest in clinical features such as an early onset of nephrolithiasis, recurrent and bilateral stones, and a strong family history that may include consanguinity or parental urolithiasis⁴. Metabolic derangements, whether primary or secondary to broader systemic diseases, further complicate this picture; conditions such as metabolic syndrome and inborn errors like cystinuria or glycogen storage diseases are associated with both a higher propensity for stone development and the presence of extra-renal complications^4,5. The interplay between tubular dysfunction, recurrent stone formation, and systemic involvement underscores the need for a comprehensive approach to management—one that addresses not only the stones themselves but also the underlying metabolic or genetic defect, through hydration, dietary modification, and targeted medical therapies⁴. Recognizing these interconnections is crucial for timely diagnosis and intervention, as untreated cases can result in ongoing kidney damage, systemic manifestations, and even life-threatening complications, thereby emphasizing the importance of multidisciplinary care and early genetic evaluation in at-risk populations⁴.

What role do diet and lifestyle play in the etiology of kidney stones?

Diet and lifestyle are deeply intertwined in the etiology of kidney stones, as both domains exert significant influence on the metabolic and physiological processes that underlie stone formation. Key dietary factors—such as high sodium, oxalate, and animal protein intake—directly affect urinary composition, promoting supersaturation of stone-forming minerals and increasing the risk of nephrolithiasis^6,7. For instance, excessive sodium consumption not only leads to augmented calcium excretion in the urine but also facilitates the crystallization of calcium-based stones, while diets rich in oxalates from foods like spinach and nuts further elevate this risk by increasing the urinary oxalate load⁶. Conversely, adequate consumption of potassium, magnesium, and calcium through balanced dietary choices acts as a protective factor by inhibiting stone formation and supporting overall renal function^7,8. Lifestyle habits such as insufficient fluid intake, sedentary behavior, and the frequent consumption of processed foods amplify these risks, as low hydration promotes urinary concentration and crystal precipitation, while poor physical activity may exacerbate metabolic disturbances that predispose individuals to stone development^6,8. This intricate interplay underscores the necessity for integrated interventions that encompass both dietary modifications and lifestyle improvements, such as increasing water intake, reducing processed and high-sodium foods, and encouraging regular physical activity to effectively prevent and manage kidney stone disease⁶. Addressing these interdependent factors through public health policies and individualized patient education is essential to mitigate the growing burden of kidney stones.

Diagnostic Approaches for Renal Calculi:

What are the most effective imaging techniques for detecting kidney stones?

Among the array of imaging modalities available for the detection of kidney stones, computed tomography (CT) scans stand out as the most effective and widely accepted technique due to their unparalleled accuracy and ability to provide detailed cross-sectional images of the kidneys and urinary tract⁸. Low-dose CT scans, in particular, have been increasingly favored for their reduced radiation exposure while maintaining diagnostic accuracy, making them a pragmatic choice in modern medical practice⁹. One of the significant strengths of CT imaging is its capacity to differentiate between uric acid and non-uric acid stones, a distinction that is essential for guiding tailored treatment strategies and predicting stone composition without the need for invasive procedures⁹. Additionally, advancements such as high-speed and dual-energy CT technology further enhance the detection of even minute uric acid stones, reinforcing CT’s role as the gold standard for initial and definitive diagnosis¹⁰. Despite this, ultrasound remains a valuable adjunct, especially in scenarios where minimizing radiation exposure is paramount, such as in pregnant women or pediatric patients; it offers a non-invasive, radiation-free alternative, albeit with lower sensitivity and specificity compared to CT¹¹. The interplay between these modalities allows for a flexible, patient-centered approach, whereby clinicians can tailor imaging choices based on clinical context, patient safety, and diagnostic clarity¹¹. Given these interconnections and the evolving landscape of imaging technology, it is crucial for healthcare systems to promote judicious use of CT and ultrasound, optimizing diagnostic pathways to ensure both accuracy and patient safety.

How do laboratory tests assist in the diagnosis and characterization of renal calculi?

Laboratory tests play a pivotal role in both the diagnosis and characterization of renal calculi, facilitating a comprehensive understanding of the underlying pathophysiology and informing patient management. The diagnostic utility of laboratory investigations is highlighted by their ability to confirm the presence of kidney stones in symptomatic individuals, as well as to distinguish nephrolithiasis from other conditions with overlapping clinical presentations, such as urinary tract infections or malignancies¹². Urinalysis, one of the most frequently utilized laboratory tests, can reveal microscopic hematuria—a finding present in up to 85% of patients with nephrolithiasis—thereby supporting the clinical suspicion of renal calculi and prompting further diagnostic workup³. Additionally, blood tests serve a dual function: they assess renal function and evaluate mineral concentrations such as calcium and uric acid, abnormalities of which are strongly associated with stone formation and can help determine the metabolic etiology of the calculi¹². Importantly, laboratory analysis of urine and stone composition enables accurate identification of the stone subtype, which is essential for tailoring both acute management and long-term preventive strategies¹². By integrating these laboratory findings, clinicians are better equipped to not only confirm the diagnosis but also to plan appropriate interventions, thereby optimizing patient outcomes and reducing the risk of recurrence¹². Hence, laboratory testing is indispensable in the holistic approach to diagnosing and managing renal calculi, underscoring the need for continued emphasis on timely and thorough laboratory assessment.

What are the differential diagnoses to consider when evaluating a patient with suspected kidney stones?

When evaluating a patient with suspected kidney stones, a comprehensive differential diagnosis is essential to ensure that other potential causes of the patient’s symptoms are not overlooked. Inflammatory bowel disease and other malabsorption disorders can present with abdominal pain and metabolic disturbances similar to those seen in nephrolithiasis, highlighting the importance of considering gastrointestinal etiologies in the diagnostic process¹³. Additionally, a detailed medication history is crucial, as certain drugs are known to precipitate stone formation or mimic stone-related symptoms, thereby influencing both diagnosis and management¹³. Medical conditions such as hyperparathyroidism and diabetes also warrant attention because they can contribute to the development of kidney stones through alterations in calcium metabolism and urinary composition, and their presence may modify both the clinical approach and prognosis¹³. Renal tubular acidosis (RTA) type I should be specifically evaluated, as it can manifest with recurrent stones and distinct electrolyte abnormalities, necessitating targeted testing and intervention¹³. Laboratory findings, such as the presence of urinary crystals, can support a diagnosis of urolithiasis, while the absence of hematuria does not definitively exclude it, underscoring the need for thorough urinalysis and imaging as part of the workup³. Furthermore, if infection is suspected based on clinical symptoms or urinalysis results, aggressive evaluation and management are needed due to the risk of severe complications, such as systemic inflammatory response syndrome (SIRS) or acute renal failure³. In summary, a multidisciplinary approach that integrates gastrointestinal, metabolic, infectious, and structural considerations is vital for accurate diagnosis and optimized patient care in cases of suspected kidney stones, and clinicians must remain vigilant for overlapping pathologies that may require prompt intervention.

Management Strategies for Renal Calculi:

What are the current medical and surgical treatment options for kidney stones?

Medical and surgical treatment options for kidney stones are diverse, reflecting the complexity of factors such as stone size, location, patient health, and the severity of symptoms¹⁴. Initially, conservative management is often recommended for smaller stones, incorporating pain management strategies with over-the-counter analgesics like ibuprofen or acetaminophen, as well as prescription pain medications in more severe cases¹⁵. In addition to symptom control, dietary modifications and specific medications aimed at facilitating stone passage or preventing recurrence are frequently employed¹⁵. However, when stones are larger, lodged in the ureter, cause persistent pain, obstruction, bleeding, or infection, surgical intervention becomes necessary¹⁶. Minimally invasive and non-invasive techniques have become the standard of care, including shock wave lithotripsy, which uses acoustic pulses to fragment stones; ureteroscopy, where a thin flexible telescope is passed from the bladder to the kidney to directly treat smaller stones; and percutaneous nephrolithotomy, which is reserved for larger or more complex stones¹⁵. During procedures such as ureteroscopy, lasers may be employed to break up stones, and a basket retrieval device can be used to remove the resulting fragments from the urinary tract¹⁷. Temporary stenting is often necessary post-procedure to ensure proper urine flow and facilitate healing, sometimes requiring the stent to remain in place for several weeks if additional operations are anticipated¹⁷. Although open surgery is rarely performed due to advancements in less invasive techniques, it remains an option in select complex cases¹⁴. Ultimately, the choice among these options is tailored to the patient’s specific clinical scenario, and all interventions must account for the risk of stone recurrence, underscoring the need for ongoing medical follow-up and possible lifestyle modification to minimize future episodes¹⁸.

How is recurrence of renal calculi prevented through patient education and follow-up?

Preventing the recurrence of renal calculi hinges on an integrated strategy that prioritizes patient education and regular follow-up care, underscoring the interconnected roles of both clinical guidance and patient engagement. Patient education serves as the foundation by equipping individuals with knowledge about risk factors, dietary modifications, and the necessity of adherence to both lifestyle and pharmacological interventions, thereby empowering them to actively participate in their own care and make informed decisions about their health³. However, education alone is insufficient without continuous follow-up, which allows healthcare providers to monitor therapeutic effectiveness, reinforce behavioral changes, and make necessary adjustments to prevention plans based on ongoing assessment, such as interpreting 24-hour urine results and responding to laboratory or clinical changes³. The interplay between education and follow-up is further enhanced by effective communication between patients and a multidisciplinary healthcare team—including urologists, nephrologists, dietitians, and nurses—which not only facilitates comprehensive support but also fosters motivation and adherence to long-term prevention protocols³. Therefore, a coordinated approach that combines robust patient education with sustained follow-up and teamwork is essential to meaningfully reduce the recurrence of renal calculi, emphasizing the need for structured intervention and consistent patient-provider collaboration.

What are the emerging therapies and future directions in the management of kidney stones?

Building on the role of genetics and metabolic dysfunction in stone formation, emerging therapies are increasingly targeting the underlying biochemical pathways and personalized patient profiles in the management of kidney stones. One promising direction is the use of combination therapies involving dual inhibitors that simultaneously modulate oxalate and calcium handling in the kidneys, aiming to address multiple contributors to stone formation for a more comprehensive preventive strategy¹⁹. This approach is complemented by advancements in enzymatic therapies, such as the development and clinical testing of oxalate-degrading agents like reloxaliase (ALLN-177), which have demonstrated significant reductions in urinary oxalate—an established risk factor for calcium oxalate stones—in high-risk populations¹⁹. The interconnection between metabolic, genetic, and environmental domains extends further with the exploration of gut microbiome interventions, as modulation of specific microbial populations may alter oxalate metabolism and thus influence stone risk¹⁹. These metabolic and microbiome-focused innovations are paralleled by technological breakthroughs in stone removal, such as advanced lithotriptors that utilize high-intensity focused ultrasound and burst wave lithotripsy, offering less invasive and more precise fragmentation with reduced tissue damage and recovery times¹⁹. To integrate these advances and effectively reduce recurrence rates, future kidney stone management must prioritize the development of tailored prevention strategies, combining pharmacological, technological, and lifestyle interventions grounded in individual genetic and metabolic profiles¹⁹. Such a multidisciplinary approach necessitates continued research, cross-specialty collaboration, and global accessibility to ensure that the benefits of these innovations reach diverse patient populations and ultimately decrease the burden of recurrent nephrolithiasis.

DISCUSSION 

The comprehensive review of renal calculi presented herein underscores the multifactorial etiology underlying stone formation, emphasizing the intricate interplay between lifestyle, dietary habits, genetic predispositions, and metabolic disorders. The elucidation of how sedentary behavior, obesity, and high-sodium or high-sugar diets contribute to alterations in urinary composition provides valuable insight into modifiable risk factors that can be targeted for prevention. Furthermore, the recognition of genetic factors and inherited metabolic abnormalities highlights the importance of early diagnosis, especially in cases presenting with recurrent or bilateral stones. The synthesis of current diagnostic modalities—particularly advanced imaging techniques like CT and ultrasound—alongside laboratory evaluation reinforces the necessity for accurate and comprehensive assessment to distinguish renal calculi from other differential diagnoses. Treatment strategies outlined, from conservative management to minimally invasive surgical interventions, reflect the advancements in technology and their tailored application based on individual patient factors. Notably, emerging therapies that target biochemical pathways involved in stone formation, such as microbiome modulation and oxalate-degrading enzymes, represent promising avenues for personalized medicine, although further research is required to establish their efficacy and safety fully. Despite these advances, several limitations persist. The heterogeneity of patient populations and variability in access to advanced diagnostic and therapeutic options may hinder the translation of these findings into widespread clinical practice. Additionally, many studies remain limited by small sample sizes and short follow-up durations, which restrict the ability to assess long-term outcomes and recurrence prevention effectively. Future research should prioritize large-scale, multicenter trials to validate emerging therapies and explore the genetic and environmental interactions influencing stone formation more comprehensively. Moreover, there is a need to develop cost-effective, accessible strategies suitable for diverse populations worldwide, particularly in resource-limited settings. The integration of technological innovations with personalized approaches holds significant potential to improve patient outcomes, reduce recurrence rates, and diminish the overall burden of nephrolithiasis. However, interdisciplinary collaboration among urologists, nephrologists, geneticists, dietitians, and researchers will be crucial to translate these advances into clinical practice effectively. Ultimately, addressing the gaps identified in current knowledge and fostering a proactive, patient-centered approach will be vital for advancing the management and prevention of renal calculi in the coming years.

CONCLUSIONS

1. Renal calculi, or kidney stones, remain a prevalent and recurrent urological condition with significant clinical and economic impact worldwide. This comprehensive review highlights that the etiology of kidney stones is multifactorial, involving genetic predisposition, dietary habits, metabolic disorders, dehydration, and environmental influences. Calcium oxalate stones continue to be the most common type, although variations in composition are influenced by geographic, dietary, and systemic health factors. Advances in diagnostic imaging—particularly non-contrast-enhanced CT—have significantly improved detection accuracy, allowing timely and precise evaluation of stone size, location, and potential complications.
2. In terms of management, current treatment approaches range from conservative measures, such as increased fluid intake and dietary modification, to pharmacologic therapies and interventional procedures including extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, and percutaneous nephrolithotomy (PCNL). The choice of treatment is influenced by factors such as stone size, composition, anatomical considerations, and patient comorbidities. Importantly, preventive strategies based on stone analysis and metabolic evaluation are critical to reduce recurrence, yet are often underutilized in clinical practice.

FUTURE DIRECTIONS

1. Future research should prioritize the development of individualized, precision-based prevention protocols that incorporate metabolic profiling and genetic risk assessment to reduce recurrence rates. There is also a need for longitudinal studies that assess the long-term efficacy and quality-of-life outcomes of various treatment modalities, particularly in high-risk and recurrent stone formers.
2. Emerging technologies such as low-dose CT, artificial intelligence (AI)-based stone classification, and non-invasive biomarkers for early detection hold promise for enhancing diagnostic efficiency while minimizing patient exposure to radiation and invasive procedures. Furthermore, expanding access to preventive education, particularly in high-prevalence regions, and developing standardized global guidelines for stone evaluation and management will be essential steps toward improving outcomes.
3. By integrating technological innovation, personalized medicine, and public health strategies, the future management of renal calculi can evolve from a reactive to a proactive model—emphasizing prevention, early intervention, and patient-centered care.

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