Kidney Stones And The Pancreas

Just When You Thought Kidney Stones Were Bad Enough

Two weeks ago I passed a kidney stone. I was getting ready to go to work and it hit me. No one can prepare you for what is to come. First there is the incessant flank pain, like a flaming hot nail hammered into you. Then the nail excruciatingly slowly travels to your groin. This is followed by non-stop urgency to urinate, only to stand there for just a few drops. Night and day of this feeling. Pain killers, Flomax, pacing....nothing seems to provide more than minimal relief. Men get to experience childbirth. Fantastic. Rock on!

Three days later, you start to pass blood and then, thankfully, it comes to an end once a tiny rock lands in the toilet bowl. I'm pretty sure I made up curse words, both in Italian and in English.

While I was lying in bed waiting for the Lord to take me, I started to think (because what else do you have to do other than pass away). Do kidney stones have any relationship to the pancreas? It turns out that they do.

Chronic Pancreatitis

The first population based cohort study on the association between kidney stones and chronic pancreatitis was done by Chen at al. and published in 2018. The researchers identified 15,848 patients with chronic pancreatitis over a 10-year period. These were compared to 62,158 patients without a history of pancreatitis who were otherwise matched for age, sex and comorbidities.

They found that there was a 1.89-fold risk of urolithiasis in patients with chronic pancreatitis. Chronic pancreatitis was associated with the development of urolithiasis in each age group, each sex, and each occupation and urbanization level. Moreover, the contribution of chronic pancreatitis to the relative risk of urolithiasis was higher in patients without comorbidities. The authors postulated on a number of possible reasons why this might be. Chronic pancreatitis leads to fat malabsorption. This might then increase intestinal oxalate absorption to promote calcium oxalate urolithiasis. Similar to hyperoxaluria seen in Crohn’s disease with steatorrhea, unabsorbed bile acids and fatty acids will increase the risk of oxalate urolithiasis by inducing calcium saponification to impair the binding between free calcium and oxalate within the intestinal lumens and to increase intestinal oxalate absorption. Furthermore, bile acids may directly increase the colonic absorption of oxalate.

Vujasinovic et al published a retrospective study in 2023 of 632 patients diagnosed with chronic pancreatitis between 2003 and 2020. 6.5% of this group developed kidney stones. Urolithiasis was associated with increasing age and male sex. Multivariable cause-specific Cox regression analysis revealed exocrine pancreas insufficiency as a independent risk factor for nephrolithiasis (adjusted HR 4.95, 95%CI 1.65-14.84; p = 0.004).

Demoulin et al. reported an observational study of 48 patients with chronic pancreatitis. 23% were found to have hyperoxaluria. Multivariate regression analysis identified clinical steatorrhea, high fecal acid steatocrit, and pancreatic atrophy as independent predictors of hyperoxaluria. Hyperoxaluria in the setting of lower fecal elastase was associated with faster decline in renal function over time.

Finally, Cartery et al. published a observational study of 12 patients who developed acute oxalate nephropathy in the setting of chronic pancreatitis. Increase in urinary oxalate excretion was found in all tested patients and hypocalcemia in nine (<1.5 mmol/L in four patients). Renal biopsy showed diffuse crystal deposits, highly suggestive of oxalate crystals, with tubular necrosis and interstitial inflammatory cell infiltrates. After a median follow-up of 7 months, three of 12 patients reached end-stage renal disease.

Complication Of Stone Treatment

In 2012, Bukeirat et al. published a case report of a 52 year old woman referred for shock-wave lithotripsy of a small stone in the right kidney. Following treatment she developed acute abdomen pain and lipase of 773. CT scan and ERCP both noted disruption of the pancreatic duct in the head of the pancreas, which was stented effectively. The patient had no other risk factors for pancreatitis and it was directly attributed to pancreas injury from the lithotripsy.

Also in 2012, Singh et al. published a case report of a 48 year old man admitted for shock-wave lithotripsy of a 9 mm left kidney stone. Within 24 hours post lithotripsy, he presented with severe abdomen pain and lipase of 7600. The patient ultimately died from complications of necrotizing pancreatitis 12 days later. He too had no other risk factors for the development of pancreatitis.

Ferrakis et al. reported on a 48 year old woman admitted for percutaneous nephrolithotomy (PCNL) for a left kidney stone in 2017. The stone was successfully fragmented and removed, followed by the placement of an 18F nephrostomy tube. Three hours later the patient developed SIRS and lipase of 798. CT was consistent with acute pancreatitis and she recovered over a period of 14 days. The authors pointed out that pancreatitis following PCNL is extremely rare with only two other case reports in the literature.

Complication Of Pancreas Cancer Surgery

Desbuissons et al. published a retrospective study of 294 patients who underwent pancreatectomy for pancreas cancer at a single institution from 2010-2017. Five developed renal dysfunction and 3 were related to oxalate nephropathy. The photomicrograph below is from one of the patient's kidney biopsies showing the characteristic oxalate crystals. The authors attributed this to pancreas insufficiency post-operatively.

Unexpected Finding On A CT Scan

Not all abdomen pain is "another kidney stone attack", even if a patient has had kidney stones before. This essay highlights the story of a 42 year old woman who was diagnosed with kidney stones based on symptoms and an abdomen x-ray. She was referred to a urologist who ordered a CT scan to determine if surgery might be needed to remove the stone. The urologist called her afterward and told her over the phone: “Also I wanted to mention one more thing, the radiologist noted . . . there is a mass . . . in your pancreas. I am going to be completely honest with you. The radiologist thinks it may be cancer.” Ultimately, the patient underwent surgery and chemotherapy; she was doing well when the piece was written in 2018.

Conclusion

Without a doubt, kidney stone attacks are humbling and unique experiences. Urolithiasis is one of the most common diseases accounting for hospital visits in the urology department, and approximately 25% of patients with urolithiasis experience recurrent renal colic after the first episode. Clinicians need to keep in mind, however, that not all hoofbeats are horses. Once in awhile, they really are zebras, in this case kidney stones actually a symptom of a neighboring organ, the pancreas!

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