Serum c-reactive protein as a predictive factor for spontaneous stone passage in patients with 4 to 8 mm distal ureteral stones

Ehab Jasim Mohammad, Kanaan Mahdi Abbas, Anas Falah Hassan, Alaa Abdulqader Abdulrazaq


Background: Ureteral stones are common problems in daily emergency department practice. Ureteric stone is responsible for 20%. Ureter obstruction caused by a ureteral stone triggers inflammatory changes in the proximal submucosal layer and prevents passage of the stone.  C reactive protein (CRP) was found to be an indicator of ureteral stone outcome. The objective of this study was to measure serum CRP for patients with 4-8 mm distal ureteric stone and use its level as predictive factor for spontaneous stone passage.

Methods: A prospective study was designed on a total of 73 patients (M=34; F=39) who were in the age group (18-50) years, who presented with ureteral colic secondary to a solitary unilateral, 4 to 8 mm distal ureteral stone. Patients were grouped according to spontaneous stone passage. The patients were selected at the urology unit, in Ghazi AL Hariri Hospital for Specialized Surgery, Medical City Complex in Baghdad from October 2014 till October 2016. The follow up continued until the stone spontaneously passed, as reported by the patient, or for a maximum period of 4 weeks.

Results: Age, BMI, and gender did not show significant difference between the two groups ;30 have spontaneous stone passage (SSP), and 43 no spontaneous stone passage (no SSP). Stone size is significantly higher in the group without SSP their median is 6 mm compared to 4 mm for SSP group. CRP is significantly elevated in no SSP group compared to SSP.  CRP, stone size and previous history of stone passage was the only significant and independent predictors of SSP (low CRP, low stone size, and positive history predict SSP).  

Conclusions: Stone size, CRP, previous Hx of stone passage are independent predictors for SSP.  Measuring serum CRP levels is useful for predicting whether spontaneous ureteral stone passage will be successful. More aggressive treatment methods such as URS should be considered when serum CRP levels is high.


CRP, ureter, stone, passage

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Picozzi SC, Marenghi C. Management of ureteral calculi and medical expulsive therapy in emergency departments. J Emergencies, Trauma Shock. 2011;4:70-6.

Renal or ureteric colic - acute; NICE CKS, April 2015. Available at

Phillips E, Kieley S, Johnson EB, Monga M. Emergency room management of ureteral calculi: current practices. J Endourol. 2009; 23(6):1021-4.

Masarani M, Dinneen M. Ureteric colic: new trends in diagnosis and treatment. Postgrad Med J, 2007;83:469-72.

Johri N, Cooper B, Robertson W, Choong S, Rickards D, Unwin R. An update and practical guide to renal stone management. Nephron Clin Pract. 2010;116:159-71.

Bultitude M, Rees J. Management of renal colic. BMJ. 2012;345:e5499.

Hesse AT, Tiselius HG. Siener R (Eds). Urinary stones, diagnosis, treatment and prevention of recurrence. 3rd ed. Karger Medical and Scientific Publishers; 2009.

Skolarikos A, Laguna MP, Alivizatos GE, Kural AR, De La Rosette JJ. The role for active monitoring in urinary stones: a systematic review. J Endourol 2010;24(6):923-30.

Turk C, Knoll T, Petrik A, Sarica K, Skolarikos A, Straub M et al. Members of the European Association of Urology (EAU) Guidelines Office: European Association of Urology Guidelines on urolithiasis. 28th ed. Milano: EAU Annual Congress; 2013.

Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE et al. Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. J Urol. 1997;158(5):1915-21.

Papadoukakis S, Stolzenburg JU, Truss MC. Treatment strategies of ureteral stones. EAU-EBU Update Series. 2006;4(5):184-90.

Ananthanarayan R, Ananthanarayan PC. Paniker's Textbook of Microbiology. 7th ed. Himayatnagar, Hyderabad: Orient Longman;1978:218.

Tillett WS, Francis T. Serological reactions in pneumonia with a nonprotein somatic fraction of pneumococcus. J Experiment Med. 1930;52(4):561-71.

Pepys MB, Hirschfield GM. C-reactive protein: a critical update. J Clin Invest. 2003:111(12):1805-12.

Murray K, Granner DK, Mayes P, Rodwell V. Harper's Illustrated Biochemistry. 28th ed New York: McGraw-Hill;2009.

Renshaw A. Henry's clinical diagnosis and management by laboratory methods. Advances in Anatomic Pathology. 2007;14(2):147.

Firestein GS, Kelley WN, Budd RC. Kelley's textbook of rheumatology: Elsevier Health Sciences; 2012.

Clyne B, Olshaker JS. The C-reactive protein 1. J Emerg Medicine. 1999;17(6):1019-25.

Ahmad H, Azim W. Medical expulsive treatment of distal ureteral stone using Tamsulosin. J Ayub Med Coll. 2015;27(1):48-50.

Patel H, Deshmukh S. Ureteral stenting can make ureteroscopic management of ureteric calculus safe and effective. IJSR. 2013;4(2):1200-2.

Sfoungaristos S, Kavouras A, Katafigiotis I, Perimenis P. Role of white blood cell and neutrophil counts in predicting spontaneous stone passage in patients with renal colic. BJU Int. 2012;110:339.

Hermanns T, Sauermann P, Rufibach K, Frauenfelder T, Sulser T, Strebel RT. Is there a role for tamsulosin in the treatment of distal ureteral stones of 7 mm or less? Results of a randomised, double-blind, placebo-controlled trial. Eur Urol. 2009;56:407.

Aboumarzouk OM, Kata SG, Keeley FX, Nabi G. Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi. Cochrane Database Syst Rev. 2011;7 (12):CD006029.

Park CH, Ha JY, Park CH, Kim CI, Kim KS, Kim BH. Relationship between spontaneous passage rates of ureteral stones less than 8 mm and serum C-reactive protein levels and neutrophil percentages. Korean J Urol.2013;54:615-18.

Griwan MS, Singh SK, Paul H, Pawar DS, Verma M. The efficacy of tamsulosin in lower ureteral calculi. Urol Ann. 2010;2:63.

Coll DM, Varanelli MJ, Smith RC. Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT. AJR. 2002;178:101.

Porpiglia F, Destefanis P, Fiori C, Fontana D. Effectiveness of nifedipine and deflazacort in the management of distal ureteral stones. Urology. 2000;56:579.

Aldaqadossi HA. Stone expulsion rate of small distal ureteric calculi could be predicted with plasma C-reactive protein. Urolithiasis. 2013;41:235.

Angulo JC, Gaspar MJ, Rodriguez N, Garcia-Tello A, Torres G, Nunez C. The value of C-reactive protein determination in patients with renal colic to decide urgent urinary diversion. Urology. 2010;76:301-6.