Kidney stones or nephrolithiasis or urolithiasis is a common problem worldwide. About 12% of the Indian population is estimated to have urinary stones and out of which 50% may end up with loss of kidney functions 1. According to a recent study by The National Health and Nutrition Examination Survey, a representative sample of the US population, men had in more propensity (10%) than women (2.857%) to develop kidney stone 2. Since, more than 5000 years ago people have employed natural plant products for a variety of purposes and incidentally, herbal therapy was the sole treatment option 3. Herbal medicines are naturally occurring, plant-derived substances that are used to treat or prevent different diseases. For examples: Gokshura, Pashanbheda, Harmala, etc.

Mineral build-ups called kidney stones can be either free or connected to the renal papillae in the renal calyces and pelvis as in Figure 1 4 . In present lifestyle, kidney stones are becoming more and more common. Kidney stones are brought on by calcium oxalate and other substances found in urine and uric acid which can occasionally crystallize when they come together 5. Identification of risk variables linked to disease development or severity may be possible with knowledge of the disease's epidemiology 6. Kidney stone is a severe urinary tract illness and a widespread issue 7. It is important to consider kidney stone disease as a systemic issue since it can cause cardiovascular damage, hypertension, insulin resistance, chronic kidney disease, and metabolic bone disease 8. Due to extrinsic and endogenous variables that adversely affect the human body, urolithiasis has developed into endemic proportions in several geographical areas 9, 10. Genetic influences involving renal stones pathogenesis have also been identified 11.

Epidemiology of kidney stones can occur at any age; however, the peak incidence is reported in persons aged 20–49 years. Males are affected more than females 12. Hypercalciuria is encountered in approximately 60% of patients with kidney stones. It is pathogenetically important since it raises urinary calcium concentration and the saturation with respect to calcium oxalate and calcium phosphate. The rise in serum calcium caused by calcium absorption raises the amount of calcium that is filtered through the kidneys and inhibits parathyroid action. Renal hypercalciuria is a condition caused by an impaired renal tubular reabsorption. Absorptive and resorptive forms of hypercalciuria exist in primary hyperparathyroidism, which promote bone resorption of calcium and raise its levels in the blood and renal calcium load. An excess of PGE2 (phenyl glycidyl ether) may also be the cause of fasting hypercalciuria when accompanied by normal serum PTH. About 30% of patients with recurrent stone disease have hypocitraturia. Acid retention, often known as acidosis due to the elevated urine pH, also causes the production of uric acid stones. The production of uric acid stones brought on by excessive urine acidity may be exacerbated by hyperuricosuria in the presence of low urinary pH and calcium oxalate stones may occur when there is hyperuricosuria and a normal urine pH (>5.5). By raising the concentration of calcium oxalate in the urine, hyperoxaluria promotes the development of stones. Around 10% of patients with stones may have hypomagnesuria, which is likely to be brought on by insufficient magnesium consumption (Figure 2) 13.

The process of calcium oxalate stone formation is depicted (Figure 3 )14. An increase in calcium oxalate accompanied by a decrease in urine volume initiates urinary stone formation and urine saturation. Among these processes, the formation of Randall’s plaque is related to crystal nucleation and growth, while the formation of free particles is related to crystal aggregation and the formation of fixed particles is related to urothelial damage and through this process, stone retention is repeated and develops into urinary stone disease (USD). The urinary microbiome could be involved in stone formation through hyperoxaluria and calcium oxalate supersaturation, biofilm formation and aggregation, and urothelial injury15 .

The early stages of stone formation are symptomless. Later, indications and symptoms of the stone disease include renal colic (severe cramping pain), flank pain (a pain in the back), hematuria (bloody urine), obstructive uropathy (a urinary tract illness), urinary tract infections, obstruction of urine flow, and hydronephrosis. These illnesses may result in symptoms including nausea, vomiting, and others connected to the stone occurrence. As a result, the expenses ensued on healthcare cost as well as the lost productivity have a negative effect on the nation’s quality of life and economy 3, 16 .

Our diet plays the main role in the evolution and inhibition of kidney stones. Environment is another factor involved in kidney stone formation. Further, more our fluid intake amount, our body weight and genetic setup are also involved in it. Following factors are specifically involved,

A blood test can determine whether there is too much uric acid or calcium in the blood. Blood test results are used to determine the kidneys' state of health and to help doctors rule out other illnesses. The level of substances such as calcium, keratin etc. are also checked.

A blood test can determine whether there is too much uric acid or calcium in the blood. Blood test results are used to determine the kidneys' state of health and to help doctors rule out other illnesses. The level of substances such as calcium, keratin etc. are also checked.

A 24-hour urine collection test is used to determine if the kidneys are excreting too many stone- forming minerals. For this test, the doctor advises collecting at least two urine samples over two days in a row. The chemicals found in urine are calcium, phosphate, uric acid, oxalate, and citrate, which is are in high levels; prove to have kidney stones.

An imaging test may be used to determine whether kidney stones are present in the urinary tract. If small kidney stones cannot be detected by a simple abdomen X-ray, there are high-speed or dual energy computed tomography imaging test choices that can detect even the smallest stones computerized tomography (CT). Other imaging tools include X-rays, getting CT scans or injecting dye into an arm; which travels through the kidneys and bladder. Other, non-invasive tests include intravenous urography and ultrasound 18, 19 .

Ureteroscopy: Ureteroscopy is the procedure for removing stones which are stuck in the ureters or bladder. This procedure is painful and contains a small wire which connects with a camera at the end. The wire is inserted into the urethra and passed into the bladder for removal of stones with a cage connected with it as in Figure 6 27.

'Ren-Cit'® Citron life Science Pune is an Ayurvedic formulation which has pharmacological properties like antiurolithic activity, lithotriptic activity, diuretic activity and thus, it improves clinical manifestations due to kidney stones by reducing inflammation, pain, and general discomfort of the kidney and bladder, including expulsion of renal calculi of all forms and sizes without bladder irritation, if taken orally for three days, as one dose of syrup after dinner. The dosing pattern is depicted in Figure 8. This therapy includes a medication as shown in Table 1 in the form of syrup (3 bottles) and capsules (10 nos.).

Figure 8

Table 1

Sr. no.	Common Name	Botanical Name	Mechanism of Action	Uses
	Gokshura	Tribulus terrestris	Increase in antioxidant enzyme activities along with decreased oxalate synthesizing biochemical parameters at higher doses 23	Helps in healthy urine flow and also helps to control blood sugar level by removing toxins from the body.
	Pasha-nbheda	Bergenia ligulata	Acts on the kidney and is able to increase the volume of urine excretion 24	Helps to breakdown Kidney stone.
	Harmala	Peganum harmala	It performs anti-inflammatory and immune modulatory effects via suppressing pro-inflammatory mediators such as prostaglandin E2, tumor necrosis factor alpha and nuclear factor-Kappa B 25	Epilepsy, Psychosis, loss of memory, chronic headache, kidney stone, dropsy, jaundice, colic and sciatica.
	Varuna bark	Crataeva nurvala	Regulating the excretion of the metabolites and waste, metabolic errors and prevents the formation of stone 26	Helps in dissolving renal calculi
	Parnabeej	Bryophyllum pinnatum	Reducing the clinical features and size of stone, dissolving and expulsion of kidney stone as well as ureteric stone 27	Helps in dissolving stones, conditions of urinary insufficiency, and inflammatory lesions.

This is the post-treatment survey of 'Ren-Cit'® of Citron life Science Pune is an Ayurvedic formulation. The data is based on the patient’s documents which included their visits for the medicine for urinary complaints and by diagnostic means were confirmed to have kidney stones. We collected the data by the survey of 50 kidney stone patients around the age group of 35-55 years by using specially designed goggle form. This Google form included a questionnaire as given in Table 2. Data is included related to patient gender, patient age, patient’s history with hypertension and diabetes. In the study pregnant women and children were excluded.

The results of the completed survey are given in the questionnaire format in (Table 3 ) as well as in Figure 9, Figure 10, Figure 11, Figure 12, Figure 13, Figure 14, Figure 15, Figure 16, Figure 17.

Figure 9

Yes 98% No 2%

Kidney stone incidences are rising globally despite significant advancements in the creation of novel medicines for the management of urinary stones. Renal stone development is still poorly understood in many ways. However, it is evident that kidney stone formation is significantly influenced by renal cell damage, crystal retention, and cell apoptosis. Thus, Ren-Cit® proved to be effective on a wide range and types of kidney stones.