This paper is a retrospective analysis of deaths ascribed to stone disease in England and Wales over a 15-year period. The data was obtained from the Office of National Statistics, based on mortality derived from death certificates. One thousand, nine hundred and fifty-four deaths were recorded as being attributable to urolithiasis. Over 91% of these were attributed to renal and ureteric stones, whereas only 141 of these were classified as ureteric only. Only a small proportion (7.9%) was due to lower tract calculi. There was a gradual rise in the number of deaths per year, from 119 in 1999 to 167 in 2013. The overall mortality is increasing in a manner which reflects the increasing burden of stone disease. A total of over 85,000 admissions (both elective and emergency) were recorded in 2014 in England alone, a rise of 12% over 15 years. There is a male preponderance for stone disease in general but the mortality is reversed at 1.5:1. This reflects data on deaths from sepsis, where females have a higher mortality than males. The deaths in the majority of these cases are thought to be due to sepsis, although this information is not always available. Other data, such as the Endourology Society study related to post-ureteroscopy infection, confirms the female preponderance. In addition, struvite stone disease is more common in women. The presence of urinary stone disease is a risk factor for end-stage renal disease, although stone formers form a small proportion of these patients, which is another possible cause of death. In conclusion, the authors say the cause of death should be sought, perhaps by a national database, so that risk factors could be identified and potential deaths avoided. This is a good paper, clear and concise in its aims and methods. It does, however, pose more questions than it answers in that it cannot give the exact cause of death and relies on death certificate data, which can be unreliable. It does illustrate some interesting points such as the increasing mortality over time and the excess female deaths and these points are worthy of further study. National audit, as ever, is the key. 

Do stones still kill? An analysis of death from stone disease 1999-2013 in England and Wales.
Klum F, Mahmalji W, Hale J, et al.
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Ciaran Lynch

Royal Liverpool and Broadgreen University Hospital Trust, Liverpool, UK.

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