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Renal Stone. Hossein Hamidi MD. Isfahan university of Medical Sciences. Epidemiology. 12% of men and 5% of women develop symptomatic stone by the age of 70 . Rate of nephrolithiasis increases with : Age Men White . Etiology :. Calcium stones 80% ( Ca ox > Ca ph ) Uric acid

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renal stone

Renal Stone

Hossein Hamidi MD.

Isfahan university of Medical Sciences

epidemiology
Epidemiology

12% of men and 5% of women develop symptomatic stone by the age of 70 .

Rate of nephrolithiasis increases with :

  • Age
  • Men
  • White
etiology
Etiology :
  • Calcium stones 80% ( Ca ox > Ca ph )
  • Uric acid
  • Struvite (Mg ,Ammonium-Phosphate )
  • Cystine

One patient may have more than one type

(eg : Ca & uric acid )

risk factors
Risk factors :
  • Hypercalciuria
  • Hyperuricosuria ( uric acid- ca ox stones )
  • Hypocitraturia
  • High protein intake ( animal > vegetable )
  • Low water intake
  • High salt diet ( prior stone )
  • Prior calcium nephrolithiasis
risk factors cont
Risk factors : cont…
  • Family history
  • Enteric oxalate absorption
  • Urinary tract infection (spinal cord injury)
  • Medications : (indinavir , sulfadiazine , trimterene)
  • Hypertension (hypercalciuria )
  • Marathon runners
  • Type of fluid taken
risk factors cont1
Risk factors : cont…
  • Gout
  • Chronic diarrheal state ( acidosis , urine volume , acid urine )
  • Cystinuria
  • Vitamine intake ( C or D ) controversial .
  • Primary hyperparathyroidism
  • Medullary sponge kidney
  • Type one distal RTA
slide11

There are two major factors that promote uric acid precipitation: a high concentration of uric acid; and an acid urine pHwhich drives the reaction toward uric acid formation,

  •       H(+)   +   Urate(-)    <—>    Uric acid
          • Relatively soluble insoluble
slide12

at a urine pH of 7.0 (a setting in which 95 percent of uric acid is present as the more soluble urate anion)

  • at a urine pH of 5.0 (a setting in which most of the uric acid is the insoluble intact acid)
slide13

the incidence of stone formation varies with the rate of uric acid excretion, ranging from 10 to 20 percent when urinary uric acid excretion is normal (upper limit of normal equals 800 mg [4.8 mmol] in men and 750 mg [4.5 mmol] in women) to as high as 40 to 50 percent when uric acid excretion exceeds 1000 mg/day (6 mmol/day) .

slide15

There are at least four types of inhibitors in urine:

  • multivalent metallic cations, such as magnesium.
  • small organic anions, such as citrate.
  • small inorganic anions, such as pyrophosphate.
  • macromolecules, such as osteopontin and Tamm Horsfall protein.
clinical manifestations
Clinical manifestations :
  • Asymptomatic
  • Passing of gravel (uric acid ) or stone
  • Pain Mild to severe

Wax & wane ( paroxysm of severe

pain lasts 20 – 60 min) .

Renal pelvic or upper ureter (flank

pain or tenderness) lower ureter

(ipsilateral testicle or labia )

clinical manifestations cont
Clinical manifestations :cont…
  • Hematuria( gross or microscopic ) in the majority of patients , the single most discriminate predictor of kid . stone in unilateral flank pain .

The absence of hematuria in acute flank pain does not exclude nephrolithiasis

  • Nausea ,vomiting , dysuria , urgency ,when the stone is entering the bladder or urethra .
diagnosis
Diagnosis:
  • Clinical manifestations
  • Family hx
  • Urinalysis – urine culture
  • Stone analysis
  • KUB
  • IVP
  • US
  • CT SCAN ( choice )
diagnosis cont
Diagnosis:cont…
  • Urinalysis : PH >7.5 infection PH < 5.5 uric acid sediment: uric acid crystals, acid urineamorphous urate

Struvite orCa ph crystalsalkaline urineCa ox crystalsPH. Independent

cystine crystal :hexagonal , struvite: mg.am.ph amm, ur. PH + UTI (proteus or klebsiella) = only struvite stone

slide33
Struvite crystalin urine sediment (Mg Ammonium Phosphate, coffin lid) only alkaline urine, pH>7
diagnosis cont1
Diagnosis:cont…
  • KUB :

* Detect : radiopaque stones ( Ca , struvite , cystine stones)

* Will miss : uric acid stone small stone stone overlying bony structures

* Will not detect : obstruction

diagnosis cont2
Diagnosis:cont…
  • IVP :high sensitivity and specificity , procedure of choice but reaction , replaced by non- contrast CT – Scan
  • Non – contrast helical CT scan : Detect both stone and UTO , the gold standard for radiologic diagnosisof stones. Radiolucent stones missed on KUB, usually detected by CT scan . Detect second sign of obs. :1- ureter dilatation 2- collecti-ng system dilatation 3- perinephric stranding .
diagnosis cont3
Diagnosis:cont…
  • U.S. :1-Choice for pregnant women . 2- Childbearing age . 3- Very sensitive for UTO . 4- Detect radiolucent stones . 5- May miss small stones and ureteral stones .
diagnosis cont4
Diagnosis:cont…
  • Recommendations :1-Dx of nephrolithiasis : actual onset of atraumatic flank pain without abdominal tenderness and with hematuria .

2- non contrast helical CT scan due to higher sensitivity and specificity than IVP and US , suggest the initial diagnostic study of choice in most cases , and is faster than IVP and slightly more expensive ($ 600 vs $ 400 ). If helical CT is not available , IVP or US are appropriate .

evaluation of a pt with established nephrolithiasis
Evaluation of a pt. with established nephrolithiasis
  • Ca stones : risk factors of ca ox same as ca ph , except :

1-hyperoxaluria and hyperuricosuria for ca ox . 2-urine PH > 5.3 , type 1 RTA for ca ph . Calcium stone formation is most often idiopathic but in other disorders :

  • Primary hyperparathyroidism
  • Medullary sponge kidney
  • Distal RTA
evaluation of a pt with established nephrolithiasis con
Evaluation of a pt. with established nephrolithiasis con...
  • Uric acid stones : occurs in:

1- persistent acid urine 2- overproduction of uric acid in gout 3- chronic diarrheal states

  • Struvite stones : only in chronic UTI due to urease producing organisms such as proteus and klebsiella .

patients have Mg. Amm. Ph. crystal in urine. Stone may grow over a period of weeks or months , if not adequately treated develop a staghorn calculus .

evaluation of a pt with established nephrolithiasis cont
Evaluation of a pt. with established nephrolithiasis cont...
  • Cystine stones : in pts. With cystinuria due to insolubility of cystine in the urine .

Diag. :1- F.Hx. 2- hexagonal crystals on urinalysis in 25% of pts. 3- measurement of urinary cystine excretion .

Risk factors : fluid intake, animal protein , (hypercalciuria, hyperuricosuria , hypocitraturia),

salt diet , Ca intake , foods with oxalate? , Vitamin D .

evaluation of a pt with established nephrolithiasis cont1
Evaluation of a pt. with established nephrolithiasis cont...
  • Medications :

Indinavir , Sulfadiazine , Triamterene .

Evaluation: 1- complete:

*multiple stones at first presentation

* active stone disease ( recurrent stone ,enlargement of old stone , passage of gravels )

2- limited :after first stone

3- targeted :first stone if : F Hx +ve, male, middle

age ,chronic diarrheal state and /or malabsorption

pathologic skeletal Fx. ,osteoporosis , UTO and/or gout,

stone composed of : cystine , uric acid , Ca ph, or struvite

evaluation of a pt with established nephrolithiasis cont radiologic evaluation
Evaluation of a pt. with established nephrolithiasiscont...Radiologic evaluation
  • IVP :site & degree ofobstruction
  • US : presence of ureteral dilatation without stone : recent passage of stone .
  • Mg Am Ph & cystine stones are opaque but less dense than Ca stones .
  • Ca ph stone in the presence of nephrocalcinosis : RTA
  • Bilateral calcification at C M J : medullary sponge kidney ( Ca ox or Ca ph stone )
  • IVP the only method of established diagnosis of MSK.
  • Staghorn calculi favors struvite stones .
evaluation of a pt with established nephrolithiasis cont radiologic evaluation1
Evaluation of a pt. with established nephrolithiasiscont...Radiologic evaluation
  • MSK is 12% -20% of Ca stone formers
  • MSK is 20% - 30% of women and those < the age of 20 .
  • MSK is associated with Calciuria, uricosuria,

citraturia, urine volume .

Diagnosis and medical treatment same as other stones .

  • Radiologic monitoring of stone : usually with US or KUB.

initially at one year , if –ve every two or four yrs.

metabolic evaluation
Metabolic evaluation
  • Blood :uric acid, Ca , bicarbonate .

low bicarb : type 1 RTA . Ca measured on 2 or 3 occasions ,if high NL (10.2- 11) , or urine Ca is high : intact PTH should measured, since Primary HP is often associated with inttermi. or mildly elevated plasma Ca . PHP suspected in women , since PHP is more common in women , whereas 80% of formers of idiopathic stones are men .

metabolic evaluation1
Metabolic evaluation
  • Twenty four hours urine collection:

urine volume , PH ,Ca , uric acid , citrate ,

oxalate , Na , Creatinine calculated . Two or

three separate collections to obtain all of these

informations . Uric acid in alkaline or plain solution , Ca

and Ox . in HCl or nitric acid solution ,Citrate in acidified solution ( needs 2or 3 sample and two or three 24 hr. urine collctions) .

Timing of collection :

  • Pt. on his or her normal diet ( not in hospital ) .
  • Two or three months after stone event or any

interventionas ( ex : ESWL ) .

management of renal ureteral stones
Management of renal & ureteral stones
  • Surgical
  • Medical

Surgical :

10% -20% require surgical management.

Stones < 5 mm pass spontaneously .

Stones > 8-10 mm pass unlikely .

management of renal ureteral stones1
Management of renal & ureteral stones

Indication of stone removal :

  • Pain
  • Obstruction
  • Infected struvite stone
  • Large stone : > 2cm or staghorn stone
  • Cystine stone
management of renal ureteral stones2
Management of renal & ureteral stones

Three surgical techniques :

  • Percutaneous nephrolithotomy
  • Rigid & flexible ureterorenoscopy
  • Shock wave lithotripsy

proximal & renal stones SWL

middle & distal ureter ureterorenoscopy

ESWL ; treatment of choice in 85% of pts.

management of renal ureteral stones cont
Management of renal & ureteral stonescont…

Medical therapy :

Medical therapy doesn’t dissolve preexisting Ca stones thus the passage of such stones can occur and does not represent a treatment failure.

Acute therapy :

Conservative : pain control , hydration , until stone passage. Average time for stone passage :

  • Stone <= 2 mm : 8 days
  • Stones 2- 4 mm : 12 days
  • Stones >= 4 mm : 22 days
management of renal ureteral stones cont1
Management of renal & ureteral stonescont…
  • Pain control:

NSAID – Narcotics-Desmopressin

NSAID are as effective as opiates , but more pain relief at 10 min ( 100 mg rectal indomethacin vs. 5-10 mg IV morphine ). Or ; iv ketorolac (60 mg ) more pain relief vs.( 50 mg) iv meperidin

NSAIDs : 1- decreased ureteral smooth muscle tone

2- discourages opiate – seeking patients

3- may induce ARF

4- should be stop 3 days before SWL(because of bleeding ).

Intranasal Desmopressin : effective for renal colic .

Hospitalization :who can not tolerate oral intake or have very severe pain .

management of renal ureteral stones cont2
Management of renal & ureteral stonescont…
  • Straining urine and bring any stone that passes .
  • Urology consultation :* urosepsis

* ARF

* failure to pass the stone after 2- 4 weeks

*stone > 5 mm

* uncontrolled pain

management of renal ureteral stones cont3
Management of renal & ureteral stonescont…

Chronic prevention of recurrent stones:

1- reactants

2- inhibitors

Monitoring of response :

  • One or two 24 hours urine at 6-8 wk after therapy .
  • Repeat values at yearly ,then q 2-4 years
  • Periodic U.S. at 1 year , then q 2-4 years
management of renal ureteral stones cont4
Management of renal & ureteral stonescont…

Dietary modification :

  • High fluid intake > 2 L /d , also at night
  • Reduced animal protein intake ( sulfuric acid) (adverse changes in urine Ca , uric acid & citrate ) 1 g / kg /d .
  • Limit Na intake : low Na diet (80-100 meq/d ),

Ca & Na reabsorption in proximal tubule

Ca excretion .

management of renal ureteral stones cont5
Management of renal & ureteral stones(cont…)
  • Calcium intake :

Limiting Ca intake not recommended .

A low Ca diet may have a second

deleterious effect in idiopathic

hypercalciuria ; wasting of Ca from the

bone and the kidney, results in diminished

bone density .

management of renal ureteral stones cont6
Management of renal & ureteral stonescont…
  • Drug therapy :

Indications :Active stone disease :

    • Formation of new stones
    • Enlargement of old stones
    • Passage of gravels

(Despite initial drug therapy over a six months

period ) .

management of renal ureteral stones cont7
Management of renal & ureteral stonescont…

Initial drug therapy :

  • Thizides for hypercalciuria
  • Potassium citrate or allopurinol for hyperuricosuria
  • Potassium citrate for hypocitraturia
  • Potassium citrate for type one RTA
management of renal ureteral stones cont8
Management of renal & ureteral stonescont…

Idiopathic hypercalciuria (not PHP or sarcoidosis )

  • Normal Ca diet ( Ca intake risk stone )
  • Low animal protein
  • Low salt diet
  • Thiazide diuretics (chlorthalidone or HCTZ )

urine Ca as much as 150 mg/d.

90% in incidence of new stones, dose 12.5-25mg/d . bone mineral density , hip fractures .

management of renal ureteral stones cont9
Management of renal & ureteral stonescont…

Idiopathic hypercalciuria : cont…

  • Avoid hypokalemia urine citrate excretion
  • Amiloride ( K- sparing diuretic ) 5-10 mg /d.

Ca reabsorption in CCT Ca excretion .

  • K HCO3 or K citrate ( 60-80 meq /d ) not Na ;

Plasma alkali Ca reabsorption Ca excretion.

Plasma alkali urine excretion of citrate .

Na causes volum expansion Na & Ca excretion.

  • Neutral phosphate (orthophosphate) : Ca excretion &

crystalization inhibitors excretion ( pyrophosphate ).

management of renal ureteral stones cont10
Management of renal & ureteral stonescont…

Hyperuricosuria : if diet is ineffective :

  • Allopurinol 100- 300 mg/d ,80% in new

stone formation .

  • Alkali therapy by K citrate , 60- 80 meq /d,

urine PH > 6 insoluble uric acid to

soluble urate salt .

management of renal ureteral stones cont11
Management of renal & ureteral stonescont…

Hypocitraturia :

  • K citrate or KHCO3 30-80 meq/d ,alkakizing the plasma citrate excretion, in contrast, KCl does not increase citrate excretion in Nl K ,because it is a non-alkalizing salt .
  • Orange juice ( K citrate ,Ca ox ,Ascorbic acid ):

citrate excretion , Ca excretion not lower, Oxalate excretion modestly increased ( ascorbic acid )

  • Lemon juice ( citrate ): (intolerant to citrate ) 4 ounce /d +

urine citrate

tap water = 2 L/d (lemonade) urine Ca

urine Ox didn’t alter

management of renal ureteral stones cont12
Management of renal & ureteral stonescont…

Enteric hyperoxaluria :

  • Fluid intake
  • Potassium citrate
  • Oral Ca Co3 ( 1- 4 gm daily)
  • Fat – oxalate diet
  • Cholestyramine (binds both Bile acid & Ox )
management of renal ureteral stones cont13
Management of renal & ureteral stonescont…

No metabolic abnormality :

  • Have more Ca & less citrate in the urine than normals , but neither is clearly abnormal .
  • Have a lower urine volume .

Treatment :

  • Thiazideeven in normocalcemic urine .
  • K citrate remains to be determined .
  • Neutral phosphate 2 g m /d .

Ca Ph stones : have persistently urine PH , Treatment : K citrate .

management of renal ureteral stones cont14
Management of renal & ureteral stonescont…

Cyctine :

  • High water intake
  • Urine Ph > 7-7.4 K citrate 3-4 meq/kg
  • Low intake of Na 50 meq/d ( cystin excretion )
  • Penicillamine , tiopronin, captopril