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NEPHROLITHIASIS. B. Wayne Blount, M.D. MPH Professor and Vice-Chair Department of Family Medicine Emory University. O BJECTIVES. Discuss the recommended work-up to diagnose nephrolithiasis Know the different treatment options for site and size specific stones

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b wayne blount m d mph professor and vice chair department of family medicine emory university

NEPHROLITHIASIS

B. Wayne Blount, M.D. MPH

Professor and Vice-Chair

Department of Family Medicine

Emory University

o bjectives
OBJECTIVES
  • Discuss the recommended work-up to diagnose nephrolithiasis
  • Know the different treatment options for site and size specific stones
  • Recognize the urgent situations of nephrolithiasis
  • Know when to seek urologic consultation
t oday s roadmap
TODAY’S ROADMAP
  • Epidemiology
  • Presentation and Diff. Dx
  • Diagnostic Work-up
  • Emergency Situations
  • Management Strategy
  • Prevention
  • Summary
e pidemiology
EPIDEMIOLOGY
  • 2-4% of general population
  • 2-3 x more common in males
  • Caucasian > Oriental > African American
  • Hot climates > temperate
r isk factors
RISK FACTORS
  • Male Gender
  • Age (to 65)
  • Low urine vol.
  • Situational
  • Geography
  • Heredity
  • Diet
  • Meds
m eds causing stones
MEDS CAUSING STONES

Drugs that promote calcium stone formation:

  • Loop diuretics
  • Antacids
  • Acetazolamide
  • Glucocorticoids
  • Theophylline
  • Vitamins D and C
m eds causing stones8
MEDS CAUSING STONES

Drugs that promote uric acid stone formation:

  • Thiazides
  • Salicylates
  • Probenecid
  • Allopurinol
m eds causing stones9
MEDS CAUSING STONES

Drugs that precipitate into stones:

  • Triamterine
  • Acyclovir
  • Indinavir
p resentation
PRESENTATION
  • Abdominal Pain
  • Renal Colic: Sudden; Not Relieved
  • Hematuria
d ifferential dx
DIFFERENTIAL Dx
  • Gynecologic Processes
  • Testicular Processes
  • Appendicitis
  • Cholecystitis
  • Hernia
  • Aneurysm
  • Tumors
r elationship of stone location to symptoms13

Relationship ofStone Location to Symptoms

Stone LocationCommon Symptom

Kidney Vague Flank Pain, Hematuria

r elationship of stone location to symptoms14

Relationship of Stone Location to Symptoms

Stone LocationCommon Symptom

Proximal Ureter Renal colic, flank pain, upper abdominal pain

r elationship of stone location to symptoms15

Relationshipof Stone Location to Symptoms

Stone LocationCommon Symptom

Middle section of Renal colic, anterior

ureter abdominal pain, flank pain

r elationship of stone location to symptoms16

Relationshipof Stone Location to Symptoms

Stone LocationCommon Symptom

Distal ureter Renal colic, dysuria, urinary frequency, anterior abdominal pain, flank pain

w ork up
Work-Up
  • History
  • P.E.
  • U.A.
  • Imaging
  • Labs
h istory
History
  • Focused
  • PM Hx
  • Fam Hx
  • Symptoms of emergencies
slide20
P.E.
  • Abdomen
  • Pelvis
  • Rectal
  • Rules out nonurologic process
slide21
U.A.
  • RBCs
  • pH
  • Crystals
  • Bacteria
  • Some pyuria expected
i maging
Imaging
  • Essential to confirm Dx & to size and locate stone
  • Several Options
i maging options
Imaging Options
  • Ultrasonography
  • KUB
  • Intravenous Pyelography (IVP)
  • Noncontrast Helical C.T.
slide24

Imaging modality Sensitivity (%) Specificity (%)

Ultrasonography 19 97

Advantages Limitations

Accessible Poor visualization of

Good for diagnosing of ureteral stones

Hydronephrosis and renal

stones

Requires no ionizing radiation

slide25

Imaging modality Sensitivity (%) Specificity (%)

Plain radiography 45 to 59 71 to 77

Advantages Limitations

Accessible Stones in middle section

& expensive of ureter, phleboliths,

radiolucent calculi,

extraurinary calcifications

and nongenitourinary

conditions

slide26

Imaging modality Sensitivity (%) Specificity (%)

Intravenous 64 to 87 92 to 94

pyelography

Advantages Limitations

Accessible Variable-quality imaging

Provides information Requires bowel preparation

on anatomy and & use of contrast media

functioning of both Poor visualization of non-

kidneys genitourinary conditions

Delayed images required in

high-grade obstruction

slide27

Imaging modality Sensitivity (%) Specificity (%)

Noncontrast helical 95 to 100 94 to 96

computed tomography

Advantages Limitations

Most sensitive & specific Less accessible and

radiologic test (i.e., facilitates relatively expensive

fast, definitive diagnosis) No direct measure of

Indirect signs of the degree of renal function.

obstruction

Provides information on non-

genitourinary conditions

l abs
Labs
  • CBC*
  • UA*
  • BMP
  • Ca
  • PO4
  • Urate
  • Urine C & S*
  • Stone Analysis*
a suggestion
A SUGGESTION

Patient with abdominal pain

History and physical examination

Renal colic suspected

Diagnostic imaging ???

Patient is pregnant, or

cholecystitis or gynecologic

process is suspected

Patient has history of radiopaque calculi

All other patients

slide30

Ultrasound

Examination

Plain-film

radiography

Intravenous pyelography if CT is not available

Noncontrast helical CT

Stone detected

Stone not detected

Stone detected

Stone not detected

Clinical suspicion of urolithiasis

m anagement 3 principles
MANAGEMENT(3 Principles)
  • Recognize Emergencies
  • Adequate Analgesia
  • Impact of size and location on Hx & Rx
m anagement 3 principles32
MANAGEMENT(3 Principles)

Recognize Emergencies

  • Adequate Analgesia
  • Impact of size and location on Hx & Rx
m anagement 3 principles33
MANAGEMENT(3 Principles)
  • Recognize Emergencies

Adequate Analgesia

  • Impact of size and location on Hx & Rx
m anagement 3 principles34
MANAGEMENT(3 Principles)
  • Recognize Emergencies
  • Adequate Analgesia

Impact of size and location on Hx & Rx

e mergencies
Emergencies
  • Sepsis with obstruction (struvite stones?)
  • Anuria
  • ARF
  • Urologic consultation
h ospitalization
Hospitalization?
  • Emergencies
  • Refractory Nausea
  • Debilitation
  • Extremes of age
  • Refractory Pain
a nalgesia
Analgesia
  • NSAIDs : also spasmolytic
  • Narcotics
  • No NSAIDs < 3 days before lithotripsy (ASA < 7 days)
  • Ketorolac
m anage the stone

Manage The Stone

After adequate analgesia and ruling out emergencies

Principles here are stone size and location

suggestions
SUGGESTIONS

Stones < 4 mm

  • Passage in 1-2 wks
  • Analgesia
  • Strain Urine
  • F/U KUB Q 1-2 wks
  • Urology if not passed in 2 wks. (certainly 4 wks as comps  3X)
  • RTC signs of sepsis
suggestions41
SUGGESTIONS

Stones > 5 mm

  • Urologic Consultation
suggestions42
SUGGESTIONS

Stones 4 – 5 mm

  • Decide based on other parameters
o ther parameters
Other Parameters
  • Location
  • Composition
  • Larger Size
  • Occupation
l ocation
Location
  • Renal stones usually can be followed
c omposition
“Composition”

Staghorn renal calculi to

urology (assoc. with

infections and kidney

damage)

slide46

Occupation

  • Pilots cannot fly even with an asymptomatic stone
  • Get early definitive Rx
l arger size
Larger Size
  • Renal calculi of 5 mm – 2 cm : Extra corporeal lithotripsy
  • Lower pole stones 5 mm – 1 cm : ECL
  • Ureteral stones 5 mm – 1 cm : ECL
slide48
Largerthan 2 cm or when ECL contraindicated or not effective:Renal & Proximal ureteral stones: Percutaneousnephrolithotomy
ureteroscopes

Ureteroscopes

Stones anywhere dependent on technician’s abilities

treatment modalities for renal and ureteral calculi
Treatment Modalities for Renal and Ureteral Calculi

Treatment Indications Advantages

Extracorporeal Radiolucent calculi Minimally invasive

shock wave Renal stones < 2 cm Outpatient

lithotripsy Ureteral stones < 1 cm procedure

Limitations Complications

Requires spontaneous passage Ureteral obstruction by

of fragments stone fragments

Less effective in patients with Perinephric hematoma

morbid obesity or hard stones

treatment modalities for renal and ureteral calculi52
Treatment Modalities for Renal and Ureteral Calculi

Treatment Indications Advantages

Ureteroscopy Ureteral stones Definitive

Outpatient procedure

Limitations Complications

Invasive Ureteral stricture or

Commonly requires injury

postoperative ureteral stent

treatment modalities for renal and ureteral calculi53
Treatment Modalities for Renal and Ureteral Calculi

Treatment Indications Advantages

Ureterorenoscopy Renal stones < 2 cm Definitive

Outpatient procedure

Limitations Complications

May be difficult to clear Ureteral stricture or injury

fragments

Commonly requires

postoperative ureteral stent

treatment modalities for renal and ureteral calculi54
Treatment Modalities for Renal and Ureteral Calculi

Treatment Indications Advantages

Percutaneous Renal stones >2 cm Definitive

nephrolithotomy Proximal ureteral stones > 1 cm

Limitations Complications

Invasive Bleeding

Injury to collecting system

Injury to adjacent structures

a suggested pathway

Confirmed stone

YES

Urgent urologic consultation

Emergency:

UROSEPSIS, Anuria, Renal Failure

NO

YES

Consider hospital admission:

Urologic consultation

Refractory pain, Refractory nausea,

Extremes of age, Debillated condition

NO

Symptoms amenable to medical management

Referral to urologic clinic

Ureteral stone < 5 mm

Renal stone or ureteral

stone > 5 mm

Trial of conservative

management

Weekly KUB radiographs

Stone passes

Stone fails to pass

within 2-4 weeks

A SUGGESTED PATHWAY
a suggested pathway56

Confirmed stone

YES

Urgent urologic consultation

Emergency:

UROSEPSIS, Anuria, Renal Failure

NO

YES

Consider hospital admission:

Urologic consultation

Refractory pain, Refractory nausea,

Extremes of age, Debillated condition

NO

Symptoms amenable to medical management

Referral to urologic clinic

Ureteral stone < 5 mm

Renal stone or ureteral

stone > 5 mm

Trial of conservative

management

Weekly KUB radiographs

Stone passes

Stone fails to pass

within 2-4 weeks

A SUGGESTED PATHWAY
slide57

Prevention

(of Recurrences)

  • Need to analyze the calculi
  • Labs for all recurrences and for children:

24° urine : Vol, pH,

Ca. PO4, Na, Urate, Oxalate, Citrate, Creatine, Ca P04, CaOx

slide59

Prevention

  • All patients : 2-3 L water Q day, 8-12 oz QHS

“B rec”

  • NaCL (2g)
  •  Animal protein (8 oz)
  •  Oxalate
  •  Calcium in diet ‘B’ rec

‘C’ Rec unless dietary excesses

calcium stones
Calcium Stones
  • In all patients, increase fluid intake to yield an output of at least 2 L of urine per day.
  • In the patient with hypercalciuria:

Dietary restriction of protein, oxalate

and sodium; no restriction of dietary

calcium

Medication: thiazides, usually given

with potassium citrate; amiloride (Midamor)

calcium stones61
Calcium Stones
  • In the patient with hypocitraturia:

Dietary restriction of protein and

sodium

Potassium citrate supplementation (sodium citrate if potassium citrate is not tolerated)

calcium stones62
Calcium Stones
  • In the patient with hyperoxaluria:

Dietary restrictin of oxalate

  • In the patient with hyperuricosuria:

Dietary restriction of purine (I.e., protein) Allopurinol (Zyloprim)

uric acid stones
Uric Acid Stones
  • Increasing fluid intake is less important for the prevention of uric acid stones than calcium stones
  • In the patient with a low urinary pH level:

Dietary restriction of protein and sodium

uric acid stones64
Uric Acid Stones
  • In the patient with hyperuricosuria:

Dietary restriction of protein and sodium

Alkalinization of urine with potassium citrate if urinary pH level is low

Allopurinol in selected situations

slide66

Risk for Renal Failure

  • Hereditary stone diseases
  • Struvite stones
  • Infection associated calculi & obstruction
  • Frequent relapses
  • No. of urologic interventions
  • Stone size
slide67

Bibliography

Portis AJ, and Sundaram CP. Diagnosis and Initial Management of Kidney Stones. Am Fam Physician 2001;63:1329-38.

Goldfarb DS and Coe FL. Prevention of Recurrent Nephrolithiasis. Am Fam Physician 1999;60:2269-76.

Bihl G and Meyers A. Recurrent renal stone disease. Lancet 2001;358:651-6.

Gambaro G, Favaro S, MD, D’Angelo A. Risk for Renal Failure in Nephrolithiasis. AJKD 2001, 37:233-243.