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RENAL STONE DISEASE. ANALYSIS OF STONES. ______________________________ Oxalate 504 (56.1%) Triple phosphate 237 (26.4%) Phosphate 119 (13.4%) Uric acid 38 (4.2%) ______________________________

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analysis of stones

ANALYSIS OF STONES

______________________________

Oxalate 504 (56.1%)

Triple phosphate 237 (26.4%)

Phosphate 119 (13.4%)

Uric acid 38 (4.2%)

______________________________

Total 898 (100%)

formation of stones

FORMATION OF STONES

Urine pH/infection Renal damage Calcium/oxalate

Tissue debris

Anatomical stasis Fixed particles inhibitors

Aggregation

Stone formation

formation of stones1
FORMATION OF STONES

1. Calcium - a) hypercalcaemia

b) hyperparathyroidism

c) hypercalciuria

2. Oxalate - G1, hyperoxalaturia

3. Cystine

4. Uric Acid

5. Infection - Urea-splitting organisms

6. Congenital / metabolic defects:

- medullary spone kidney

- renal tubular acidosis

clinical presentation
CLINICAL PRESENTATION

1. Flank/loin pain, colicky + radiation

- haematuria

- nausea and vomiting

- chills/fever/frequency, if infected

2. Loin tenderness

3. Bilateral stones : renal failure

investigations
INVESTIGATIONS

1. IVU and DTPA

  • Serum creatinine calcium
  • Urine pH

4. 24-hour urine

5. Urine cultures

6. Stone analysis

metabolic abnormalities n 392
METABOLIC ABNORMALITIES(N = 392)

Hypercalciuria 28%

Hyperoxaluria 16%

Hyperuricosuria 14%

Cystinuria 0.5%

Hyperparathyroidism 1%

Primary oxalosis 0.25%

Renal tubular acidosis 0.25%

indications for treatment
INDICATIONS FOR TREATMENT

Presence of symptoms and / or obstructive uropathy in a functioning kidney

treatment of renal stones
Treatment of Renal Stones

Four Options 1) conservative

2) non-invasive: ESWL

3) minimal invasive : PCNL, URS

4) open surgery

New technology :  morbidity,  hospital stay,

 invasiveness

management of renal calculi by eswl
MANAGEMENT OF RENAL CALCULI by ESWL

< 2cm in diameter and/or surface area < 500 mm2

Treatment : ESWL monotherapy

> 2cm in diameter and/or surface area > 500 mm2

Treatment : PCNL +/- ESWL

Combination therapy

management of renal calculi by eswl1
MANAGEMENT OF RENAL CALCULI by ESWL

> 2cm in diameter and/or

surface area > 500 mm

J Stents + ESWL with repeated

treatments required

eswl for staghorn stones
ESWL for Staghorn Stones

PCNL + ESWL as main option

ESWL monotherapy is discouraged

Open surgery has a place for large

complete staghorn calculi

contra indications to the use of eswl
Contra-indications to the Use of ESWL

Absolute contra-indications

  • Pregnancy
  • Untreated urinary tract infection
  • Distal obstruction to the stone that cannot be bypassed by a stent
  • Untreated bleeding diatheses
  • Non-functioning kidney
results of percutaneous nephrolithotripsy pcnl
Results of Percutaneous Nephrolithotripsy PCNL

Indications : High stone burden or failed ESWL

Success : Stones free 82%

Insignificant fragments 15%

Failure : Stones > 4cm in diameter 3%

management of ureteric stones
MANAGEMENT OF URETERIC STONES

-Stones < 0.5 cm in diameter doesn’t pass

spontaneously 4 to 6 weeks and /or causing

symptoms : ESWL monotherapy

-Stones > 0.5 cm in diameter & < 1 cm in

diameter : ESWL monotherapy

management of ureteric stones1
MANAGEMENT OF URETERIC STONES

Stones > 1 cm in diameter : trial of ESWL monotherapy

Patient counselled:

1. Repeat session may be necessary

2. URS/PCNL/ureterolithotomy

results of uretroscopic lithotripsy urs
RESULTS OF URETROSCOPIC LITHOTRIPSY (URS)

Achieved stone free status = 85% to 90%

Failures:

1. Access problems

2. Stone migration

Flexible URS for upper third ureteric calculi

especially in the male

slide36

Ureteric stone

suitable for ESWL

slide39

URS with

Guide wire

open stone surgery
OPEN STONE SURGERY

2% incidence of all stone treatments

Indications:

1.Complex stone burden 38%

2. Non-functioning kidneys 20%

3. Failure of MIS 16%

4. Others 26%

prevention of stones
PREVENTION OF STONES

1. Treatment of causes

2. Dietary manipulations

3. Medications - indication duration

dietary advice
DIETARY ADVICE

1. Hydration

2. Avoid oxalate-rich food

3. Avoid calcium-rich food ?

4. Avoid refined carbohydrates

5. Increase crude fibres

medications
MEDICATIONS

1. Thiazides

2. Allopurinol

3. Antibiotics

4. Sodium bicarbonate

5. Potassium citrate

6. Magnesium salts

7. Pyridoxine

cystine stone
Cystine Stone
  • 1% of stone population
  • Autosomal recessive
  • Round stones in calyces
  • Large staghorn stones
  • Hexagonal crystals
medical treatment cystine
Medical Treatment - Cystine
  • Volume at 2.5 l/day
  • Increase pH to > 7.0
  • Decrease dietary protein
  • D-penicillamine, thiola
  • Side-effects : marrow / nephrotic
indinavir stone
Indinavir Stone
  • Protease inhibitor for HIV
  • Not radio-opaque
  • Cannot see on CT scan
  • Poor solubility
  • Prophylaxis – acidification of urine
congenital oxalosis
Congenital Oxalosis
  • Autosomal recessive
  • Dystrophic calcifications in blood vessels
  • Multiple nephrocalcinosis in young
  • Early renal failure
  • Disease recur in transplanted kidney
  • Treatment with high dose pyridoxine
nanobacteria
Nanobacteria
  • Small size 50-500 nm
  • Atypical, cytotoxic, filterable 0.22 ųm
  • Slow doubling time – 3 days
  • Present in 90% human stones?
  • Act as the nidus
  • Sensitive to tetracycline

T Jarrett 1999