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Renal Stone

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

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  1. Renal Stone Hossein Hamidi MD. Isfahan university of Medical Sciences

  2. Epidemiology 12% of men and 5% of women develop symptomatic stone by the age of 70 . Rate of nephrolithiasis increases with : • Age • Men • White

  3. 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 )

  4. An oxalate stone

  5. A calcium phosphate stone

  6. 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

  7. 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

  8. 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

  9. Pathophysiology

  10. 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

  11. 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)

  12. 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) .

  13. 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.

  14. www.hdcn.com/symp/02asn/asp2/asp2.htm

  15. Histologic images showing sites of Randall's plaque and its progression

  16. Ca Oxalate crystals attached to renal papilla

  17. 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 )

  18. 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 .

  19. Diagnosis: • Clinical manifestations • Family hx • Urinalysis – urine culture • Stone analysis • KUB • IVP • US • CT SCAN ( choice )

  20. 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

  21. Uric acid crystals

  22. Calcium oxalate crystals

  23. Struvite crystalin urine sediment (Mg Ammonium Phosphate, coffin lid) only alkaline urine, pH>7

  24. Ca phosphate crystals

  25. Cystine crystals

  26. Indinavir

  27. 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

  28. 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 .

  29. 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 .

  30. 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 .

  31. 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

  32. 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 .

  33. 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 .

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