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Renal Stones

Renal Stones. Dr. Shahram Sajjadieh M.D. Nephrologist. Epidemiology. 12% of men and 5% of women develop symptomatic stone by the age of 70 . Rate of nephrolithiasis increases with : Age Men White race. Etiology. Calcium stones 80% ( Ca ox > Ca ph ) Uric acid

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Renal Stones

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  1. Renal Stones Dr. ShahramSajjadieh M.D. Nephrologist

  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 race

  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. 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

  5. Risk factors : cont… • Family history • Enteric oxalate absorption • Urinary tract infection (spinal cord injury) • Medications : (indinavir , sulfadiazine , triamterene) • Hypertension (hypercalciuria ) • Vasectomy • Marathon runners

  6. Risk factors : cont… • Type of fluid taken : *Soft drinks acidified with phosphoric acid. 8 ounce/day of caffeinated or decaffeinated *Coffee*Tea and Wine in women . *Grapefruit juice 44% , *Tomato juice 29% *Orange juice or ? *Lemon juice 4 ounce (120 ml/day ) .

  7. 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

  8. 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)

  9. Clinical manifestations :cont… • Hematuria( gross or microscopic ): in the majority of patients . • Flank pain: the single most discriminate predictor of kidney stone is 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 .

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

  11. 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

  12. Diagnosis:cont… • KUB : * Detect : radioopaque stones (Ca , struvite , cystine stones) * Will miss : uric acid stone small stone stone overlying bony structures * Will not detect : obstruction

  13. Diagnosis:cont… • IVP : high sensitivity and specificity , procedure of choice but with allergic reaction , replaced by non-contrast CT–Scan

  14. Diagnosis:cont… • 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- collecting system dilatation 3- perinephric stranding . Exception : 1- stones due to Indinavir (non-opaque , minimal obstruction ) 2- phleboliths overlying on ureter .

  15. 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 .

  16. 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 . If helical CT is not available , IVP or US are appropriate .

  17. Calcium Oxalate Stone

  18. Calcium Oxalate Dihydrate Crystals

  19. Calcium Oxalate Monohydrate Crystals

  20. Calcium Oxalate Crystals

  21. Uric Acid Crystals

  22. Hexagonal cystine crystals (pathognomonic for cystinuria)

  23. Triple Phosphate Crystals (Coffin Lid)

  24. Indinavir Crystals

  25. Evaluation of a patient 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

  26. Evaluation of a patient with established nephrolithiasis cont... • Uric acid stones : occurs in: 1- persistent acid urine 2- overproduction of uric acid in gout 3- chronic diarrheal states • Cystine stones : in pts. With cystinuria due to insolubility of cystine in the urine .

  27. Evaluation of a patient with established nephrolithiasis cont... • 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 . • Medications : Indinavir , Sulfadiazine , Triamterene

  28. Evaluation of a patient with established nephrolithiasis cont... • 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 .

  29. Evaluation of a patient with established nephrolithiasis cont... • . 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

  30. Urinary abnormalities in patients evaluated for nephrolithiasis Hypercalciuria( M > 250, F > 225 mg / 24 hr ) 51% Hyperuricosuria( M > 750, F > 700 mg / 24 hr ) 42% Hypocitraturia( M < 250, F < 300 mg / 24 hr )34% Hyperoxaluria( > 40 mg / 24 hr )34% Hypomagnesuria( < 5 mEq / 24 hr ) 26% Low urine volume( < 1500 ml / 24 hr )61% No diagnosis2% • Excluding cystinuria and infection stones

  31. 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 .

  32. 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.

  33. Medullary Sponge Kidney All calyces show outward brushlike appearance

  34. 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 interrmitent stone formation. 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 .

  35. 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 ) .

  36. Infectious Theory in the Pathogenesis of Nephrolithiasis • Nanobacteria may act as nidus for kidney stone formation. • Promoters and inhibitors of stone formation may have important roles in the progress of kidney stone formation on the initial nidus, nanobacteria.

  37. Scanning EM of Calcified Nanobacteria Cultured in Serum Free Condition

  38. Hyperoxaluria • The role of Oxalobacter Formigenes: • Oxalate degrading, colonic G- anaerobic bacteria • Natural colonization at age ~ 1 yr • 100% colonization by age 3 - 10 yrs • 75% colonization by adult age • Completely absent in the majority of patients with: • cystic fibrosis • enteric hyperoxaluria • Prolong Ab Rx

  39. Effect of High Protein Diet on Urinary Parameters J Clin Endocrinol Metab 71:861, 1990

  40. Prevention of Further Stones Dietary modification: High fluid intake ( urine out put > 2.5 L ) Low oxalate diet ( hyperoxaluria ) Low salt diet ( < 6 g salt; hypercalciuria, cystinuria ) Moderate Ca restriction ( hypercalciuria ) Low protein / purine diet ( hyperuricosuria, hypercalciuria, hypocitraturia )

  41. Prevention of Further Stones Pharmacological Rx: K- citrate ( Urocit - K, Polycitra - K ) • Corrects acidosis • Alkalinizes urine • Increases urine citrate • Dose: 20 mEq bid - tid Thiazide diuretics ( + salt restriction ) • Reduce hypercalciuria • Cause hypokalemia hypocitraturia • Add K - citrate ± Amiloride

  42. Prevention of Further Stones Pharmacological Rx: Allopurinol ( hyperuricosuria ) Mg supplement ( hypomagnesuria ) Ca supplement ( enteric hyperoxaluria ) Pyridoxine ( B6 ) ( PH - Type I ) Captopril, D-penicillamine, Tiopronin (cystinuria ) Acetohydroxamic acid ( urease inhibitor )

  43. The Effect of K-citrate on Hypocitraturic Ca-oxalate Stone Disease Pre-Rx Post-Rx -30 -36 -12 -18 -24 0 6 24 -6 30 12 18 36 Months J Urol. 150:176, 1993

  44. Management of renal & ureteral stones • Surgical • Medical Surgical : 10% -20% require surgical management. Stones < 5 mm pass spontaneously . Stones > 8-10 mm pass unlikely .

  45. Management of renal & ureteral stones Indication of stone removal : • Pain • Obstruction • Infected struvite stone • Large stone : > 2cm or staghorn stone • Cystine stone

  46. 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.

  47. 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

  48. 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 .

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