Nephrolithiasis

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  • 1. Nephrolithiasis
    Patrick Carter MPAS, PA-C
    Clinical Medicine I
    March 14, 2011
  • 2. Objectives
    For nephrolithiasis, describe the:
    Etiology
    Epidemiology
    Pathophysiology
    Risk factors
    Signs and symptoms
    Diagnostic work-up
    Treatment
  • 3. Nephrolithiasis
  • 4. Nephrolithiasis
    One of the most common urological problems in the US
    ~13% of American men
    ~7% of American women
    Prevalence is increasing throughout the industrialized world
  • 5. Nephrolithiasis
    Constituents of renal stones
    Uric acid
    Cystine
    Struvite (MgNH4PO4)
    Calcium oxalate and calcium phosphate stones make up 75–85%
  • 6. Nephrolithiasis
    Calcium stones
    More common in men
    Average age of onset is in the 20’s or 30’s
    50% of patients will form another within the next 10 years, usually one every 2-3 years
  • 7. Nephrolithiasis
    Uric acid stones
    5–10% of kidney stones
    Also more common in men
    Half of patients also have gout
    Usually familial
    Cystine stones
    Uncommon, only ~1% of cases
  • 8. Nephrolithiasis
    Struvite stones
    Common and potentially dangerous
    Mainly in women or patients who require chronic bladder catheterization
    Result from UTI’s with urease-producing bacteria (Proteus species)
    Can produce a large stone with a "staghorn" appearance
  • 9. Staghorn Stones
  • 10. Nephrolithiasis
    Epidemiology
    Third most common type of renal disease after UTI and prostate disease
    240,000–720,000 Americans per year
    Men > women 3-4:1
    More common in areas of high humidity and elevated temperatures
    More common in the summer
  • 11. Nephrolithiasis
    Risk factors
    Gout
    Chronic UTI’s
    Family history
    Medications
    Antacids
    Loop diuretics
    Vitamin C in large doses
    EtOH
  • 12. Acute Nephrolithiasis
    Signs and symptoms
    May be asymptomatic
    Flank pain with radiation to testicle or vulva
    Pain is often severe and patient cannot stay in one position
    Hematuria
    Frequency, urgency +/- dysuria
    CVA tenderness
  • 13. Acute Nephrolithiasis
    Diagnostic studies
    Stone analysis if any stones recovered
    Urinalysis for hematuria, pyuria, crystals, altered pH
    pH < 5 correlated with uric acid or cystine stones
    pH > 7.5 is suggestive of struvite stones
    KUB x-ray will show calcium, struvite and cystine stones
    Renal ultrasound
    CT Scan is imaging is 1st line
  • 14. KUB X-Ray
  • 15. IV Pyelogram
  • 16. CT Scan
  • 17. Acute Nephrolithiasis
    Treatment
    Initial management  fluids and analgesics
    Most stones < 5 mm will pass spontaneously
    Strain urine for stones
  • 18. Acute Nephrolithiasis
    Treatment
    Indications for stone removal
    Intractable pain
    Severe obstruction
    Serious bleeding
    Infection
    Stones > 10 mm
  • 19. Acute Nephrolithiasis
    Treatment
    Methods of stone removal
    Retrograde passage of a flexible basket
    Pyelolithotomy and ureterolithotomy
    Lithotripsy
    Extracorporeal
    Percutaneous
    Endoscopic
  • 20. Specific Treatments
    Calcium stones
    Hypercalciuria
    Low-sodium and low-protein diet
    Thiazide diuretic
    Hyperuricosuria
    Low-purine diet
    Allopurinol 100 mg PO twice daily
    Primary hyperparathyroidism  parathyroidectomy
  • 21. Specific Treatments
    Calcium stones
    Hyperoxaluria
    Low-oxalate diet
    Cholestyramine – binds oxalate
    Uric acid stones
    Potassium citrate to raise urine pH
    Low-purine diet
    Allopurinol
  • 22. Specific Treatments
    Cystine stones
    High fluid intake > 3 L per day
    Low-salt diet
    Raising urine pH > 7.5
    Struvite stones
    Complete removal of the stone followed by sterilization of the urinary tract
    If cannot tolerate surgery, acetohydroxamic acid
    Limited by side effects
    Headache tremor, thrombophlebitis
  • 23. Questions?