Urinary stone evaluation in laboratory and clinical significance

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Urinary Stones or Urolithiasis is a common, painful and destructive disease. It has a habit of recurrence. About half of Stones recur with in 5 to 7 years of first episode.
Stone disease tests are very useful to know cause of Stone formation. This is essential for focal prophylactic treatment to prevent recurrance.

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Urinary stone evaluation in laboratory and clinical significance

  1. 1. Dr. Sanjeev Mehta MDDr. Sanjeev Mehta MD Ahmedabad, INDIAAhmedabad, INDIA www.urolab.net Metabolic Evaluation & Stone Analysis Practical implications
  2. 2. Role of laboratory • What lab can not tell you, you will not know. • What it tells you in error, you will not correct by using your instincts, your medical experience or your art. • Misdirected treatment : unreasonable expenses. • The Kidney Stone Handbook; Gail Savitz & co auth.
  3. 3. Stone : Supersaturation of Urine
  4. 4. Stone Promoting and Inhibiting Factors PROMOTORS INHIBITORS Calcium Inorganic : Magnesium Sodium Phosphorus Oxalate Citrate Urate Organic : Nephrocalcin Cystine Tomm-Horsfall Protein Low Urine Ph Urinary Prothrombin fragment. Tomm-Horsfall Protein Bacterial products
  5. 5. Evaluation of Stone Disease ROUTINE BLOOD AND URINE TESTS STONE ANALYSIS. 24 HRS URINE METABOLIC PROFILE New advances in Stone analysis, Blood and Urinary Chemical analysis can find out 90-95% cause.
  6. 6. Clinical usefulness 1.Identify treatable metabolic abnormality 2.Identify underlying medical disease that predisposes to stone formation. 3.Outline a treatment plan.
  7. 7. A. Routine Tests BLOOD low K, and HCO3- RTA High Uric acid - Uric acid diathesis High Calcium- pri hyperparathyroidism Low phosphorus- renal phosphorus leak. Parathyroid ; sos URINE pH > 7.5 – infection lithiasis pH < 5.5 – Uric acid lithiasis Sediments for crystalluria Urine culture Qualitative cystine
  8. 8. Renal Stone Analysis • Essential step in the examination and initial treatment of Urolithiasis. • Yields fundamental information about ; - Metabolic abnormality. - Presence of infection. - Possible artifacts. - Drug metabolism.
  9. 9. Technique Integrated analysis with Infra-red spectrometry Xenthene and Ca.oxalate Dihydrite
  10. 10. INTEGRETED ANALYSIS ; Mixed Stone
  11. 11. 11 Actually up to 65 different chemical compounds are found in urinary calculi.
  12. 12. Clinical significance of Stone analysis • Three categories : 1.Composition and hardness of Renal Stones. 2.Composition and its predictive value. 3.Composition and related metabolic abnormalities. Kourambas J, Aslan P, Teh CL, Mathias BJ, Preminger GM.J Endourol. 2001 Mar;15(2):181-6
  13. 13. Clinical Significance: Hardness pattern in Stone. • Useful in describing consistency in individual. • Formulation of treatment strategies. - Number of re-treatments. - Number of Shock waves. • Energy index (KV x number of shock waves). Ringdén I, Tiselius HG, Scand J Urol Nephrol. 2007;41(4):316-23
  14. 14. Hardness Factor of Stone Calcium Oxalate Dihydrate 1.0 Calcium Oxalate Monohydrate 1.3 Hydroxy-peptite 1.1 Brushite 2.2 Uric Acid/ Urate 1.0 Cystine 2.4 Carbonate Apatite 1.3 Struvite 1.0 Mixed Stone 1.0 * Ringden I, Scand J Urol Nephrol.2007;41(4):316-23
  15. 15. Clinical value : Calcium • Present in approximately 80% stones. • Combines with phosphate or oxalate or both. • Risk factors : hypercalciuria, Hyperoxaluria. hyperuricosuria. predominantly acid or alk urine. hypocitraturia. low urine volume.
  16. 16. Calcium Stones ….. Pure calcium Stones • More Acid urine • Low Urine volume • High Oxalate excretion Mixed Stone formers • pH is higher • High Calcium • High Calcium excretion • High recurrence rate * Schroeppel j Smith et all ; J Am Soc Nephrol 1997;8:568A
  17. 17. Calcium Stone….. Ca-oxalate Monohydrate • Hypo- megnesuria • Acidic Urine • Low Urine volume • Hardness + • Ca-ox Dihydrate • Hyper-calciuria • Alkaline Urine • Hypo-citraturia • Hardness ; less
  18. 18. Renal tubular acidosis Carbonate apattite • Consider RTA • Increases with amount • (5-39%) Brushite Stones • Consider RTA
  19. 19. Struvite Stone Magnesium Ammonium Phosphate • Mixed Stone : Infection. ‘Proteus’ • Strains of staphylococci, pseudomonas and kelbsiella. • Rarely; E.coli. • Urine Ph. Is < 7.5
  20. 20. Ammonium Urate • Calcium oxalate – containing calculi, may start hyperuricosuria. • Elders : associated with infection. • Children : May as result of hyperuricosuria, but No UTI
  21. 21. Brushite : Amm. Calcium Phosphate • Sizable stone burden. Increasing trend • High recurrence rate , 3 yrs • Familial tendency • Hypercalciurea and underlying metabolic abnormality. • Extreme Alkaline Urine. J Urol. Oct 2010; 184(4): 1367–1371.
  22. 22. Dahilite ( Carbonate apatite) • Phosphate stone • Infection in body. • May not accompanying sign of disease. • RTA • Disorder of phosphate metabolism. • Rare in pure form ( 2-3%).
  23. 23. Uric Acid URIC ACID • Hyperuricemia, hyperuricosuria. • Low Urine Ph. < 6.2 • Causes: - Gout. - Myeloproliferative dis. - Chemotherapy and Radiotherapy.
  24. 24. Cystine CYSTINE • Cysteinuria. • Autosomal recessive disorder. • Occurs predominantly in pure form. • XENTHENE Most frequent causes: - Xanthinuria. - Absence of Xanthene oxidase. • Genetic autosomal hereditary recessive enzyme disorder. • Trigger : Allopurinol Treating Gout.
  25. 25. Urine: Metabolic Evaluation 24 hrs Urine collections: multiple parameters Stone risk factors : Quantitation Volume and pH Calcium Oxalate Citrate Uric acid. Creatinine
  26. 26. Metabolic Evaluation: 24 hrs Urine • Dietary risk factors: Sodium, Potassium Magnesium Urinary analysts : phosphorus, sulphate, Urea Children : state sample Repeat 24 hrs Urine collection 4-6 weeks post interventi
  27. 27. GOLD STANDARD Supersaturation value. •High risk parameter can be monitored. Graphic presentation
  28. 28. Super-saturation : Gold standard….
  29. 29. Conclusion • Advancement in laboratory can now diagnose cause of stone formation uo tp 90% cases. • By appropriate Stone analysis and metabolic evaluation can effectively treat impact of Nephrolithiasis and prevent recurrence .
  30. 30. Conclusion: Significance • Advancement in laboratory can diagnise cause of Stone disease up to 90% • Impact mitigated by appropriate metabolic evaluation. • Identify risk factor. • Focused medical treatment • Significantly reduces recurrence • Social and financial burden. • Batter quality of life
  31. 31. Thank you ! For further details contact: sanjeev@urolab.net Phone: +91 79 40380380

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