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Litiasis urinaria fisiopatología

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AUTOR: GUILLERMO ORRICO VELÁZQUEZ
CORRE: memorrico@hotmail.com

Published in: Health & Medicine
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Litiasis urinaria fisiopatología

  1. 1. LITIASIS URINARIA II: Fisiopatología Guillermo Orrico Velázquez. Residente de Segundo año Urología. 12/10/15. León, Guanajuato. Unidad Medica de Alta Especialidad. Centro Medico Nacional del Bajío.
  2. 2. Litiasis urinaria Metabolismo mineral Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Calcio Fosforo Magnesio Oxalato Clasificación de la nefrolitiasis
  3. 3. Litiasis urinaria Metabolismo mineral  Calcio •La ingesta diaria de calcio va de 600 – 900 mg/día •30 % al 40 % del calcio de la dieta se absorbe en el intestino  100 – 300 mg / día •90 %  intestino delgado •10%  colon •La absorción es inversamente proporcional a su consumo Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  4. 4. Litiasis urinaria Metabolismo mineral  Calcio •El calcio iónico es absorbido •Calcio no ionizado  no absorbido 60 %  complejos de calco solubles • Fosfato • Citrato • Oxalato • Sulfato • Ácidos grasos •Factor contribuyente  pH Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  5. 5. Litiasis urinaria Metabolismo mineral  Calcio •Ruta paracelular  No saturable •Ruta transcelular  Saturable y dependiente de la vitamina D Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  6. 6. Litiasis urinaria Metabolismo mineral  Calcio •Alfa hidroxilasa •PTH •Calcitriol Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Pre- Vitamina D3 25 – Hidroxivitamina D3 1,25 (OH) 2D3 Borde en cepillo intestinal 7- Dihidrocolesterol
  7. 7. Litiasis urinaria Metabolismo mineral  Calcio •Prepro PTH  Pre PTH  PTH •Estimulo principal  calcio sérico Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 87 aminoácidos
  8. 8. Litiasis urinaria Metabolismo mineral  Calcio •PTH  reclutamiento de osteoclastos  resorción ósea de calcio y fosforo •Calcitriol  aumento de la absorción intestinal de calcio transcelular Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Aumento del calcio sérico Aumento de la carga filtrada de calcio
  9. 9. Litiasis urinaria Metabolismo mineral  Fosfato •60 % del fosfato de la dieta es absorbido por el intestino delgado •Paso al plasma  Carga filtrada de fosfato  se absorbe en los túbulos renales Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Eliminación de fosfato 60 %  orina 40 %  heces
  10. 10. Litiasis urinaria Metabolismo mineral  Fosfato •Ruta paracelular  No saturable  altas concentraciones de Fosfato •Ruta transcelular  Saturable  bajas concentraciones de Fosfato Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 pH Absorción pH Absorción
  11. 11. Litiasis urinaria Metabolismo mineral  Fosfato •Ruta paracelular  No saturable •Ruta transcelular  Saturable • Dependiente de la vitamina D • Cotrasporte  Na-P ATPasa Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 1,25 (OH) 2D3 P P ATP asa
  12. 12. Litiasis urinaria Metabolismo mineral  Magnesio •Absorbido por el íleon distal en su mayoría •Parcialmente por el colon Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  13. 13. Litiasis urinaria Metabolismo mineral  Magnesio •Transporte activo • Calcitriol •Difusión simple Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  14. 14. Litiasis urinaria Metabolismo mineral  Oxalato •Se genera a partir del metabolismo de la glicina, hidroxiprolina y la vitamina C  85% •Se absorbe  6 % – 14 % de la dieta •Todo el tracto intestinal •Factores del individuo  absorción 10 % - 72 % •Resección de intestino delgado y colon integro  incremento marcado en la absorción de oxalato Gary C Curhan. Prevention of recurrent calcium stones in adults. Up
  15. 15. Litiasis urinaria Metabolismo mineral  Oxalato •Hiperoxaluricos  absorben mas oxalato •10-50% del oxalato urinario es derivado de la dieta •98%  ultrafiltrable •Disposición curvilínea •Alto ingesta  poco consumo Gary C Curhan. Prevention of recurrent calcium stones in adults. Up
  16. 16. Litiasis urinaria Metabolismo mineral  Oxalato •Factores que intervienen en la absorción de oxalato Gary C Curhan. Prevention of recurrent calcium stones in adults. Up Campieri et al, 2001 Formadores de cálculos de oxalato de calcio hiperoxaluria leve mostró una reducción del 24% al 40% en oxalato urinario Bacterias degradantes de oxalato O. formigenes Complejos Calcio Magnesio
  17. 17. Litiasis urinaria Clasificación de la nefrolitiasis •Contenedoras de calcio •75 % •No contenedoras de calcio •25% Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  18. 18. Litos de calcio Hipercalciuria •Es la anomalía mas común en los pacientes formadores de litos de calcio  35 % - 65 % •Superposición de calcio urinario entre individuos formadores y no formadores de litos de calcio •Hipercalciuria aumento de la saturación •Placas de Randall  directamente proporcional a los niveles de calcio urinario Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Riñón normal Filtra 270 mmol Ca/día Reabsorbe 266 mmol Ca/día Riñón normal Orina 4 mmol Ca/día
  19. 19. Litos de calcio Hipercalciuria Definición •Calcio urinario  > 200mg/día •Después de un apego dietético de 1 semana •Calcio  400 mg/ dia •Sodio  100 mg / dia Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Parques y Coe (1986) > 4 mg / kg / día >7 mmol / día en hombres >6 mmol / día en mujeres
  20. 20. Litos de calcio Hipercalciuria Park 1974  hipercalciuria idiopática •Hipercalciuria de absorción •Hipercalciuria renal •Hipercalciuria de resorción Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  21. 21. Litos de calcio Hipercalciuria de Absorción •Aumento de la absorción intestinal de calcio •Aumento de la excreción urinaria de calcio • > 0,2 mg / mg de creatinina, después de una carga oral de calcio. •55% de los pacientes con hipercalciuria Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Normal < 0.11 mg / mg Creatinina Calcio sérico permanece normal
  22. 22. Litos de calcio Hipercalciuria de Absorción Hipersensibilidad a la vitamina D Alteraciones gen  VDR Perdida renal de fosfato y aumento de la producción de Vitamina D Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  23. 23. Litos de calcio Hipercalciuria de Absorción Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Tipo I Tipo II Calcio urinario elevado a pesar de una dieta baja en calcio < 400mg/ día Calcio urinario se normaliza con una dieta baja en calcio
  24. 24. Litos de calcio Hipercalciuria Renal •98 % del calcio filtrado es reabsorbido •65 % - 70 % del calcio absorbido en TCP Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  25. 25. Litos de calcio Hipercalciuria Renal •98 % del calcio filtrado es reabsorbido •65 % - 70 % del calcio absorbido en TCP Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Riñón normal Filtra 270 mmol Ca/día Reabsorbe 266 mmol Ca/día 98 %
  26. 26. Litos de calcio Hipercalciuria Renal •Defectos en la absorción renal de calcio •Perdida de calcio urinario (Ayuno > 0,11 mg / dl ) •Aumento de la PTH  Resorción ósea •Aumento 1,25 (OH) 2D3  absorción aumentada de calcio por intestino Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Calcio sérico permanece normal
  27. 27. Litos de calcio Hipercalciuria Renal •No presentan disminución del calcio urinario con agentes de quelantes del calcio por vía oral • Fosfato de celulosa •Pobre respuesta a la adinistracion de hidroclototiazida • Reducción de excreción de calcio * Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  28. 28. Litos de calcio Hipercalciuria de resorción •Poco frecuente •Hiperparatiroidismo primario  5 % •Aumento de PTH  aumento de la resorción ósea de calcio •Aumento de calcitriol  aumento de la absorción intestinal de calcio Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Hipercalcemia Hipercalciuria Hipofosfatemia
  29. 29. Litos de calcio Hipercalciuria de resorción •Sospechar hiperparatiroidismo •PTH elevado •Hipercalcemia •Hipercalciuria Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Relación cloruro – fosfato > 33 Hipofosfatemia < 2.5 mg/dl
  30. 30. Litos de calcio Hipercalciuria de resorción •Desafío de Tiazida •Disminuirá la excreción renal de calcio Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Calcio sérico
  31. 31. Litos de calcio Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Estados hipercalcemicos Mecanismo Tiazidas Disminución de la eliminación renal de calcio Tumores malignos PTHrP 60 % CA pulmonar y Ca mama 15 % CA renal 10 % Mieloma y Limfoma Sarcoidosis Lepra Tuberculosis Granuloma  producen alfa hidroxilasa  Calcitriol Glucocorticoides Promueven PTH  Aumento de la resorción ósea Disminución del calcio intestinal Sx Cushing y litiasis 50% activo 27% curados
  32. 32. Litos de calcio Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Estados hipercalcemicos Hipotiroidismo Feocromocitoma Hipertiroidismo Enfermedad de Addison Enfermedad de Paget SIDA
  33. 33. Litos de calcio Hiperoxaluria •Definida como el oxalato urinario > 40 mg / día •Sobresaturación •Nucleación •Agregación •Retención Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Normal 34 mg / día
  34. 34. Litos de calcio Hiperoxaluria primaria •Trastorno autosómico recesivo raro en el metabolismo •Alteración de la conversión de glioxiato  glicina •connversión oxidativa de glioxilato  oxalato •oxalato urinario > 100 mg / día Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  35. 35. Litos de calcio Hiperoxaluria primaria •Alanina glioxilato aminotransferasa •Reductasa glioxilato hidroxipiruvato • Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Tipo I Tipo II AGXT GRHPR
  36. 36. Litos de calcio Hiperoxaluria primaria IRC  50 % de los pacientes en 15 años Mortalidad global de 15 % Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Mecanismos lesivos Lesión urotelial Toxicidad por oxalato IRC Fibrosis intersticial Nefrocalcinosis grave
  37. 37. Litos de calcio Hiperoxaluria entérica •Causa adquirida mas común •Se asocia con los estados diarreicos crónicos •Resección intestinal •Malabsorción de grasas  saponificación de los ácidos  Ca, Mg •Complejación reducida de oxalato •Biodisponibilidad aumentada para la absorción Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  38. 38. Litos de calcio Hiperoxaluria alimentaria •Proteína animal •Frutos secos •Suplementos de acido ascórbico •Restricción severa calcio Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Hiperoxaluria idiopática •Mayor tasa de flujo y trasporte en la membrana de eritrocitos de individuos de la península arábiga que padece nefrolitiasis de oxalato
  39. 39. Litos de calcio Hipocitraturia •Citrato  20% de la función inhibitoria 1.-Forma complejos con el calcio, reduciendo así la disponibilidad de calcio iónico para interactuar con oxalato o fosfato 2.-Inhibe directamente la nucleación espontánea de oxalato de calcio Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  40. 40. Litos de calcio Hipocitraturia •Se define como < 320 mg / día • Hombres < 0,6 mmol / día •Mujeres < 1,03 mmol / día •Presente en el 10 % de individos formadores de litos de calcio Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Estado acido –base Menor pH Menor citrato urinario
  41. 41. Litos de calcio Hiperuricosuria •Se define ácido úrico urinario > 600 mg /día •Formadores de litos de calcio  10 % de los formadores de litos de calcio Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 pH < 5.5 forma no disociada de acido urico  litos ácido úrico pH > 5.5 Urato de sodio  litos de Oxalato de calcio
  42. 42. Litos de calcio Hiperuricosuria •Gota •Trastornos linfoproliferativos y mieloproliferativo •Mieloma múltiple •Policitemia •Trastornos hemolíticos •Hemoglobinopatías Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  43. 43. Litos de ácido úrico Generalidades •Mamíferos producen enzima hepática uricasa •Cataliza la conversión de acido úrico  alantoína •Los humanos y dálmatas no sintetizan uricasa • Alantoína es de 10 a 100 veces más soluble en la orina Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  44. 44. Litos de ácido úrico Generalidades •El ácido úrico es un ácido débil con un pKa de 5,35 a 37 ° C •50 % del ácido úrico está presente como la urato de sodio y 50 % ácido úrico libre •Urato de sodio es 20 veces más soluble •pH de la orina es una factor crítico en la determinación de la solubilidad ácido úrico Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 pH 5 Pequeñas cantidades se saturan pH > 6. 5 Altas concentraciones permanecen solubles Bajo volumen urinario Hiperuricosuria
  45. 45. Litos de ácido úrico Generalidades Determinantes Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  46. 46. Litos de cistina Cistinuria •Trastorno autosómico recesivo •Defecto en el transporte tubular intestinal y renal de aminoácidos dibásicos •La cistina es un dímero, compuesto de dos moléculas de cisteína unidos a través de un enlace disulfuro •Pobre solubilidad Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  47. 47. Litos de cistina Cistinuria •Cistina condiciones normales •Filtración •Absorción •Intracelular  cistina  cisteína •Condiciones patológicas •Falta de absorción  sobresaturación Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  48. 48. Litos de cistina Cistinuria •Excesiva excreción urinaria de cistina •Menor pH = menor solubilidad Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 pH Solubilidad 5 300 mg/ L 7 400 mg/ L 9 1000 mg/ L
  49. 49. Litos de cistina Consorcio Internacional de cistinuria (2002) •Cistinuria tipo A  cromosoma 2 •Cistinuria Tipo B cromosoma 19 •Cistinuria tipo AB cromosoma 2 y 19 Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Cistinuria Pras (1994) •Cistinuria tipo I •Cistinuria tipo II •Cistinuria tipo III sobre la base de los niveles de cistina urinaria
  50. 50. Litos de infección Generalidades •Se componen principalmente de magnesio fosfato de amonio MgNH4PO4 puede contener fosfato de calcio •Von Struve descubrió fosfato amónico magnésico en guano "estruvita" •Brown (1901) primero teorizó bacterias productoras de urea ,aislo Proteus vulgaris de una pieda •Hager y Magath (1925) una enzima bacteriana hidroliza urea •Sumner (1926) aislo ureasa de Canavalia ensiformis. Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  51. 51. Litos de infección Generalidades Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45 Urea Ureasa Amoniaco Co2 pH urinario 7.2 - 8 hidrolisis Amonio HCO3 H2CO3 + H2O H+ Magnesio Fosfato
  52. 52. Litos de infección Bacteriología •Patogenos productores de ureasa •Proteus •Klebsiella •Pseudomonas •Especies de Staphylococcus Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  53. 53. Litos de infección Epidemiologia •Corresponden el 15 % del toal de las litiasis urinaria •Relación hombre: mujer  1:2 •Ancianos •Defectos congénitos del tracto urinario •Diabéticos •Estasis urinaria Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  54. 54. Litos misceláneos Litos misceláneos Litos de matriz Indinavir Guaifenesina Efedrina Tiazidas Xantina Amonio ácido Triamtereno Alan J. Wein , Louis R. Kavoussi, MD, Andrew C. Novick, Alan W. Partin. Campbell-Walsh, Urología. Elsevier Saunders. 10th edition, 2012. Chapter 45
  55. 55. LITIASIS URINARIA II: Fisiopatología Guillermo Orrico Velázquez. Residente de Segundo año Urología. 12/10/15. León, Guanajuato. Unidad Medica de Alta Especialidad. Centro Medico Nacional del Bajío.

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