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