renal calculi and its management

1. RENAL CALCULI AND ITS
MANAGEMENT
Presented by
Karan choudhary
CON AIIMS JODHPUR

2. INTRODUCTION
•A kidney stone, is a solid concentration or crystal
aggregation formed in the kidneys from dietary
minerals in the urine.
•A calculus often called a stone, is a concretion of
material, usually mineral salts, that forms in an organ
or duct of the body.
•Formation of calculi is known as lithiasis which can
cause a number of medical conditions.
•Urinary stones are typically classified by their location
in three types.

3. RENAL CALCULI / KIDNEY
STONES /NEPHROLITHIASIS
•Renal calculi is the stone formed in renal tubules,
calyces or pelvis when increase urinary concentration
of substances such as calcium, oxalates, calcium
phosphatase and uric acid.

4. INCIDENCE AND PREVALENCE
•More common in men than in women.
•In India it most commonly occurs in the ‘stone belt’.
(Maharashtra, Gujarat, Rajasthan, Punjab, Haryana,
Delhi, Madhya Pradesh, Bihar, and West Bengal)
•The incidence is higher in persons with family history
of stone formation.
•Most common in summer months
•The incidence is higher in persons with family history
of stone formation.

5. ETIOLOGY AND RISK FACTORS
•Infection
•Urinary stasis
•Periods of immobility
•With inflammatory bowel disease and with an
ileostomy or bowel resection.
•Some medications also cause stones e.g., antacids,
acetazolamide vitamin D.
•Urine PH and solute load affect the formation of
stones.

6. Continued…
•Increased calcium concentrations in blood and urine
promote precipitation of calcium and formation of
stones (about 75% of all renal stones are calcium-
based).
•Hyperparathyroidism
•Tumour of parathyroid gland
•Renal tubular acidosis
•Cancers (multiple myeloma)
•Excessive intake of milk

7. Continued…
•Granulomatous diseases (sarcoidosis, tuberculosis),
which may cause increased vitamin D production by
the granulomatous tissue.
•Fracture and prolonged immobilization due to
resorption of bone
•Large intake of dietary protein and calcium
•Excessive amount of tea and fruit juices that elevate
the urinary oxalate levels
•Prolong catheterisation

8. TYPES OF URINARY STONES
•There are five major categories of stones:
1. Calcium stone
2. Struvite stone (Triple phosphate stone):-
3. Uric acid stones
4. Cystine stones
5. Other e.g., Xanthine etc.

9. CALCIUM STONES
•It is the most common 80% .
•Alkaline in nature so urine ph is
alkaline and risk of UTI.
•Irregular in shape.
•Covered with sharp projections,
which cause bleeding.

10. URIC ACID STONES
•About 8% of renal stones
contain uric acid.
•Caused by excessive dietary
purine or gout patient.
•Red to yellow colour
•Acidic in nature so urine ph
is acidic in nature

11. STRUVITE STONE
•About 10% of all the renal stones
contain magnesium ammonium
phosphate
•Associated with chronic urinary tract
infection.
•Caused by urea splitting bacteria
(Proteus, Pseudomonas,
Staphylococcus)
•Alkaline in nature.
•more common women then the man

12. CYSTEINE STONES
• A rare type of kidney stone.
•Stones made up of chemical called cysteine.
•Caused by excessive consumption of methionine
(essential amino acid )and cystine (non essential AA)
•Acidic in nature.

13. PATHOPHYSIOLOGY
•

14. CLINICAL MANIFESTATIONS
•Pain (pain pattern depend on location of obstruction ) -
MC symptom in 75% of people.
•It may be worse on movement, particularly on
climbing stairs.
•sharp pain in the flank area, back or lower abdomen.
•Pyuria
•Nausea
•vomiting

15. CONTD,,,
•Sleep disturbance and discomfort.
•Cloudy or foul smelling urine
•Fever or chills if infection present
•Abdominal discomfort
•Haematuria
•Urinating small amount of urine

16. ASSESSMENT AND DIAGNOSTIC FINDINGS
History and Physical examination
•Dietary, medication and family history.
•patient drinking enough?
•Profession, enquire about UTI
•Long illness bedridden patient
•Abdomen tense and rigid
•Tenderness present

17. Diagnosis is confirmed by
•X-ray films of the kidneys, ureter, and bladder (KUB)
•Non contrast spiral CT called CT/KUB commonly
used in renal colic patient.
•Ultrasonography
•Intravenous urography or pyelogram (IVP)
•Retrograde pyelography.

18. Conted,,
•Blood chemistries - serum calcium, phosphorus,
sodium, potassium, bicarbonate, uric acid, BUN, and
creatinine levels.
•24-hour urine test - for measurement of calcium,
uric acid, creatinine, sodium, pH, and total volume.
•Chemical analysis is carried out to determine their
composition when stones are recovered.

19. MEDICAL MANAGEMENT
The basic goals of management are:
•The immediate objective of treatment of renal or
ureteral colic is to relieve the pain until its cause can
be eliminated.
•To eradicate the stone
•To determine the stone type
•to prevent nephron destruction
•To control infection
•To relieve any obstruction that may be present.

20. PHARMACOLOGICAL MANAGEMENT
1. Analgesic:
• Narcotic analgesic: Morphine sulphate is DOC for parenteral use.
• Opioid analgesics: to prevent shock and syncope (resulting from the
excruciating pain).
⎯Note: Most stones are 4mm or less in size and will probably pass
spontaneously.
2. Alpha-adrenergic blockers: by relaxing the smooth muscles in the
ureter, can be used to facilitate stone passage. E.g., Tamsulosin or
terazosin
3. NSAIDs - specific pain relief by inhibiting the synthesis of
prostaglandin E.
5. Antiemetic agent -(metoclopramide)

21. Dietary Recommendations for Prevention of
Kidney Stones
•Restricting protein to 60 g/day is recommended to
decrease urinary excretion of calcium and uric acid.
•Oxalate-containing foods (spinach, strawberries, tea,
peanuts, and wheat bran) may be restricted.
•Restrict calcium in the diet (when stones are clearly
due to excess dietary calcium)
•Liberal fluid intake along with dietary restriction of
protein and sodium.
•Increase fluid intake.

22. SURGICAL MANAGEMENT
•Indications:
•Stones too large for spontaneous passage (usually
greater than 7 mm).
•Stones associated with symptomatic infection.
•Stones causing impaired renal function.
•Stones causing persistent pain or worsening of
symptoms.
•Patient with only one kidney.

23. Ureteroscopy
•It involves first visualizing the
stone and then destroying it.
•A stent may be inserted and
left in place for 48 hours or
more after the procedure to
keep the ureter patent.
•Hospital stays are generally
brief, and some patients can be
treated as outpatients.

24. ESWL(extracorporeal shockwave lithotripsy)
•It is a non-invasive procedure to break up stones in the
calyx of the kidney.
•After the stones are fragmented to the size of grains of
sand, the remnants of the stones are spontaneously
voided.
•An average treatment comprises between 1,000 and
3,000 shocks.
•The patient is observed for obstruction and infection
resulting from blockage of the urinary tract by stone
fragments.

26. Percutaneous nephrostomy or a percutaneous
nephrolithotomy
•A nephroscope is introduced through the dilated
percutaneous tract into the renal parenchyma and the
stone may be extracted with forceps or by a stone
retrieval basket.
•Small stone fragments and stone dust are irrigated and
suctioned out of collecting system.
•Larger stones may be further reduced by ultrasonic
disintegration and then removed with forceps or a
stone retrieval basket.

28. Open Surgical Procedures
•Pyelolithotomy
•Nephrolithotomy
•Nephrectomy
•Ureterolithotomy-

29. NURSING MANAGEMENT
•Nursing Assessment
•Assess for pain and discomfort as well as nausea,
vomiting, diarrhoea, and abdominal distention.
•Severity, location and radiation of pain are determined.
•Symptoms of UTI (chills, fever, dysuria, frequency, and
hesitancy) and obstruction (frequent urination of small
amounts, oliguria, or anuria).
•See for Haematuria
•Precipitating factors: episodes of dehydration, prolonged
immobilization, and infection.

30. NURSING DIAGNOSES
•Acute pain related to inflammation, obstruction, and abrasion of the
urinary tract.
•Impaired Urinary Elimination related to stimulation of the bladder
by calculi, renal or ureteral irritation, mechanical obstruction and
inflammation as evidenced by urgency and frequency; oliguria
(retention); haematuria.
•Disturbed sleep pattern related to acute pain as manifested by
decreased sleep duration.
•Risk of deficient fluid volume related to nausea and vomiting as
manifested by decreased appetite and fatigue.
•Deficient knowledge regarding prevention of recurrence of renal
stones.

31. •Relieving pain
•Opioid analgesic agents (intravenous or intramuscular
administration may be prescribed to provide rapid
relief) or NSAIDs for immediate relief.
•The patient is encouraged and assisted to assume a
position of comfort.
•If activity brings some pain relief, the patient is assisted
to ambulate.
•The pain level is monitored closely, and increases in
severity are reported promptly to the physician so that
relief can be provided and additional treatment initiated.
•

32. PREVENTING RECURRENT KIDNEY STONE
•Follow prescribed diet closely.
•During the day, drink fluids enough to excrete greater
than 2,000 mL of urine every 24 hours (preferably 3,000
to 4,000 mL) to assist in the passage of stone fragments.
•Avoid sudden increases in environmental temperatures,
which may cause excessive sweating, dehydration and
fall in urinary volume.
•Avoid activities that cause excessive sweating and
dehydration.

33. SUMMARY
•Today we have discussed introduction, definition of
urolithiasis and nephrolithiasis, their incidences and
causes /risk factors. Classification/ Types of urinary
stones, its pathophysiology, clinical manifestations,
assessment and diagnostic findings, medical,
surgical and nursing management, potential
complications and prevention of kidney stones.

34. CONCLUSION
•A calculus (plural calculi), often called a stone, is a
concretion of material, usually mineral salts, that
forms in an organ or duct of the body. These are
common and recur frequently. Nurse should educate
the preventive strategies to the patient such as drinking
adequate water and avoiding dehydration and high
temperature areas.

35. Reference
•Brunner & Suddarths. Textbook of Medical Surgical Nursing, 13th Edition
Volume -2 .New Delhi: Wolters Kluwer; 2015;
•Black.M.J, Haawks.J.H. Medical Surgical Nursing. VoII. 7th Edition. New
delhi Saunders publication.
•Lewis. S. Heitkemper M. Medical surgical Nursing. 6th edition. Missouri:
Elseveir’s publications.
•Li DF, Gao YL, Liu HC, Huang XC, Zhu RF, Zhu CT. Use of thiazide
diuretics for the prevention of recurrent kidney calculi: a systematic
review and meta-analysis. J Transl Med. 2020 Feb 28;18(1):106. doi:
10.1186/s12967-020-02270-7.
•Rodgers AL, Siener R. The Efficacy of Polyunsaturated Fatty Acids as
Protectors against Calcium Oxalate Renal Stone Formation: A Review.
Nutrients. 2020 Apr 12;12(4). pii: E1069. doi: 10.3390/nu12041069.