Lifestyle recommendation in patient of kidney stones to reduce the risk

1. Lifestyle
recommendation
in patient
of kidney stones
to reduce the risk…
By
Siddesh Dhanaraj

2. Introduction
 One of the mostcommon afflictions of modern
society
 The lifetime prevalenceof kidney stone disease is estimated
at 1% to15%
 The age of peak incidence in men 30 to 69 years and in women 50
to 79years.

3. Types of renal calculi

4. Diagnostic evaluation
 Must identify associated metabolic
disorders responsible for recurrent stone
disease.
 Medications
 Dietary excesses, inadequate fluid intake or
excessive fluid loss

5. Indications for Metabolic Evaluation
 Strong family history ofstones
 Recurrent stoneformers
 Intestinal disease (particularly chronicdiarrhea)
 Solitary kidney
 Renal insufficiency
 Anatomicabnormalities

6.  Pathological skeletal fractures
 Osteoporosis
 History of urinary tract
infection with calculi
 Personal history ofgout
 Infirm health (unable to tolerate repeat
stone episodes)
 Stones composed of cystine, uricacid,
struvite

7. Multichannel blood screen
 Basic metabolic panel (sodium, potassium,chloride,
carbon dioxide, blood urea nitrogen,creatinine)
 Calcium
 Intact parathyroid hormone
 Uric acid

8. Urine
 Urinalysis
 pH > 7.5: infection lithiasis
 pH < 5.5: uric acidlithiasis
 Sediment forcrystalluria
 Urine culture
 Urea-splitting organisms: suggestive ofinfection
lithiasis
 Qualitative cystine

9. Radiological investigations

10. X-ray KUB
 Most common imagingtechnique
 Used in the follow up of patientsduring or after
treatment for stones, particularly after ESWL.
 Limited value if the stone isradiolucent.

11. Intravenous pyelography:
 Outdated
 Uses :
 Radiolucent stones,
 Anatomic abnormalities
 All urologists can interpretthe
x rays.

12. Ultrasonography
 No radiationexposure
 Detects radiolucentstones
 Adjunt in ESWL
 Inefficient in detecting smallstones

13. CT urography
 Investigation of
choice inthe
imaging of kidney
stones.
 Sensitivity : ~95%
 Specificity: ~98%
 Information regarding the composition of
stones
 Confirms the diagnosis in which USG in
equivocal

14. MRI
 Provide 3D image withoutradiation
 Lower accuracyand
 Expensive

15. Stone analysis
 Direct furthermanagement
 Struvite: infection lithiasis.

16. Conservative medical management
 Made for all patients regardless of the underlying etiology of their
stonedisease
 Calculi smallerthan 0.5 cm pass spontaneously

17. Fluid recommendations
 Volume:
 daily urine outputof 2 L (Borghi et al, 1999).

18.  Carbonated water protection againstrecurrent stone formation.
 Citrus Juices provide increased urinaryvolumeand increased urinary citrate
excretion.

19. Dietary Recommendations
 Decreased animal proteinintake.
 Sodium restriction
 Combined : stone episodes decrease roughly by 50%

20. Obesity
 Increase risk of stoneepisodes
 Metabolicsyndromeand stone disease: potential
correlation
 Dietary calcium restriction actually increases stone
recurrence risk.

21. Evaluationn of conservative management
 Re-evaluation after 3-4months
 If metabolic or environmental abnormalitieshave
been corrected:
 Continue treatment and thepatient
 Followup every 6 to 12 monthswith repeat 24-hour
urine testing.

22. If, however,
A metabolicdefect persists,
A more Selective medical therapy
may beinstituted…

23. Selective medical therapy
Narcotic
Relieves pain, dulls the senses and causes drowsiness. May become addictive.
Nonsteroidal anti-inflammatory drug
Relieves pain, decreases inflammation and reduces fever.
Diuretic
Increases urine production to get rid of excess salt and water.

24. Surgical management
(Ureteroscopy for Urolithiasis Outpatient Surgery)
 Symptomatic renal stones in patientswithout any other etiology ofpain.
 Ureteroscopy (URS) is a form of minimally invasive surgery using a small
telescope that is passed through the urethra and into the ureter to remove
a stone. Often the stone requires fragmentation with a laser which then allows
the smaller fragments to removed with a grasping device. Only about 10-15%
or urethral stones require surgical intervention. URS is approximately 95%
successful in removing stones in the lower ureter and about 85-90%
successful in treating and removing stones in the upper ureter and kidney.

25. Minimally invasive surgeries
 Percutaneous nephrolithotomy(PNL)
 Extracorporeal shock wave lithotripsy(ESWL)
 Retrograde intrarenal surgery(RIRS)
 Laparoscopic and robotic stonesurgery

26. Open surgical management
1. Nephrolithotomy
2. Pyelolithotomy
3. Extended pyelolithotomy

27. PRE OPERATIVE EVALUATION

28. Pre-procedural antimicrobials
 Bacteriologic evaluation of the urine is mandatory for all
patients
 Antimicrobial prophylaxis for all cases of percutaneous
renal surgery (Wolf et al, 2008).

29.  Antimicrobial coverage should includeorganisms
common to the urinarytract:
 Escherichia coli,
 Proteus sp.,
 Klebsiella sp.,
 Enterococcus sp.
 and theskin:
 Staphylococcus aureus,
 coagulase-negative Staphylococcus sp.,
 group A Streptococcus sp.)

30. Percutaneous nephrolithotomy
 Indications:
1. Stone size >2 cm in size
2. Staghorn stones
3. Hard stone not fragmented by ESWL
4. Urinary tract obstruction that need correction

31.  Complications:
 Acute and delayed hemorrhage
 Collecting system injury
 Visceral injury
 Pleural injury
 Metabolic and physiologic complications

32. Post op fever and sepsis
Neuromusculoskeletal complications
Venous thromboembolism
Tube dislodgement
Collecting system obstruction
Loss of renal function
Death

33. POSTPROCEDURAL NEPHROSTOMY DRAINAGE
Malecot’scatheter Balloon catheter

34. Copecatheter
Ureteral stent

35. Extracorporeal Shockwave Lithotripsy
 Most patients harboring “simple” renal
calculi can be treated satisfactorily with
SWL
 Outpatient procedure
 Indication
 stone size < 2 cm size

36. Contraindications
Pregnancy
Large abdominal aortic aneurysm
Uncorrectable bleeding disorder
Body habitus
Obstruction distal to the stone

37. Complications:
Fragments may become impacted in the ureter
Hematuria
Renal hematoma
Infection
Kidney damage

38. Retrograde Intrarenal Surgery (RIRS)

39. Indications:
Failed ESWL
RIRS assisted ESWL
Radiolucent stones
Calyceal diverticular stone

40.  Used in patients with ESWLcontra-indications:
 Bleeding disorder oranticoagulant
 Obesity
 Pregnancy

41.  Complications:
 Sepsis
 Steinstrasse
 Stricture
 Uretericinjury
 UTI
Steinstrasse
Stricture Ureteric injury

42. Anatrophic nephrolithotomy
 Gold standard for staghorn calculi
 Removal of all calculi and open surgical correction of the anatomical
obstruction

43.  Complications:
 Pulmonary complications
 Post op renal hemorrhage
 Stone recurrences
 Urinary extravasation

44. Pyelolithotomy
 Effective, especially for extra renalpelvis
 For pelvicstone

47. Lifestyle
recommendation
in patient
of kidney stones
to reduce the risk…

50. Thank You