The document discusses nephrolithiasis (kidney stones) and pyelonephritis (kidney infection). It covers the types, risk factors, pathogenesis, clinical manifestations, diagnosis and treatment of both conditions. Calcium oxalate stones are the most common type of kidney stones. Risk factors for stone formation include dietary factors like calcium intake as well as urinary abnormalities. Pyelonephritis is commonly caused by gram-negative bacteria ascending from the bladder. It can cause kidney swelling and damage if left untreated.

1. NEPHROLITHIASIS
ROD PRASAD
GROUP 3A

2. INTRODUCTION
 Nephrolithiasis, or kidney stone disease, is a common, painful, and costly
condition.
 Although nephrolithiasis is rarely fatal, patients who have had renal colic report
that it is the worst pain they have ever experienced.
 Nephrolithiasis is a global disease.
 Data suggest an increasing prevalence, likely due to Westernization of Iifestyle
habits (e.g. dietary changes, increasing BMI) .
 Up to 19% of men and 9% of women will develop at least one stone during
their lifetime.
 The prevalence is -50% lower among black individuals than among whites.
 The incidence of nephrolithiasis also varies by age, sex, and race.

3. TYPES OF CALCULI
 It is clinically important to identify the stone type, which informs prognosis and selection
of the optimal preventive regimen.
 There are various types of kidney stones:
 Calcium oxalate stones are most common(-75%)
 calcium phosphate ( - 1 5%)
 uric acid (-8%)
 struvite (-1 %)
 and cystine (<1 %)
 Many stones are a mixture of crystal types (e.g. calcium oxalate and calcium phosphate)
and also contain protein in the stone matrix.
 Rarely, stones are composed of medications, such as acyclovir, indinavir, and
triamterene.

4. TYPES OF CALCULI

5. PATHOGENESIS

6. RISK FACTORS
DIETARY
► Calcium
► Sodium
► Oxalate
► Animal protein
► High potassium intake
► Vitamin C supplementation
► Decreased fluid intake
NON DIETARY
► Age
► Race
► Body size
► Environmental factors (hot, dry)
► Occupational factors
► Ethnicity
URINARY
► Decreased urine volume
► Hypercalciuria
► High urine oxalate excretion
► Low urine citrate
► Urine uric acid levels
► Urine pH level ≤ 5.5 ( ≥ 6.5 for
phosphate stones)

7. CLINICAL MANIFESTATIONS
 Severe pain (abdominal or flank)
 Pain in groin, labia or testicles
 Nausea and vomiting
 Fatigue
 Fever or chills
 Cloudy or foul smelling urine
 Dysuria, polyuria and hematuria
 High BP and respiration

8. RENAL COLIC PAIN
 When a stone moves into the ureter, the discomfort often begins with a sudden onset
of unilateral flank pain.
 The intensity of the pain can increase rapidly, and there are no alleviating factors.
 The pain may radiate depending on the location of the stone.
 If the stone lodges in the upper part of the ureter, pain may radiate anteriorly.
 If the stone is in the lower part of the ureter, pain can radiate to the ipsilateral testicle
in men or the ipsilateral labium in women.

9. DIFFERENTIAL DIAGNOSIS OF PAIN
LOCATION DIAGNOSIS
Right ureteral pelvic junction Acute cholecystitis
If the stone blocks the ureter
as it crosses over the right pelvic brim
Acute appendicitis
Blockage at the left pelvic brim Acute diverticulitis
Ureterovesical junction Patient may experience urinary
urgency and frequency.
Bacterial cystitis in women
Other conditions Muscular or skeletal pain, herpes zoster,
duodenal ulcer, AAA, ureteral stricture or
foreign body obstruction

10. DIAGNOSIS
HISTORY
 Number and frequency of episodes of
kidney stones
 UTIs, bariatric surgery, gout,
hypertension, and diabetes mellitus.
 A family history of stone disease may
reveal a genetic predisposition.
 A complete list of prescriptions and over
the counter medications as well as
vitamin and minerals is essential.
 Dietary habits and fluid intake.
PHYSICAL EXAMINATION
 Weight
 BP
 Costovertebral angle tenderness
 Lower extremity edema
 Signs of primary hyperparathyroidism
and gout.

11. DIAGNOSIS
 LABORATORY EVALUATION
 Electrolyte, calcium, creatinine and uric acid
 PTH levels for exclusion
 Urinalysis for RBC and WBC
 24-h urine samples while consuming their usual diet and usual volume of
fluid.
 The following factors should be measured:
 Total volume, calcium, oxalate, citrate, uric acid, sodium, potassium,
phosphorus, pH, and creatinine.

12. DIAGNOSIS
 IMAGING
 Helical CT scan
 Abdominal X ray
 Ultrasound
 Retrograde pyelogram
 Cystoscopy

13. TREATMENT
INITIAL MANAGEMENT
 fluids and analgesics
 Most stones < 5 mm will pass
spontaneously
 Strain urine for stones
STONE REMOVAL
 Intractable pain
 Severe obstruction
 Serious bleeding
 Infection
 Stones > 10 mm

14. METHODS OF REMOVAL
 Retrograde intrarenal surgery
 Pyelolithotomy and ureterolithotomy
 Lithotripsy
 Extracorporeal
 intracorporeal

15. PYELONEPHRITIS

16. INTRODUCTION
 Inflammation of the parenchyma and lining of renal pelvis of kidney.
 It causes the kidneys to swell and may permanently damage them.
 Pyelonephritis can be life-threatening.
 When repeated or persistent attacks occur, the condition is called chronic
pyelonephritis.
 The chronic form is rare, but it happens more often in children or people
with urinary obstructions.

17. RISK FACTORS
 Female : Shorter urethra
 Male : uncircumcised infant
 Bacterial colonization inside prepuce and urethra
 Catherization
 DIRECT: Bacteria carried directly into bladder during insertion
 INDIRECT:
 Facilitation of bacterial access via
 lumen of catheter
 Tracking up between outside catheter and urethral wall

18. RISK FACTORS
 Structural renal abnormalities, including vesicoureteric reflux (VUR).
 Calculi and urinary tract catheterisation.
 Stents or drainage procedures.
 Pregnancy.
 Diabetes.
 Primary biliary cirrhosis.
 Immunocompromised patients.
 Neuropathic bladder.
 Prostate enlargement.

19. ETIOLOGY
GRAM NEGATIVE
 E.coli (common)
 Proteus mirabilis,
 Citrobacter,
 klebsiella,
 enterobacter,
 proteus pseudomonas aeruginosa
GRAM POSITIVE
 Staph.saprophyticus,
 Staph. Epidermidis enterococcus,
 Corynebacteria
 Lactobacilli
► The uropathogens causing pyelonephritis vary by clinical syndrome but are usually
enteric gram-negative rods that have migrated to the urinary tract.
► The susceptibility patterns of these organisms vary by clinical syndrome and by
geography.

20. ETIOLOGY
VIRAL
 Rare
 Polyomaviruses , JC and BK strains
 Cytomegalovirus and rubella
 Korean hemorrhagic fever virus
 Mumps and HIV
 Recovered in urine in absence of UTI
PARASITIC
 Fungi : candida and histoplasma
capsulatum
 Protozoa : trichomonas vaginalis
 Helminth: schistosoma haematobium

21. PATHOGENESIS
 Normal urine flow disruption ( obstruction ) Incomplete bladder
emptying > 2-3ml residual urine infection ascent of infection
pyelonephritis.

22. CLINICAL FEATURES
 Mild Pyelonephritis:
 low-grade fever
 with or without lower-back or costovertebral-angle pain
 Severe Pyelonephritis:
 High fever “picket-fence” 72hr
 Nausea
 vomiting
 flank and/or loin pain

23. FORMS OF PYELONEPHRITIS
 Emphysematous pyelonephritis:
 exclusively in diabetic patients
 production of gas in renal and perinephric tissues
 bilateral papillary necrosis
 rise in the serum creatinine level
 Xanthogranulomatous pyelonephritis:
 chronic urinary obstruction (often by staghorn calculi)
 chronic infection
 Suppurative destruction of renal tissue

24. LABORATORY DIAGNOSIS
 The Urine DipstickTest:
 Rapid diagnostic test
 Appearance of WBC in urine
 test for nitrite & leukocyte esterase
 Urinalysis:
 WBC in cast shape due to of
pyelonephritis
 No WBC, no infection
 Urine Culture
 Significant bacteriuria= 105 cfu/ml
 symptoms: 1 +ve cuture = infection
 Symptoms: 102 cfu/ml = propable
infection
 Asymptomatic: 2 +ve cultures =
infection
 False negative : antibiotics, antiseptics,
renal TB, diuresis.

25. MICROSCOPY OF URINE
 Assessed with Gram-stained uncentrifuged urine
 Microscopic bacteriuria is found in >90% of specimens with colony counts
of at least 105 /mL
 The detection of bacteria by urinary microscopy constitutes firm evidence
of infection, but the absence of microscopically detectable bacteria does
not exclude the diagnosis
 Pyuria (WBC > 5/HPF) is demonstrated in nearly all acute bacterial UTIs
 Look also for RBCs, WBC casts
 Associated hematuria may indicate urinary calculi.

26. IMAGING
 Contrast-enhanced helical/spiral CT (CECT) scan is the best investigation in
adults where diagnosis is in doubt, improvement does not occur after 72
hours of treatment, or deterioration occurs.
 Non-contrast helical/spiral CT scans will pick up moderate-to-severe
disease but may be normal in milder cases.
 In pregnant women, ultrasound or MRI is preferred.

27. TREATMENT
 Fluoroquinolones the first- line therapy for acute uncomplicated pyelonephritis.
 Oral TMP-SMX (one double-strength tablet twice daily for 14 days) also is effective for
treatment of acute uncomplicated pyelonephritis if the uropathogen is known to be
susceptible.
 If the pathogen's susceptibility is not known and TMP SMX is used as an initial IV 1g
dose of ceftriaxone is recommended.
 Options for parenteral therapy for uncomplicated pyelonephritis include
fluoroquinolones an extended- spectrum cephalosporin with or without
anaminoglycoside

28. REFERENCE
 Wiener, C. (2008). Harrison's principles of internal medicine. New York:
McGraw-Hill, Medical Pub. Division.
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672131/
 https://msdmanuals.com/professional/genitourinary-disorders/urinary-
tract-infections-utis/chronic-pyelonephritis
 https://patient.info/doctor/pyelonephritis

29. THANK YOU.