Renal calculli Veeresh VG RN

OUTLINE OF THE CONTENT
DEFINITION OF RENAL CALCULI
INCIDENCE OF RENAL CALCULI
RISK FACTORS FOR RENAL CALCULI
CLASSIFICATION OF RENAL CALCULI
ETIOLOGY : PATHOPHYSIOLOGY
SITES OF IMPACTION

OUTLINE OF THE CONTENT
• SIGNS AND SYMPTOMS OF RENAL
CALCULI
• COMPLICATIONS OF RENAL CALCULI
• DIAGNOSIS OF RENAL CALCULI
• MANAGEMENT OF RENAL CALCULI
• VEDIO ON ESWL

INTRODUCTION
Kidney stones (called renal calculi (from
Latin renes, "kidney" and calculi, "pebbles")
are solid concretions or crystal aggregations
formed in the kidneys from dietary minerals.

DEFINITION OF RENAL CALCULI
Renal calculi a condition in which there is a
formation of stones within the renal system
that is kidney, urethra and bladder.

INCIDENCE OF RENAL CALCULI
 Kidney stones are a significant source of
morbidity with an annual incidence of 1–2 per
1000 and a lifetime prevalence of 3–5%.
 80% of those with kidney stones are men;
most stones in women are due to either
metabolic defects (such as cystinuria) or
infection.

INCIDENCE OF RENAL CALCULI CONT...
 Recurrence rates are estimated at 50% over a
10 year period and 75% over 20 years, with
some experiencing ten or more episodes over
the course of a lifetime.
 The incidence of urolithiasis increases to 20-
25% in the Middle East, partly due to the
increased risk of dehydration in hot climates.

INCIDENCE OF RENAL CALCULI CONT...
Men most commonly experience their first
episode between age 30- 40 years, while for
women the age at first presentation is
somewhat later.

RISK FACTORS OF RENAL CALCULI
 Occupation
 Family history (cystinuria inherited metabolic
disorder)
 Dietary pattern of family diet high in
calcium, vitaminD, milk, protein, oxalate,
alkali.
 Dehydration
 Small bowel disease : Krohn’s disease
 Medical conditions: Hypercalcuria
Hyperparathyrodism, and Gout

RISK FACTORS OF RENAL CALCULI CONT…
 Urinary tract infection
 Urinary stasis
 Immobility
 Urinary tract obstruction
 Hypercalcemia

CLASSIFICATION OF RENAL CALCULI
Kidney stones are typically classified by their
1. Location
2. Chemical composition

CLASSIFICATION OF RENAL CALCULI…
1. Location
Urolithiasis
Nephrolithiasis
Calyceal
ureterolithiasis
cystolithiasis.

Urolithiasis refers to stones originating
anywhere in the urinary system, including the
kidneys and bladder.
Nephrolithiasis refers to the presence of such
calculi in the kidneys.

Calyceal calculi refers to aggregations in
either the minor or major calyx, parts of the
kidney which pass urine into the ureter.
The condition is called ureterolithiasis when a
calculus or calculi are located in the ureter.
Stones may also form or pass into the bladder,
condition referred to as cystolithiasis.

Calcium-containing stones
Struvite stones
Uric acid stones

Calcium-containing stones
Calcium-containing stones represent about
80% of cases.
These typically contain calcium oxalate either
alone or in combination with calcium
phosphate
The formation of calcium phosphate stones is
associated with conditions such as
hyperparathyroidism and renal tubular acidosis

Struvite stones
• 10-15% of urinary calculi are composed of
struvite (ammonium magnesium phosphate).
• Struvite stones (also known as "infection
stones“ “Staghorn stone”, urease or triple-phosphate
stones), form most often in the
presence of infection by urea-splitting bacteria.

Struvite stones cont…..
The enzyme urease, these organisms metabolize
urea into ammonia and carbon dioxide.
This alkalinizes the urine, resulting in favorable
conditions for the formation of struvite stones.
 Proteus vulgaris
 Klebsiella,
 Enterobacter
 Ureaplasma urealyticum are the most common
organisms

Struvite stones cont…..
These infection stones are commonly observed in
people who have factors which predispose them
to urinary tract infections, such as those with
spinal cord injury and other forms of neurogenic
bladder, ileal conduit urinar diversion,
vesicoureteral reflux, and obstructive uropathies.

Uric acid stones
About 5-10% of all stones are formed from uric
acid.
Uric acid stones may form in association with
conditions that cause hyperuricosuria (an
excessive amount of uric acid in the urine) with
or without high hyperuricemia (an excessive
amount of uric acid in the serum)

Uric acid stones cont…..
People afflicted with xanthinuria often produce
stones composed of xanthine
People with certain rare inborn errors of
metabolism have a propensity to accumulate
crystal-forming substances in their urine. For
example, those with cystinuriaform stones
composed of cystine

ETIOLOGY : PATHOPHYSIOLOGY
Supersaturation of urine
Inhibitors of stone formation
Calcium
others

ETIOLOGY : PATHOPHYSIOLOGY
Supersaturation of urine
When the urine becomes supersaturated (when
the urine solvent contains more solutes than it
can hold in solution) with one or more crystal-forming
substances,
a seed crystal may form through the process of
nucleation.

Heterogeneous nucleation (where there is a
solid surface present on which a crystal can
grow) proceeds more rapidly than
homogeneous nucleation (where a crystal must
grow in liquid medium with no such surface),
because it requires less energy.
Adhering to cells on the surface of a renal
papillae, a seed crystal can grow and aggregate
into an organized mass.

• Depending on the chemical composition of the
crystal, the stone-forming process may proceed
more rapidly when the urine pH is unusually
high or low.

ETIOLOGY : PATHOPHYSIOLOGY CONT.
Inhibitors of stone formation
Normal urine contains chelating agents such as
citrate that inhibit the nucleation, growth, and
aggregation of calcium-containing crystals.

Inhibitors of stone formation:
Other endogenous inhibitors include
calgranulin(an S-100 calcium binding protein),
nephrocalcin (an acidic glycoprotein),
prothrombin F1 peptide, and bikunin (uronic
acid-rich protein).
 When these substances fall below their normal
proportions, stones can form out of an
aggregation of crystals.

Calcium
People who take supplemental calcium have a
higher risk of developing kidney stones
In the Women's Health Initiative,
postmenopausal women who consumed
1,000 milligrams of supplemental calcium and
400 IU of vitamin D per day for 7 years had a
17% higher risk of developing kidney stones
than subjects taking a placebo.

Calcium
This is perhaps related to the role of calcium in
binding ingested oxalate in the gastrointestinal
tract.
Unlike supplemental calcium, high intakes of
dietary calcium do not appear to cause kidney
stones and may actually protect against their
development

Role of dietary animal protein
Animal protein than the body needs, and as the
excess amino acids are broken down and
excreted, the sulfurous amino acids (typically
derived from animal rather than vegetarian
foods) cause calcium to be excreted in the
urine.

• Red meat also contains acids that need to be
excreted and this acidity constitutes another
risk factor for kidney stones
• High intake of animal protein also presents a
greater uric acid load to be excreted by the
kidney. This in turn acidifies the urine,
increasing the risk of uric acid stones.

Other
Water fluoridation may increase the risk of
kidney stone formation.
Ingestion of vitamin C supplements is
associated with an increased incidence of
kidney stones.

Other
Alcohol consumption, binge drinking can lead
to systemic dehydration, which can in turn lead
to the development of kidney stones.
Astronauts seem to show a higher risk of
developing kidney stones during or after space
flights of long duration.

UROLITHIASIS – SITES OF IMPACTION

SIGNS AND SYMPTOMS OF RENAL CALCULI
Obstruction of urine flow through one or both
ureters.
Oliguria (reduced urinary volume) caused by
obstruction of the bladder or urethra by a stone or
rarely, simultaneous obstruction of both ureters by
two separate stones.
Postrenal azotemia and
Hydronephrosis (distension and dilation of the
renal pelvis and calyces

SIGNS AND SYMPTOMS OF RENAL CALCULI…
Flank pain
Costovertebral
tenderness
Cool, moist skin
Pallor,
Diaphoresis
Diagram showing the typical
location of renal colic, from below
the rib cage to just above the pelvis

Frequency and urgency in urination
dysuria,
Chills and fever
Hematuria
Nausea and vomiting

• Hallmark symptoms of
kidney stones include
renal colic, fever,
blood, pus in the urine,
and painful urination.
• Pain, most commonly
felt in the flank, lower
abdomen and groin (a
condition called renal
colic.

Renal colic, which typically comes in waves
lasting 20 to 60 minutes, is caused by peristaltic
contractions of the ureter as it attempts to expel
the stone.
It typically begins in the flank or lower back,
often radiating to the groin or in men, to the
testes.
Renal colic can be associated with nausea and
vomiting.

COMPLICATIONS OF RENAL CALCULI
 Chronic Urinary Tract Infection
 RENAL OBSTRUCTION
 UTERO-VESICAL REFLUX
 HYDRO NEPHROSIS
 PYELO NEPHROSIS
 Acute Renal Failure
 Chronic Renal Failure

DIAGNOSIS OF RENAL CALCULI
Diagnosis of kidney stones is made on the basis
of information obtained from the
History,
Physical examination,
Urinalysis, and
Radiographic studies

DIAGNOSIS OF RENAL CALCULI…
History and physical examination
Clinical diagnosis is usually made on the basis of
the location and severity of the pain, which is
typically colicky in nature (comes and goes in
spasmodic waves).
Physical examination may reveal fever and
tenderness at the costovertebral angle on the
affected side.

 Urinalysis
Provides excellent information about renal function and
condition relative to fluids and Electrolytes
 Urinalysis – know normal (color, odor, consistency &
related teaching)
 Clean catch – know teaching of method and purpose
 Culture and Sensitivity – know teaching
 Urine chemistry pyuria, proteinuria, hematuria, and
wbc’s count.

Urinalysis
pH: Indicates acidity or alkalinity
 Normal range 4.5-8.0
 Normal for urine 6.0 (acid)
Osmolality
 pinpoints fluid balance
 normal = 300-1200 mOsm/kg
 example: as urine Osm. increases. urine
volume decreases (urine more concentrated)

Electrolytes
Not frequently measured
Requires 24-hour specimen
Changes in urinary electrolytes highly
suggestive of renal impairment
Sodium extremely suggestive of type of acute
renal failure
<20 mEq/L = pre-renal
Normal or high >20 mEq/L

Creatinine Clearance test
A direct measurement of glomerular
filtration rate
Best indicator of overall kidney function
Clearance expressed in ml/min
 Normal: male 90-139mL/min
female 80-125mL/min
Measured by completing a 24 hr urine with
corresponding blood test.

Serum Creatinine
 By-product of muscle metabolism
 Appears in serum in amts. proportional to body
muscle mass
 Fluctuates little – excreted entirely by kidneys
 Normal about 0.7-1.5 mg/dL
• ↓ elderly and with low muscle mass
• Creatinine: >1.5 (>50% loss), >4.8 (75% loss)
and >10 (90% loss)

• BUN/Creatinine Ratio
Normal ratio = between 6:1 to 20:1
When both BUN and [Cr] levels increase at same
rate (ratio remains normal) – suggestive of renal
dysfunction
When BUN rises faster then [Cr] (ratio increased)
suggestive of dehydration, hypo perfusion,
protein catabolism, GI bleeds

DIAGNOSTICS: KUB
KUB (kidney, ureters,
bladder)
No preparation
No contrast
Shows:
• Stones
• Strictures
• Calcifications
• Obstructions

DIAGNOSTICS: INTRAVENOUS PYELOGRAM
IVP/ IVU
 Series of x-ray after
dye injection
 To measure size,
shape, etc of kidneys
 Detect obstructions
 Assess for masses
Client preparation and
teaching important
nursing function

DIAGNOSTICS: RENAL ARTERIOGRAM
Angiogram
 Inject contrast into
renal artery via
femoral catheter
 Visualize renal
vascular
abnormalities
 Same prep as IVP
 Monitor for bleeding
after procedure

DIAGNOSTICS: MRI: ARTERIAL
 New and thought to
be more useful than
other artery/venous
grams
 Very expensive

DIAGNOSTICS: CYSTOGRAM
Cystogram
 Contrast into
bladder
 Evaluate bladder
and vesicoureteral
reflux

DIAGNOSTICS: RETROGRADE PYELOGRAM
RETROGRADE
PYELOGRAM
 x-ray after contrast
into kidneys.
 Done by
cystoscope and
urethral catheters
placed into renal
pelvis

DIAGNOSTICS OF RENAL CALCULI
• Ultrasound – differentiates between fluid and
mass, notes obstructions (no dye)
• Cystoscopy – direct visualization of bladder, can
be used for diagnosis or treatment (no dye)
• Biopsy – used for definitive diagnosis (no dye)

MANAGEMENT OF RENAL CALCULI
• Medical management
• Surgical management
• Nursing management

MANAGEMENT OF RENAL CALCULI
Medical management
• 85% of the time, it is possible to spontaneously
pass a kidney stone with urination
• Stones larger than 6 millimeters will almost
always require some form of intervention,
however.
• Assuming there is no high-grade obstruction or
associated infection in the urinary tract, and
symptoms are relatively mild, various non-surgical
measures can be used to encourage the
passage of a stone.

MANAGEMENT OF RENAL CALCULI…
Analgesia
 requires intravenous administration of NSAIDs
or opioids in an emergency department setting.
 Intravenous acetaminophen appears to be
effective.

Alpha adrenergic blockers
 as tamsulosin (Flomax) may increase the
spontaneous passage of the stone by 30%.

Diuretics (dietary and medicinal)
 One of the recognized medical therapies for
prevention of stones is the thiazide diuretics.
 Thiazides inhibit the formation of calcium-containing
stones by reducing urinary calcium
excretion, an effect independent of their
diuretic properties.

Urine alkalinization
 The mainstay for medical management of uric
acid stones is alkalinization (increasing the
pH) of the urine. Uric acid stones are among
the few types amenable to dissolution therapy,
referred to as chemolysis.
 Acetazolamide (Diamox) is a medication that
alkalinizes the urine.

Allopurinol
 For people with hyperuricosuria and calcium
stones, Allopurinol (Zyloprim) is one of the
few treatments.

 Allopurinol interferes with the production of
uric acid in the liver.
 The drug is also used in patients with gout or
hyperuricemia (high serum uric acid levels).
 Dosage is adjusted to maintain a reduced
urinary excretion of uric acid.
 Serum uric acid level at or below
6 milligrams/100 mL) is often a therapeutic
goal for patients with gout or hyperuricemia.

 Diet
 for the calcium stones ( acid ash with limited
intake of calcium and milk products
 for oxalates stones ( alkaline ash with
limited intake of foods high in oxalates
 for uric acid stones ( alkaline ash with
limited intake of foods high in purine
 A high fluid of 3000ml per day after episode
of urolithiasis to produce urine output of 2L
per day
 Intravenous therapy (fluid replacement )
 Activity as tolerated

Surgical management
Invasive management
Non invasive managements

Non invasive managements
 Electro hydraulic lithotripsy
 Ultrasonic lithotripsy
 Laser impulse (holmium laser)
 Extra corporeal shock wave lithotripsy

 Electro hydraulic lithotripsy

 Ultrasonic lithotripsy
 Laser impulse
 Extra corporeal shock wave lithotripsy
Extracorporeal shock wave lithotripsy (ESWL)
involves the use of a lithotriptor machine to
deliver externally-applied, focused, high-intensity
pulses of ultrasonic energy to cause
fragmentation of a stone over a period of
around 30–60 minutes.

Invasive managements
 Percutaneous nephrostolithotomy
 Cystolithophaxy
 Pyelolithotomy (incision into renal pelvis)
 Cystotomy(bladder calculi)
 Nephrotomy
 Ureteroscopic surgery

Nursing management
 Maintain proper nutrition
 Force fluids 3 Liter / day
 Assess renal status
 Monitor and record vital signs, urine output,
input and output, daily weight, specific gravity,
lab studies, and urine pH.
 Administer medication as prescribed
 Allay the patient anxiety

 Continue straining urine and giving warm baths
and warm soaks to flanks to reduce pain
Instruct on home care
Increase fluid intake during hot
Weather, illness, and exercise
Void when urge is felt
Test urine PH
Increase fluid at night and void frequently

NURSING DIAGNOSIS
• Acute pain related to irritation of stone and
inadequate pain control or comfort as
manifested by complaints of pain, facial
grimicing, restlessness.
• Ineffective therapeutic regimen management
related to lack of knowledge about
prevention, recurrence, diet, fluid
requirement as manifested by questions that
indicate lack of knowledge.

Renal calculli Veeresh VG RN

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