This document summarizes a lecture on metabolic stone work-up with a focus on 24-hour urine evaluation. It discusses guidelines for metabolic testing, specific abnormalities found on 24-hour urine tests like hypercalciuria and hyperoxaluria, and how to interpret results and guide treatment. Case examples from a litholink database are also reviewed to demonstrate real-world applications of 24-hour urine testing and metabolic stone work-up.
This document discusses nephrolithiasis (kidney stones). It begins with a case of a 78-year-old man who presented with gross hematuria and was found to have a kidney stone. The stone was removed, and analysis showed it was calcium oxalate. The document then reviews epidemiology, natural history, stone formation process, clinical presentation, evaluation, etiologies including calcium, uric acid, struvite and cystine stones, and treatment options including medical management and urological interventions.
This document provides information on evaluating and managing patients with low-risk kidney stones. It discusses evaluating a patient's risk factors, performing metabolic testing including blood and urine tests, identifying any anatomical abnormalities, and analyzing stone composition. For treatment, it recommends increased fluid intake, dietary modifications like reducing protein and sodium, and medical therapy tailored to the underlying metabolic abnormality causing stone formation. The goal is to reduce stone recurrence through lifestyle and medical interventions.
Hypercalcemia- Approach to the Diagnosis Palak Choksi.pptxMahdisalimi8
This document discusses the approach to diagnosing and treating hypercalcemia. It reviews calcium metabolism and the role of parathyroid hormone. Symptoms of hypercalcemia are described for the neurological, gastrointestinal, skeletal, renal, and cardiovascular systems. Causes of hypercalcemia include primary hyperparathyroidism, malignancy, granulomatous diseases, vitamin D toxicity, and certain drugs. The diagnostic approach involves measuring PTH, phosphorus, vitamin D, and PTH-rP levels. Treatment options aim to increase calcium excretion or decrease bone resorption/absorption and include IV fluids, calcitonin, bisphosphonates, glucocorticoids, loop diuretics, and dial
Hypercalcemia- Approach to the Diagnosis Palak Choksi.pptxHedaiaMustafa
This document reviews the approach to diagnosis and treatment of hypercalcemia. It begins by describing calcium metabolism and the role of parathyroid hormone and vitamin D. Symptoms of hypercalcemia are then outlined affecting the central nervous system, gastrointestinal tract, skeleton, kidneys, and cardiovascular system. Causes of hypercalcemia including primary hyperparathyroidism, malignancy, granulomatous diseases, and medications are discussed. The document concludes by outlining treatments to reduce calcium levels including intravenous fluids, calcitonin, bisphosphonates, glucocorticoids, loop diuretics, and dialysis.
This document provides an overview of fluid therapy and electrolyte disturbances. It discusses the basic physiology of body fluids, including total body water content and distribution. It then covers various electrolyte abnormalities like hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypomagnesemia, and hypermagnesemia. It also addresses acid-base balance disturbances and different intravenous fluid options for fluid resuscitation and maintenance.
The document provides information about fluid and electrolyte balance. It discusses the distribution and composition of body fluids, normal fluid exchange, and electrolyte disturbances including hypovolemia, hypervolemia, hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypomagnesemia, and hypermagnesemia. It also covers parenteral fluid therapy including intravenous fluids, methods of calculating fluid transfusion rates, and management of fluid balance in surgical patients.
This document provides an overview of urinalysis including its indications, methods of collection and preservation, physical and chemical examination, and microscopic examination. A urinalysis is a common medical test that can screen for and diagnose diseases of the kidneys, urinary tract, and other bodily systems by analyzing the physical characteristics, chemical components, and cellular contents of a urine sample. Key aspects covered include normal versus abnormal physical findings, chemical testing using dipsticks, and microscopic evaluation of urine sediment.
The document discusses disorders of calcium metabolism. It presents two clinical scenarios: a 59-year-old woman with hypercalcemia found on labs during a routine visit, and a 9-year-old boy admitted to the emergency department with acute pancreatitis and hypocalcemia after falling off his bike. It then outlines topics like the different forms of calcium, calcium homeostasis, regulation of calcium metabolism by parathyroid hormone, vitamin D, and calcitonin, and disorders like hypercalcemia, hypocalcemia, hyperparathyroidism, and hypoparathyroidism.
This document discusses nephrolithiasis (kidney stones). It begins with a case of a 78-year-old man who presented with gross hematuria and was found to have a kidney stone. The stone was removed, and analysis showed it was calcium oxalate. The document then reviews epidemiology, natural history, stone formation process, clinical presentation, evaluation, etiologies including calcium, uric acid, struvite and cystine stones, and treatment options including medical management and urological interventions.
This document provides information on evaluating and managing patients with low-risk kidney stones. It discusses evaluating a patient's risk factors, performing metabolic testing including blood and urine tests, identifying any anatomical abnormalities, and analyzing stone composition. For treatment, it recommends increased fluid intake, dietary modifications like reducing protein and sodium, and medical therapy tailored to the underlying metabolic abnormality causing stone formation. The goal is to reduce stone recurrence through lifestyle and medical interventions.
Hypercalcemia- Approach to the Diagnosis Palak Choksi.pptxMahdisalimi8
This document discusses the approach to diagnosing and treating hypercalcemia. It reviews calcium metabolism and the role of parathyroid hormone. Symptoms of hypercalcemia are described for the neurological, gastrointestinal, skeletal, renal, and cardiovascular systems. Causes of hypercalcemia include primary hyperparathyroidism, malignancy, granulomatous diseases, vitamin D toxicity, and certain drugs. The diagnostic approach involves measuring PTH, phosphorus, vitamin D, and PTH-rP levels. Treatment options aim to increase calcium excretion or decrease bone resorption/absorption and include IV fluids, calcitonin, bisphosphonates, glucocorticoids, loop diuretics, and dial
Hypercalcemia- Approach to the Diagnosis Palak Choksi.pptxHedaiaMustafa
This document reviews the approach to diagnosis and treatment of hypercalcemia. It begins by describing calcium metabolism and the role of parathyroid hormone and vitamin D. Symptoms of hypercalcemia are then outlined affecting the central nervous system, gastrointestinal tract, skeleton, kidneys, and cardiovascular system. Causes of hypercalcemia including primary hyperparathyroidism, malignancy, granulomatous diseases, and medications are discussed. The document concludes by outlining treatments to reduce calcium levels including intravenous fluids, calcitonin, bisphosphonates, glucocorticoids, loop diuretics, and dialysis.
This document provides an overview of fluid therapy and electrolyte disturbances. It discusses the basic physiology of body fluids, including total body water content and distribution. It then covers various electrolyte abnormalities like hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypomagnesemia, and hypermagnesemia. It also addresses acid-base balance disturbances and different intravenous fluid options for fluid resuscitation and maintenance.
The document provides information about fluid and electrolyte balance. It discusses the distribution and composition of body fluids, normal fluid exchange, and electrolyte disturbances including hypovolemia, hypervolemia, hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypomagnesemia, and hypermagnesemia. It also covers parenteral fluid therapy including intravenous fluids, methods of calculating fluid transfusion rates, and management of fluid balance in surgical patients.
This document provides an overview of urinalysis including its indications, methods of collection and preservation, physical and chemical examination, and microscopic examination. A urinalysis is a common medical test that can screen for and diagnose diseases of the kidneys, urinary tract, and other bodily systems by analyzing the physical characteristics, chemical components, and cellular contents of a urine sample. Key aspects covered include normal versus abnormal physical findings, chemical testing using dipsticks, and microscopic evaluation of urine sediment.
The document discusses disorders of calcium metabolism. It presents two clinical scenarios: a 59-year-old woman with hypercalcemia found on labs during a routine visit, and a 9-year-old boy admitted to the emergency department with acute pancreatitis and hypocalcemia after falling off his bike. It then outlines topics like the different forms of calcium, calcium homeostasis, regulation of calcium metabolism by parathyroid hormone, vitamin D, and calcitonin, and disorders like hypercalcemia, hypocalcemia, hyperparathyroidism, and hypoparathyroidism.
Fluid and Electrolyte Management in Surgery.pptOlofin Kayode
This document provides an outline and introduction to fluid and electrolyte management in surgery. It discusses the normal distribution and balance of body water and electrolytes like sodium, potassium, calcium and magnesium. It describes various fluid and electrolyte disorders that can occur including volume disturbances, concentration disturbances and composition disturbances. It covers causes, clinical features and treatment of conditions like hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia and acid-base imbalances. The document emphasizes the importance of fluid and electrolyte management in the perioperative care of surgical patients.
This document provides an overview of fluid and electrolyte physiology and therapy. It discusses the distribution and composition of body water, normal fluid exchange, and electrolyte disturbances including hypovolemia, hypervolemia, hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypomagnesemia, and hypermagnesemia. It also covers parenteral fluid therapy including intravenous fluids, methods of calculating infusion rates, and fluid management in surgical patients.
1. Acute kidney injury (AKI) is the sudden deterioration of renal function that can range from mild to severe. It is a global problem associated with high morbidity and mortality.
2. AKI is classified based on location of injury (pre-renal, intrinsic, post-renal), urine output, and severity of decline in renal function. Common causes include sepsis, nephrotoxins, and decreased renal perfusion.
3. Management involves treating the underlying cause, maintaining fluid/electrolyte balance, and potentially renal replacement therapy for complications like fluid overload or severe electrolyte imbalances. Outcomes depend on factors like age, cause, and need for dialysis.
This document discusses potassium balance and disorders of potassium levels. It begins by outlining the vital functions of potassium ions in the body and factors that influence potassium balance. It then details the causes, clinical features, diagnostic approaches, and therapies for hypokalemia and hyperkalemia. For hypokalemia, it discusses etiologies such as decreased intake, increased losses, and transcellular shifts. It outlines clinical consequences, diagnostic testing, and management including oral or IV potassium replacement. For hyperkalemia it similarly discusses etiologies, clinical consequences, and emergency, temporizing, and chelating therapy approaches.
Urine reflects the overall metabolic and kidney functions of the body. It can be used for diagnosis of structural and functional disorders of the urinary system as well as for monitoring diseases and detecting systemic disease processes. Urine can be analyzed for various properties including pH, protein, ketone bodies, blood, and bile salts and bile pigments to provide information about the patient's condition. Various tests exist for qualitative and quantitative analysis of these urine components.
This document provides a classification and overview of the diagnostic criteria for nephrolithiasis (kidney stones). It classifies the causes of nephrolithiasis into calcium based calculi, uric acid based calculi, cystinuria, infective (struvite) calculi, and low urine volumes. For each category, it describes the underlying metabolic abnormalities and risk factors that can lead to stone formation, such as hypercalciuria, hyperoxaluria, hypocitraturia, and urinary tract infections. It also discusses specific conditions like renal tubular acidosis and cystinuria that are associated with stone formation.
Hypercalcemia is commonly caused by primary hyperparathyroidism or malignancy. It can be life-threatening in severe cases. Diagnosis involves measuring serum calcium, PTH, and assessing for underlying causes. Treatment depends on the underlying condition but may involve surgery for hyperparathyroidism or addressing the malignancy. Complications can impact the kidneys, GI tract, cardiovascular system, muscles and bones.
This document discusses the normal and abnormal constituents found in urine. It provides information on the typical composition and output of urine and how urine can be used to diagnose kidney and urinary tract abnormalities as well as systemic diseases. Common normal constituents of urine are listed along with how various substances may be elevated or reduced depending on conditions like diabetes or kidney dysfunction. The document also covers urine analysis techniques including physical, chemical, and microscopic examination and how to properly collect and preserve urine samples.
This document discusses the normal and abnormal constituents found in urine. It provides information on the typical composition and output of urine and how urine can be used to diagnose kidney and urinary tract abnormalities as well as systemic diseases. Common normal constituents of urine are listed along with how various substances may be elevated or reduced depending on conditions like diabetes or kidney dysfunction. The document also covers urine analysis techniques including physical, chemical, and microscopic examination and how to properly collect and preserve urine samples.
- The document discusses evaluation and management of hypercalcemia. The most common causes are primary hyperparathyroidism and malignancy. Diagnostic workup includes serum calcium, PTH, and history of medications. Hypercalcemic crisis is a medical emergency requiring aggressive intravenous hydration and diuretics, calcitonin, bisphosphonates, or dialysis. Optimal treatment involves identifying and addressing the underlying cause of hypercalcemia.
This document discusses the composition and functions of the various body fluids. It begins by explaining that body fluids help maintain homeostasis, transport nutrients and waste, and comprise 60-80% of body weight depending on age and body type. The two main fluid compartments are intracellular fluid within cells and extracellular fluid outside cells. Extracellular fluid further includes interstitial fluid between cells and plasma in blood. The document then examines the distribution and movement of fluids, factors that influence fluid balance, and specialized fluids like urine, blood, and cerebrospinal fluid. It provides details on urine composition, collection and analysis.
This document discusses the examination of urine, including its typical composition, indications for urinalysis, and procedures for collecting and analyzing urine samples. Key points covered include the various substances measured in a urinalysis and their clinical significance, such as glucose, proteins, ketones, and cells. Methods for physical examination of urine properties like volume, color, odor and chemical tests are outlined. Preservation techniques and sources of contamination are also reviewed.
Kidney stones form when substances in urine become highly concentrated and solidify in the kidneys. They cause pain and other symptoms. Risk factors include family history, diet high in animal protein or sodium, and medical conditions. Diagnosis involves medical history, urine and blood tests, and imaging. Treatment includes pain relief, increased fluid intake, dietary changes such as limiting oxalate or sodium, and medications like thiazide diuretics or potassium citrate depending on the stone type. Follow up involves periodic urine and blood tests and imaging to monitor stone recurrence and treatment effectiveness.
This document provides information on renal tubular physiology and various renal tubulopathies. It discusses the functions of the proximal tubule, loop of Henle, distal tubule, and collecting duct. Specific tubulopathies summarized include cystinuria, X-linked hypophosphatemic rickets, proximal renal tubular acidosis, Fanconi syndrome, cystinosis, Bartter syndrome, pseudo-Bartter syndrome, and Gitelman syndrome. The summaries focus on the underlying defects, characteristic clinical features, biochemical abnormalities, and treatments for each condition.
This document discusses calcium and phosphate metabolism. It covers:
1. Calcium is found mainly in bones, soft tissues, and extracellular fluid. The majority is stored in bones.
2. Calcium levels are regulated by parathyroid hormone, vitamin D, and calcitonin which act on bones, kidneys and intestines to increase or decrease calcium absorption and resorption.
3. Hypercalcemia can be caused by primary hyperparathyroidism, cancer, multiple myeloma or excessive vitamin D intake. Hypocalcemia results from vitamin D deficiency or renal failure and causes symptoms like muscle spasms.
This document discusses metabolic evaluation and prevention strategies for kidney stone disease. It recommends stone analysis for all patients to classify them as high or low risk for recurrence. For high risk patients, specific metabolic evaluation includes measuring stone-related substances like calcium, oxalate, and citrate in 24-hour urine samples. Based on stone composition and test results, treatment targets the underlying metabolic abnormality to reduce recurrence rates by up to 46%. Proper stone analysis, metabolic workup, and preventive measures can minimize stone formation and risk of chronic kidney disease.
1. Urinalysis provides important information for diagnosing and managing various renal and metabolic conditions. It involves examining the physical and chemical properties of a urine sample, as well as inspecting it microscopically.
2. The timing and method of urine collection depends on the tests being performed. A first morning midstream sample is preferred for routine analysis but random or postprandial samples are also used.
3. Normal urine has characteristics such as a yellow color, slight acidity, and absence of protein, glucose, and ketones. Abnormal findings provide clues to diseases like urinary tract infections or kidney disorders.
This document discusses hypercalcemia, which is defined as a serum calcium level above 10.5 mg/dl. It outlines the various causes of hypercalcemia including primary hyperparathyroidism, certain cancers, granulomatous diseases, and certain medications. The clinical presentation of hypercalcemia can include symptoms affecting the stones, bones, abdominal organs, psyche, and other nonspecific symptoms. Diagnosis involves blood tests to measure calcium and PTH levels along with imaging tests. Treatment focuses on rehydration, bisphosphonates, glucocorticoids, calcitonin, surgery, and dialysis depending on the severity and underlying cause of the hypercalcemia.
This document discusses renal tubular acidosis (RTA). It describes the different types of RTA (proximal, distal, and hyperkalemic) and explains their pathophysiology. For each type it covers the mechanisms of impaired acidification, clinical manifestations like acidosis and electrolyte abnormalities, and treatments involving bicarbonate replacement. Key points are that proximal RTA involves impaired bicarbonate reabsorption, distal RTA impaired hydrogen ion secretion, and hyperkalemic RTA impaired aldosterone effects. Diagnosis involves assessing the nature of the metabolic acidosis through blood and urine tests.
Neonatalology
Electrolyte disturbance
Most common in neonate
And need more attention and management
We do management
Causes
Risk factors for this problem so its common and need early treatment for the front of the front door and the front door is locked in the door and the front door is locked and the front
Fluid and Electrolyte Management in Surgery.pptOlofin Kayode
This document provides an outline and introduction to fluid and electrolyte management in surgery. It discusses the normal distribution and balance of body water and electrolytes like sodium, potassium, calcium and magnesium. It describes various fluid and electrolyte disorders that can occur including volume disturbances, concentration disturbances and composition disturbances. It covers causes, clinical features and treatment of conditions like hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia and acid-base imbalances. The document emphasizes the importance of fluid and electrolyte management in the perioperative care of surgical patients.
This document provides an overview of fluid and electrolyte physiology and therapy. It discusses the distribution and composition of body water, normal fluid exchange, and electrolyte disturbances including hypovolemia, hypervolemia, hyponatremia, hypernatremia, hypokalemia, hyperkalemia, hypocalcemia, hypercalcemia, hypomagnesemia, and hypermagnesemia. It also covers parenteral fluid therapy including intravenous fluids, methods of calculating infusion rates, and fluid management in surgical patients.
1. Acute kidney injury (AKI) is the sudden deterioration of renal function that can range from mild to severe. It is a global problem associated with high morbidity and mortality.
2. AKI is classified based on location of injury (pre-renal, intrinsic, post-renal), urine output, and severity of decline in renal function. Common causes include sepsis, nephrotoxins, and decreased renal perfusion.
3. Management involves treating the underlying cause, maintaining fluid/electrolyte balance, and potentially renal replacement therapy for complications like fluid overload or severe electrolyte imbalances. Outcomes depend on factors like age, cause, and need for dialysis.
This document discusses potassium balance and disorders of potassium levels. It begins by outlining the vital functions of potassium ions in the body and factors that influence potassium balance. It then details the causes, clinical features, diagnostic approaches, and therapies for hypokalemia and hyperkalemia. For hypokalemia, it discusses etiologies such as decreased intake, increased losses, and transcellular shifts. It outlines clinical consequences, diagnostic testing, and management including oral or IV potassium replacement. For hyperkalemia it similarly discusses etiologies, clinical consequences, and emergency, temporizing, and chelating therapy approaches.
Urine reflects the overall metabolic and kidney functions of the body. It can be used for diagnosis of structural and functional disorders of the urinary system as well as for monitoring diseases and detecting systemic disease processes. Urine can be analyzed for various properties including pH, protein, ketone bodies, blood, and bile salts and bile pigments to provide information about the patient's condition. Various tests exist for qualitative and quantitative analysis of these urine components.
This document provides a classification and overview of the diagnostic criteria for nephrolithiasis (kidney stones). It classifies the causes of nephrolithiasis into calcium based calculi, uric acid based calculi, cystinuria, infective (struvite) calculi, and low urine volumes. For each category, it describes the underlying metabolic abnormalities and risk factors that can lead to stone formation, such as hypercalciuria, hyperoxaluria, hypocitraturia, and urinary tract infections. It also discusses specific conditions like renal tubular acidosis and cystinuria that are associated with stone formation.
Hypercalcemia is commonly caused by primary hyperparathyroidism or malignancy. It can be life-threatening in severe cases. Diagnosis involves measuring serum calcium, PTH, and assessing for underlying causes. Treatment depends on the underlying condition but may involve surgery for hyperparathyroidism or addressing the malignancy. Complications can impact the kidneys, GI tract, cardiovascular system, muscles and bones.
This document discusses the normal and abnormal constituents found in urine. It provides information on the typical composition and output of urine and how urine can be used to diagnose kidney and urinary tract abnormalities as well as systemic diseases. Common normal constituents of urine are listed along with how various substances may be elevated or reduced depending on conditions like diabetes or kidney dysfunction. The document also covers urine analysis techniques including physical, chemical, and microscopic examination and how to properly collect and preserve urine samples.
This document discusses the normal and abnormal constituents found in urine. It provides information on the typical composition and output of urine and how urine can be used to diagnose kidney and urinary tract abnormalities as well as systemic diseases. Common normal constituents of urine are listed along with how various substances may be elevated or reduced depending on conditions like diabetes or kidney dysfunction. The document also covers urine analysis techniques including physical, chemical, and microscopic examination and how to properly collect and preserve urine samples.
- The document discusses evaluation and management of hypercalcemia. The most common causes are primary hyperparathyroidism and malignancy. Diagnostic workup includes serum calcium, PTH, and history of medications. Hypercalcemic crisis is a medical emergency requiring aggressive intravenous hydration and diuretics, calcitonin, bisphosphonates, or dialysis. Optimal treatment involves identifying and addressing the underlying cause of hypercalcemia.
This document discusses the composition and functions of the various body fluids. It begins by explaining that body fluids help maintain homeostasis, transport nutrients and waste, and comprise 60-80% of body weight depending on age and body type. The two main fluid compartments are intracellular fluid within cells and extracellular fluid outside cells. Extracellular fluid further includes interstitial fluid between cells and plasma in blood. The document then examines the distribution and movement of fluids, factors that influence fluid balance, and specialized fluids like urine, blood, and cerebrospinal fluid. It provides details on urine composition, collection and analysis.
This document discusses the examination of urine, including its typical composition, indications for urinalysis, and procedures for collecting and analyzing urine samples. Key points covered include the various substances measured in a urinalysis and their clinical significance, such as glucose, proteins, ketones, and cells. Methods for physical examination of urine properties like volume, color, odor and chemical tests are outlined. Preservation techniques and sources of contamination are also reviewed.
Kidney stones form when substances in urine become highly concentrated and solidify in the kidneys. They cause pain and other symptoms. Risk factors include family history, diet high in animal protein or sodium, and medical conditions. Diagnosis involves medical history, urine and blood tests, and imaging. Treatment includes pain relief, increased fluid intake, dietary changes such as limiting oxalate or sodium, and medications like thiazide diuretics or potassium citrate depending on the stone type. Follow up involves periodic urine and blood tests and imaging to monitor stone recurrence and treatment effectiveness.
This document provides information on renal tubular physiology and various renal tubulopathies. It discusses the functions of the proximal tubule, loop of Henle, distal tubule, and collecting duct. Specific tubulopathies summarized include cystinuria, X-linked hypophosphatemic rickets, proximal renal tubular acidosis, Fanconi syndrome, cystinosis, Bartter syndrome, pseudo-Bartter syndrome, and Gitelman syndrome. The summaries focus on the underlying defects, characteristic clinical features, biochemical abnormalities, and treatments for each condition.
This document discusses calcium and phosphate metabolism. It covers:
1. Calcium is found mainly in bones, soft tissues, and extracellular fluid. The majority is stored in bones.
2. Calcium levels are regulated by parathyroid hormone, vitamin D, and calcitonin which act on bones, kidneys and intestines to increase or decrease calcium absorption and resorption.
3. Hypercalcemia can be caused by primary hyperparathyroidism, cancer, multiple myeloma or excessive vitamin D intake. Hypocalcemia results from vitamin D deficiency or renal failure and causes symptoms like muscle spasms.
This document discusses metabolic evaluation and prevention strategies for kidney stone disease. It recommends stone analysis for all patients to classify them as high or low risk for recurrence. For high risk patients, specific metabolic evaluation includes measuring stone-related substances like calcium, oxalate, and citrate in 24-hour urine samples. Based on stone composition and test results, treatment targets the underlying metabolic abnormality to reduce recurrence rates by up to 46%. Proper stone analysis, metabolic workup, and preventive measures can minimize stone formation and risk of chronic kidney disease.
1. Urinalysis provides important information for diagnosing and managing various renal and metabolic conditions. It involves examining the physical and chemical properties of a urine sample, as well as inspecting it microscopically.
2. The timing and method of urine collection depends on the tests being performed. A first morning midstream sample is preferred for routine analysis but random or postprandial samples are also used.
3. Normal urine has characteristics such as a yellow color, slight acidity, and absence of protein, glucose, and ketones. Abnormal findings provide clues to diseases like urinary tract infections or kidney disorders.
This document discusses hypercalcemia, which is defined as a serum calcium level above 10.5 mg/dl. It outlines the various causes of hypercalcemia including primary hyperparathyroidism, certain cancers, granulomatous diseases, and certain medications. The clinical presentation of hypercalcemia can include symptoms affecting the stones, bones, abdominal organs, psyche, and other nonspecific symptoms. Diagnosis involves blood tests to measure calcium and PTH levels along with imaging tests. Treatment focuses on rehydration, bisphosphonates, glucocorticoids, calcitonin, surgery, and dialysis depending on the severity and underlying cause of the hypercalcemia.
This document discusses renal tubular acidosis (RTA). It describes the different types of RTA (proximal, distal, and hyperkalemic) and explains their pathophysiology. For each type it covers the mechanisms of impaired acidification, clinical manifestations like acidosis and electrolyte abnormalities, and treatments involving bicarbonate replacement. Key points are that proximal RTA involves impaired bicarbonate reabsorption, distal RTA impaired hydrogen ion secretion, and hyperkalemic RTA impaired aldosterone effects. Diagnosis involves assessing the nature of the metabolic acidosis through blood and urine tests.
Neonatalology
Electrolyte disturbance
Most common in neonate
And need more attention and management
We do management
Causes
Risk factors for this problem so its common and need early treatment for the front of the front door and the front door is locked in the door and the front door is locked and the front
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UCSF-litholink.pdf
1. Metabolic Stone Work-Up: Focus on
the 24-hr Urine Evaluation
Kevan M. Sternberg
Associate Professor, Division of Urology
University of Vermont
@kevanms42
2. • Nothing to disclose
• Content from:
o AUA Core Curriculum
o AUA Guidelines
o Dr. John Asplin Stone Camp
Disclosures
2
3. • Background
• Guidelines and basics
• Specific diagnoses/metabolic abnormalities
• Litholink case- reviews
Objectives
3
4. • Prevalence= 1:11 (8.8%) adults in the U.S
o Likely underestimated
• Stone disease is increasing
o With children as well, particularly adolescents
• Resulting increase cost associated with nephrolithiasis
o $ 4.5 Billion
• Gender gap narrowing
Background
4
5. • Chronic, systemic condition w/multiple contributing
factors:
o Genetics
o Diet
o Lifestyle
o Medical comorbidities
• Associated systemic conditions:
o Obesity
o Metabolic syndrome
o Type 2 DM
o HTN
Nephrolithiasis
5
6. • For all newly diagnosed stone patients
o Detailed medical history
• medications
o Dietary history
o Serum chemistries
• Electrolytes, calcium, creatinine, uric acid
o Obtain PTH if high/ high normal serum calcium
Metabolic Testing- AUA Guidelines
6
7. Medications Mechanism
Carbonic anhydrase inhibitors
(topiramate, acetazolimide, zonisamide)
Metabolic Acidosis
Vitamin C Hyperoxaluria
Probenecid Hyperuricosuria
Ca/Vit D Hypercalciuria
Triamterene, Guafenacin, Ephedrine,
Indinivir
Stone from med crystalization
Pertinent Medications
7
8. • Urinalysis/ Urine culture
o Urine pH, signs of infection
o Urease producing bacteria:
• Gram –; Proteus mirabilis, Klebsiella Pneumonae, Pseudomanas
• Gram +; Corynebacterium, Staphylococcus aureus,
Staphylococcus epidermidis
• Obtain a stone composition at least once
o Uric acid, cystine, calcium phosphate, struvite- important in
identifying etiology
• Review imaging if available
o Stone burden and distribution
8
9. • High risk
o Family history
o Malabsorptive bowel disease
o Bowel surgery- resection, bypass
o Gout
o Met-S
o Osteoporosis
o Young age
• Recurrent
• Interested first timers
Who requires metabolic testing/ 24-h Urine?
9
10. • Goal- To help guide medical and dietary intervention to
decrease risk of stone recurrence
• 1 vs. 2 tests- no clear answer
• Patients should be instructed to do what they were doing
at the time the stone was formed
(diet/medication/supplement/etc.)
• Collections likely differ when done at home vs. work.
o Most do their test on a weekend/Sunday for convenience.
o May be best to have 2 tests/patient- one home and on work?
24-hr Urine Testing
10
12. • Volume
o > 2.5L
• Calcium
o < 200 mg/day
• Oxalate
o < 40 mg/day
• Uric acid
o < 800 for men, < 750 for women
• pH
o 5.8-6.2
• Citrate
o > 450 for men, > 550 for women
24-h Urine Parameters
12
13. • Creatinine- accuracy of collection
o Weight-base values for men (20-25 mg/kg) and
o Women (15-20 mg/kg)
• Sodium
• Potassium
• Protein parameters:
o PCR (protein catabolic rate)
o UUN (reflects total protein intake)
o Sulfate (sulfa containing Amino Acids/net acid load =
methionine)
• Super saturation indices
o monitor effectiveness of tx
13
15. • >4 mg/kg/day or > 200 mg/day (ca, Na restricted diet)
• Improper ca handling (GI tract, kidney, bone)
• Increases risk of bone disease and osteoporosis
o Bone mineral density is important
• Absorptive- increased absorption from intestine
o PTH normal or suppressed
• Renal- impaired reabsorption from prox and distal
tubules
o PTH increased and 1,25 vit D synthesis à increased intestinal
ca absorption and bone resorption
• Resorptive- primary hyperparathyroidism
Hypercalciuria
15
16. • Main players- Calcium, Sodium, and animal protein.
• Stone formers- more Na sensitive
• Na goal should be 120
• When patients are instructed to drink more fluids, often
there is a tendency to increase salt intake à
hypercalciuria.
• Sugar and caffeine can also affect calcium output.
• Protein loading/protein shakes à significant
hypercalciuria
Hypercalciuria and Diet
16
17. • Consider primary HPT even if high normal PTH
• If borderline results, have blood work done fasting-
accounts for the diurnal variation.
• Draw Ca at same time as PTH
• Take patient off of thiazide (~2 weeks) if working up
Primary HPT
o Thiazides can cause hypercalcemia
Hypercalcemia
17
18. • High serum Ca, low/suppressed PTH à
o Consider malignancy (PTHrp, bony metastasis),
o Granulomatous disease-
• sarcoid (extrarenal source of 1,25 Vit D from alveolar
macrophages/granulomas)
• Tuberculosis
• Silicosis
o thiazides, Ca supplements
o Thyrotosicosis
o Vit D intoxication
o 24-hydroxylase deficiency (can’t metabolize 1-25 Vit D resulting
in hypercalcemia)
Additional Hypercalcemia Causes
18
19. • If elevated serum Ca and low PTH (its not HPT)- check
1-25 Vit D level
• Primary HPT can occur in the setting of normocalcemia
• If PTH elevated and normocalcemic-
o check renal function (PTH increases in CKD) and
o vit D levels (25 OH) -make sure no deficiency (>30) also can
increase PTH
19
20. • Don’t start a thiazide if any level of hypercalcemia
• Thiazides great for hypercalciuria + HTN
o Typical doses of HCTZ or the thiazide component in combo pills
are typically too low to impact Ca excretion.
o Chlorthalidone and Indapamide
• Greater % fall in urine ca
Thiazide Diuretics
20
21. • *** Be mindful of hypokalemic effects of thiazides. Can
place on K immediately or follow BMP.
o Hypokalemia can lead to hypocitraturia
• Hyperglycemia (rare) affecting diabetic management
• Gout
o Increased uric acid
• ED
Thiazide Side Effects
21
22. • >700 mg/day
• Can lead to calcium oxalate stone formation
o Heterogenous nucleation
• Causes:
o Excess purine intake from animal protein
o Gout
o Myeloproliferative disorders
o Chemotherapy/tumor lysis
o Meds- probenecid, losartan, salicylates
o Rare hereditary conditions
Hyperuricosuria
22
23. • Types:
o Dietary- oxalate rich foods, vitamin C
o Enteric- malabsorption (IBD, celiac, pancreatitis)
• Mechanism- fatty acid saponification of calcium à increased free
luminal oxalate
• Typical findings- low volume, low pH, low ca/Na/citrate, high Ox
o Primary
• Oxalate absorption impacted by:
o Dietary calcium intake
o Oxalobacter formigenes (oxalate degrading bacterium)
Hyperoxaluria
23
24. • Autosomal recessive genetic disorder of glyoxalate
metabolism
• Endogenous overproduction of oxalate
• Recurrent nephrolithiasis
• Renal damage à renal failure
• 3 types (type 1 most common and most sever)
• Young age of presentation
• Urine oxalate levels > 80-100 mg/day
• Liver/kidney transplant
Primary Hyperoxaluria
24
25. • <320 mg/day
• Citrate excretion depends on systemic acid-base status
• Hypocitraturia occurs with acidosis
• Causes of hypocitraturia-
o RTA type 1 (distal)- impaired H ion secretion in distal tubule à
can’t excrete acid load à systemic acidosis
• Hypokalemia, high urine pH, very low citrate
o Chronic diarrhea- loss of bicarbonate à systemic acidosis
o Medications- thiazides (hypokalemia, intracellular acidosis),
carbonic anhydrase inhibitors (prevent bicarb reabsorption in
nephron)
o Idiopathic
Hypocitraturia
25
26. • Can’t excrete acid load
o NH4 (ammonium) will not be high on 24-h testing
• Treatment with Urocit K
o Ph rises but citrate goes up and ca excretion goes down
• Citrate complexes ca and is a direct crystal inhibitor
• Topiramate, acetazolamide, zonisamide (carbonic
anhydrase inhibitors) à stones
o Hard to get citrate to go up with Urocit-K
RTA and CaP Stones
26
27. • Urine pH <5.5
• Main factor leading to uric acid stone formation
o Low volume and hyperuricosuria also contribute
• Can have heterogenous nucleation à CaOx stones
• Uric acid stones more common in DM type 2
o Insulin resistance à impaired renal ammonium excretion
Low Urine pH
27
28. • Acid production- from methionine/cysteine (sulfate
excretion/H2SO4) and lysine/arginine
o Higher sulfate excretion = higher acid load
• Alkali production- aspartate/glutamate and organic
anions
• Diets are net acid producing
• SO4 (sulfate) and NH4 (ammonium) should travel
together
o Sulfate is our dietary acid load
o Ammonium is our acid excretion/what we pee out
Acid-Base
28
29. • Alkali therapy
o High pH, suppressed NH4 secretion
• Urease activity
o High pH, high NH4
• Met syndrome, hyperkalemia, inadequate alkali tx
o Low pH (can’t get rid of acid as NH4, suppressed NH4 secretion
(insulin resistance)
• GI alkali loss, diarrhea (looses alkali in the gut and
kidneys must secrete acid), hypokalemia
o Low pH, ammonium >> sulfate
• If both sulfate and ammonium are high- that is a normal
response- to a high protein diet (should trend together)
29
30. • Need an alkaline urine to solubilize cystine
• Want SS cystine to be <0.8
• Capacity – Unique parameter to Litholink
o assess risk of further cystine stone formation
o particularly when on a thiol
• Neg capacity= bad (supersaturated);
• Pos capacity= good (undersaturated)
• Cystine stone formers have high pH at baseline
Cystinuria
30
31. • Not all cystine forming pts need meds- do not need to
start Thiola immediately
• Initial management = diet
o Hydration
o Low salt diet
o Low protein diet- not a huge benefit to protein limitation in terms
of cystine excretion
31
32. • Alkalinization- solubility goes up in general with
increasing pH
• Thiol drugs: pH must be high for meds to work
• Thiol binding to cystine occurs quicker with higher pH
• Need pH of 7.5 for thiol drugs to work
• Make sure you test siblings (25% chance)
o Autosomal recessive
32
33. • Potassium citrate vs. calcium citrate
o Only 20-30% of ca is absorbed, much more K absorption àget
more alkali
• Thiazides and alkali together- do not get as much of an
increase in citrate vs. alkali alone
Medications- Pearls
33
45. Thank You
45
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