Adult Medical-Surgical Adult Medical-Surgical Nursing Nursing

Renal Module: Renal Module:

Renal Calculi - UrolithiasisRenal Calculi - Urolithiasis

Renal Calculi: DescriptionRenal Calculi: Description

Renal calculi occur from a super-Renal calculi occur from a super-saturation of urinesaturation of urine

This leads to crystallisation and This leads to crystallisation and gravel or stone formationgravel or stone formation

Renal Calculi: PrevalenceRenal Calculi: Prevalence

Highest prevalence is in 30-50 year Highest prevalence is in 30-50 year males males

Risk is increased by a lack of Risk is increased by a lack of substances like magnesium and substances like magnesium and citrates in the urine (substances citrates in the urine (substances which prevent crystallisation) which prevent crystallisation)

Renal Calculi: ClassificationRenal Calculi: Classification

Main types of stones are:Main types of stones are:

Calcium oxalate Calcium oxalate ((majormajor typetype, , independentindependent ofof urineurine pHpH)) }75%}75%

Calcium phosphateCalcium phosphate ( (alkalinealkaline urineurine) )

Uric acid Uric acid ((acidacid urineurine) (5-10%)) (5-10%) Struvite Struvite (related to bacteria and (related to bacteria and

infection (infection (alkalinealkaline urineurine) (15%)) (15%)

Renal Calculi: AetiologyRenal Calculi: Aetiology

Family history: Family history: genetic pre-dispositiongenetic pre-disposition Dehydration: Dehydration: hot climates, inadequate fluid hot climates, inadequate fluid

intake, sports activities intake, sports activities Frequent urine infectionsFrequent urine infections/ catheter/ catheter StasisStasis Immobility Immobility Calcium imbalance related to diseaseCalcium imbalance related to disease Diet rich in animal protein Diet rich in animal protein (↑ calcium/ (↑ calcium/

uric acid)uric acid)

Renal Calculi: Renal Calculi: Related ComplicationsRelated Complications

Obstruction of renal tract. Leads to: Obstruction of renal tract. Leads to: Retention and stasis of urine Retention and stasis of urine Hydroureter and hydronephrosis Hydroureter and hydronephrosis Destruction of nephrons Destruction of nephrons Non-functioning kidney/ renal failureNon-functioning kidney/ renal failure

InfectionInfection

Direct destruction of nephrons: (“Staghorn” Direct destruction of nephrons: (“Staghorn” calculus as a space-occupying lesion) calculus as a space-occupying lesion)

Renal Calculi: Renal Calculi: Clinical ManifestationsClinical Manifestations

May be symptomlessMay be symptomless If in renal pelvis, deep ache over loin, If in renal pelvis, deep ache over loin,

may track to suprapubic area or may track to suprapubic area or genitaliagenitalia

Haematuria; pyuriaHaematuria; pyuria Acute pain when fragment dislodged Acute pain when fragment dislodged

(inflammation, trauma, oedema)(inflammation, trauma, oedema) Extreme colic if fragment sticks in Extreme colic if fragment sticks in

ureter = “Renal colic”ureter = “Renal colic”

Renal ColicRenal Colic

Severe colicky spasmodic pain over Severe colicky spasmodic pain over loin, wave-like reaching genitalialoin, wave-like reaching genitalia

Nausea and vomiting, sweatingNausea and vomiting, sweating May have diarrhoeaMay have diarrhoea Haematuria Haematuria Desire to void but little urine outputDesire to void but little urine output (Prostaglandin E2 release increases (Prostaglandin E2 release increases

contractility to forward stone,contractility to forward stone,↑ ↑ blood blood flow and pressure in ureter = pain)flow and pressure in ureter = pain)

Renal Calculi: DiagnosisRenal Calculi: Diagnosis

Xray: KUB (kidneys, ureters, bladder)Xray: KUB (kidneys, ureters, bladder) Ultrasound scanUltrasound scan Intravenous or retrograde pyelogram Intravenous or retrograde pyelogram

(not if acute)(not if acute) Kidney function tests (KFT): blood Kidney function tests (KFT): blood

urea, creatinine, calcium, urea, creatinine, calcium, phosphorus, uric acidphosphorus, uric acid

Urine culture; 24 hour urine calcium, Urine culture; 24 hour urine calcium, uric acid, creatinine, sodium, pHuric acid, creatinine, sodium, pH

Renal Calculi/ Colic: Renal Calculi/ Colic: Acute ManagementAcute Management

Pain relief: Pain relief: Narcotic often requiredNarcotic often required NSAID (↓ prostaglandin synthesis) NSAID (↓ prostaglandin synthesis) AntispasmodicAntispasmodic Anti-emeticAnti-emetic AntibioticsAntibiotics Intravenous fluid (flushing and dilution Intravenous fluid (flushing and dilution

effect)effect) Removal of calculi (sieve urine)Removal of calculi (sieve urine)

Renal Calculi: Methods of Removal Renal Calculi: Methods of Removal

Lithotripsy with flushing and Lithotripsy with flushing and retrieval:retrieval:

Via cystoscopyVia cystoscopy Extra-corporeal shock-wave Extra-corporeal shock-wave

lithotripsy (ESWL)lithotripsy (ESWL)

SurgerySurgery

Renal Calculi: Methods of Removal Renal Calculi: Methods of Removal

Via Cystoscopy:Via Cystoscopy: Laser, ultrasound or shock-wave Laser, ultrasound or shock-wave

lithotripsy to fragment the stonelithotripsy to fragment the stone Irrigation and flushingIrrigation and flushing Forceps/ basket retrieval of stone or Forceps/ basket retrieval of stone or

fragmentsfragments Ureteric catheter (stent) left 48 hours Ureteric catheter (stent) left 48 hours

to keep patency until inflammation to keep patency until inflammation subsides (and following all surgical subsides (and following all surgical procedures) procedures)

Renal Calculi: Methods of Removal Renal Calculi: Methods of Removal

ESWL: Extra-corporeal Shock-ESWL: Extra-corporeal Shock-Wave LithotripsyWave Lithotripsy

Irrigation and flushingIrrigation and flushing

Several treatments as an outpatient Several treatments as an outpatient to fragment the calculusto fragment the calculus

Renal Calculi: Methods of Removal Renal Calculi: Methods of Removal

Surgery:Surgery:

Percutaneous Pyelolithotomy Percutaneous Pyelolithotomy (“Staghorn”) or Ureterolithotomy and (“Staghorn”) or Ureterolithotomy and forceps/ basket retrievalforceps/ basket retrieval

Open surgery: Pyelolithotomy or Open surgery: Pyelolithotomy or Ureterolithotomy and irrigation of Ureterolithotomy and irrigation of fragments (less often used now) fragments (less often used now)

Renal Calculi: Renal Calculi: Long-term ManagementLong-term Management

Diet and fluidsDiet and fluids

LifestyleLifestyle

MedicationsMedications

Renal Calculi: Renal Calculi: Long-term Management/ DietLong-term Management/ Diet

DietDiet (according to type of calculi): (according to type of calculi): Reduce animal protein, salt, oxalatesReduce animal protein, salt, oxalates Increase fluid intake especially Increase fluid intake especially

before sleeping at nightbefore sleeping at night Juices as cranberry to acidify alkaline Juices as cranberry to acidify alkaline

urine where appropriateurine where appropriate Potassium citrate to alkalise acid Potassium citrate to alkalise acid

urine where appropriateurine where appropriate

Renal Calculi: Renal Calculi: Long-term Management/ LifestyleLong-term Management/ Lifestyle

LifestyleLifestyle::

Avoid dehydrationAvoid dehydration Avoid exposure to hot weatherAvoid exposure to hot weather Avoid strenuous exerciseAvoid strenuous exercise Increase water intake especially at Increase water intake especially at

nightnight Void regularly to avoid stasis of urine Void regularly to avoid stasis of urine

Renal Calculi: Renal Calculi: Long-term MedicationsLong-term Medications

Calcibind: binds dietary calcium in the Calcibind: binds dietary calcium in the intestinal tractintestinal tract

Thiazide diuretic: monitors calcium Thiazide diuretic: monitors calcium levels related to increased levels related to increased parathormoneparathormone

Allopurinol: reduces uric acid levels in Allopurinol: reduces uric acid levels in blood and urineblood and urine

Prophylactic antibiotics where chronic Prophylactic antibiotics where chronic infection infection

Renal Calculi: Renal Calculi: Nursing ConsiderationsNursing Considerations

Health education about condition and Health education about condition and measures to controlmeasures to control

Awareness of acute management of Awareness of acute management of renal colicrenal colic

Preparation for surgical procedures Preparation for surgical procedures and post-operative care and post-operative care

Watch for signs of obstruction from Watch for signs of obstruction from fragments. Sieve all urinefragments. Sieve all urine