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Kidney StonesKidney Stones(Urolithiasis, (Urolithiasis,
Nephrolithiasis)Nephrolithiasis)
By: E. Salehifar (PharmD, By: E. Salehifar (PharmD, BCPS)BCPS)
BackgroundBackground
Evidence of stones in a 7000 yo Evidence of stones in a 7000 yo Egyptian mummyEgyptian mummy
Very common (2.7 million visits, Very common (2.7 million visits, >600/000 emergency situations)>600/000 emergency situations)
Men>WomenMen>Women More stones pass out without any More stones pass out without any
interventionintervention Treatment with various techniquesTreatment with various techniques
Renal Tract StonesRenal Tract Stones
CalciumCalcium UrateUrate CystineCystine Infection (Struvite)Infection (Struvite) OthersOthers
Stone Stone typetype
% of % of patientspatients
Visible Visible on X-rayon X-ray
Risk Risk factors in factors in urineurine
CaCa 8080 yesyes ↑↑ca, ca, oxalate, oxalate,
↓↓citrate,citrate,
↓ ↓ volvol
UrateUrate 1010 nono ↑↑urate, urate, ↓pH, ↓ ↓pH, ↓ VolVol
CystineCystine 22 weaklyweakly ↑↑cystinecystine
InfectioInfection n (Struvite)(Struvite)
55 yesyes pH↑, pH↑, infectioninfection
OthersOthers 33
Calcium StonesCalcium Stones
Calcium OxalateCalcium Oxalate Calcium PhosphateCalcium Phosphate Calcium CarbonateCalcium Carbonate
Stone FormationStone Formation Causes are unclear Causes are unclear ↑↑urine concentration of Ca, Oxalate, urine concentration of Ca, Oxalate,
phosphate, uric acid and cystine phosphate, uric acid and cystine ↓ ↓ citrate citrate Drugs: Loop diuretics, ↑ Vit D, IndinavirDrugs: Loop diuretics, ↑ Vit D, Indinavir food?, family history, UTI, blockage of the food?, family history, UTI, blockage of the
urinary tract, Debris or other crystals urinary tract, Debris or other crystals Nephrocalcinosis Nephrocalcinosis (mainly in medulla)(mainly in medulla): :
Hyperparathyroidism, Distal RTA (>70%), Hyperparathyroidism, Distal RTA (>70%), cystic kidney disease cystic kidney disease
Ca Stones FormationCa Stones Formation
Hypercalciuria (In 50% of Hypercalciuria (In 50% of nephrolithiasis)nephrolithiasis) Idiopathic, Hyperparathyroidism, ↑Vit D, Idiopathic, Hyperparathyroidism, ↑Vit D,
MalignanciesMalignancies associated with obesity & HTNassociated with obesity & HTN
↑↑urine concentration of oxalateurine concentration of oxalate Diet, ileal disease, primary hyperoxaluria Diet, ileal disease, primary hyperoxaluria
type 1type 1 ↑↑urine concentration of phosphateurine concentration of phosphate ↓ ↓ citrate ( idiopathic, Distal RTA)citrate ( idiopathic, Distal RTA)
Clinical PresentationClinical Presentation
Often do not cause any symptomsOften do not cause any symptoms Renal colic with intense flank pain Renal colic with intense flank pain
often radiating to the groin, burning often radiating to the groin, burning sensation sensation
Sometimes with nausea, vomiting, Sometimes with nausea, vomiting, hematuria, (fever and chills in hematuria, (fever and chills in infected patients) infected patients)
DiagnosisDiagnosis
Plain Radiography (Ca, Struvite) Plain Radiography (Ca, Struvite) Sonography (size & location of all Sonography (size & location of all
stone types)stone types) <6 mm pass spontaneously, >1 cm will <6 mm pass spontaneously, >1 cm will
notnot CT ScanCT Scan IVP (Intravenous Pyelogram)IVP (Intravenous Pyelogram)
InvestigationsInvestigations Exclude bowel disease, diarrhea & the use of Exclude bowel disease, diarrhea & the use of
antacids and diureticsantacids and diuretics Diet assessment: Fluid, protein, Na, Ca, Diet assessment: Fluid, protein, Na, Ca,
Oxalate, Purine & vit DOxalate, Purine & vit D Family historyFamily history Stone analysisStone analysis Baseline: Baseline: UrineUrine Analysis,Analysis, serum Ca, P, urate, Ca, P, urate,
BUN, CrBUN, Cr Recurrent stones: 24-h urine collectionRecurrent stones: 24-h urine collection
Volume, Osmolality, Ca, P, Oxalate, Citrate, Urate, Volume, Osmolality, Ca, P, Oxalate, Citrate, Urate, Na, Cr, pH as well as serum Na, K, Cl, bicarbonateNa, Cr, pH as well as serum Na, K, Cl, bicarbonate
PreventionPrevention
Lifestyle changesLifestyle changes To drink more liquidsTo drink more liquids Dairy product ?, Calcium pills?Dairy product ?, Calcium pills? ↓ ↓ meat ( patients with acidic urine), ↓ meat ( patients with acidic urine), ↓
vit Dvit D ↓ ↓ Oxalate (beets, chocolate, coffee, Oxalate (beets, chocolate, coffee,
cola, nuts, rhubarb, spinach, cola, nuts, rhubarb, spinach, strawberries, tea, wheat bran) strawberries, tea, wheat bran)
TreatmentsTreatments
GeneralGeneral Water (>2-3 lit/day), Pain killersWater (>2-3 lit/day), Pain killers
MedicalMedical SurgicalSurgical Stone removalStone removal
Extracorporeal Shock Wave Lithotripsy Extracorporeal Shock Wave Lithotripsy (ESWL)(ESWL)
Percutaneous NephrolithotomyPercutaneous Nephrolithotomy Ureteroscopic removal Ureteroscopic removal
Medical TherapyMedical Therapy
Hydrochlrothiazide (with low Na diet)Hydrochlrothiazide (with low Na diet) AllopurinolAllopurinol Citrate potassiumCitrate potassium Thiola and Cuprimine (to ↓ cystine in Thiola and Cuprimine (to ↓ cystine in
the urine)the urine) UTI Prevention (after removal of UTI Prevention (after removal of
struvites)struvites) ParathyroidectomyParathyroidectomy
Surgical TreatmentSurgical Treatment
Was necessary until 20 years ago Was necessary until 20 years ago Recovery time: 4-6 W Recovery time: 4-6 W Surgery for stone that:Surgery for stone that:
Does not pass after a reasonable time & causes Does not pass after a reasonable time & causes constant painconstant pain
Is too large to pass or is caught in a difficult placeIs too large to pass or is caught in a difficult place Blocks the flow of urineBlocks the flow of urine Causes ongoing UTICauses ongoing UTI Damages kidney tissue or causes bleedingDamages kidney tissue or causes bleeding Has grown larger (as seen on followup X ray)Has grown larger (as seen on followup X ray)
Extracorporeal Shock Wave Extracorporeal Shock Wave Lithotripsy (ESWL)Lithotripsy (ESWL)
The most frequently used procedureThe most frequently used procedure Most need mild anesthesia with short Most need mild anesthesia with short
recovery timerecovery time Complications:Complications:
HamaturiaHamaturia Bruising in back or abdomen (ASA Bruising in back or abdomen (ASA
should be avoided)should be avoided) Discomfort caused by stone passage Discomfort caused by stone passage
(stent in ureter)(stent in ureter) Is not ideal for large stonesIs not ideal for large stones
Percutaneous Percutaneous NephrolithotomyNephrolithotomy
(PN or PCN)(PN or PCN) For large stone or difficult location For large stone or difficult location
for ESWLfor ESWL Some type of energy probe may be Some type of energy probe may be
needed to break the large stonesneeded to break the large stones Many need to nephrostomy tubeMany need to nephrostomy tube Hospitalization for several daysHospitalization for several days Advantage to ESWL: Stone removal Advantage to ESWL: Stone removal
by surgeonby surgeon
Ureteroscopic Stone Ureteroscopic Stone RemovalRemoval
For mid and lower ureter stonesFor mid and lower ureter stones Passage of fiberoptic ureteroscope, Passage of fiberoptic ureteroscope,
stone removal by cage-like device or stone removal by cage-like device or shattering with a shock waveshattering with a shock wave
A small tube or stent may be A small tube or stent may be inserted inserted
Hope Through ResearchHope Through Research
Why do some people continue to have Why do some people continue to have painful stones?painful stones?
How can we predict, or screen, those at How can we predict, or screen, those at risk for getting stones?risk for getting stones?
What are the long-term effects of What are the long-term effects of lithotripsy?lithotripsy?
Do genes play a role in stone formation?Do genes play a role in stone formation? What is the natural substance(s) found What is the natural substance(s) found
in the urine that blocks stone formation?in the urine that blocks stone formation?
For More Information!For More Information!
www.afud.orgwww.afud.org (American Foundation (American Foundation for Urologic Disease)for Urologic Disease)
www.urologyhealth.orgwww.urologyhealth.org (American (American Urology Association)Urology Association)
www.kidney.orgwww.kidney.org (National Kidney (National Kidney Foundation)Foundation)