kidney stones (urolithiasis, nephrolithiasis) by: e. salehifar (pharmd, bcps)

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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

Urinary TractUrinary Tract

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

Calcium OxalateCalcium OxalateCalcium PhosphateCalcium Phosphate

Calcium CarbonateCalcium Carbonate

Urate StonesUrate Stones

StruviteStruvite

CystineCystine

OthersOthers

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)

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)

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

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)