Minitopic Nephrolithiasis

INTRODUCTION Calcium stone(75~85%) Calcium oxalate , Calcium phosphate Uric acid stone(5~8%) Cystein stones(1%) Struvite stones(10~15%) 가장 흔하며 Hypercalciuria 및 hyperoxliuria 로 인해 발생하는 calcium stone, hyperuricosuria 로 발생하는 uric acid stone, 신장에서 cystein 이 재흡수 되지 않아 발생하는 cystein stone, 및 Struvite stone 이 있습니다.

Diagnosis

Acute treatment(1) Renal Colic: Treating Pain Opiates and NSAIDS - Ketorolac, meperidine, morphine Aid passage of renal stones Less than 10mm in diameter - tamsulosin[a-antagonist] - nifedipine Double –blind RCT : Ketolac 60mg IM vs meperidine 100-150mg :Ketolan better relief and quiclker discharge Ketolan provids effective pain relief with less sedation than opiates Among Opiates. meperidine causes N/V & Contraindicated if Decreased renal fx 통증의 치료로는 ketolac, meperidine. 의 ej=lk Renal stone 의 대기 요법 배출 를 돕는 ㅇ’i으로는

Acute treatment(2) -when to hospitalize >5mm , parenteral tx required for pain Meta-analysis of 327 studies Ureteral stones Clinical guidelinens: 98% of <5mm stones passed spontaneously Obstructed and infected tract → Absolute Ix for emergent intervention → Can lead to urosepsis & irriversible injury Bilateral obsturction , obstruction in solitary kidney. decreased fuction Metaanal에서 5mm 이ㅏ히히ㅏ의ㅏ 돌은 지ㅏ연 배출되었고., 이에 대기요법을 기대해보기 어려운 5 mm 이시ㅏㅇ의 stone

Acute treatment(3) -when to consider intervention For Larger stones Ureteroscopy more appropriate ESWL must fragment stones into smaller pieces Lead better clearance of stone fragments → minimize stone recurrence Ureteral Stones Clinical Guidelines Panel & Europian association of urology Proximal ureter: 1cm↓ → ESWL 1st 1cm ↑ → PCN or ureteroscopy Distal ureter: ESWL or ureteroscopy For Patients c ESWL: consider subsequent tx with tamsulosine Staghorn calculi Percutaneous nephrolithotomy should be 1st treatment ESWL monotherapy should not be used Ureteral ~ 의 기ㅏ이드리ㅏ이ㄴ 에 띠르면., prox ureter 의 1cm 이히ㅏ에서는 ESWL 미ㅏㄹ디ㅏㄴ부에 AUA guideline에서는 수술을 시해8ㅇ히ㅏ여 기ㅏ능히ㅏㄴ 모든 결석을 제거해ㅇㅇ’ㅑ 히ㅏ는데.,

Preventive Treatment Preventive? Pathogenesis Supersaturation High urinary solute concentration Urine Volume↓ Urinary PH Acid: uric acid., cystein stone Alkali: Calcium phosphate, MgNH4PO4 Nucleation Urinary inhibitors of crystal formation Citrate., magnes’ium., uropontin., nephrocalcin, glycoprotein Preventive? Red bo8o8lk 522

Preventive Treatment -Role of fluid intake & Diet Advise at least 2~2.5L/d maintain urine volume at least 2L Dilkution of poor soluable salts : calcium oxalate, calcium phosphate and cystein Diet Only 1 RCT with positive results: -Greater calcium intake have fewer stones -most likely d/t ability of dietary calcium to bind oxalate in the intestine and prevent absorption Uric acid stones, cystein stones: limit animal pro8te’in intalke-> urine alkalizatioin D’iet 에 대8해8서ㅡㄴ=는 그동이ㅏㄴ

Preventive 1) Thiazide Lower urinary Ca excretion Stimulating renal calcium absorption Chlorothalidone 12.5mg /day or hydrochlorothiazide 25mg BID Can cause hypokalemia → Lower citrate excretion → Should be supplemented potassium citrate or given potassium sparing agents such as spironolactone

Preventive 2) Citrate Inhibitor of crystalization of calcium oxalate and calcium phosphate “Increase ‘in Ur’ine pH: ‘increase I’n Calkc’ium pho8sphate sto8nes Adequate flku’id ‘intalke Th’iaz’ide use to8 lo8wer ur’inary calkc’ium excret’io8n ‘if ur’ine pH ‘increase o8r ‘if Calkc’ium pho8sphate sto8ne o8ccurs O*range ju’ice and lkemo8nade: c’itrate excret’io8n

Preventive-Uric acid stones/Hyperuricouria Uric acid: ↓solubility of calcium oxalate Hyperuricosuria(-),