Kim Applebee Alex Kaullen

Kim Applebee Alex Kaullen
Kidney Stones Kim Applebee Alex Kaullen

تعریف مقدمه شیوع انواع تشخیص درمان

Definition Renal Lithiasis Renal Calculi
Kidney Stones are small, hard deposits of mineral and acid salts on the inner surfaces of the kidneys Alternative names include: Renal Lithiasis Renal Calculi Nephrolithiasis (Kidney Stone Disease) Stones are classified by their location in the urinary system and their composition of crystals.

Statistics Incidence Rate: More than 1 million cases annually in US
1 in 272 or 3.6 per 1000 Americans develop stones annually. 80% of stones under 2mm in size 90% of stones pass through the urinary system spontaneously Generally stone smaller than 6mm are passable (National Institute of Diabetes and Digestive and Kidney Diseases; NIDDK) (National Kidney and Urologic Disease Information Clearinghouse; NKUDIC)

Kidney Stone Formation
Causes: Highly concentrated urine, urine stasis Imbalance of pH in urine Acidic: Uric and Crystine Stones Alkaline: Calcium Stones Gout Hyperparathyroidism Inflammatory Bowel Disease UTI Medications Lasix, Topamax, Crixivan Explain crystalization

Types of Stones Calcium Oxalate Most common Calcium Phosphate Struvite
More common in woman than men. Commonly a result of UTI. Uric Acid Caused by high protein diet and gout. Cystine Fairly uncommon; generally linked to a hereditary disorder. When oxalate combines with calcium, which prevents the oxalate from being absorbed in the intestinal tract. It then goes through the kidneys where is can pose a problem. Stones classified by majority of crystal that they are composed of. Foods high is oxalate, rhubarb, star fruit, beets, beet greens, collards, okra, refried beans, spinach, Swiss chard, sweet potatoes, sesame seeds, almonds and soy products, vitamin D, metabolic disorders, and bypass surgery increase calcium oxalate concentration in urine.

Broad classification Calcium containing stones 75%
Non calcium containing stones 25%

Urinary tract stones Aetiology WHEN TO INVESTIGATE ? & HOW ?

Risk Factors for Calcium Stone-Formation Anatomical abnormality
Age Gender Season/climate Fluid Intake Stress/diet Occupation Mobility Metabolic disorders Genetic disorders Anatomical abnormality Family history

Occupation, Low Urine Volume and Urolithiasis

Urinary Risk Factors for Stone-Formation
Low urine volume (<1L/24hrs) Alteration in urinary pH (<5.5,>7.5) Hypercalciuria (>4mg/kg/24hrs) Hyperoxaluria (45mg/24hrs) Hyperuricosuria (>600mg/24hrs) Hypocitraturia (<250mg/24hrs) Hypomagnesiuria (<50mg/24hrs)

Calcium Stone-Formation

Infected Stone-Formation
  Urinary NH4+  CaP and MAP supersaturation   Urinary pH Urinary tract infection with a urea- splitting organism  Nucleation and agglomeration  Urinary mucoprotein Abnormal crystalluria Infection stone  Urinary citrate  Inhibitory activity  Urinary phosphate

Uric Acid Stone-Formation  Uric acid supersaturation
Age Sex (M > F) Genetic disorders Metabolic disorders  Dietary purine  Urinary uric acid  Renal NH3 production  Dietary acid Uric acid stone  Urinary pH  Uric acid supersaturation Abnormal crystalluria  Urinary volume  Fluid intake  Fluid loss  Ambient temperature

Cystine Stone-Formation
 Tubular reabsorption of cystine  Urinary cystine  Cystine supersaturation Abnormal crystalluria Cystine stone Possible metabolic factors

It is important to discontinue any medications that interfere with the metabolism of calcium, oxalate and uric acid prior and during investigation

Diagnostic evaluation for single stone formers
History, P/E Medications Fluid intake Biochemical screen U&E, Ca,PO4, uric acid, bicarbonate PTH if Ca is elevated Urine PH>7.5 Infected stones PH<5.5 Uric acid Sediment for crystalluria Urine culture –urea splitting organisms Xray Stone analysis

Risk factors for stone recurrence
Children Black patients White males with positive family history Chronic diarrhoeal /Malabsorbtive states Gout Cystine/struvite/uric acid stones Nephrocalcinosis Osteoporosis Pathological fractures

Extensive Investigation
VISIT 1 History, P/E, diet, radioogical evaluation 2X24 urinary collections for calcium, oxalate, uric acid, citrate, urinary sodium, creatinine excretion on random diet Dietry instructions for restricted diet VISIT 2 24hr urine collection on restricted diet Fast and calcium load test Parathyroidlevels

Case Study It is a hot summer day, and you are an RN in the emergency department (ED). S.R., an 18-year-old woman, comes to the ED with severe flank and abdominal pain and N/V. S.R. looks very tired, her skin is warm to touch, and she is perspiring. She paces about the room doubled-over and is clutching her abdomen. S.R. tells you that the pain started early this morning and has been pretty steady for the past hours. She gives a history of working outside as a landscaper and takes little time for water breaks. Her past medical history (PMH) includes 3 kidney stone attacks, all during late summer. Exam findings are that her abdomen is soft and w/o tenderness, but her left flank is extremely tender to touch, palpation, and percussion. You place S.R. in one of the examination rooms and take the following VS 118/98, 90, 20, 99 F. UA shows RBC of 50 to 100 on voided specimen, WBC 0.

What key factors are important to consider?

Signs and Symptoms Additional S/S: What are the key findings?
Presence of UTI Fever or Chills Pain in groin, labia or testicles Cloudy or foul-smelling urine Dysuria Persistent urge to void What are the key findings? Severe flank pain Abdominal pain Nausea and vomiting Fatigue Elevated temperature, BP, and respirations UA positive for RBC Objective Data: perspiration, clutching of the abdomen, doubled-over. Steady Pain Left flank tendernes pain typically starts at side or back, just below your ribs, and radiates to ones lower abdomen and groin. Often begins when stone reaches ureters

What additional information should you ask this patient?

Additional Information
Family history Current medications Frequency of urination Do you experience pain while urinating? What is your typical diet? How did patient’s kidney stones resolve themselves in the past?

Identify this patient’s risk factors.

Risk Factors Hx of 3 kidney stone attacks High sodium High protein
Additional risk factors: Family or Personal Hx Gender (male) Age (20-55) Race (Caucasian) Diet High sodium High protein Food high in oxalate Vit A/D, grapefruit juice Sedentary Lifestyle Obesity High Blood Pressure What are her risk factors? Past Medical History Hx of 3 kidney stone attacks Dehydration/Lack of Fluids Occupational exposure Labor Intensive Outdoors Weather/Climate Hot, dry

Abnormal Lab Values BUN Creatinine Urine Analysis

Diagnostic Studies Test and Diagnostics: Blood Analysis Urine Analysis
CT Scan Abdominal x-ray Ultrasound Retrograde Pyelogram Cystoscopy Intravenous pyelography Blood analyis-look at calcium levels Intravenous pyelography: A contrast dye is injected into a vein in your arm and a series of X-rays is taken as the dye moves through your kidneys, ureters and bladder. Helps determine stone location and extent of blockage. Not for pt with renal failure.

What questions do you need to ask before a patient has an IV pyelogram?
IVP = Used to localize the degree and site of obstruction or to confirm the presence of a radiolucent stone)

Answer: Check BUN and Creatinine levels prior to IVP
Do you have a history of renal failure? Contraindicated with renal failure Have you ever have a reaction to iodine? Contrast contains iodine Is there a possibility you could be pregnant? Are you currently taking any medications? Metformin may react with contrast Check BUN and Creatinine levels prior to IVP Need to check the patient’s renal function because this test is contraindicated in patients with renal failure. Contrast has iodine in it. Contraindicated if on metformin.

What are Nursing Interventions?
Nursing Diagnosis: Acute pain r/t obstruction from renal calculi as manifested by patient being doubled-over, pacing around the room, and patient verbalizing pain upon assessment. Goal: patient will state pain is at a manageable level within 2 hours of admission. What are Nursing Interventions?

Nursing Goal/Interventions:
Administer pain medication as ordered by physician. Provide non-pharmaceutical techniques such as imagery and/or meditation to relieve pain. Patient will determine manageable pain level. Patient will be asked about any concerns and/or fears that may be associated with pain. Provide emotional support for the patient. Reassess patient’s pain levels within 1 hour after administration of pain medications.

What are Nursing Interventions?
Nursing Diagnoses: Deficient knowledge r/t fluid requirements and dietary restrictions as manifested by reoccurring stones. Goal: Patient will state methods to prevent future stones by the time patient is D/C. A plan of care will also be created with the patient before patient is D/C to prevent reoccurrence of kidney stones. Risk for infection r/t kidney stone obstruction of urinary tract causing stasis of urine. Goal: Patient’s urine will be yellow and clear upon D/C and patient will not have a fever. UA with show no indication of UTI or other infection. What are Nursing Interventions?

Treatment Two Focuses of Treatment:
Treatment of acute problems, such as pain, n/v, etc Identify cause and prevent kidney stones from reoccurring Acute Treatment: Pain Medication!!! Strain urine for stones Keep Hydrated Ambulation Diet Restrictions Emotional Support Invasive Procedure (may be necessary) do not need to over-hydrate since stone has already formed ( ml/day) -encourage patient to keep mobile to promote movement of the stone from the upper to lower part of the ureter. Avoid foods high in ____: depends on the type of stone.

Surgical Procedures Lithotripsy: used to break into smaller fragments allowing it to pass through the urinary tract. Extracorporeal Shock-Wave (ESWL) Percutaneous Ultrasonic Electrohydraulic Laser Surgical Therapy Nephrolithotomy (Kidney) Pyelolithotomy (Renal Pelvis) Ureterolithotomy (Ureter) Basket Extraction Surgery may be needed to remove a kidney stone if it does not pass after a reasonable period of time and causes constant pain is too large to pass on its own or is caught in a difficult place blocks the flow of urine causes an ongoing urinary tract infection damages kidney tissue or causes constant bleeding has grown larger, as seen on follow-up x rays ESWL, shock waves that are created outside the body travel through the skin and body tissues until they hit the denser stones. The stones break down into small particles and are easily passed Nephrolithotomy: surgeon makes a tiny incision in the back and creates a tunnel directly into the kidney

Prevention Drink 3 liters of fluid per day (14 cups) Water
Patient Education Hydration Drink 3 liters of fluid per day (14 cups) Water Lemonade (citrate decrease stone formation) Diet Low sodium Watch amounts of oxalate Low protein Exercise/Increase Activity Medication

Professional Resources
Renal Disease: A Manual of Patient Care by Lynn Wenig Kagan, RN, PhD Differential Diagnosis: Renal and Electrolyte Disorders by Saulo Klahr, MD MedLine Plus

Journal Article #1 Purpose: Determine effectiveness of an herbal supplement made out of varuna and banana stems, “Herbmed,” on kidney stones Study: 77 patients participated in a randomized, placebo, double-blinded study that was conducted in India from July 2007 to February Two groups were formed: Group A with calculi 5-10mm and Group B with calculi >10mm. Results: Patients relieving the herbal supplement showed a 33% reduction in the size of their kidney stone. Conclusion: Herbmed is an herbal treatment that may have promising effects in reducing kidney stone size and expulsion.

Journal Article #2 Purpose: To determine the possible effects fructose has on the formation of kidney stones. Study: The researchers looked at three different cohorts (older woman, younger women, and men) over combined 48 years of follow up new symptomatic kidney stones were documented among these three cohorts. Results: The results from the study showed that there is a positive correlation between the intake of fructose and the development of kidney stones. Conclusion: Fructose intake can increase insulin resistance which lowers the pH in the urine and increases ones’ risk for the development of uric acid kidney stone. Nurses need to adequately assess the patient’s diet and educate patients on ways to prevent stones.

Journal Article #3 Purpose: The study looked specifically at anxiety associated with treatment, surgery, for kidney stones. Study: The anxiety of 66 patients was assessed before and after treatment, using three forms of measurement tools: palmar sweat test, visual analogue scale, and Speilberger state anxiety questionnaire. The two groups that were compared were open surgery to minimally/non-invasive treatment. Results: The results from the study showed no significant change in the questionnaire answers between the three indicators of anxiety. But, there was a fair reduction in the analogue scores post-operatively in-patients who had open surgery. These same patients also had a lower palmar sweat response. But, pre-operatively patients who going to have open surgery had higher analogue scores. Conclusion: The two primary causes of anxiety were pain and being under anesthesia. Open surgery treatment resulted in lower levels of anxiety than non-invasive treatments.

Joey has a Kidney Stone….

References Ackley, B.J., & Ladwig, G.B. (2006). Nursing diagnosis handbook. St. Louis: Mosby, INC.. Asselman, M., & Verkoelen, C. (2008). Fructose intake as a risk factor for kidney stone disease. Kidney International, 73(2), Retrieved from CINAHL with Full Text database. Brown, S. (1990). Quantitative measurement of anxiety in patients undergoing surgery for renal calculus disease. Journal of Advanced Nursing, 15(8), Retrieved from CINAHL with Full Text database. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G., & Bucher, L. (2007). Medical surgical nursing. St.Louis: Mosby, INC. . Pagana, K.D., & Pagana, T.J. (2007). Diagnostic and laboratory test reference. St. Louis: Mosby, INC. Patankar, S., Dobhada, S., Bhansali, M., Khaladkar, S., & Modi, J. (2008). A prospective, randomized, controlled study to evaluate the efficacy and tolerability of Ayurvedic formulation "varuna and banana stem" in the management of urinary stones. Journal of Alternative & Complementary Medicine, 14(10), Retrieved from CINAHL with Full Text database. (2008, June 16). Kidney Stones. Retrieved from (2009). Kidney Stones. Retrieved from (2009, June 23). Kidney Stones. Retrieved from (2009, September 30). Kidney Stones. Retrieved from (2009, October 8). Kidney Stones in Adults. Retrieved from (2009, October 8). Kidney and Urologic DiseasesSstatistics for the United States. Retrieved from

Kim Applebee Alex Kaullen
Kidney Stones Kim Applebee Alex Kaullen

Definition Renal Lithiasis Renal Calculi
Kidney Stones are small, hard deposits of mineral and acid salts on the inner surfaces of the kidneys Alternative names include: Renal Lithiasis Renal Calculi Nephrolithiasis (Kidney Stone Disease) Stones are classified by their location in the urinary system and their composition of crystals.

Statistics Incidence Rate: More than 1 million cases annually in US
1 in 272 or 3.6 per 1000 Americans develop stones annually. 80% of stones under 2mm in size 90% of stones pass through the urinary system spontaneously Generally stone smaller than 6mm are passable (National Institute of Diabetes and Digestive and Kidney Diseases; NIDDK) (National Kidney and Urologic Disease Information Clearinghouse; NKUDIC)

Kidney Stone Formation
Causes: Highly concentrated urine Imbalance of pH in urine Acidic: Uric and Crystine Stones Alkaline: Calium Stones Gout Hyperparathyroidism Inflammatory Bowel Disease Urine stasis UTI Medications Lasix Topamax Crixivan Explain crystalization 49

Types of Stones -Types of Stones (Chart pg1170)
-Most stones contain more than one crystals. Classified by crystal that makes up the majority of the stone. Calcium Oxalate: Most common. Foods high is oxalate, rhubarb, star fruit, beets, beet greens, collards, okra, refried beans, spinach, Swiss chard, sweet potatoes, sesame seeds, almonds and soy products, vitamin D, metabolic disorders, and bypass surgery increase calcium oxalate concentration in urine. Calcium Phosphate Struvite stones: Most often found in women. Result of UTI. Tend to be a stag’s-horn shape. Uric acid stones. Formed of uric acid, a byproduct of protein metabolism. Caused by high protein diet and gout. Cystine stones: Fairly uncommon. Caused by kidneys over excreting amino acid which is general linked to a hereditary disorder. When oxalate combines with calcium, which prevents the oxalate from being absorbed in the intestinal tract. It then goes through the kidneys where is can pose a problem. 50

Case Study It is a hot summer day, and you are an RN in the emergency department (ED). S.R., an 18-year-old woman, comes to the ED with severe flank and abdominal pain and N/V. S.R. looks very tired, her skin is warm to touch, and she is perspiring. She paces about the room doubled-over and is clutching her abdomen. S.R. tells you that the pain started early this morning and has been pretty steady for the past hours. She gives a history of working outside as a landscaper and takes little time for water breaks. Her past medical history (PMH) includes 3 kidney stone attacks, all during late summer. Exam findings are that her abdomen is soft and w/o tenderness, but her left flank is extremely tender to touch, palpation, and percussion. You place S.R. in one of the examination rooms and take the following VS 118/98, 90, 20, 99 F. UA shows RBC of 50 to 100 on voided specimen, WBC 0.

What are key factors are important to consider?

Signs and Symptoms What are the key findings? Additional S/S:
Severe flank pain Abdominal pain Nausea and vomiting Fatigue Elevated temperature, BP, and respirations UA positive for RBC Objective Data: perspiration, clutching of the abdomen, doubled-over. Steady Pain Left flank tendernes Additional S/S: Presence of UTI Fever or Chills Pain in groin, labia or testicles Cloudy or foul-smelling urine Dysuria Persistent urge to void pain typically starts at side or back, just below your ribs, and radiates to ones lower abdomen and groin. Often begins when stone reaches ureters 53

What additional information should you ask this patient?

Additional Information
Family history Current medications Frequency of urination Do you experience pain while urinating? What is your typical diet? How did patient’s kidney stones resolve themselves in the past?

Identify this patient’s risk factors.

Risk Factors Hx of 3 kidney stone attacks High sodium High protein
Additional risk factors: Family or Personal Hx Gender (male) Age (20-55) Race (Caucasian) Diet High sodium High protein Food high in oxalate Vit A/D, grapefruit juice Sedentary Lifestyle Obesity High Blood Pressure What are her risk factors? Past Medical History Hx of 3 kidney stone attacks Dehydration/Lack of Fluids Occupational exposure Labor Intensive Outdoors Weather/Climate Hot, dry

Abnormal Lab Values

Diagnostic Studies -Test and Diagnostics
-Blood Analysis: Search for elevated calcium or uric acid. -Urine Analysis: Search for stone-forming minerals, -Urine Culture -CT Scan -Abdominal xray: helps monitor stone size -Ultrasound: may miss small stones -Retrograde Pyelogram -Cystoscopy: -Intravenous pyelography: A contrast dye is injected into a vein in your arm and a series of X-rays is taken as the dye moves through your kidneys, ureters and bladder. Helps determine stone location and extent of blockage. Not for pt with renal failure.

What questions do you need to ask before a patient has an IV pyelogram?
IVP = Used to localize the degree and site of obstruction or to confirm the presence of a radiolucent stone) 60

Answer: Check BUN and Creatinine levels prior to IVP
Do you have a history of renal failure? Contraindicated with renal failure Have you ever have a reaction to iodine? Contrast contains iodine Is there a possibility you could be pregnant? Are you currently taking any medications? Metformin may react with contrast Check BUN and Creatinine levels prior to IVP Need to check the patient’s renal function because this test is contraindicated in patients with renal failure. Contrast has iodine in it. Contraindicated if on metformin. 61

Nursing Dx

Outcomes/interventions?

Our outcomes and Interven.
Invention for casestudy and general treatment Foods to avoid 64

Treatment Two Focuses of Treatment:
Treatment of acute problems, such as pain, n/v, etc Identify cause and prevent kidney stones from reoccurring Acute Treatment: Pain Medication!!! Strain urine for stones Keep Hydrated Ambulation Diet Restrictions Emotional Support Invasive Procedure (may be necessary) do not need to over-hydrate since stone has already formed ( ml/day) -encourage patient to keep mobile to promote movement of the stone from the upper to lower part of the ureter. Avoid foods high in ____: depends on the type of stone. 65

Surgical Procedures Lithotripsy: used to eliminate the stone form the urinary tract. Types: extracorporeal shock-wave, percutaneous ultrasonic, electrohydraulic, and laser. Nephrolithotomy (Kidney) Pyelolithotomy (Renal Pelvis) Ureterolithotomy (Ureter) Basket Extraction

Prevention Drink 3 liters of fluid per day (14 cups) Water
Patient Education Hydration Drink 3 liters of fluid per day (14 cups) Water Lemonade (citrate decrease stone formation) Diet Low sodium Watch amounts of oxalate Low protein Exercise/Increase Activity Medication

Professional Resources
Renal Disease: A Manual of Patient Care by Lynn Wenig Kagan, RN, PhD Differential Diagnosis: Renal and Electrolyte Disorders by Saulo Klahr, MD MedLine Plus

Journal Article #1 Purpose: Determine effectiveness of an herbal supplement made out of varuna and banana stems, “Herbmed,” on kidney stones Study: 77 patients participated in a randomized, placebo, double-blinded study that was conducted in India from July 2007 to February Two groups were formed: Group A with calculi 5-10mm and Group B with calculi >10mm. Results: Patients relieving the herbal supplement showed a 33% reduction in the size of their kidney stone. Conclusion: Herbmed is an herbal treatment that may have promising effects in reducing kidney stone size and expulsion.

Journal Article #2 Purpose: To determine the possible effects fructose has on the formation of kidney stones. Study: The researchers looked at three different cohorts (older woman, younger women, and men) over combined 48 years of follow up new symptomatic kidney stones were documented among these three cohorts. Results: The results from the study showed that there is a positive correlation between the intake of fructose and the development of kidney stones. Conclusion: Fructose intake can increase insulin resistance which lowers the pH in the urine and increases ones’ risk for the development of uric acid kidney stone. Nurses need to adequately assess the patient’s diet and educate patients on ways to prevent stones.

Journal Article #3 Purpose: The study looked specifically at anxiety associated with treatment, surgery, for kidney stones. Study: The anxiety of 66 patients was assessed before and after treatment, using three forms of measurement tools: palmar sweat test, visual analogue scale, and Speilberger state anxiety questionnaire. The two groups that were compared were open surgery to minimally/non-invasive treatment. Results: The results from the study showed no significant change in the questionnaire answers between the three indicators of anxiety. But, there was a fair reduction in the analogue scores post-operatively in-patients who had open surgery. These same patients also had a lower palmar sweat response. But, pre-operatively patients who going to have open surgery had higher analogue scores. Conclusion: The two primary causes of anxiety were pain and being under anesthesia. Open surgery treatment resulted in lower levels of anxiety than non-invasive treatments.

Joey has a Kidney Stone….

References Asselman, M., & Verkoelen, C. (2008). Fructose intake as a risk factor for kidney stone disease. Kidney International, 73(2), Retrieved from CINAHL with Full Text database. Brown, S. (1990). Quantitative measurement of anxiety in patients undergoing surgery for renal calculus disease. Journal of Advanced Nursing, 15(8), Retrieved from CINAHL with Full Text database. Lewis, S.L., Heitkemper, M.M., Dirksen, S.R., O'Brien, P.G., & Bucher, L. (2007). Medical surgical nursing. St.Louis: Mosby, INC. . Patankar, S., Dobhada, S., Bhansali, M., Khaladkar, S., & Modi, J. (2008). A prospective, randomized, controlled study to evaluate the efficacy and tolerability of Ayurvedic formulation "varuna and banana stem" in the management of urinary stones. Journal of Alternative & Complementary Medicine, 14(10), Retrieved from CINAHL with Full Text database. (2008, June 16). Kidney Stones. Retrieved from (2009). Kidney Stones. Retrieved from (2009, June 23). Kidney Stones. Retrieved from (2009, September 30). Kidney Stones. Retrieved from (2009, October 8). Kidney Stones in Adults. Retrieved from (2009, October 8). Kidney and Urologic DiseasesSstatistics for the United States. Retrieved from

Medical Management of Stone Disease
Presenter: David Galvin Moderator: Mary Dononvan 8th May 2006

Introduction Lifetime risk 5-15% of stone formation
Annual incidence is 0.5% in Europe Increasing use of ESWL means stones are rarely analysed and recurrences are higher Increasing need for metabollic evaluation Overlap of urine supersaturation between stone and non-stone formers Factors: Promoters / Inhibitors / Anatomical

1 Slide on Stone Formation
Urine supersaturation of stone forming salts Exceeds the Solubility Product (SP) Depending on pH - crystals grow and aggregrate (metastable) Exceeds the Formation Product (FP) New crystals form and grow Crystals need to be FIXED or RETAINED for stones to form

Other Factors Promoters Infection Pyrophosphates Inhibitors Citrate
Magnesium Glycoaminoglycans

Effect of pH on Urinary Solubility of Lithogenic Substances
Ammonium Urate Uric Acid Cystine Solubility Phosphate pH Effect of pH on Urinary Solubility of Lithogenic Substances

Stone Composition STONE Struvite Whewellite Whedellite Dahlite
Brushite Whitlockite Utricite MINERAL Magnesium Amonium Phosphate Ca Oxalate Mononhydrate Ca Oxalate Dihydrate Carbonate Apatite Ca Hydrogen PO Dihydrate Beta Tricalcium Phosphate Uric Acid

Metabollic Work Up

Who Needs Metabollic Work Up ?
Recurrent Stone Formers All Children (struvite / cystine) Family History (cystine / xanthine / 2,8 DHA) At-risk for Recurrence Groups Black women Altered Calcium / Oxalate / Uric acid metabolism

Metabollic Disease 1 Altered Calcium Metabolism Hyperparathyroidism
Renal Tubular Acidosis (RTA) Medullary Sponge Kidney (MSK) Osteoporosis Sarcoidosis Form CaOx or CaP stones

Metabollic Disease 2 Altered Oxalate Metabolism
Primary Hyperoxaluria - Type 1 and 2 Enteric Hyperoxaluria Crohn’s Disease Ulcerative Colitis Intestinal Resection Malabsorption syndromes Form CaOx stones

Metabollic Disease 3 Altered Uric Acid Metabolism
Secondary to Cell Death Neoplasms, radiation, chemotherapy, anaemia Secondary to Enzyme defects Gout, Lesch-Nyhan syndrome Altered Uric acid Excretion Renal insufficiency, Metabollic acidosis Form Uric acid stones

Analysis: First Time Stone Formers
Urine Tests Urinalysis pH < Acidic urine constantly RTA > 7 Infection Erythrocytes, Leucocytes, Nitrites Specific Gravity >1.01 Dehydration Microscopy and Culture Spot Cystine (Brand’s test)

Analysis: First Time Stone Formers
Blood Tests Serum Calcium Urate High (>380) Uric acid stones Low (<120) Xanthine stones Creatinine

Recurrent Stone Formers: Full Metabollic Workup
Full Medical History GI disorders Including Medications (diuretics, Vitamin C) Family history Full Dietary History Stone Analysis Chemical analysis (dated) IR Spectroscopy or Xray Diffraction Bloods Urines CT Urogram +/- DEXA scan

Recurrent Stone Formers: Full Blood Work Up
Calcium Phosphate Urate Creatinine Parathyroid Hormone Optional ABG Bone Profile Renal Profile

Full Urine Analysis pH, Volume, Specific Gravity
Urinalysis Urine Microscopy and Culture Spot Cystine (Brands’) Test 24 Hour Urine Collection pH, Volume, Specific Gravity Calcium, Phosphate, Uric acid, Oxalate, Creatinine, Citrate Optional: Magnesium, Ammonium, Cystine Diet Assesment: Urea, Na, K, Cl and Sulphate

24 Hour Urine Collection Acidification of 24 hour urine
Prevents precipitation of calcium salts Prevents oxidation of ascorbic acid to oxalate Preservative (acid) solution 5% Thymol in Isopropanol, or 6M HCL (only if not testing for uric acid)

Additional Tests 1 If: 24 hour Calcium > 5mM (Hypercalciuria)
No response to medication / diet Differentiate between Absorpitive (type 1 or 2), Renal and Resorptive Hypercalciuria Calcium Loading Test 24 hours of low calcium diet / calcium poor water Next day: Initial urine (Blank) at 7am Followed by Calcium load (1g) at 9 am Second urine sample (Loading) at 12 pm

Hypercalciuria Idiopathic (20%) Absorptive (30%)
Excess intestinal absorption Type 1: Not affected by calcium intake Type 2: Only increases with increased intake Renal Reduced Calcium Reabsorption in distal tubule Leads to  PTH and secondary hyperparathyroidism Resorptive Secondary to primary hyperparathyroidism Increased intestinal absorption and bone resorption

Additional Tests 2 If: Urinary pH tested on several days does not drop < 5.8 RTA results in reduced H+ secretion in distal tubule Reduced HCO-/Cl- exchange leading to  Cl reabsorption = Hyperchloraemic Metabollic Acidosis = Increased mobilistaion of calcium and Phosphate from bone Ammonium Chloride loading test Taking one ammonium chloride tablet hourly between 8 am and 1 pm, five hourly urine samples are collected for pH analysis If pH falls < 5.4, there is no Renal Tubular Acidosis If pH does not fall, do ABG If bicarbonate and pH are low = Complete RTA If bicarbonate and pH are normal = Incomplete RTA

Renal Tubular Acidosis
Proximal and Distal RTA Only Distal RTA is important for stone disease 0.5% of all stone formers have Complete Distal RTA and are acidotic 3-5% of all stone formers have Incomplete Distal RTA and are not acidotic

Additional Tests 3 If: 24 hour urines demonstrate Hyperoxaluria
Need to differentiate between excess endogenous production (primary) and excess absorption (enteric) [13C2] Oxalate Absorption test 2 day test involving regular urine sampling A labelled oxalic acid dose is given at 8 am Day 2 The amount of labelled oxalate excreted in the urine is calculated > 10% oxalate absorption is abnormal and suggests enteric

Evaluating the Results
pH Urinary Calcium Uric acid Oxalate Citrate Phosphate Serum Urate Low or Normal High Low - High or Normal Struvite High >7 Uric Acid Low < 6 Xanthine Cystine Low <6

Interventions: General & Specific

General Measures Fluid Intake: 2.5 - 3 litres / day
Coffee / tea / juice / alcohol best avoided Ideally produce lts urine / day Maintain specific gravity > 1.01 Diet Encourage fresh fruit / veg / low fat products Avoid Animal fats and calories. Small meals. Lose weight. Exercise.

1. Calcium Oxalate 70-75% of all stones. M>F 2:1. 30-50 years
CaOx Monohydrate form in high oxalate conditions. Very hard and dark brown. CaOx Dihydrate form in high Ca or Mg conditions. Yellow and softer. Urine Low 24 hr citrate, volume and pH High 24 hr calcium, oxalate and uric acid

1. Calcium Oxalate Needs to looked for and treated
If Hypercalciuric  Measure PTH Look for low serum phosphate, raised ionised serum calcium and urinary cAMP Hypercalciuria > 8 mM/24 hrs Present in up to 56% of CaOx stone formers In recurrent formers, treatment can be started at 5 mM/24 hrs Hyperoxaluria present in 20-50% of patients It should be treated or recurrence rates are high Hypocitraturia in 50% of CaOx stone formers Needs to looked for and treated

1. Calcium Oxalate Hyperparathyroidism 80% Adenoma 15% Hyperplasia
5% PT carcinoma RTA - Complete Distal Correct acidosis with NaHCO- or K+ citrate (12-18mM/d)

1. Calcium Oxalate Diet Reduce Animal Protein Intake
Generally - no reduction in calcium intake But cut out hard cheese Restrict Calcium if > 8 mM/24 hrs Negative Ca+ balance leads to bone resorption Reduce Hi-Oxalate Foods (only 8% from diet) Spinach, nuts, chocolate, tea, rhubarb, berries High fiber diets to bind minerals in intestine

1. Calcium Oxalate Medical Tx if UCa > 5mM despite diet
Aim is urinary alkalinisation: Potassium Citrate (9-12g/d) Citrate binds Calcium and enhances excretion Care in Renal failure, Hypertension, Hyperkalaemia Sodium Bicarbonate (4.5g/d) Sodium can cause hypercalciuria ! Magnesium ( mg/d) Can be given if pH is normal or alkaline Care in renal failure

1. Calcium Oxalate Medical Tx if UCa > 8mM despite diet Options:
Thiazide Diuretics (Hydrochlorothiazide) Increases Calcium reabsorption in distal tubules Dose 25-50mg/d. Give with K citrate. Care: Gout, Diabetes, Impotence (!), Hypokalaemia Orthophosphates

1. Calcium Oxalate Primary Hyperoxaluria Pyridoxine (Vitamin B6)
Encourage normal Calcium Intake K Citrate Enteric Hyperoxaluria May be due to reduced Ca intake and less binding to Ox, High Vitamin C intake or Idiopathic Treat by Increasing Calcium Intake if Low, Give Oral Magnesium if Normal. Reduce fat Intake.

2. Uric Acid Stones 3 - 15% of all stones. Radiolucent.
Most patients are > 60 years old Only form in acidic urine (pH < 5.8) Low urine pH = Uric acid stone High urine pH = Urate stone Protein / purine rich diet - Alcohol excess % of gout sufferers form stones Chemolytic treatment is 90% effective

2. Uric Acid Stones Findings Serum Hyperuricaemia >380 Urine
Urine pH by strip constantly < 6.0 Low volume < 2lts Uric acid > 4mM/l (Hyperuricosuria)

2. Uric Acid Stones Treatment: Urinary Alkalinization
Aim pH of (Patient monitored with pH strips) Potassium Citrate / Sodium Bicarbonate Citrus juices / High bicarb mineral water Decrease Uric acid excretion Low purine diet Allopurinol Adenine  Hypoxanthine  Xanthine  Uric acid Instead Xanthine oxidase converts alloprurinol to oxypurinol Increase urine dilution (3 lts / day)

3. Struvite 4 - 6% of all stones
Always due to urease producing bacteria: Proteus / Pseudomonas / Klebsiella (gram -) Splitting urea forms NH4 and HCO3 =  pH F > M (2:1). Especially in fertile age / pregnancy Commonest stone in children < 5 years UTI increases ammonium and pH > 7 This reduces phosphate solubility Urinary Citrate and Volume are often low Magnesium Ammonium Phosphate stones

3. Struvite Serum Raised Uric acid > 380 Possibly raised Creatinine
Urine pH > 7 Leucocytes / Nitrites on urinalysis 24 hour urine Low Volume / Alkaline Urine pH > 7 Raised 24 hr Ammonium and Phosphate

3. Struvite Principles Complete Stone Removal
Eliminate urinary obstruction Treat underlying infection Treatment Long term antibiotic prophylaxis Acidify urine: pH < 6.2 L-methionine or Ammonium Chloride Dilution of urine (reduce bacterial concentration) Well balanced diet

4. Cystine Cystine stones are the result of an Inborn, Heritable (AR) Renal defect (1% of stones) Tubular reabsorption of 4 amino acids is reduced Only Cystine is poorly soluble Usually presents in teens (rarely childhood) Stone constituent is always excreted in excess Requires lifelong consistent treatment

4. Cystine Weakly radio-opaque Serum is normal Urine
24 hr Volume is low Quantitative analysis: Cystine > 8 mM Calcium / Oxalate and Uric acid may also be elevated Send MSU. UTI may be alkalinising urine.

4. Cystine Poor response to EWSL Often require auxillary procedures
Stent encrustation occurs quickly Chemolysis rarely possible but may be obtained by alkalinisation

4. Cystine Treatment Urine dilution
Urine volume > 3.5 lts / day (1.5 lts of urine at night) Urine Alkalinisation pH > 7.5. Use Alkaline citrate or Sodium Bicarb. Measure pH regularly throughout the day. Medications to reduce Urinary Cystine Ascorbic acid. Thiola (-mercaptopropionylglycine) Diet Low sodium. Low protein (avoid methionine). Drink juice.

Summary Modern therapies especially ESWL have made metabollic work up difficult Assessment is essential to reduce recurrence First timers: Urinalysis, MSU, Serum Calcium and Creatinine Recurrent Stone Formers: Serum and 24 hour urine analysis. Stone analysis. Metabollic anomalies in up to 85%

Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.),
STONE DISEASE ( Brief Overview ) Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.), Professor & HOD, Dept. of Urology, Sri Ramachandra Medical College & Research Institution Consultant Urologist & Renal Transplant Surgeon, Sri Ramachandra Hospital, Porur, Madras.

COMPARATIVE INCIDENCES OF FORMS OF URINARY LITHIASIS
Stone analysis in Percentage Form of Lithiasis India USA Japan UK Pure Calcium Oxalate Mixed Calcium Oxalate and Phosphate Magnesium Ammonium Phosphate (Struvite ) Uric Acid Cystine

Cause of Stone Disease Supersaturation of urine is the key to stone formation Intermittent supersaturation - Dehydration Crystal aggregation Bacterial Infection Defects in transport of Calcium and Oxalate by Renal epithelia E.Coli infection increases matrix content in urine . Proteus makes urine alkaline

Inhibitors & Promoters of Stone Formation in Urine
Inhibits crystal Growth - Citrate – complexes with Ca Magnesium – complexes with oxalates Pyrphosphate - complexes with Ca Zinc Inhibits crystal Aggregation Glycosaminoglycans Nephrocalcin Tamm- Horsfall Protein PROMOTERS Bacterial Infection Matrix Anatomic Abnormalities – PUJ obst., MSK Altered Ca and oxalate transport in renal epithelia Prolonged immobilisation Increased uric acid levels I.e taking increased purine subs– promotes crystalisation of Ca and oxalate ?? Nanobacteria – seen in 97% of renal stones

SOME DISEASES ASSOCIATED WITH HYPERCALCAEMIA & HYPERCALCIURIA
Hyperparathyroidism Leukemia Sarcoidosis Lymphoma Multiple myeloma Myxedema Hyperthyroidism Adrenal Insufficiency Metastatic Malig. Neoplasm's Vit. D Intoxication

TYPES OF KIDNEY / URETER STONES
OXALATE (CALCIUM OXALATE) PHOSPHATE URIC ACID & URATE CYSTINE

Uncommon Stones XANTHINE STONES – (Autosomal Recessive . Def of Xanthine Oxidase leading to Xanthinuria) DIHYDROXYADENINE STONE – ( Def. of enzyme adenine phospo ribosyl transferase ) SlLICATE STONES – Rare in humans ( excess intake of Antacid with Mg Trisilicate. Mostly in cattle due to ingestion of Sand ) MATRIX - Infection by Proteus - Radiolucent (all calculi have some amt ( 3%) of matrix but matrix calculus has 65% Matrix content in calculi)

Uncommon Stones TRIAMTERENE
– Anti-hypertensive used with hydroclorothiazide – spare Potassium. Mostly found as a nucleus in Ca oxalate or uric acid calculus Indinavir Stones - Drug to treat AIDS (4 to13%) Ephedrine or Guifenesin – Cough medicine - Radiolucent

Stones – Chemical Constituents
Whewelite – Calcium Oxalate Monohydrate – CaC2O4-H2O Weddelite - Calcium Oxalate dihydrate – CaC2O4-2H2O Brushite – Calcium Hydrogen phosphate dihydrate – CaHPO4 2H2O Whitlockite - TriCalcium Phosphate – Ca2(PO4)2 Struvite – Magnesium Ammonium hexahydrate – MgNH4PO4-6H2O

DD of Radiolucent filling defect on IVU in Ureter or Kidney
Must Know Uric Acid Calculus Matrix Calculus Sloughed Papilla Blood Clots TCC Renal Cysts Vascular Lesions Know For Brownie Points Xanthine Calculus Hydroxyadenine Calculus Ephederine Calculus Infection due to gas forming Org. Fungal Ball Tuberculoma Malacoplakia Hypertrophied Papilla Renal pseudo-tumour

OXALATE (CALCIUM OXALATE)
ALSO CALLED MULBERRY STONE COVERED WITH SHARP PROJECTIONS SHARP ® MAKES KIDNEY BLEED (HAEMATURIA) VERY HARD RADIO - OPAQUE Under microscope looks like Hourglass or Dumbbell shape if monohydrate and Like an Envelope if Dihydrate

PHOSPHATE STONE USUALLY ® CALCIUM PHOSPHATE
SOMETIMES ® CALCIUM MAGNESIUM AMMONIUM PHOSPHATE OR TRIPLE PHOSPHATE SMOOTH ® MINIMUM SYMPTOMS DIRTY WHITE RADIO - OPAQUE Calcium Phosphate also called ‘Brushite’ appears like Needle shape under microscope

PHOSPHATE STONES IN ALKALINE URINE ¯ ENLARGES RAPIDLY ¯ TAKE SHAPE OF CALYCES ¯ STAGHORN ® Struvite can form Stag-horn and appear like coffin lid under microscope

CALCIUM PHOSPHATE STONES
Hyperparathyroidism Ca P Renal Tubular Acidosis K CO2 Medullary Sponge Kidney - PTH Hormone Promotes renal production of 1-25-dihyroxycholecalciferol – active Vit.D and also increases absorption of Calcium and decreases Phosphorus absorption from Kidneys

URIC ACID & URATE STONE HARD & SMOOTH MULTIPLE YELLOW OR RED-BROWN
RADIO - LUCENT (USE ULTRASOUND) Under microscope appear like irregular plates or rosettes pKa of uric acid 5.75 – at this pH 50% of uric acid insoluble. If pH falls further - uric acid more insoluble

CYSTINE STONE AUTOSOMAL RECESIVE DISORDER USUALLY IN YOUNG GIRLS
DUE TO CYSTINURIA - CYSTINE NOT ABSORBED BY TUBULES MULTIPLE SOFT OR HARD – can form stag-horns PINK OR YELLOW RADIO-OPAQUE Under microscope appears like hexagonal or benezene ring – ask for first morning sample

CYSTINE STONE - Management
High Fluid Intake and Alkalanise Urine – dissolve most of the smaller cystine stones D-Pencillamine or MPG (Mercaptopropionylglycine) binds to cystine that is soluble in urine Side effects of Pencillamine restricts it use – Allergic rashes, GI problems- Nausea, Vomiting, Diarrhoea MPG better tolerated Large obstructive stones – Surgery required first pKa of cystine is 8.3, hence alkalinisisation above pH7.5 helps to dissolve the stones Cyanide Nitroprusside Calorimeteric Test for detecting Cystinuria. If positive do amino acid chromatography

Surgical Conditions and Stone Disease
Regional ileitis and Ileal Bypass Surgery for eg Obesity can lead to increase oxalate absorption and stone ds ileostomies - In Chr. Diarrhoea with– Bicabonate loss – systemic acidosis and acidic urine – increases risk of Uric Acid stones

HISTORY A. IS PATIENT DRINKING ENOUGH ? B. PROFESSION
C. ENQUIRE ABOUT UTI ® STONES D. FAMILY HISTORY E. LONG ILLNESS ® BEDRIDDEN ® STONES

MANAGEMENT OF STONES HISTORY : A. FIND OUT IF DRINKING ENOUGH LIQUIDS
(NOT DRINKING ENOUGH IMPORTANT CAUSE OF STONE FORMATION & GROWTH) Urinary supersaturation of salts in concentrated urine Atleast drink 3 lits to avoid stone formation

HISTORY (Cont...) B. ASK ABOUT THEIR PROFESSION DEHYDRATION ® STONES CAN FORM e.g. MARATHON NEAR A FURNACE, BRICK - LAYER, LABOURERS & WEAVERS TRUCK & BUS DRIVERS

HISTORY (Cont...) C. ENQUIRE ABOUT UTI ® STONES D. FAMILY HISTORY
E. LONG ILLNESS ® BEDRIDDEN ® STONES Zero Gravity state – astronauts on long space flights more prone to stones

CLINICAL FEATURES 1. PAIN IN 75 % OF THE CASES “RENAL COLIC” IF SEVERE AND ACUTE A) KIDNEY STONE FIXED PAIN IN THE LOIN B) URETERIC STONE PAIN RADIATES ® LOIN TO GROIN Both Stomach & Kidney supplied by celiac ganglion hence Nausea & vomiting common in renal colic

CLINICAL FEATURES (Contd....)
2) HAEMATURIA CAN BE FRANK OR ONLY FOUND ON DIP - STICK OR LAB. 3) PYURIA - IF INFECTION CAN HAVE PUS IN URINE

ON EXAMINATION 1. ACUTE PRESENTATION ABDOMEN TENSE AND RIGID
TENDERNESS PRESENT IN THE LOIN 2. IN ROUTINE PRESENTATION NO FINDINGS IN ABDOMEN

INVESTIGATIONS 1. FULL BLOOD COUNT TO CHECK FOR ANAEMIA IF GOING FOR SURGERY 2. SERUM ELECTROLYTES PLUS UREA / CREATININE / CALCIUM / URIC ACID / PHOSPHATE

INVESTIGATIONS (Cont...)
3. 24-HOURS URINE FOR ELECTROLYTES (Only if recurrent stone former) CALCIUM / OXALATE / URIC ACID / CYSTINE / CITRATE

4. PLAIN KUB X-RAY OF ABDOMEN (Mandatory) 5. IVU OR IVP (INTRA VENOUS UROGRAM) 6. ULTRASOUND (Mandatory)

INVESTIGATIONS IVU OR IVP (INTRA VENOUS UROGRAM) Not Mandatory
1in 40,000 patients die due to anaphylactic reaction to contrast Useful for radio-lucent stones & to detect Congenital Anomalies in Urinary tracts

CT – TO LOOK AT UNUSUAL ANATOMY OF THE KIDNEY To differentiate cause of acute colic – stone or anuria Suspected due to stone disease 8. DMSA OR DTPA OR MAG3 RENOGRAM - TO STUDY FUNCTION OF EACH KIDNEY.

Bilateral Ureteric Calculus in a patient presenting with Anuria
Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows on Gantry. These are rapidly performed and do not require contrast agents for reconstruction.

MANAGEMENT OF UROLITHIASIS
Non-invasive approach to urinary calculas-HALLMARK of last 20 yrs. Lithotripters – 1.Extra Corporeal Shock wave 2.Intra Corporeal Better fiber optics – Miniturisation of Telescopes Accessories - Innovative variety

Modern Management of Urolithiasis
ESWL Ureterorenoscopy Percutaneous Nephrolithotomy Laparoscopic Approach to stones Open Ureterolithotomy, Pyelolithotomy or Nephropyelolithotomy is required in less than 1 to 2% of modern stone management

TREATMENT (IDEALLY) MAJORITY : 80 TO 85 % of all stones can be treated by - EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) MINORITY : 15 TO 20 % SHOULD NEED MINIMALLY INVASIVE SURGERY (PCNL / URETEROSCOPY) (LESS THAN 1 % SHOULD NEED OPEN SURGERY)

EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)
SHOCK WAVES GENERATED UNDER WATER CAN TRAVEL THROUGH BODY WITHOUT ANY APPRECIABLE LOSS OF ENERGY. WHEN THEY ENCOUNTER STONES THE CHANGES IN DENSITY CAUSES ENERGY TO BE ABSORBED AND REFLECTED BY THE STONE & THIS RESULTS IN FRAGMENTATION OF THE STONES.

ESWL – For Urinary Tract Calculus

ESWL- FOUR MAIN ELEMENTS
ENERGY SOURCE FOCUSING DEVICE COUPLING DEVICE LOCALIZATION DEVICE

ESWL Urinary obstruction Infection Declining Renal Function
Absolute Contra-indication- Pregnancy Relative Contra-Indications for ESWL – Renal Colic Urinary obstruction Infection Declining Renal Function Significant Hematuria

COUPLING DEVICE “WATER BATH” “WATER FILLED CUSHION”
(KEEP PATIENT’S DRY)

ESWL-HISTORY 1963-EXPERIMENTS WITH “ SHORT WAVES” IN W.GERMANY BY PHYSICISTS AT DONIER SYSTEMS LTD 1980-DORNIER HUMAN MODEL ( HM-3) LITHOTRIPTER ARRIVED ON MARKET (STILL GOLD STANDARD WHEN COMPARING RESULTS WITH NEW MEASUREMENTS

ESWL & STAGHORNS Dornier HM-3 Monotherapy for STAGSHORNS -
30% Stone Free Rate (In Dilated Collecting System ) PCNL has higher overall Success Combination of PCNL & ESWL can give a stone free rates of 90% For ALL STONES IN THE KIDNEY

COMPRESSION-TENSILE WAVE CAUSES:
“Implosion” Rather than “Explosion”

ESWL & URETERIC CALCULI
For fragmentation fluid medium around stone necessary If stones impacted fragmentation may not occur “PUSH & BANG”-success Marginally HIGHER THAN “in situ ESWL” Trial of “in situ ESWL” – first choice “In situ ESWL” FAILS- “Rescue procedure”

ESWL COMPLICATIONS Haematuria – is quite common ( short term antibiotics Recommended ) Incomplete stone Fragmentation & Obstruction “Stienstrasse” ( stone street ) usually due to a large “ Leading fragment” ( Stents Recommended prior to ESWL for Calculi > 1.5 cm )

DESIGN BASIC LITHOTRIPSY

Renal Lithiasis Blood Pressure Study ( Patients treated 1984-1986 Dallus Study)
First Follow Up Second Follow Up No.Pts Annualized Rate No.Pts Annualized Rate of Hypertension of Hypertension ESWL % % non-ESWL % % Total

Basic Principles of “SHOCK WAVE” Lithotripsy

FRAGMENTATION BY SHOCK WAVES
ON COLLISION OF “ SHOCK WAVES” WITH CALCULI- ON FRONT SURFACE – COMPRESIVE FORCES ON BACK SURFACE OF THE STONE- REFLECTION OF COMPRESSION PULSE CREATES NEGATIVE OR TENSILE WAVE THAT TRAVEL BACK WARD THROUGH CALCULI ONCE TENSILE FORCE EXCEEDS “ COHESIVE STRENGTH” OF CALCULI- FRAGMENTATION OCCURS

ESWL – SPARK GAP/ EHL Electro-hydraulic Generator Located at Base of Water Bath Produces Shock wave by Electric Spark Gap of 15,000 to 25,000 Volts Lasting 1 Sec High Voltage Spark Discharge Rapidly- evaporates Water & Generators A “Shock Wave” by expanding Sarrounding Liquid

Mechanism of Stone Fragmentation by ESWL
On Front Surface – Compresive or positive Forces On Back Surface Of The Stone- Reflection Of Compression Pulse Creates Negative Or Tensile Wave That Travel Back Ward Through Calculi Once Tensile Force Exceeds “ Cohesive Strength” Of Calculi- Fragmentation Occurs Cavitation – Small air bubbles

Steinstrasse ( or Stone Street) – Post ESWL

Diet & Fluid Advice High Fluid Intake Restrict Salt (Na)
Oxalate Restrict Avoid high intake of Purine food Increased citrus fruits may help If hypercalciuria restrict Ca intake Role of Potassium Citrate in preventing Cal Oxalate stone ds – KCit lowers urinary calcium whereas Na Citrate does not lower Calcium due to Sodium load

LIQUIDS Moderate Amounts : High Amounts : Apple Juice Cocoa
Beer Fresh Tea Coffee Cola FOODS : Almonds, Asparagus, Cashew Nuts, Currants, Greens, Plums, Raspberries, Spinach

HIPPOCRATIC OATH : “I Will not cut, even for the stone, but leave such procedures for the practitioners of the craft”

Urinary Calculi Dave Pettersson MS4 Diagnostic Radiology August 2007

The Problem Many people get them…
12% lifetime incidence of urolithiasis. (Sierakowski) Expenditure on urinary stones is rising… $2 billion in (Pearle)

The Problem Care for urolithiasis is shifting from the inpatient to outpatient setting. Minimally invasive treatments are replacing others. So why the rise in cost? Does inappropriate imaging have something to do with it? (Pearle)

Goals Basics of urinary tract stone disease
Selecting the appropriate imaging option Findings on imaging

Epidemiology After first episode, stones tend to recur… Who gets them?
-12% lifetime incidence -Men affected 3 times as often as women -Incidence rises until age 60 After first episode, stones tend to recur… At 1 year 15% of patients will get another stone At 5 years… 35% At 10 years… 50% (Uribarri)

Five Common Stone Types
Percent of all stones Etiologic Factors Calcium Oxalate/ Calcium Phospahte 75 Underlying Metabolic disorder… (e.g., idiopathic hypercalcuria, hyperoxaluria) No metabolic disorder identified in 25% Struvite 10–15 Renal Infection… (Proteus, Klebsiella) Uric Acid 6 50% idiopathic; Hyperuricemia, hyperuricosuria Cystine 1-2 Renal tubular defect (Sandhua)

Why stones form… Urine becomes supersaturated…
1. Decreased urine volume 2. Abnormal urine pH 3. Absence of inhibitors 4. Infection A Portland Native!

Why stones form… Acidic urine: Uric acid, Cystine, Ca Oxalate
1. Decreased urine volume… Urine concentrates, supersaturates & crystals precipitate. 2. Urine pH affects solubility… Acidic urine: Uric acid, Cystine, Ca Oxalate Alkaline urine: Ca phosphate, struvite Promotes precipitation of:

Why stones form… 3. Absence of inhibitors
Citrate, glycosaminoglycans and Tam Horsfall proteins tend to inhibit stone formation 4. Infection: Urea-splitting organisms (Proteus, Klebsiella) generate ammonia and alkalinize urine Proteus Urease Staghorn calculi (struvite)

Who gets stones… Those with metabolic disorders that affect the concentration of urine solutes … Secondary: Hypercalciuria: primary hyperPTH, type 1 RTA, sarcoid Hyperoxaliuria: Crohn’s or other ileal disease with intact colon Hyperuricosuria: gout, myelo- and lymphoprolipherative disorders Idiopathic: hypercalciuria hyperoxaliuria hyperuricosuria hypocitraturia

Who gets stones… Those with structural kidney disease
Polycystic Kidney Disease Medullary Sponge Kidney (Learningradioplogy.com) (Emedicine.com) Horseshoe Kidney

Who gets stones… Zero gravity promotes bone demineralization causing elevated calcium levels in urine.

Who gets stones… Often, no underlying cause is found.

How they form… Two hypotheses…
Stones form in the renal medulla and are extruded by the collecting ducts Stones form on papilla A. Calcium oxalate stone at tip of renal papilla. B. Plaque and medullary collecting ducts exposed following stone removal. (Urologic Clinics of North America)

The fate of a stone… Depends on size and location of stone (Teichman)

Complications… A stone can lodge in the ureter, obstruct urine flow and dilate the proximal collecting system. Elevated hydrostatic pressure in the collecting system can have detrimental effects on kidney function… hydroureter hydronephrosis urine extravasation renal failure infection pyelonephritis perinephric abscess urosepsis

Presentation… + (Rolling Stones)

Presentation… Renal colic: Mechanism for pain:
-acute onset of sharp, spasmodic flank pain -episodes of severe pain last 20 – 60 minutes -location of pain depends on location of stone Mechanism for pain: -stone lodges in ureter -ureteral spasm and hyperperistalsis ensue -distention of renal capsule causes pain Stones are found most commonly at… The ureteropelvic junction The iliac vessels The ureterovesical junction

Presentation… Hematuria (microscopic or gross):
-90% of patients have hematuria on first day of pain -only 65% will have hematuria on days 3 and 4 (Kobayashi) -Sometimes nausea and vomiting (if celiac ganglion irritated) -May also see signs and symptoms secondary to complications

Presentation… Staghorn caluli are typically asymptomatic
Staghorn Coral Staghorn Calculus Staghorn Fern Staghorn caluli are typically asymptomatic (unless there is obstruction or infection)

Diagnosis… The standard work-up for suspected
renal colic begins with imaging... However, few patients fit neatly into algorithms. (Portis)

Diagnosis… For patients with flank pain and history of stones…
For patients with flank pain and a suspected first episode of urolithiasis… Non-Contrast Helical CT is recommended. For patients with flank pain and history of stones… Plain Film Radiograph is appropriate (ACR Appropriateness Criteria)

How is imaging helpful? Establish cause of pain & hematuria
Rule-out other potential causes of pain Stone size, location and density dictate treatment plan and expected course… Stone <5 mm will likely pass Stones >10 mm very unlikely to pass spontaneously

Diagnosis… After a patient’s first stone, should she/he be worked-up to find an underlying cause? Or should this evaluation be saved for the second bout of renal colic? There is no consensus!

Diagnosis… If a patient’s history, physical exam and labs are suggestive of uncomplicated urolithiasis, is a CT necessary? …many sources say yes. (Portis, Teichman,) But will CT results change management?

Diagnosis… The American College of Radiology recommends either IVP or non-contrast CT for evaluation of suspected first-time urolithiasis. (

Diagnosis… A work-up to find the underlying cause for stone formation might include… 24 hour urine Ca PO4 uric acid Oxalate Citrate Na Cr pH Blood test BMP PO4 PTH uric acid Spot urine UA urine sediment urine culture stone fragment analysis

Non-Contrast Helical CT
The preferred study for work-up of suspected urinary tract calculi. 1. Fast 2. No contrast 3. Characterize size & location of stone… (and guide management ?) 4. Characterize degree of urinary tract obstruction 5. Higher sensitivity (96%) and specificity (98%) for ureterolithiasis than any other study (ACR) 6. Able to evaluate for other sources of pain. 7. Cost of CT is comparable to IVP (Pfister) 8. Virtually all stones are radiopaque

Normal Urinary Anatomy (CT Urography)
Opacified upper ureters (arrows) Normal renal pelves enhanced with contrast (arrows) (McTavish)

Normal Urinary Anatomy (CT Urography)
Opacified lower ureters (arrows) Opacified distal ureters (arrows) (McTavish)

ureterovesical junction
Find the stone… Most commonly, the stone can be seen directly as an opacity within the urinary tract. Impacted calculus at ureterovesical junction Stone in left ureter (Catalano)

CT Findings… Staghorn calculus in right renal pelvis (Curhan)

CT Findings… Sometimes the ureteral mucosa is damaged
by the adjacent stone and becomes inflamed, edematous, and thickened. This can be seen on CT as a soft tissue rim surrounding the opaque stone… Soft-tissue rim sign (Rochester)

Soft-tissue rim sign… Sharp crystals of calcium oxalate
can damage adjacent ureteral mucosa (SEM micrograph) (Catalano) Ureteral stone (arrowheads) in right pelvis with periureteral stranding and soft-tissue rim sign

CT Findings… If a stone can’t be seen directly, then secondary signs of urolithiasis can help make the diagnosis… Perinephric fat stranding (secondary to edema) Hydronephrosis (dilation of kidney) Hydroureter: (dilation of ureters)

Secondary Signs on CT… Perinephric Stranding (Varanelli) (Catalano)

Secondary Signs on CT… Hydroureter Hydronephrosis
Hydronephrosis in right kidney (long arrow) and tiny right renal calculus (short arrow). Left kidney is normal. Dilated renal pelvis (arrowhead) with minimal surrounding fat-tissue stranding (Catalano) (McDonald)

Utility of Secondary Signs

CT Images of Stones There is ureteral dilation and perinephric
stranding, but I can’t see a stone. Why? The stone recently passed (dilation and stranding persist after passage). Indinavir stones (protease inhibitor for HIV) are one of the few stones not seen on CT (rare) The CT section thickness is too wide (discussed in a few slides) There is another cause for ureteral obstruction (look for alternate diagnosis)

Beware of Phleboliths…
Calcified remnants of thrombi in veins. Easily mistaken for urinary calculi on CT… Calcifications are consistent with ureteral stone (red arrowhead) and phleboliths (yellow arrowheads). (Urologystone.com)

Phleboliths -Often appear opaque on CT
-Have central lucency on plain film If uncertain about plebolith vs. urolith… Try to determine location. If in ureter, then calcification is a urolith If soft tissue rim is present, then likely a urolith If tail sign present, then opacity is likely a phlebolith (see right) If uncertainty persists, then a follow-up CT with contrast will opacify ureter Tail sign: tail of soft-tissue attenuation (arrow) extending anterior to phlebolith (Boridy)

CT Section Width A stone can be missed if the section width is too great, due to the effect of partial volume averaging. 5.0 mm 3.0 mm 1.5 mm CT images of same patient, at same level. The stone could easily be missed when the CT section width is 5.0 mm. This stone measured 3.0 mm. (Memarsadeghi)

Intravenous Urograpgy/Pyelography (IVU/IVP)
Intravenous contrast is filtered by the kidney and concentrated in the urine… Sequential radiographs are obtained to see how contrast moves through the urinary tract… This highlights urinary tract anatomy and provides information about renal function

IVU (IVP) Allow assessment of renal function
Until the mid 1990’s, IVU was study of choice for evaluation of suspected urolithiasis. Currently, it is the study of choice when CT is not available. (ACP) Advantages Allow assessment of renal function Shows location and degree of obstruction Assess size of stone (sometimes) Disadvantages Requires contrast Can take a while to complete Fail to identify alternate diagnoses IVP study showing normal urinary anatomy

IVP Urogram shows dilatation of left ureter
and collecting system caused by calcific distal ureteral stone (arrow). (Sudha) An abnormal IVU study showing obstructed, dilated left ureter and collecting system (Sudha)

CT vs IVP IVP was the standard for imaging of suspected urolithiasis until the mid 1990’s. IVP was replaced by Non-Contrast Helical CT as imaging study of choice for evaluation of suspected urolithiasis.

Why is CT preferred over IVP?
1. CT is faster 2. CT is safer as it does not require contrast 3. Overall, CT is more cost effect than IVP (Initial CT is more expensive than initial IVP, but with IVP there is the need for more follow-up imaging) (Pfister) 4. CT is more reliable in diagnosing nephrothiliasis 5. CT is more reliable in diagnosing alternate causes of flank pain 6. CT and IVP have same reliability at diagnosing obstruction (ACR, Smith) However, CT generates twice the radiation exposure of IVP (6.5 mSv vs. 3.3 mSv) (Pfister, Thompson)

KUB… Patients with a history of stones don’t
A plain film radiograph of the Kidneys, Ureters, and Bladder KUB… First choice of imaging in diagnosis of suspected urolithiasis in patinets with a history of stone disease and previous KUBs (ACR) Patients with a history of stones don’t need a CT for each episode of renal colic. Stone in right kidney

Plain Film Radiography…
For evaluating initial episodes of suspected urolithiasis, the KUB’s sensitivity for detecting stones is low (58%- 62%) (ACR) KUB will detect: calcium stones struvite cystine stones KUB will miss: uric acid stones small stones stones obscured by bones Radiograph of left kidney shows a large stone (arrow) (Susah).

Radiographs… Small calcification (arrow), suspected
for ureteral stone. (Catalano) View of pelvis shows radiopaque calculus. (Zagoria)

Ultrasonography (US)…
First choice for diagnosis of urolithiasis in… 1. pregnant patients 2. children Sonographic scan shows dilated intrarenal collecting system, consistent with obstructive urolithiasis. (Catalano)

US… Advantages 1. Safe, non-invasive…
Nephrolithiasis (arrows) without hydronephrosis (Sheafor) Advantages 1. Safe, non-invasive… ideal for pregnant patients & children 2. Sensitive for detecting urinary tract dilation

Disadvantages 1. Urinary tract dilation can take hours to develop, so the diagnosis of obstructive uropathy may be missed at the initial evaluation. 2. May miss small stones and stones in ureters 3. Patients need to be hydrated before exam 4. Stone size cannot be accurately measured US… ureteral stone (arrow) hydroureter (arrowheads) (Catalano)

Color Doppler Sonogram…
A ureteral calculus can obstruct urine flow and prevent the normal peristaltic expulsion of urine into the bladder, i.e. the “jet”. Scan of ureterovesical jets shows normal right color jet (R) and absent left jet (L) consistent with obstruction of the left ureter. (Catalano)

CT Urography… Used primarily for further work-up of abnormalities seen on initial unenhanced CT Axial CT urography image showing a filling defect in the right renal pelvis consistent with a large urothelial tumor. 3-D coronal reconstruction of CT urography image, showing contrast-enhanced renal collecting system, ureters, and bladder. Note duplicated system on left side. (

Magnetic Resonance Urography (MRU)
Limited role in evaluation of urinary tract stones. Dilatation of left ureter and collecting system (both images) (Sudah)

MRU MR urography can replace conventional
excretory urography (IVU) when the latter is contraindicated or undesirable. (Sudah) The ureteral stone is seen as a filling defect (arrow)

Treatment… Hydration Analgesia (IV or PO) (NSAIDS & Opiods) &
Stones <5mm are likely to pass spontaneously Stones >10mm are very unlikely to pass spontaneously Also, distal stones are more likely to pass spontaneously When to hospitalize? Obstruction Infection Intractable pain Not taking PO

Treatment… Another algorithm… (for what it’s worth). (Curhan) ESWL =
extracorporeal shockwave lithotripsy (Curhan)

Treatment… Most patients will likely benefit from
increased fluid intake (> 2 L/day) If an underlying cause has been identified in a recurrent stone former, then long-term treatments may be considered… Calcium stones: 1. thiazide diuretic 2. low sodium diet for hypercalciuria 3. DO NOT decrease Ca intake (causes hyperoxaliuria and osteoporosis)

Treatment… Struvite stones (Magnesium ammonium phospahate):
Hypocitraturia: potassium citrate replacement Treatment… Struvite stones (Magnesium ammonium phospahate): typically require stone removal with percutaneous nephrolithotomy 2. antibiotics to treat urease-producing bacteria Uric acid stones: 1. urine alkalinization (potassium citrate); 2. allopurinol Cystine stones: 1. high fluid intake 2. urinary alkalinization (potassium citrate)

Review Non-contrast helical CT is the study of choice for evaluation of a first episode of suspected urolithiasis. However, for suspected urolithiasis in a known stone former… consider a plain film radiograph first…. It may lower healthcare costs!

References ACR. American College of Radiology Appropriateness criteria: Acute onset flank pain Boridy IC, et al. Ureterolithiasis: value of the tail sign in differentiating phleboliths from ureteral calculi at nonenhanced helical CT. Radiology Jun;211(3): Catalano O, et al. Suspected Ureteral Colic: Primary Helical CT Versus Selective Helical CT After Unenhanced Radiography and Sonography AJR 2002; 178: Chen MY, et al. Can noncontrast helical computed tomography replace intravenous urography for evaluation of patients with acute urinary tract colic? J Emerg Med 1999 Mar-Apr;17(2): Curhan GC, et al. Diagnosis and acute management of suspected nephrolithiasis. UTDOL.com Accessed August 24, 2007. Kobayashi T, et al. Impact of date of onset on the absence of hematuria in patients with acute renal colic. J Urol 2003 Oct;170(4 Pt 1): McDonald MM, et al. Assessment of Microscopic Hematuria in Adults. American family physician. Vol. 73 No. 10 May 15, 2006 McTavish JD, et al. Genitourinary Imaging: Multi–Detector Row CT Urography: Comparison of Strategies for Depicting the Normal Urinary Collecting System. Radiology 2002;225: Memarsadeghi M, et al. Unenhanced Multi–Detector Row CT in Patients Suspected of Having Urinary Stone Disease: Effect of Section Width on Diagnosis. Radiology 2005;235: Pearle MS, et al. Urologic diseases in America project: urolithiasis. J Urol 2005; 173:848. Pfister SA, et al. Unenhanced helical computed tomography vs intravenous urography in patients with acute flank pain: accuracy and economic impact in a randomized prospective trial. Eur Radiol Nov;13(11): Epub 2003 Jul 24. Portis AJ. Diagnosis and Initial Management of Kidney Stones American Family Physician - Volume 63, Issue 7 (April 2001) Rochester A, et al. Assessment of the Clinical Utility of the Rim and Comet-Tail Signs in Differentiating Ureteral Stones from Phleboliths AJR 2001; 177:

Sandhua C, et al. Urinary Tract Stones—Part I: Role of Radiological Imaging in Diagnosis and Treatment Planning. Clinical Radiology. Volume 58, Issue 6, June 2003, Pages Sierakowski B, et al. The frequency of urolithiasis in hospital discharge diagnoses in the United States., Invest. Urol. 15 (1978), p. 438. Sudah M, et al. MR Urography in Evaluation of Acute Flank Pain: T2-Weighted Sequences and Gadolinium-Enhanced Three-Dimensional FLASH Compared with Urography. AJR 2001; 176: Sudah M, et al. Genitourinary Imaging: Patients with Acute Flank Pain: Comparison of MR Urography with Unenhanced Helical CT. Radiology 2002;223: Sheafor DH, et al. Nonenhanced Helical CT and US in the Emergency Evaluation of Patients with Renal Colic: Prospective Comparison. Radiology. 2000;217: Smith RC, et al. Acute flank pain: comparison of non-contrast-enhanced CT and intravenous urography. Radiology 1995 Mar;194(3): Teichman J. Acute Renal Colic from Ureteral Calculus. NEJM Volume 350: February 12, 2004. Uribarri J et al. The first kidney stone. Ann Intern Med 1989 Dec 15;111 (12): Urologic Clinics of North America. Pathogenesis of Renal Calculi. Volume 34, Issue 3 (August 2007) Varanelli MJ, et al. Relationship Between Duration of Pain and Secondary Signs of Obstruction of the Urinary Tract on Unenhanced Helical CT AJR 2001; 177: Zagoria, et al. Abdominal Radiography After CT Reveals Urinary Calculi: A Method to Predict Usefulness of Abdominal Radiography on the Basis of Size and CT Attenuation of Calculi. AJR 2001; 176:

Kim Applebee Alex Kaullen

Similar presentations

Presentation on theme: "Kim Applebee Alex Kaullen"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Kim Applebee Alex Kaullen

Similar presentations

Presentation on theme: "Kim Applebee Alex Kaullen"— Presentation transcript:

Similar presentations

About project

Feedback