1. Relevance of Stone Analysis in Clinical Practice An Update Sindh Institute of Urology and Transplantation Karachi, Pakistan Prof. Mirza Naqi Zafar Department of Pathology

2. Incidence of stones in India Comparison of paediatric stone formers in India and UK BMJ, 1931

3. Malignancies 4% Miscellaneous 9% Prostate 25% Trauma 2% Urolithiasis 59% Spectrum of Adult Urological Diseases n=19732

4. PUV (3.1%) Urolithiasis 9358 (62%) PUJO (10%) Primary VUR (3.1%) Stricture urethra (2.7%) Others (10.6%) Extrophy Epispadias Hypospadias Neuropathic Bladder Spectrum of Paediatric Urological Diseases n=15093

5. Age n=20,000 Age in Years % of patients Female Male SIUT DATA

6. Laboratory Work-up of Stone Formers Blood Complete Blood picture Renal function Calcium Uric acid Phosphate Optional Magnesium Plasma oxalate PTH Blood gases Genetic Analysis Spot Urine Routine analysis Crystalluria Culture & sensitivity 24 hour Urine Analysis Urinary risk factors Calcium Uric acid Phosphate Oxalate Citrate Cystine screening Others Optional Ammonium Test to exclude RTA Stone Analysis

7. Chemical Composition of Stones Identify metabolic conditions prevailing during stone formation Help develop treatment and preventative strategies to reduce risk factors

8. Methods of analysis for stone composition Chemical Fourier transformation infrared spectroscopy (FTIR) Scanning electron microscopy

9. Frequency of Compounds in Stones Formers CompoundsRenal n=4348 Renal n=2798 p. Value Calcium Oxalate 376386.5% 203172%0.01 Calcium Phosphate Apatite 211748.6% 74326%0.001 Uric Acid 94821.8% 2077%0.001 Ammonium Hydrogen Urate 57013.1% 148253%0.001 Struvite 2996.8% 27810%0.01 Others 952.1% 110.4%0.91 Adult: Pure = 1864 (34.5%) Paediatric: Pure = 1794 (38.6%) AdultPaediatric

10. Changing Composition 21345 1 Ca OX 2 Struvite 3 Ca OX 4 Ca PO 4 5 Ca PO 4

11. Frequency of Compounds in Core and Surface of Pediatric Renal Stone Formers (n=1831) CoreSurface

12. Age Frequency of AHU and CaOx Stones Age (Yrs) Number AHU (584) AHU+CaOx (1129) CaOx (737) In children most stones start as Ammonium Urate

13. ESWL development at SIUT DL50 EDAP SLK HM4 DLS II SLXF2 Electrohydraulic PizoceramicElectromagnetic

14. Lithotripsy Fragments

15. Age Frequency of Patients for Stone Analysis n=10040

16. SEM with EDS Analysis of Fragments Calcium phosphate Calcium oxalate monohydrate X 2000 Ammonium acid urate

17. Stone Composition Relationship to Imaging

18. Stone Density By X rays

19. CT Pyelograms and Hounsfeld Units

20. Scanning electron microscopy Ammonium Hydrogen Urate and Calcium Oxalate stones SEM x 1000 AHU Stone Abundance of organic matrix and small crystalline component Organic Matrix Crystal structures SEM x 1000 CaOx Stone Abundance of crystalline component and small organic matrix

21. Relationship of Hounsfeld units (HU) and HU Density In Stones With Single Constituent

22. HU and HUD in Pure stones and their mixtures

23. Stone Composition Relationship with Metabolic Risk Factors

24. General aspects of Urinary Stone Formation

25. Unstable zone Metastable zone Undersaturated zone Crystal dissolution Solubility product Heterogeneous nucleation Induced nucleation Crystal growth Crystal agglomeration Formation product band Homogenous nucleation Increasing relative supersaturation Saturation Dynamics in Stone Formation

26. Metabolic Studies in Adult Stone Formers and Controls at SIUT VariableStone-formers ControlsP (chi-square) Urine Urine volume <1000 mL/24 h76 (20)28 (16)NS Hypercalciuria, >250 mg/24 h30 (08)08 (4.7)NS Hyperuricosuria, >700 mg/24 h38 (10)0<0.001 Hyperoxaluria, > 40 mg/24 h195(51.8)38 (22)<0.001 Hyperphosphaturia, >800 mg/24 h45 (11.9)16 (9.5)NS Hyponatriuria, <300 mg/24 h45 (11.9)0<0.001 Hypocitraturia, <300 mg/24 h214 (57)60 (35)<0.001 Hypomagnesuria, <60 mg/24 h126 (33.7)08 (4.7<0.001 Normal 48 (12.7)98 (58)<0.001 Blood Hypercalcaemia, >10.57.45.0NS Hyperuricaemia, >6.512.90<0.001 Hypokalaemia, K<3.535.05.0<0.001 Source: BJUI 2002; 89:62

27. Urinary Risk Factors in Stone Formers and Siblings Percent  UA  Na  Oxalate  Citrate  PO4 p=0.04 Not significant Stone former (n=615) Sibling (n=78)  Ca  NH4  Volume p=0.02p=0.03p=0.004

28. Urinary Risk Factors in CaOx Stone Formers n=228 Vol ↓ U.A↑ Cal↑ Ox ↑ Phos ↓ pH ↓ Mg ↓ Cit ↓ Na ↓ K↓K↓ Concentrated Urine High Uric Acid High Calcium High Oxalate Low pH Low Citrate Low Magnesium Low Phosphate Low Sodium Low Potassium Calcium Oxalate Crystallization

29. Urinary Risk Factors in AHU Stone Formers n=193 Vol ↓ U.A↑ Amm ↑ K ↓ Na ↓ Mg ↓ Cit ↓ pH 6-7 Protein ↑ Concentrated Urine High Uric Acid High Ammonia High Protein Melien pH in the normal range Low Sodium Low Potassium Low Citrate Low Magnesium Help crystallization Ammonium Urate Formation Preferential

30. Crystallization Studies in the native urine of Calcium Oxalate Stone Formers Laube N, Schneider A, Hesse A. A new approach to calculate the risk of calcium oxalate crystallization from unprepared native urine. Urol Res. 2000;

31. Crystallization Index The Bonn risk index (BRI) is a new strategy for the evaluation of the risk of calcium oxalate stone formation BRI determines the capacity of native urine to produce calcium oxalate crystals taking into account both lithogenic and inhibitory factors present in the urine. Crystallization of calcium oxalate is induced in native urine by addition of ammonium oxalate in unprepared urine.

32. Bonn Risk Index Machine

33. Induced crystals in native urine Ca Oxalate (mono aggregation)

34. Real Time Scans Patient Sibling

35. Before surgery After surgery Mean BRI 1.4 ± 1.4 3.4 ± 1.8 Crystallization index BRI before and after stone surgery p < 0.002

36. Impact of Dietary and Medical Management on Urinary Risk Factors At presentation n = 1892 Follow-up n = 1575 p. Value Hypovolumia31%5%0.0001 Hyperuricosuria26%6%0.0001 Hypercalciuria26%5%0.0001 Hyperoxaluria43%15%0.0001 Hypocalciuria20%5%0.0001 Hyponatriuria38%11%0.0001 Hypokaluria47%8%0.0001 Hypocitraturia87%10%0.0001 Rizvi et al: Indian Journal of Urology 2012

37. In multiplicity of factors Stones hold the final answer ! Pre-urinary Risk factors Urinary Risk factors Chemical physical consequences Anomalous crystalluria Genetic factors Age and sex Familiarity Race Low volume Hypercalciuria Hyperoxaluria Hyperuricuria pH alterations Low citrate Low magnesium Low pyrophosphate GAG deficit Tamm-Horsefall Nephrocalcin Super saturation Low inhibitory power Cell damage Number Size Aggregation Stone Environmental factors Climate/season Profession/social class Nutritional factors Body weight Animal proteins Carbohydrates Fats Calcium Oxalate Salt Potassium Magnesium Vegetable fibres Hydration Meschi T et al, Urologia Int, 2004