Download presentation
Presentation is loading. Please wait.
1
NEPHROLITHIASIS SCOPE OF THE PROBLEM
Incidence 0.10 – 0.5% population/yr High cost in yearly health care dollars High morbidity: pain, obstruction, bleeding, infection, loss of work Males >>Females except for infection related stones
2
COMMON STONES Calcium oxalate Calcium phosphate Struvite-apatite
Cystine Uric acid
3
STONE EVALUATION Stone History Family History Medications
Dietary Considerations Urologic Procedures Radiologic Studies Urinalysis Stone Analysis Metabolic Evaluation
4
STONE HISTORY Total number of stones Frequency of analgesic use
Time off work Symptoms: renal colic, renal ache History of UTI, gout, diarrhea, malabsorption, myeloproliferative disorders
5
STONE EVALUATION Stone History Family History Medications
Dietary Considerations Urologic Procedures Radiologic Studies Urinalysis Stone Analysis Metabolic Evaluation
6
STONE-PROVOKING MEDICATIONS
STONE TYPE MECHANISMS Acetazolamide Ca ox, Ca phos Hypercalciuria Vitamin C Ca ox Hypocitraturia Calcium supplements Hyperoxaluria Vitamin D Antacids Theophylline Nifedipine Probenecid, ASA Uric Acid Hyperuricosuria
7
DIETARY CONSIDERATIONS IN NEPHROLITHIASIS
Fluids Dairy products Salt Protein Animal Vegetable Oxalate Alcohol
8
STONE EVALUATION Stone History Family History Medications
Dietary Considerations Urologic Procedures Radiologic Studies Urinalysis Stone Analysis Metabolic Evaluation
9
UROLOGIC PROCEDURES Anatrophic Nephrolithotomy
Percutaneus Nephrolithotomy Extracorporeal shock lithotripsy Ureteroscopy (laser)
10
RADIOLOGIC APPEARANCE OF CALCULI
Radiopaque Calculi Radiolucent Calculi Calcium Oxalate Uric Acid Calcium Phosphate Struvite-Apatite Cystine
11
STONE EVALUATION Stone History Family History Medications
Dietary Considerations Urologic Procedures Radiologic Studies Urinalysis Stone Analysis Metabolic Evaluation
12
URINALYSIS CRYSTALLURIA
Calcium Oxalate Calcium Phosphate-Apatite, Brushite Struvite—Magnesium Ammonium Phosphate Uric Acid Cystine
15
STONE EVALUATION Stone History Family History Medications
Dietary Considerations Urologic Procedures Radiologic Studies Urinalysis Stone Analysis Metabolic Evaluation
16
STONE ANALYSIS RADIOPAQUE STONES
STONE TYPE METABOLIC ETIOLOGY Calcium oxalate Hypercalciuria, Hyperoxaluria Hyperuricosuria, Hypocitraturia Hypomagnesiuria Calcium phosphate Hypercalciuria, PHPT, Distal RTA Sodium Alkali Therapy Struvite or Carbonate-apatite UTI Cystine Cystinuria
17
STONE EVALUATION Stone History Family History Medications
Dietary Considerations Urologic Procedures Radiologic Studies Urinalysis Stone Analysis Metabolic Evaluation
18
METABOLIC CLASSIFICATION OF NEPHROLITHIASIS
Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia Hypomagnesiuria Altered urinary pH Cystinuria Low urinary volume
19
METABOLIC EVALUATION OF NEPHROLITHIASIS
Blood Chemistries CBC PTH Urine Urianalysis Culture & Sensitivity Cystine 24-Hour Urine Collections Random Diet Restricted Diet Fast and Calcium Load Test
20
24 HOUR URINE COLLECTIONS
TOTAL VOLUME SODIUM pH Potassium Calcium Uric acid Phosphorus Oxalate Magnesium Creatinine Citrate Sulfate
21
NEPHROLITHIASIS COEXISTENCE OF METABOLIC DERANGEMENTS N=1270
CATEGORY PERCENT Hypercalciuria 60 Hyperuricosuria Calcium Nephrolithiasis 36 Uric Acid Nephrolithiasis 10 Hyperoxaluria 7 Hypocitraturia 31 Hypomagnesiuria Infection 6 Cystinuria <1 Low Urinary Volumes 15 No Metabolic Abnormality 4 Difficult to Classify 5
22
CYSTINE STONES Decreased renal tubule absorption of cystine, ornithine, lysine and arginine (COLA) Autosomal recessive Large, radiopaque, often staghorn Rx: thiola, D-penicillamine, captopril
23
INFECTION – STRUVITE STONES
urease Urea CO2 + NH NH4+ NH4 + Mg2 + PO Struvite Carbonate + PO carbonate apatite
24
INFECTION – STRUVITE STONES
Radiopaque, staghorn Women > men Associated with chronic infection with urease producing organisms Poor prognosis: Rx: surgery, lithotripsy, antibiotics, acetohydroxamic acid
25
URIC ACID STONES Associated with gout, GI disease, neoplasm
Radiolucent Fluids, diet, alkali, allopurinol
26
DEFINITIONS OF HYPERCALCIURIA
24 hour Urinary Calcium Excretion > 200 mg/day 1 week on Ca and Na restricted diet (40 mg Ca, mEg Na) 24 hour Urinary Calcium Excretion > 4 mg/kg/day 24 hour Urinary Calcium Excretion > 250 mg/day-females, > 300 mg/day--males
27
FAST AND CALCIUM LOAD TEST
Normal fasting value <0.11 mg Ca/mg Cr (GFR) Normal postload value <0.20 mg Ca/mg Cr
29
ABSORPTIVE HYPERCALCIURIA
Primary Defect – increased intestinal absorption of Ca Location of Lesion – Jejunum Inheritance – autosomal dominant Animal Model – genetically Hypercalciuric rat Skeletal Status – normal to increased cortical bone density Calcium Balance - normal
30
ABSORPTIVE HYPERCALCIURIA
Sodium Cellulose Phosphate Urinary Ca > 350 mg/day Side effects – hyperoxaluria, hypomagnesiuria Thiazide + Potassium Citrate Amiloride
32
RENAL HYPERCALCIURIA Primary Defect – impaired tubular reasborption of Ca Location of Lesion - ? Proximal tubule No effect of Diet on Calcium Excretion 1,25-(OH)2D3 – increased Skeletal Status – decreased cortical bone density Calcium Balance - negative
33
RENAL HYPERCALCIURIA Thiazide Potassium Citrate
35
PRIMARY HYPERPARATHYROIDISM
Primary Defect – parathyroid glad adenoma or hyperplasia 1,25-(OH)2D3 – PTH- dependent increased renal synthesis Skeletal Status – decreased cortical bone density
36
PRIMARY HYPERPARATHYROIDISM
Surgical Management Medical Management Estrogen Orthophosphates
38
RENAL PHOSPHATE LEAK ABSORPTIVE HYPERCALCIURIA TYPE III
Primary Defect – increased urinary phosphate 1,25-(OH)2D3 – increased Skeletal Status – decreased bone density Calcium Balance – negative Role of Diet
39
RENAL PHOSPHATE LEAK TREATMENT
Orthophosphates
40
MANIFESTATIONS OF THE HYPERCALCIURIAS
FEATURE AH RH PHPT RPL Serum Ca Normal High Serum Phos Low PTH Normal/Low Enhanced Fasting Urinary Ca <0.11 >0.11 Postload Urinary Ca >0.20
41
TREATMENT OF NEPHROLITHIASIS CONSERVATIVE MANAGEMENT
Fluids to maintain 3-8 L Urinary Volume/Day Diet No Calcium Restriction Sodium Restriction Limited Purine Intake Oxalate Restriction
Similar presentations
