1. Minitopic
Nephrolithiasis

2. 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.

3. Diagnosis

4. 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 mg
: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

5. 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

6. 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.,

7. 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

8. 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

9. 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

10. 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

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