2. Kidney Stones (Urolithiasis, Nephrolithiasis)
By: E. Salehifar (PharmD, BCPS)

3. Background Evidence of stones in a 7000 yo Egyptian mummy
Very common (2.7 million visits, >600/000 emergency situations)
Men>Women
More stones pass out without any intervention
Treatment with various techniques

4. Urinary Tract

5. Renal Tract Stones
Calcium
Urate
Cystine
Infection (Struvite)
Others

6. Ca 80 yes ↑ca, oxalate, ↓citrate, ↓ vol Urate 10 no ↑urate, ↓pH, ↓ Vol
Stone type
% of patients
Visible on X-ray
Risk factors in urine Ca 80
yes
↑ca, oxalate,
↓citrate,
↓ vol
Urate 10 no
↑urate, ↓pH, ↓ Vol
Cystine 2
weakly
↑cystine
Infection (Struvite) 5
pH↑, infection
Others 3

7. Calcium Stones
Calcium Oxalate
Calcium Phosphate
Calcium Carbonate

8. Calcium Oxalate Calcium Phosphate

9. Calcium Carbonate

10. Urate Stones

11. Struvite

12. Cystine

13. Others

14. Stone Formation Causes are unclear
↑urine concentration of Ca, Oxalate, phosphate, uric acid and cystine
↓ citrate
Drugs: Loop diuretics, ↑ Vit D, Indinavir
food?, family history, UTI, blockage of the urinary tract, Debris or other crystals
Nephrocalcinosis (mainly in medulla): Hyperparathyroidism, Distal RTA (>70%), cystic kidney disease

15. Ca Stones Formation Hypercalciuria (In 50% of nephrolithiasis)
Idiopathic, Hyperparathyroidism, ↑Vit D, Malignancies
associated with obesity & HTN
↑urine concentration of oxalate
Diet, ileal disease, primary hyperoxaluria type 1
↑urine concentration of phosphate
↓ citrate ( idiopathic, Distal RTA)

16. Clinical Presentation
Often do not cause any symptoms
Renal colic with intense flank pain often radiating to the groin, burning sensation
Sometimes with nausea, vomiting, hematuria, (fever and chills in infected patients)

17. Diagnosis Plain Radiography (Ca, Struvite)
Sonography (size & location of all stone types)
<6 mm pass spontaneously, >1 cm will not
CT Scan
IVP (Intravenous Pyelogram)

18. Investigations
Exclude bowel disease, diarrhea & the use of antacids and diuretics
Diet assessment: Fluid, protein, Na, Ca, Oxalate, Purine & vit D
Family history
Stone analysis
Baseline: Urine Analysis, serum Ca, P, urate, BUN, Cr
Recurrent stones: 24-h urine collection
Volume, Osmolality, Ca, P, Oxalate, Citrate, Urate, Na, Cr, pH as well as serum Na, K, Cl, bicarbonate

19. Prevention Lifestyle changes To drink more liquids
Dairy product ?, Calcium pills?
↓ meat ( patients with acidic urine), ↓ vit D
↓ Oxalate (beets, chocolate, coffee, cola, nuts, rhubarb, spinach, strawberries, tea, wheat bran)

20. Treatments General Medical Surgical Stone removal
Water (>2-3 lit/day), Pain killers
Medical
Surgical
Stone removal
Extracorporeal Shock Wave Lithotripsy (ESWL)
Percutaneous Nephrolithotomy
Ureteroscopic removal

21. Medical Therapy Hydrochlrothiazide (with low Na diet) Allopurinol
Citrate potassium
Thiola and Cuprimine (to ↓ cystine in the urine)
UTI Prevention (after removal of struvites)
Parathyroidectomy

22. Surgical Treatment Was necessary until 20 years ago
Recovery time: 4-6 W
Surgery for stone that:
Does not pass after a reasonable time & causes constant pain
Is too large to pass or is caught in a difficult place
Blocks the flow of urine
Causes ongoing UTI
Damages kidney tissue or causes bleeding
Has grown larger (as seen on followup X ray)

23. Extracorporeal Shock Wave Lithotripsy (ESWL)

24. Extracorporeal Shock Wave Lithotripsy (ESWL)
The most frequently used procedure
Most need mild anesthesia with short recovery time
Complications:
Hamaturia
Bruising in back or abdomen (ASA should be avoided)
Discomfort caused by stone passage (stent in ureter)
Is not ideal for large stones

25. Percutaneous Nephrolithotomy (PN or PCN)

26. Percutaneous Nephrolithotomy (PN or PCN)
For large stone or difficult location for ESWL
Some type of energy probe may be needed to break the large stones
Many need to nephrostomy tube
Hospitalization for several days
Advantage to ESWL: Stone removal by surgeon

27. Ureteroscopic Stone Removal

28. Ureteroscopic Stone Removal
For mid and lower ureter stones
Passage of fiberoptic ureteroscope, stone removal by cage-like device or shattering with a shock wave
A small tube or stent may be inserted

29. Hope Through Research
Why do some people continue to have painful stones?
How can we predict, or screen, those at risk for getting stones?
What are the long-term effects of lithotripsy?
Do genes play a role in stone formation?
What is the natural substance(s) found in the urine that blocks stone formation?

30. For More Information!
(American Foundation for Urologic Disease)
(American Urology Association)
(National Kidney Foundation)