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RGU Exam 3 > Calculus Disease > Flashcards

Calculus Disease Flashcards

1
Q

Age of peak incidence of renal stones

A
  • 30-60
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2
Q

Male:Female ratio of renal stones

A
  • 3:1
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3
Q

Risk factors for renal stones

A
  • 30-60
  • Male
  • Family history (3x risk)
  • Increasing chance w/ weight
  • History of stones

*within 1yr - 10-15%

*5yrs - 50-60%

*10yrs - 70-80%

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4
Q

Factors influence stone formation

A
  • Diet
  • Climate
  • Genetics
  • Gender
  • Water supply (hard water inc. chance)
  • Occupation/stress
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5
Q

Diet factors that contribute to stone formation

A
  • Oxalate
  • Animal protein and fat
  • Vit. D and C
  • Phosphorous
  • Calcium
  • Fish oils
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6
Q

Most common renal stone

A
  • Calcium oxalate (up to 80%)
  • Calcium oxalate monohydrate; hard
  • Calcium oxalate dihydrate; less hard
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7
Q

Renal stone assoc. w/ hyperparathyroidism and renal tubular acidosis

A
  • Calcium phosphate
  • Often contain calcium oxalate
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8
Q

Effects of animal protein in stone formation

A
  • Inc. calcium, sulfate, uric acid
  • Dec. pH, citrate
  • All increased risk factors for recurrent stone formation
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9
Q

Most important factor in the formation of stones?

A
  • Urine volume
  • Dilute urine really prevents the crystallization of anything
  • 2.5L or more urine necessary
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10
Q

Urine pH which promotes renal stone formation

A
  • pH below 5.5 or above 7.5
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11
Q

Uric acid stones

A
  • Accounts for 5-10% of renal stones in USA
  • 24-40% of gout pts develop uric acid stones
  • 25% of pts w/ uric acid stones develop gout
  • Prevalence is 2-39% worldwide
  • Solubility of stone formation is dependent upon pH of <5.5
  • Form secondary to lack of uricase
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12
Q

Urica acid stone etiology

A
  • Uric acid is the end product of purine metabolism (breakdown of protein)
  • Increased dietary purine intake
  • Uricosuric drugs impair uric acid reabsorption from proximal tubule
  • Obesity and alcohol consumption
  • Myelo- and lymphoproliferative diseases
  • Inborn metabolic disorders
  • Chronic diarrheal syndromes
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13
Q

Uric acid stones clinical characterisitcs

A
  • Renal colic (not that specific)
  • Hematuria (not that specific)
  • Low urinary pH (<5.5) (specific)

- Neg. plain x-rays (uric acid is radioluscent)

*calcium oxalate/phosphate are radio-opaque so will show up on x-ray as long as they are large enough

  • CT or U/S confirmation
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14
Q

Struvite calculi

A
  • Named in honor of Baron H.C.G. von Struve
  • Composed of magnesium ammonium phosphate and carbonate apatite
  • Also referred to as “infection”, “urease” and “triple phosphate stones”
  • Compries 10-15% of all human urinary stones
  • More prevalent in females than males (3:1)
  • Most prevalent form in those w/ supravesical diversions and neurogenic bladders
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15
Q

Struvite calculi predisposing factors

A
  • Urinary infection w/ urease-synthesizing organism is an essential prerequisite
  • Bacteria are contained within the interstices of concretions and are protected from antibiotic therapy
  • Urine pH is generally >7.5`
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16
Q

Urease producing organisms

A
  • Organisms that cause struvite calculi
17
Q

Struvite calculi clincal manifestations

A
  • Branched or staghorn calculi are commonly infection induced
  • Pts often have few symptoms: females may have recurrent cystitis
  • Often assoc. w/ long term use of indwelling catheters
  • May have non struvite elements
  • Recur often in pts who do not undergo complete removal
18
Q

Cystinuria

A
  • Inborn error of metabolism characterized by a disturbance in renal and intestinal handling of cystine
  • Result is an excessive excretion of cystine
  • More common in 2nd and 3rd decades
  • Both sexes w/ equal prevalence
  • Urinalysis reveals hexagonal crystals
19
Q

Xanthine stones

A
  • Gene mutation results in xanthine oxidase enzyme deficiency
  • Inability to convert xanthine into uric acid
  • No specific treatment to reliably prevent stones
20
Q

Medical managemnt for 1st time stone former

A
  • Should evaluate and treat single stone formers as other individuals w/ recurrent stone disease
  • No difference b/w solitary and recurrent stone disease
  • 21% of 860 consecutive pts. —> 1st time stone formers

*71% of these pts. had metabolic abnormalities

*relapse rate similiar to multiple stone formers

21
Q

Absolute indicators for a work-up in 1st time stone formers

A
  • B/L stones
  • Recurrent stones
  • Family hx
  • Children
  • Solitary kidney (1 kidney)
  • African american
  • Skeletal disease
  • Bowel disease
  • Bowel surgery
  • Medical condition

Any pts. w/ stones composed of cystine, uric acid or struvite

22
Q

Relative indicators for a work-up in 1st time stone formers

A
  • Pilots or freq. business travelers
  • 1st time stone formers aged <20 or >50
  • Pts w/ difficult to treat stones
  • Immuno-compromised pts
  • 1st time female stone formers
23
Q

Urinary stone conservative medical management measures

A
  • High fluid intake (>3L/day)
  • Sodium restriction
  • Oxalate restriction
  • Avoid purine gluttony
  • Increase citrus fruit intake
  • Moderate calcium restriction in hypercalciuric pts.
24
Q

Allopurinol

A
  • Treats hyperuricosuria
  • Reduces uric acid synthesis
  • Lowers urinary uric acid
  • Retards spontaneous nucleation of calcium oxalate
  • May be useful w/ dietary purine overindulgence
25
Q

Potassium citrate for hyperuricosuria

A
  • Effective alternative to allopurinol
  • May reduce urinary saturation of calcium oxalate
  • Inhibits urate induced crystallization of calcium oxalate
  • Useful in mild to moderate hyperuricosuria (<800mg/day) w/ coexistent hypocitraturia
  • Helps to increase urinary pH above 5.5
  • Works as an adequate alkalinizing agent
  • Can also use sodium bicarbonate
26
Q

Gouty Diathesis treatment

A
  • Potassium citrate
  • Helps to increase urinary pH above 5.5
  • Works as an adequate alkaliniznig agent
  • Can also use sodium bicarbonate
27
Q

Enteric hyperoxaluria treatment

A
  • Multifactorial management
  • Oral calcium or magnesium to decrease urinary oxalate
  • Restrict dietary oxalate
  • Alkalization w/ liquid potassium citrate to correct metabolic acidosis and hypocitraturia
  • High fluid intake
  • Calcium citrate
28
Q

Hypocitraturia treatment

A
  • Potassium citrate
  • Restores normal urinary citrate in all causes
  • Lowers urinary saturation and inhibits crystallization of calcium salts
  • May correct the metabolic acidosis and hypokalemia found in pts. w/ distal RTA
  • Corrects the hypocitraturia due to bicarbonate loss from the intestinal tract
  • Thiazide therapy may induce hypocitraturia
29
Q

Uric acid calculi treatment

A
  • Increased urinary volume (2-3L)
  • Urinary alkalization (don’t overdo it)

*K-citrate lowers urinary calcium and increases citrate

*sodium bicarbonate

  • Reduce purine rich foods and increase fiber
  • Can try Allopurinol for persistently high excretion (>850 mg/day)
30
Q

Struvite calculi management

A
  • Diagnostic eval
  • Biochemical eval of blood and urine
  • Bacteriologic eval
  • Raciologic documentation
  • Surgical removal of all stones and correction of anatomic defect
  • Long term antibiotic suppression
  • Treatment of underlying metabolic derangement (only 14%)
31
Q

Acetohydroxamic acid

A
  • Used to treat struvite calculi
  • Has been shown to reduce the urinary saturation of struvite and retard stone formation
  • May prevent recurrence of new stones and inhibit the growth of stones in pts w/ chronic urea splitting organisms
  • May cause dissolution of existing struvite calculi in some pts
32
Q

Extracorporeal shockwave lithotripsy (ESWL)

A
  • Least invasive way of surgically removing stones
  • Stone is imaged w/ U/S or fluoroscopy
  • Focused shockwave is used to break up stone
33
Q

Extracorporeal shockwave lithotripsy (ESWL) disadvantages

A
  • May require multiple procedures
  • Not indicated for larger stones
  • Not for mid or lower ureteral stones
  • Less effective in cystine or calcium oxalate monohydrate stones
  • Potential complications

*“steinstrasse”; bunch of small stones now obstruct ureter

*bleeding

*infection

*kidney dmg

34
Q

Ureteroscopy

A
  • Very common technique for treating stones
  • Bladder then ureteral orifice entered
  • Stone is visualized
  • Laser removal, basket extraction used to remove stone
  • Stent often placed
  • Flexible and semirigid ureteroscopes available
35
Q

Ureteroscopy disadvantages

A
  • Not indicated for very large stones
  • Lower pole stone difficulties
  • More invasive than ESWL
  • Potential complicatoins

*ureteral strictures

*stent discomfort

*bleeding

*infection

36
Q

Percutaneous nephrolithotomy (PCNL)

A
  • Surgical technique for removing stones
  • Reserved for larger stones >2cm and staghorns
  • Collective system entered thru a flank approach
37
Q

Percutaneous nephrolithotomy (PCNL) disadvantages

A
  • Must be able to tolerate prone position
  • Most invasive (open nephrolithotomy rarely performed)
  • Potential complications

*bleeding

*infection

*kidney dmg

38
Q

Only type of stone that can be treated medically w/o invasive procedures

A
  • Uric acid stones; can be dissolved

RGU Exam 3 (19 decks)

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