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Renal Exam III > Clinical aspects of nephrolithiasis > Flashcards

Clinical aspects of nephrolithiasis Flashcards

1
Q

Epidemiology of nephrolithiasis

A 
•Incidence:
–3-4/1000men/year
–1-2/1000women/year
•Lifetime risk
–12% in men
–6% in women
•Age
–30-60 in men
–20-30 in women
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2
Q

Types of stones based on composition

A 
•Calcium stones (80%)
–Calcium oxalate
–Calcium phosphate
•Uric acid stones (5-10%)
•Struvite(Mag/Ammonium/phosphate) stones (10-15%)
•Cystinestones (less than 1%)
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3
Q

Types of stones based on location

A
  • Kidneys
  • Ureter
  • Bladder
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4
Q

Etiology of nephrolithiasis

A

•Process of crystallization
–Too much solute
–Too little solvent (water)
–“Other” physical conditions (stasis, ph)

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5
Q

Risk Factors for Stone Formation

•Calcium stones

A 
–Hypercalciuria
•Higher salt in the diet
•Higher non-dairy animal protein diet
•High Sucrose content in the diet
•Hyperparathyroidism
•HypercalciuricHypocalcemia
–Hyperoxaluria
•Increased intake in high oxalate-containing food
•Decreased in oral calcium intake
–Hypocitraturia
–High urine pH
•RTA type I
–Low urine volume
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6
Q

Decreased in oral calcium intake

A

low calc in diet, bc it binds oxalate out of the absorption process, so it doesnt get absorbed, so dont have too much or too little calcium

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7
Q

major risk factors for calcium stone urinary

A 
lower volume
higher calcium
higher oxalate
lower citrate
higher ph
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8
Q

major risk factors for calcium stone anatomic

A

medullary sponge kidney

horseshoe kidney

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9
Q

majore risk factors for calcium stone diet

A 
lower fluid intake
lower dietary calcium
higher oxalate
lower potassium
higher animal protein
higher sodium
higher sucrose
higher fructose
lower phytate
higher vitamin c
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10
Q

medical condition at risk for calcium stones

A

primary hyperparathyroidism
gout
obesity
diabetes mellitus

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11
Q

Risk Factors for Stone Formation

•Uric acid stones

A 
–Hyperuricemia/hyperuricuria
•Gout
•Polycythemia Vera
•Tumor lysissyndrome
–Low urine pH
•obesity, type 2 diabetes mellitus, and high non-dairy animal protein intake

metabolic syndrome - htn, obesity, cholesterol, uric acid, hyerglycemia

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12
Q

Risk factors for stone formation struvite stones

A

–Chronic UTI with ureaseproducing bacteria (Proteus or Klebsiella)

these bacteria produce ammonia by urease

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13
Q

risk factor for cysteine stones

A

cystinuria autosomal recessive disorder

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14
Q

Clinical Manifestation of stones

A 
•Asymptomatic during formation
•Renal colic when stone moves through and/or obstructs one of the ureters
•Micro-or macro-hematuria
•Sometimes associated with UTI
–Fever/leukocytosis/pyuria/sepsis

paind from spasm in a hollow organ

pt cant get comfortable keep moving around trying to get comfortable

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15
Q

Renal colic

A
  • Sudden
  • Acute
  • Severe
  • Non-remitting with positional changes
  • Abdominal or back pain
  • Unilateral
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16
Q

Differential Diagnosis

A
  • Acute cholecystitis
  • Acute appendicitis
  • Acute cystitis/pyelonephritis
  • Acute diverticulitis
  • Muscular or skeletal pain
  • Herpes zoster
  • Duodenal ulcer
  • Abdominal aortic aneurysm
  • Ureteralobstruction by materials other than a stone
  • Pelvic Inflammatory Disease
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17
Q

Diagnosis

A 
•Usually based on clinical presentation
•Urine: RBC, WBC, crystals
•Leukocytosis, ARF
•Imaging
–Plain film: May show Calcium stones
–IVP—used less frequently now
–CT-renal protocol—gold standard
–US—may show intrarenalstones and/or hydronephrosis. Not sensitive for ureteralstones
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18
Q

Treatment

A
  • Treatment of acute attack
  • Treatment after acute attack
  • Prevention of recurrences
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19
Q

Treatment of acute attacks

A 
•Medical Therapy
–Pain control
–Nausea control
–Propulsive therapy
•Calcium channel blockers
•Alfa-blockers - tamsulosin
•Surgical Therapy
–Ureteroscopywith stone removal and stent placement
–Percutaneousnephrostomy
20
Q

under 5 mm?

A

95% will pass

21
Q

Treatment after acute attack

A

ECWL (lithotripsy) if large stones

nephrostomy

22
Q

Prevention of Recurrences overview

A

•Analyze the stone
•Collect the information about dietary preferences and fluid intake
•Serum Ca, Phosphorus, uric acid
•If Ca is elevated, do hypercalcemiawork-up
–PTH, Vit D level, Protein electrophoresis
•24 urine collection for Ca, urate, oxalate, citrate
•Increase fluid Intake
•Dietary Modification

23
Q

Prevention of Recurrence calcium stones

A

–Calcium Stones
•Adequate dietary Calcium intake
–From food, not from supplements
–Not too much, not too little
–Likely binds oxalate and prevents its absorption
•Restriction of nondairy animal protein (e.g., meat, chicken, seafood)
•Avoidance of spinach (the highest oxalate-containing food).
•Reducing sodium intake to less than 3g/day
–It will decrease concurrent urinary excretion of calcium
–Decreasing sucrose intake, which may increase urinary calcium excretion
•Increasing potassium-rich foods.

24
Q

Prevention of Recurrences

•Uric Acid Stones

A

–Increasing urine pH by
•Reducing the intake of animal proteins
•Increasing the intake of alkali-rich foods (fruits and vegetables)
•Oral bicarbonate

25
Q

Prevention of Recurrences

•Medications

A

–Thiazides
•Increase calcium reabsorption and decreases urine Calcium
–Allopurinol
•Decreases uric acid in the serum and urine
–Potassium Citrate
–Magnesium
•Forms

26
Q

Gestational Age

A

number of weeks of pregnancy from last normal menstrual period

27
Q

AGA (Appropriate for Gestational Age)

A

birth weight between the 10thand 90thpercentiles for a given gestational age

28
Q

SGA (Small for Gestational Age)

A

birth weight

29
Q

LGA (Large for Gestational Age)

A

> 90thpercentile for the given gestational age

30
Q

LBW (Low Birth Weight Infant)-

A

an infant who weighs

31
Q

VLBW (Very Low Birth Weight Infant

A

Infant)-

32
Q

Preterm

A
33
Q

term

A

Term-38-42 weeks gestation

34
Q

postterm

A

Post-term->42 weeks gestation

35
Q

infant death

A

a death occurring any time from birth to but not including 1 year of age

36
Q

perinatal death

A

a death occurring between the 28thweek of gestation and 28thday of life

37
Q

Fluid Considerations in the Newborn

•Total Body Water (TBW)

A

–In early fetal development TBW constitutes almost 95 % of total body weight
–At birth in the term infant TBW is approximately 75% of the total weight
–During the first week of life term infants will typically loss about 10% of their birth weight
–After decreased urinary output in the first 24-48 hours a diuresis occurs with loss of extracellular water
–In preterm infants the weight loss can be up to 15%

38
Q

Sodium Balance in the Newborn

A
  • Total sodium content determines the volume of ECF. So renal sodium handling is a critical component in maintaining proper volume
  • Sodium is freely filtered by the glomerulus and almost completely reabsorbed in the tubular system
  • In term infants, like adults fractional sodium excretion is
39
Q

Parameters Associated with Fluid Management in the Newborn

A
  • Urine output-1-3 ml/kg/hr
  • Hypernatremia-Sodium > 150mmol/L
  • Hyponatremia-Sodium
40
Q

Signs of excessive water loss

A 
–Excessive wtloss
–Dry oral mucosa
–Sunken anterior fontanelle
–Capillary refill > 3seconds
–Tachycardia
–Decreased BP
–Metabolic acidosis
41
Q

Acute Renal Failure

A
  • Definition of ARF in the newborn is based on a rapid elevation in the concentration in the blood of BUN, creatinine and other cellular waste products resulting from diminished GFR
  • Cannot define a specific creatinine level to call ARF as measurements immediately after birth reflect the mother’s creatinine as well as the infant
  • Normal creatinine levels depend on gestational age
  • Urine output can be used as an indicator of ARF-usually less than 0.5 ml/kg/hour
42
Q

Acute Renal Failure in the Newborn

•PrerenalCauses

A 
–Sepsis
–Hypovolemia
–Hemorrhage
–Hypoxia Ischemia
–Cardiac Failure
–Hypotension
–Hyperviscosity
43
Q

Renal (Intrinsic ) Causes

A 
•ATN
–Hypoxia-ischemia
–Toxins
•Drugs
–Aminoglycosides
–Contrast Agents
•ACE inhibitors
•Vascular
–Renal vein or artery thrombosis
•Congenital parenchymal disease
•Maternal drugs
•Transient acute renal failure of the newborn
44
Q

Post Renal Causes (Obstructive)

A 
•Congenital obstruction
–Ureteral
–Urethral
–Bladder
–Pelvic mass
•Calculi
45
Q

Fundamental Knowledge

A
  • Hypernatremicdehydration in the neonatal period is well described arising from disproportionate deficit of body water relative to body sodium coupled with the extracellular water loss that occurs in this age range
  • Most common cause is lactation failure
  • Infants can loose water through the skin at a rapid rate, especially with non bullous ichthyosis
46
Q

GO THROUGH CASE

A

NOW

Renal Exam III (17 decks)

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