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FA17 Nephrology > Kidney Stones > Flashcards

Kidney Stones Flashcards

1
Q

pathophys of kidney stones

A

dissolved salts in urine condense into solid and obstruct urtheral pathway

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2
Q

natural prevention of kidney stones

A

increasing amount of urine and decreasing amount of solute in urine

citrate and magnesium can block formation

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3
Q

types of stones (5)

A
  1. calcium
  2. struvite
  3. uric acid
  4. cystine
  5. miscellaneous
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4
Q

Calcium stones

occur when?

A

MC type of stone, occurs w/elevated Ca excretion

Hyperparathyroidism
resorptive hypercalcemia
renal hypercalciuria
immobilization syndrome

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5
Q

randall’s plaque

A

collection of subepithelilal calcification of renal papillae

serves as anchoring surface for calcium oxalate stones

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6
Q

diet restriction and calcium stones

A

diet that restricts calcium can increase calcium stone formation bc less Ca to bin to collate in lumen

this results in increased oxalate absorption in gut and recruitment of calcium in bones

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7
Q

struvite stones

A

typically in UTI infections caused by urea splitting bacteria

produce excess ammonia phosphate and elevate pH levels (decrease solubility of phosphate)

MC cause of stag horn calculi

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8
Q

urea splitting bacteria

A

UTI from these species cause struvite stones

Klebsiella, Proteus, Staphylococcal species

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9
Q

staghorn calculi

A

struvite stones MC cause

lg stones that form cast of renal pelvis

poor abx penetration, can lead to urosepsis

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10
Q

uric acid stones

A

10% of stones

radiolucent, urine is typically acidic

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11
Q

cystine stones

A

rare

founding pts with cystinuria (genetic disorder)

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12
Q

Misc. causes of stones

A 
Indinavir (HIV drug) 
trimterine (Abx) 
Acetazolamide (glaucoma drug) 
Xanthine (caffeine) 
silicate
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13
Q

why are kidney stones so painful?

A

obstruction of hollow viscus organ and hydronephrosis causing pressure against GEROTA’s fascia

migrating but non obstructive stones can cause pain

stones in the KIDNEY don’t cause pain

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14
Q

Cr levels in obstructive kidney stones

A

no rise in serum CR

other kidney can compensate 185% of baseline

if Cr rises, suggests kidney dysfunction

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15
Q

determining probability of passage of stone:

A

size
shape
location
degree of urinal obstruction

bizarre/irregularly shaped stones have lower spontaneous passage rate

complete obstruction = lower rate of spontaneous passage

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16
Q

common sites of obstruction

A

ureteropelvic junction (UPJ)
Pelvic brim
UVJ

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17
Q

probability of spontaneous passage of kidney stones in 4 weeks

A

98% <5mm
60% 5-7
39% >7

stone size on radiograph is larger, stone on CT is actually smaller

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18
Q

classical clinical feature of kidney stone

A

acute onset of crampy intermittent flank pain that radiates to the groin

visceral pain, n/v

unable to find comfort

tachycardia, HTN, diaphoresis

hematuria

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19
Q

location of pain

A

upper utter refer pain to plank

mid ureter radiate to lower quadrant of abdomen

distal ureter refers to pain in groin

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20
Q

3 important things to clarify in history

A

asses risk factors for stone development

prior stone related outcome

important mimickers

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21
Q

risk factors for poor outcome

A

renal function at risk

history of difficulty stones

infections

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22
Q

serious mimickers to consider in kidney stone

A

AAA
renal artery infarction
aortic dissection

AAA is often misdiagnosed as kidney stone

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23
Q

distinguishing AAA from kidney stone

A

stones don’t usually present in men older than 60

stones dont cause hypotension

24
Q

distinguish renal artery thrombosis from stone

A

swelling of infarcted kidney can cause hematuria BUT

non contrast CT can distinguish

25
Q

patients with at risk renal function

A 
DM
HTN 
Renal insufficiency 
single kidney 
horseshoe kidney 
transplanted kidney
26
Q

patient with difficult stones

A

extraction
stent
urterostomy tubes
liphotripsy

27
Q

diagnosis of urologic stone disease

A

clinical suspicions
presence of hematuria
imaging (not often)

28
Q

lab eval (4)

A
  1. pregnancy (ectopic consideration - all women = preg test)
  2. UA (rule out infection)
  3. renal function
  4. hematuria
29
Q

imaging in kidney stones

A

confirms presence
r/o other diagnoses
identifies complications
defines stone location

30
Q

who gets imaging in stone workup?

A

pts with first time stones

CT scanning reveals alternative diagnosis 33% of patients

31
Q

non contrast CT of A and P

A

images obtained from top of kidney to bladder base

urterial dilation*
perinephric fat stranding*
dilation of collecting system
enlargement

faster, no need for contrast damage, an see other pathology

32
Q

plan abdominal radiograph

A

90% of stones are radiopaque (density similar to bone) - calcium

struvite and cystine less able to see

uric acid stones are unable to be seen

not good to diagnose but good to see if stone is passing

33
Q

US in stones

A

good if pt can’t use CT

may miss stones <5mm, mid arterial stones

information on size, renal blood and urine flow

34
Q

ED tx

A

pain and n/v control
antibiotics for those w/evidence of infection
medical expulsion therapy

IV fluids to correct electrolyte imbalance

35
Q

NSAIDs

A

primary choice of analgesics, direct action on ureter by inhibiting prostaglandin synthesis

avoid in its with high risk bleeding, DM, renal insufficiency, pregnancy

36
Q

IV NSAID +dosing

A

ketorolac (Toradol)

<55 w.o. PMH of DM, renal insufficiency or GI bleeding - 30 mg

60-63 no CI - 15mg

> 65 - avoid

37
Q

narcotics use

A

good analgesic

do not affect care of pain

second line

morphine, percocet

38
Q

antiemetic agents

A

Odansteron (Zofran)

Metoclopradmide (Reglan)

39
Q

Metoclopramide (Reglan)

A

blocks dopaminergic receptors in CNS

less sedating, can provide pain provide

40
Q

medical expulsion therapy

A

alpha blockers are DOC

benefit in stones of distal third of ureter

(tamsulosin) Flowmax mc alpha blocker

41
Q

surgical treatments used in kidney stones

A

Shock wave lithotripsy
Ureterscopy
Percutaneous nephrolithotomy
open surgery

42
Q

SWL

A

renal calculi <3 cm

NOT recommended for stones >3 cm

utilized high energy shock waves to stone and break it down, then pass small fragments in urine

43
Q

success of SWL depends on

A

number and density of stones
total number and rate of shocks
stone size
chemical composition

44
Q

URS when is it used?

A

tx of choice for majority of middle and distal ureteral stones measuring > 3 cm

used in management of stones that have failed SWL, stones in proximal ureter and intrarenal

45
Q

URS process

A

breaks up stones to less than 1 mm, pass painlessly

successful in 90% of cases

can place stents after to help passage

46
Q

when is stenting performed

A

urinary tract abnormalities

solitary kidneys

residual edema or inflammation secondary to stone or endoscopic removal

47
Q

PNL

A

placement of small caliber nephrostomy catheter thru flank into renal collecting system – cath is dilated and enter the kidney to grab and remove the stone

48
Q

open stone surgery

A

used in management of complex renal and ureteral calculi

<1% of pts

49
Q

indications for open stone surgery y

A

failed other procedures
complex (stag horn)
complex anatomy
morbid obesity

50
Q

preventative treatment

A

thiazide diuretics (increased calcium reabsorption)

allopurinol or potassium citrate (uric acid)

51
Q

disposition

A

<6 mm stone w/o impairment discharged with follow up

52
Q

indications for hospitalization

A

intractable pain

stone > 6mm

evidence of infection

evidence of worsening renal impairment

irregular or proximal stone

return to ED

53
Q

patients should return to ED if

A

fever
vomiting
intractable pain

54
Q

urology follow up

A

w/in 7 days

allows etiology of stone to be evaluated and prophylactic strategy should be arranged

55
Q

pregnancy

A

1 in 1500 pregnancies, most often in secondary third trimester

diagnostic study of choice: ultrasound

can use CT or MRI with OBGYN consult

NSAIDs can’t be used - narcotics instead

can use medical expulsive therapy

FA17 Nephrology (13 decks)

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