Kidney Stones Medical Management Flashcards
Initial work up for patient with newly diagnosed stones
-Medical history (Obesity, hyperthyroidism, gout, RTA type 1, DM2, hyperparathyroidism, malabsorptive GI states)
-Dietary history (calcium intake, fluid intake, meat intake, oxalate foods)
-Medications (probenecid, protease inhibitors, triamterene, chemo, topamax, zonisamide)
-Serum chemistries (CMP, calcium
-UA with micro
-Quantify stone burden
-Further metabolic workup for recurrent stone formers or high risk/interested first time stone formers
When should PTH be checked?
High or high-normal Ca
CaPhos stone
High urinary calcium
Also check Vitamin D
Metabolic testing components
24hr urine (1-2x)
When should testing be done for primary hyperoxaluria?
> 75mg/day in adults without bowel dysfunction
Recommend urine volume for stone formers
2.5L/day
Counseling re: calcium intake and calcium stones
1000-1200mg a day
Recommendations for calcium oxalate stones
2.5L urine per day
Limit calcium to 1000-1200mg
Limite oxalate rich foods (potatoes, spinach, nuts, soy, pumpkin, chocolate, processed meats, beans)
DASH diet
Increase fruits/vegetables and citrate intake
Decrease protein intake if uric acid high
thiazide if urine calcium high (add K too)or empirically
Kcit if low urinary citrate or empirically
Allopurinol if recurrent CaOx and high urinary uric acid and normal urinary calcium
Recommendations for cystine stones
4L intake per day
Limit sodium to 2300mg or less daily
Limit animal protein intake
Alkalinize urine with kcit
Tiopronin (2nd line)
Treatment for stone former with low pH and uric acid or cystine stones
Kcit
Should allopurinol be used for uric acid stone formers?
not routinely
Recommendations for struvite stones
Clear stone burden
Treat infection
Consider AHA - watch for phlebitis and hypercoag
When should 24hr urine be repeated after starting a drug for stones?
within 6 months and annually thereafter
What type of stones form with urease splitters?
struvite
what bacteria produce urease
proteus, providencia, klebsiella, pseudomonas
Side effects of SWL
Hematoma
Hemorrhage
Residual stones
HTN
Sepsis
Obstruction
ESWL procedure
Localize stone
Go slow (60hz)
Pause
Management of ureteral avulsion
Stent (if possible)
NT and staged repair
U-U (if high)
Reimplant (if distal) +/- Psoas hitch/Boari
Ileal ureter
Autotransplant
Nephrectomy
do NOT do transUU if unilateral stone former
Indications for intervention for a patient on MET
Persistent poorly controlled pain
Intractible N/v
Fever, leukocytosis
Worsening AKI
Failure to progress
Patient preference
hypercalciuria definition
> 200mg in 24hr urine specimen
Causes of hypercalcemia
HyperPTH
Sarcoid
Hyperthyroid
MM
Paget’s
Milk Alkali
VitD intoxication
Types of hyperoxaliuria
Primary - congenital - can cause renal failure - treatment is liver transplant
Acquired - usually enteric deficit (IBD, GI bypass, short gut)
Lasix scan interpretation
<12 min non-obstructed
12-20 mins equivocal
>20 min obstructed