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Renal Week 3 > Kidney Stones - NACE > Flashcards

Kidney Stones - NACE Flashcards

1
Q

What is the lifetime risk of getting a kidney stone?

A

10% of people will get a kidney stone in their lifetime

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2
Q

T or F: by the age of 70 women are twice as likely as men to get a kidney stone.

A

False, women are HALF as likely as men to get kidney stones

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3
Q

After getting a kidney stone, what is the recurrence risk of it coming back?

A
  • 5% per year recurrence risk (1/20 ppl who have had a kidney stone will get another one within the next year)
  • This is a high rate of Recurrence
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4
Q

What factors effect the concentration of solutes that may precipitate in the urine causing stones?

A

Amt of Solute:
• Filtered Load
• Tubular Secretion
• Tubular Reabsorption

Vol. of Solvent:
• Salt and Water Balance

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5
Q

What are the 4 types of solute that account for the majority of stones?

A
  • Calcium Salts (75%)
  • Stuvite (15%)
  • Uric Acid (10%)
  • Cysteine
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6
Q

What causes Cystinuria?
• how common is this?
• Epidemiology?
• Why must we catch this?

A

Cystinuria = GENETIC disorder of reabsorption in the Tubules

How Common/Epidemiology?
• Found in 1-2% of ADULT stones
• 5% of stones in CHILDREN

Why worry?
• Can cause LOSS of kidney function if left untreated

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7
Q

T or F: urine pH can provide a major clue to the type of stone that is likely to form in someone’s urine

A

True, pH is a MAJOR TARGET for INTERVENTIONS to prevent recurrent stones

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8
Q

Why are natural inhibitors so important?

A

Because the urine is typically supersaturated with solutes that comprise stones

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9
Q

Where is Tamm-Horsfall mucoprotein located and what would happen if you inhibited its formation?

A

Tamm-Horsfall is made in the THICK ASCENDING LOOP OF HENLE.

• it BINDS solutes, so preventing its formation would LEAD SO STONE FORMATION

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10
Q

T or F: presence of a foreign body in the kidney of ANY type will increase the propensity to form stones.

A

TRUE, calcium stone may from around Uric Acid or even Nanobacteria

*This is just seeding a cystalization

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11
Q

What is the utility of looking at crystals in the urine of a normal person?
• what about someone with a stone?

A
  • NO utility in looking at stones in a normal person who doesn’t have stone
  • IN someone WITH a stone, the crystals in the urine may tell you about COMPOSITION of the stone
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12
Q

Where are stones most likely to form?

• why is this?

A

Stones = most likely to form in the LOW URINE FLOW areas

  • CALYCES and PELVIS are therefore the most common places to see stone formation
  • stasis and stone formation is also the reason you can see bladder stones
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13
Q

T or F: stones are more likely to form in areas of obstruction.

A

True

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14
Q

What are the 2 subtypes of Calcium stones formed?
• which is more common?
• How does urine pH affect each of these?

A

2 types:
• Calcium Oxalate (60%) - INDEPENEDENT of pH

• Calcium Phosphate (15%) - FORMS STONES IN ALKALINE ENVIRONMENT

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15
Q

What are some drugs known to cause kidney stones?

A
  • Indinavir
  • Triamterene
  • Acyclovir
  • Sulfadiazine
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16
Q

Explain the ways that Ca2+ may increase in concentration leading to stone formation?

A

Increased Filtered Load:
=> Exogenous - inc. intake
=> Endogenous - inc. PTH, Vit. D. Sarcoid, Ideopathic

Decreased Renal Reabsorption:
• EXCESS DIETARY Na+
• Pharmacologic => LOOP diuretics

Decreased Urine Volume

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17
Q

Besides Ca2+, the concentration of what other substance is important to the formation of Ca2+ stones?

A

Oxalate, remember this forms stones indepedently of pH

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18
Q

Oxalate

• how is its concentration increased?

A 
INCREASE filtered Load (ONLY):
Exogenous:
• Dietary XS 
• Low Ca2+ diet 
• bowel pathology

Endogenous:
• Increased Production

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19
Q

How can you treat Calcium Oxalate Crystals that are caused by too much Ca2+?

A

Reduce Ca2+:
• avoid Ca2+ supplement BUT DO NOT RESTRICT DIETARY Ca2+
• Potassium Citrate +/- allopurinol

Reduce Na+:
• THIAZIDE DIURETICS
• SODIUM RESTICTION

Dilute:
• Adequate Fluids
• Less Animal Protein, and Salt

also look for any underlying causes of hypercalcemia

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20
Q

What type of stones do you have a fairly high risk of getting with type I RTA?

A

• CaP, because this type of RTA PREVENTS ACIDIFICATION in the DISTAL TUBULE

= More Basic Environment and Decreases Citrate concentration

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21
Q

What is the more common cause of Uric Acid Kidney Stone formation: underexcretion or overproduction?
• exceptions?

A

Underexcretion = most common cause

• Ppl. with GOUT tend to OVERPRODUCE uric acid so both factors contribute to stone formation

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22
Q

Contrast the formation of CaP, Uric Acid, and Struvite stones.

A

CaP stones - form in a BASIC environment

Stuvite stones - form in a BASIC environment

Cysteine Stone - from in ACIDIC environment

Uric Acid stones - form in ACIDIC environment

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23
Q

What recommendations and prescriptions should be written to prevent Uric Acid crystal formation in patients.

A

Dietary Modifications:
• Increase Fluids
• Less Animal Protein
• Less EtOH

Drug Treatments:
• Allopurinol
• Potassium Citrate

24
Q

When is the ONLY time you see Stuvite Stones forming?

A
  • Presence of Increased Urinary NH4+ concentration and Alkaline pH
  • this ONLY occurs with UTI with urease-producing organism (proteus, Serratia, Klebsiella, Mycoplasma)
25
Q

What reaction is catalyzed by Urease?
• what common bacteria cause UTIs and carry urease?
• what is unique about the urine in this scenario?

A

Rxn:
• Urea => 2NH3 + CO2, NH3 takes a proton and becomes NH4+

Bugs:
• Proteus
• Serratia
• Klebsiela
• Mycoplasma

UNIQUE URINE:
• Patients have BASIC urine with INCREASED NH4+ (this is the opposite of what happens in acidosis)

26
Q

T or F: symptoms in people who get Struvite stones are more related to Infections than presence of stones.

A

TRUE

27
Q

What Therapies are given to people with Struvite Stones?

A

ANTIBIOTICS
INCREASE FLUID INTAKE
• stone removal

Urease inhibitors are not a great idea - lots of side effects

28
Q

What Therapeutic Agent is effect at treating Cystine, Calcium, and Uric Acid stones but not struvite stones?

A

Potassium Citrate

29
Q

Where does the defect take place that leads to cystinuria?

• what therapies can we give these pts?

A

• PROXIMAL tubular reabsorption defect

Therapies:
• make urine basic
• PENICILLAMINE
• potassium citrate

30
Q

T or F: Cystinuria should be suspected in children who present with kidney stones

A

True, most commonly they present around age 12

31
Q

How much should you increase fluid consumption to prevent kidney stones?

A

• Increase Fluid Intake to greater than 2L per day

32
Q

Hypercalciuria
• Lifestyle Modifications
• Pharmological Treatment

A

Lifesytle:
• Sodium Moderation (less than 200 mmol/L per day)
• Protein Moderation

Pharmological:
• Hydrochlorothiazide
• Indapamide + Potassium Alkali

33
Q

HypOcitraturia
• Lifestyle Modifications
• Pharmological Treatment

A

Lifestyle:
• Protein Moderation

Pharomological:
• Potassium Citrate

34
Q

Hyperoxaluria
• Lifestyle Modifications
• Pharmological Treatment

A

Lifestyle:
• Oxalate Restriction
• Avoidance of Ca2+ restriction

Pharmological:
• Pyridoxine for Pirmary Hyeroxaluria

35
Q

Hyperuricosuria
• Lifestyle Modifications
• Pharmological Treatment

A

Lifestyle:
• Purine Restriction

Pharm:
• Allopurinol

36
Q

Low Urinary pH
• Lifestyle Modifications
• Pharmological Treatment

A

Lifestyle:
• Protein Restriction

Pharm:
• Potassium Citrate

37
Q

Cystinuria
• Lifestyle Modifications
• Pharmological Treatment

A

Lifestyle:
• High Fluid Intake (Greater than 3L per day)

Pharm:
• Potassium Citrate
• D-penicillamine
• Beta-mercaptopropionyl-glycine

38
Q

UTI treamtent

A

Abx.

39
Q

What makes patients who have kidney stones symptomatic?

A

• Patients become symptomatic when the stone Moves

40
Q

**Where is the stone going to get caught?

A
  • Angulations
  • Urteropelvic Junction
  • Iliac Vessel Crossing
  • Bladder entry or Outlet
41
Q

What should be in your differential of someone who has pain from kidney stone?

A
  • Diverticulitis, Appendicitis, Hernia
  • Acute Cholecystitis, Acute Appendicitis, Pyelonephritis
  • AAA (BE SURE to exclude this one)
42
Q

What are you looking for in Urinanalysis to confirm Kidney stone?

A
  • Crystals
  • Microscopic Hematuria
  • Urine Concentration
  • pH
  • Evidence of Infection
43
Q

T or F: you will get evidence about elevated Ca, Cysteine, etc from UA.

A

FALSE, these values come from 24 hour collection, NOT from UA

44
Q

What stones are radiolucent (translucent on x-ray)?

A

Uric Acid Stones - all other stone types are radiopaque

45
Q

What would be your 1st choice technique to look for a kidney stone?
• what would be the most sensitive?

A

Ultrasound would be 1st choice because of Low Radiation and Fair Accuracy
• Problem is you can’t see ureteral stones

Helical CT - most sensitive, but exposes the pt. to radiation

46
Q

What are the size limitations on passage of kidney stones?

A

Less than 5mm will usually pass

Greater than 7mm probably won’t

47
Q

What do you do if kidney stones don’t pass?

A

Can be fragmented using Lithotripsy

48
Q

How should you control pain associated with kidney stones?

• what should you do if a patient brings you the stone back?

A

NSAIDs (they are safer than opiates)

Note: Try to control their vomitting and send them home with a strainer

SEND STONES OFF TO ANALYSIS ALWAYS

49
Q

What is the most common metabolic abnormality in Calcium Stone formers?

A

• HypercalenURIA, not hypercalcemia

50
Q

IMPORTANT How do you determine if a 24 hour urine collection is complete?

A

The AMOUNT of Creatinine

MALES:
• should excrete 10mg/lb of lean body wt. per day

FEMALES:
• excrete 15% less

51
Q

What is the most common abnormality causing kidney stones?

A

LOW URINE VOLUME

52
Q

ABSOLUTELY DO NOT LOWER DIETARY Ca2+ to Prevent CaOx stones why?

A

• You will just absorb more oxalate

Note: you can use allopuriol to treat b/c Urate typically goes with it

53
Q

What is the best advice to give a patient so that they keep their urine diluted?

A

• Tell them to keep their urine looking clear

54
Q

Where does dietary oxalate come from?

A

• Chocolate and Nuts

55
Q

T or F: urine protein concentration determines stone risk.

A

FALSE, dietary protein determines this

Renal Week 3 (16 decks)

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