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MHD > Nephrolithiasis > Flashcards

Nephrolithiasis Flashcards

1
Q

What is the pain with a stone in the upper tract?

A
  • flank pain

- upper anterior abdominal pain

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2
Q

What is the pain with a stone in the lower tract?

A
  • groin pain

- ipsilateral testicular/labial pain

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3
Q

What is an atypical presentation of a stone?

A
  • painless hematuria

- persistent UTI

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4
Q

What is the most common type of stone? What are the two next common?

A

70-80%=calcium oxalate or calcium phosphate
10-15%=uric acid
10-15%=magnesium ammonium phosphate a.k.a struvite

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5
Q

What are the steps for stone formation?

A
  1. supersaturation
    - increased urinary ion excretion
    - decreased urine volume
  2. nucleation
    - crystal growth and aggregation
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6
Q

What are the promoters of crystallization?

A
  1. hydrogen ions (low pH)
  2. sodium
  3. magnesium
  4. uric acid
  • sites of prior injury
  • gravity dependent locations (lower pole calyx)
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7
Q

What are inhibitors of crystallization?

A
  1. high urine flow rates

2. citrates and other substances

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8
Q

What are the states that lead to calcium stones?

A
  1. HYPERCALCIURIA*
  2. +/-hypercalcemia
  3. chronic metabolic acidosis
  4. low urine volume
  5. hyperuricosuria
  6. hyperoxaluria
  7. hypocitraturia
  8. high protein, low carb diet
    - mark acid load, decreased calcium balance
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9
Q

What are causes of calcium stones?

A
  1. idiopathic
  2. hyperparathyroidism*
  3. vitamin D excess
  4. sarcoidosis (D production in granules)
  5. glucocorticoid excess
  6. RTAs (basic urine)
  7. Hyperthyroidism
  8. Malignant neoplasms
  9. loop diuretics
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10
Q

How do calcium and oxalate interact in the lumen of the GI tract, how does this affect how they interact in the kidney?

A

Lumen:
dietary calcium binds oxalate and impedes oxalate absorption
Kidney:
absorbed oxalate binds urinary calcium and can lead to stone formation

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11
Q

What are factors that favor calcium stone formation?

A
  1. high dietary oxalate
  2. increased fractional oxalate absorption
    - low dietary calcium
    - IBD (via fat malabsorption)-dietary calcium binds to FFAs in small bowel
  3. Increased endogenous oxalate production-genetic causes
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12
Q

What causes uric acid stones?

A

ACIDIC URINE

  1. chronic metabolic acidosis
  2. low urinary pH
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13
Q

What causes struvite stones?

A

Chronic upper respiratory tract infection with urease producing bacteria:

  1. proteus species
  2. haemophilus species
  3. klebsiella species
  4. ureaplasma urealyticum
  • results in ammonia and persistently alkaline urine–> promotes struvite formation
  • more common in women, chronic urinary obstruction (neurogenic bladder)
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14
Q

What causes cystine stones?

A

Cystinuria: autosomal recessive condition

GI and renal transport disorder of four amino acids:

  1. cystine
  2. ornithine
  3. arginine
  4. lysine

-cystine insoluble in normally- acidic urine, so cystinuria in genetic disorders leads to stones

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15
Q

What is the preferred method of detecting stones?

A

CT without contrast

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16
Q

Do you need to retrieve the stone?

A

yes it is crucial

17
Q

How do you prevent future calcium stones?

A
  • low sodium, low animal protein diet
  • normal dietary calcium
  • medication: thiazide diuretics–>decrease calcium excretion in urine
18
Q

How do you prevent future uric acid stones?

A

low purine, low animal protein diet

Medications:
1st line: 
-sodium bicarbonate, potassium citrate
-alkalinize urine, maintain ph>6.5 
2nd line:
allopurinol 
-decrease uric acid levels
-useful with hyperuricemia, marked hyperuricosuria
-also useful in patients that cannot maintain urine ph>6.5
19
Q

HOw do you prevent struvite stones?

A

eradicat infection with antibiotic therapy

  • complete removal of all stones-including residual fragments, often requires intervention
  • prevent future UTIs
20
Q

How do you prevent future cystine stones?

A

alkalinize urine
-sodium bicarbonate, potassium citrate

-D-penicillin, tiopronin (increase solubility)

21
Q

What does vitamin C do to oxalate?

A

facilitates urine oxalate excression

22
Q

WHat are foods high in purines?

A

meats
-offal, seafood, shellfish
alcohol

23
Q

What are foods high in oxalate?

A 
black tea
chocolate
soymilk
nuts 
berries 
beans, spinach, okra
beets rhubarb
carrots
celery swiss chard
sweet potatoes
24
Q

If you have hyperuricosuria what should you do?

A

low purine, low animal protein diet

allopurinol therapy

25
Q

If you have hypocitraturia what should you do?

A

low animal protein diet
increase fruits/veggies (high in citrate)
citrate supplements (potassium citrate)

MHD (81 decks)

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