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clin med > Nephrolithiasis > Flashcards

Nephrolithiasis Flashcards

1
Q

nephrolithiasis: it is common, ___% of people have some time in their life. Men or women more?

A

12% have at some time in their life
Men > women
4:1 ratio

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2
Q

what age do most people get kidney stones?

A

Most often 20-40 years old

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3
Q

risk for kidney stones ______ after the first one.

A

increases, once you have one its more likely youll get another

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4
Q

what is the most important predisposing factor for kidney stones? what are two following important factors?

A

More in high humidity and high temperatures (more likely dehydrated)
- FH and genetics

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5
Q

stones: Form in ________ and move_______

A

Form in proximal tract (near kidney) and move distally

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6
Q

5 types of salts that cause kidney stones. which is the most common?

A
  1. Calcium oxalate (most common 80%)
  2. Calcium phosphate
  3. Struvite
  4. Uric acid
  5. Cystine
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7
Q

will calcium oxalate show up on xray ?

A

likely YES

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8
Q

what two factors of urine cause stones?

A

low volume and altered pH

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9
Q

acidic vs basic (alkaline) urine?

A

Acidic urine, low pH, usually <5.5: Decreases solubility of uric acid
Alkaline urine, high pH : Decreases solubility of calcium phosphate and magnesium ammonium phosphate

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10
Q

which type of stone is from alkaline urine ?

A

struvite

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11
Q

is urine naturally acidic or basic?

A

acidic

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12
Q

nephrolithiasis is asymptomatic until ________ or _______

A

inflammation or obstruction

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13
Q

what is the pain like with kidney stones? (description and location/radiation)

A

acute and quickly unbearable

  • waxes and wanes: “renal colic”
  • flank: can radiate to back, groin, legs, suprapubic, or labia
  • CVA tenderness
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14
Q

if it is renal colic, where is the stone usually located?

A

ureter

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15
Q

what are the associated symptoms of kidney stones?

A
  • Nausea and vomiting (but any severe pain can cause this)
  • Hematuria, dysuria, urinary frequency
  • Fever and chills
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16
Q

kidney stone pts often are static or waking around?

A

VERY restless, uncomfortable

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17
Q

kidney stones, if an ileus (lack of movement of the intestines) is present, then there might be ________ _______

A

abdominal distention

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18
Q

why might a CBC be helpful for kidney stone Dx?

A

WBC may indicate infection, but can also indicate inflammation. iIf negative WBC, could rule out systemic infection presenting as flank pain

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19
Q

what is the most critical Dx for kidney stones?

A

visualization of the stone

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20
Q

pH of urine: if <5.5 or if >7.5 … what type of stones are you thinking it is?

A

Urinary pH
pH < 5.5 think of uric acid or cystine stones
pH > 7.5 think struvite stones

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21
Q

what are you checking UA for?

A

pH, blood, crystals, pyuria (usually) or bacteriuria (maybe)

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22
Q

what are 4 other labs you can do for kidney stones? (besides UA and CBC)

A

urine culture, CMP, 24hr urine collection, stone analysis (to determine content)

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23
Q

what are three types of imaging for kidney stones? which is the most common?

A
  1. CT (most common)
  2. plain film KUB (kidney, ureters, bladder)
  3. US
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24
Q

when would US be the best imaging in regards to kidney stones?

A

looking more for obstruction like blocked and enlarged kidney (hydronephrosis- a must not miss)
*can also use CT for this

25
Q

what kind of stones could you see on x-ray?

A

calcium or cystine stones would show up (both radiopaque)

- uric acid stones would NOT be seen (radiolucent)

26
Q

what is IVP and what do we use now instead of this?

A

IV pyelogram - inject a die in and take an xray

- use helical CT now

27
Q

why do we use CT over Xray? who would you not want to use either for?

A

you can see radiolucent stones

  • on Xray you can only see radiopaque ones
  • don’t use if pregnant (use US instead)
28
Q

what is the “test of choice” for flank pain?

A

helical CT

29
Q

if someone has a history of stones and now has symptoms of a stone, do you need imaging?

A

NO

30
Q

three goals of txt for stones?

A
  1. determine if theres an obstruction
  2. pass or extract stone
  3. prevent formation of future stones
31
Q

what is stone expulsive therapy?

A

alpha blockers or Ca++ channel blockers (usually for 2 wks) to encourage ureteral smooth muscle relaxation
-for immediate decrease in pain and enhanced rate of stone passage (a controversial txt option)

32
Q

are lots of fluids good for kidney stone pts?

A

kind of, you give it to them to make them pee and pass the stone but it might increase the pain, better for prevention than txt

33
Q

what do you do for asymptomatic stones? what if they grow or become symptomatic?

A

No treatment just monitoring with renal ultrasound

If growing or symptomatic, intervention needed

34
Q

If urine is obstructed/infected need to do what?

A

If urine is obstructed/infected need to bypass obstruction or get rid of stone

35
Q

If infection proximal to an obstructing stone, need what?

A

admission for abx and drainage

36
Q

what can you give for pain txt of kidney stones?

A

pain control:

  1. narcotics (morphine, meperidine, and butorphanol)
  2. Toradol
37
Q

what is the caution with prescribing toradol?

A

NSAID ADRs and not good for the elderly

38
Q

stone expulsive therapy: outcomes are clearly in favor if stone is ______

A

<10 mm

39
Q

which are the preferred agents to use for stone expulsive therapy?

A

those that effect BP less (use tamsulosin)

40
Q

likelihood of passing a stone (without intervention) based on size : <5mm, 5-10mm, >10mm

A

<5mm: about 80% will pass
5-10mm: about 20% will pass
>10mm: Won’t pass without intervention

41
Q

stone <5mm: will likely pass ______ within ____ to ____ weeks.

A

Outpatient, will likely pass spontaneously within 2-4 weeks

42
Q

txt of stone <5mm (3 parts)

A
  1. Oral hydration-drink a lot
  2. Strain urine to catch and analyze stone
  3. Oral analgesics- frequently need opioids
    Combination NSAID and opioid better than either alone
43
Q

txt of stone 5-10mm (2 parts)

A
  1. Increased fluids and oral analgesics

3. Elective lithotripsy or ureteroscopy

44
Q

what is a lithotripsy (ESWL)?

A

Extra corporal shock wave lithotripsy

- uses anesthesia, dissolving stones with ultrasound waves

45
Q

what is ureteroscopy?

A

Ureteroscopy- scope through bladder up ureter, visualize stone and laser or grasp with instrument

46
Q

what are the indications for ureteroscopic stone extraction? (4)

A

Indication: severe pain, unresponsive to medications, fever, persistent nausea and vomiting

47
Q

if there is an obstruction (regardless of stone size) what are two txt options?

A

ureteral stent or percutaneous nephrostomy

48
Q

what is a ureteral stent?

A

tube that bypasses stone in ureter

49
Q

what is percutaneous nephrostomy?

A

tube into collecting system of kidney to relieve obstruction of urine

50
Q

three options for txt of stone >10mm

A
  1. Extracorporal shock wave lithotripsy if renal stone <2cm or ureteral stone <1cm
  2. Percutaneous nephrolithotomy (i.e. surgery) for stones > 2cm
  3. Ureteroscopic fragmentation
51
Q

what is the most important preventative step for all stone types?

A

prevention of dehydration (drink 2x water that you normally drink)

52
Q

___% of stones recur in __ years

A

50%, 5 years

53
Q

prevention of Ca oxalate stones (3 parts)

A
  1. Water, lemonade (incr. Citrate)
    ~Double normal intake
  2. Thiazide diuretics (decrease urinary calcium)
  3. Decrease dietary protein and Na
54
Q

increase in _____ will decrease Ca-oxalate stones.

A

Paradoxically, ↑Ca++ will decrease Ca-oxalate stones!

55
Q

prevention of cystine stones

A
  1. Increase fluids

2. alkalinization of the urine with acetazolamide

56
Q

prevention of uric acid stones

A
  1. low protein diet
  2. allopurinol to decrease levels
  3. urinary alkalinization
57
Q

prevention of struvite stones

A
  1. antibiotics (what’s the bug?) (proteus)
  2. acidification of urine
  3. cranberry juice
58
Q

2 complications of stones

A

infection and obstruction

clin med (88 decks)

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