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Gen Med Unit 5 > Nephrolithiasis and Urolithiasis > Flashcards

Nephrolithiasis and Urolithiasis Flashcards

1
Q

define nephrolithiasis

A

renal stones or calculi

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2
Q

Where do stones usually form?

A

Most commonly develop in the renal pelvis or calyces

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3
Q

What are stones usually composed of?

A

calcium oxalate or a combination of calcium and phosphate

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4
Q

What demographic are stones seen in?

A

Male > Female 3rd/4th decades, equal in 6th/7th decades

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5
Q

What type of stones are usually seen in middle aged males?

A

calcium

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6
Q

True/false: stones rarely occur in children

A

true

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7
Q

What is the most common type of stone composition for bladder calculi?

A

Most common is calcium oxalate followed by uric acid

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8
Q

What demographic are bladder calculi most prevalent in?

A

Men w/ BPH

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9
Q

What are predisposing factors for bladder calculi

A
  1. Dehydration
  2. Infection
  3. Change in urine pH (nl 5.8-5.9)
    A. Calcium based stones in pH 5.5-6.8
    B. Uric acid & Cystine stones in pH < 5.5
    C. Struvite stones in pH>7.2
  4. Obstruction to urine flow
  5. Sedentary occupations
  6. High temp/humidity
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10
Q

What metabolic factors predisopse ppl to bladder stones?

A 
Hyperparathyroidism
Renal tubular acidosis
Hyperuricemia
Dietary
-High protein/salt
Renal disease
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11
Q

What is the pathophys of bladder stones?

A
  1. Calculi form when substances that are normally dissolved in the urine precipitate
  2. In appropriate conditions, stone forming substance forms crystal that becomes trapped in urinary tract
  3. Trapped crystal attracts other crystals to form stone
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12
Q

How large are bladder stones, on average?

A

<5mm

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13
Q

What are 3 common sites for ureteral stones to form?

A
  1. Ureteropelvic junction
  2. Crossing of ureter at iliac vessels
  3. Ureterovesicular junction
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14
Q

Where are common places for stones to occur?

A

Stones may form in papillae, renal tubules, calyces, renal pelvis, ureter or bladder

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15
Q

What type of composition of stones is most prevalent?

A

Calcium based stones

  • Calcium oxalate
  • Calcium phosphate
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16
Q

What pH do calcium stones form at?

A

pH 5.5-6.8

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17
Q

What is the cause of calcium based stones?

A

80% idiopathic

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18
Q

What are some risk factors for calcium based stones?

A

Immobilization
Hyperparathyroidism
Renal tubular acidosis
Excessive intake of Vit. D and Calcium (rare)

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19
Q

What comorbidity is often seen with calcium based stones?

A

hypercalciuria

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20
Q

What are the 3 types of absorptive hypercalciuria?

A
  1. Type I
    - Independent of calcium intake
  2. Type II
    - Diet dependent (rare)
  3. Type III
    - Secondary to renal phosphate leak
    - Increased Vit. D synthesis
    - Increases small bowel absorption of calcium
21
Q

What pH causes the formation of struvite stones?

A

pH >7.2

22
Q

What is the most common composition of staghorn shaped horns?

A

Struvite

23
Q

Who is more likely to develop struvite stones?

A

F > M, 10% of all stones

24
Q

What often precipitates struvite stones?

A

Often precipitated by infection:
Proteus, Klebsiella, Pseudomonas
-Breaks down urea, ↑ pH → precipitates magnesium + phosphate + ammonium crystals

25
Q

What are some complications of struvite stones?

A

Destroy renal parenchyma

26
Q

What pH precipitates the development of uriic acid stones?

A

pH <5.5

27
Q

What % of total kidney stones are uric acid?

A

5-10%

28
Q

Pathophys of uric acid stones

A
  1. Results from breakdown of purines from protein
  2. Uric acid enters bloodstream and kidneys
  3. Usually occur with calcium stones
  4. Poorly visible on KUB
29
Q

At what pH do Cystine stones form?

A

pH< 5.5

30
Q

Pathophys of cystine stones

A

Genetic mutation
-Poor bowel absorption of amino acids
-Cystine leaks into urine
Due to excessive amounts of cystine

31
Q

Who gets cystine stones?

A

Due to excessive amounts of cystine
1% stones in adults
6-8% stones in children (avg 12 yr)

32
Q

What are the characteristics of cystine stones?

A

rapid growth and recurrence

33
Q

What are complications of cystine stones?

A

Renal failure

34
Q

Define Staghorn calculi

A
  1. Branched stones
    A. Struvite >Calcium Oxalate
  2. Stones of the calyceal and pelvic collecting system
  3. Can continue to grow in renal pelvis and calyces
  4. Forms a branching stone that can result in renal failure if not removed surgically
35
Q

sxs of nephrolithiasis

A 
1. Severe colicky flank pain
A. Referred pain (males)
2. Nausea and vomiting
3. Diaphoresis
4. Fever & chills 
A. Infection
5. Hematuria 
A. When calculi abrade ureter
6. Urgency and frequency
A. If stone lodged at UV junction
36
Q

What DS are indicated for stones?

A 
1. Urinalysis w/micro
A. pH
-7.2 suggests struvite stones
-5.5-6.8 suggests calcium-based stones 
B. Hematuria & crystals
2. 24 hour urine collection 
A. Determines levels of calcium, oxalate, phosphorous, citrate, and uric acid excretion
3. Urine C&S if febrile/pyuria
4. Calculus analysis
5. Serum calcium, phosphate, BMP, CBC if febrile
37
Q

What imaging studies are indicated for stones?

A
  1. Kidney-Ureter-Bladder (KUB) X-ray
  2. Renal ultrasound
    A. Detects hydronephrosis and radiolucent stones not seen on KUB
  3. Spiral CT
    A. Almost all stones visible on noncontrast CT
    B. Study of choice
38
Q

What is the Tx for stones?

A 
1. ↑ Fluids 
A. Double previous fluid intake 
2. Stones < 6mm usually pass spontaneously
3. Antibiotics if UTI
4. Narcotic analgesics or NSAIDs
A. Ketorolac (Toradal) 30-60 mg IM
5. Alpha-1-Antagonist
A. Tamsulosin (Flomax)
39
Q

How are calcium based stones treated?

A
  1. Restrict sodium (100 mEq/d)
  2. Thiazide diuretic in Type I hypercalciuria
    A. HCTZ or clorthalidone
  3. Avoid excessive animal protein*
  4. ↓ dietary calcium* by 50% in Type II hypercalciuria
  5. OTC orthophosphates (K-Phos, Neutra-Phos) in Type III hypercalciuria
  6. ↑ potassium rich foods
  7. +/- ↓ vit. C & oxalate rich foods (spinach, rhubarb, nuts, legumes)
  8. Limit sucrose & fructose
  9. Lemonade to ↑ urine citrate level
40
Q

How are uric acid stones treated?

A
  1. Allopurinol 100-300 mg qd
  2. Raise urine pH (goal 6.1-7)
    A. Potassium citrate or potassium bicarbonate
    B. Lemonade
41
Q

How are cystine stones treated?

A
  1. Modest reduction in sodium & protein intake
  2. Raise urine pH (goal >7)
    A. Potassium citrate or potassium bicarbonate
    B. Lemonade
  3. Last resort
    A. Penicillamine (Cuprimine)
    (DMARD) Disease -Modifying Anti-Rheumatic Drug
    -Chelating effect
42
Q

What procedures can be used to tx stones?

A
  1. Percutaneous ultrasonic lithotripsy
  2. Extracorpeal shock wave lithotripsy
  3. Laser Therapy

A. Shatter calculi into small fragment
B. Fragments removed by suction or natural passage w/ J-stent

43
Q

Describe Percutaneous Ultrasonic Lithotripsy

A
  1. 1 cm incision in back or mid side of abdomen
  2. Nephroscope passed to site of stone and shattered by ultrasound waves
  3. Fragments can be manually removed
44
Q

Describe Extracorpeal Shock wave lithotripsy

A
  1. Uses sound waves to break up stones in proximal or distal ureter
  2. For stones < 3 cm in diameter
  3. Shock waves crush stones into tiny sand-like pieces that usually pass easily through the urinary tract
45
Q

Describe Laser lithotripsy

A
  1. General anesthesia
  2. Flexible ureteroscope inserted through urethra and passed through the bladder and up the ureter to the stone
  3. The light energy of the laser is transported through a light guide to the stone
  4. Stone fragmentation occurs when pulses of intense laser light are applied
  5. The fragments are then passed by the patient or removed with a basket
46
Q

How are stones that are too large to be passed treated?

A
  1. Ureteroscopy and manipulation of calculus to remove stones too large for normal passage
    A. Used for proximal or distal ureteral stones
47
Q

What a re the indications for admission for stones?

A
  1. Complete or high-grade unilateral urinary obstruction
  2. Bilateral obstruction
  3. Obstruction in a solitary kidney
  4. Obstruction with fever or leukocytosis
  5. Azotemia
  6. Inability to tolerate PO
  7. Uncontrollable pain
48
Q

What is the most important piece of pt education?

A

Hydration

Gen Med Unit 5 (8 decks)

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