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IM NEPHRO > Tubulointerstitial > Flashcards

Tubulointerstitial Flashcards

1
Q

Most common stone type

A

calcium oxalate

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2
Q

Next common stone types in order

A
  • calcium phosphate,
  • uric acid,
  • struvite and
  • cystine
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3
Q

Increasing prevalence of stone is due to

A

Westernization of lifestyle habits

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4
Q

Economic impact in stone formation affects

A

workiing age

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5
Q

Urine is what kind of solution

A

Supersaturated

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6
Q

calcium oxalate stones grow on calcium phosphate at the tip of the renal papilla

A

Randall’s plaque

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7
Q

may be the initiating event of calcium phosphate formation

A

Tubular plugs of calcium phosphate

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8
Q

Risk Fators: Diet

A
  • high animal protein ,
  • high oxalate,
  • high sodium,
  • high sucrose
  • high fructose
  • low calcium
  • high potassium
  • Vit C supplements
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9
Q

Risk Fators: Diet
Results

  • Higher intake of animal protein -
  • Higher Na and sucrose -
  • Higher K intake -
    ° Vitamin C supplements -
A
  • Higher intake of animal protein - increased calcium nd UA excretion, decreased urinary citrate excretion
  • Higher Na and sucrose - increase Ca excretion
  • Higher K intake - decreases Ca excretion, increase urinary citrate
  • Vitamin C supplements - increased risk of calcium oxalate stones in MEN (high urinary oxalate levels) - AVOID
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10
Q

Risk Factors: Fluids and Beverages

A
  • Risk increases as urine volume decreases (risk doubles if <1L/day)
  • Fluid intake - main determinant or urine volume
  • Sugar sweetened beverages - increases risk
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11
Q

Associated with reduced risk of Nephrolithiasis

A
  • Coffee,
  • tea,
  • beer,
  • wine and
  • orange juice
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12
Q

NEPHROLITHIASIS
RISK FACTORS - NON DIETARY

A
  • Age, race, body size and environment
  • Weight gain increases risk
  • Environmental and occupational
    + Hot environment
    + Lack of ready access to water or bathroom
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13
Q

NEPHROLITHIASIS
URINARY RISK FACTORS

A
  • URINE VOLUME
    + Readily modifiable
  • URINE CALCIUM
    + Increased excretion increases risk calcium oxalate and phosphate stones
  • URINE OXALATE
    + Increased risk
  • URINE CITRATE
    + Natural inhibitor
    + metabolic acidosis decreases its excretion
  • URINE URIC ACID
    + Excess purine congumption and genetic conditions with overproduction of uric acid
  • URINE pH
    + Uric acid <5.5
    + Calcium phosphate >6.5
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14
Q

2 most common presentations of Nephrolithiasis

A
  • renal colic
  • painless gross hematuria
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15
Q

Urine sediments found

A
  • WBC,
  • RBC,
  • crystals
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16
Q

no need to wait for other tests to start treatment if this is done

A

Urinalysis

17
Q

Diagnosis confirmed of NEPHROLITHIASIS by

A

helical CT non-contrast

18
Q

Goal in NEPHROLITHIASIS

A

maintain euvolemia

19
Q

Drugs that increase rate of spontaneous stone passage

A

Alpha blockers

20
Q

Uro intervention postponed unless with ___, low probability of stone passage (___ or with anatomic abnormality) or ___

A
  • UTI
  • > 6mm
  • intractable pain
21
Q

Least invasive method for NEPHROLITHIASIS

A

ESWL

22
Q

More than half of 1st timers will have recurrence within

A

10 years

23
Q

Test used for NEPHROLITHIASIS

A
  • Electrolytes , crea, calcium and uric acid
  • PTH with vitamin D: when high calcium
  • U/A with sediments, sutures
  • 24 hour urine collection - cornerstone on which therapeutic recommendations are made
  • Stone analysis (uric acid low Hounsfield unison CT)
  • Gold Standard - helical CT without contrast
24
Q

NEPHROLITHIASIS
PREVENTION OF NEW STONE FORMATION

A
  • Depends on the stone type and results of the metabolic evaluation
  • Modification of urine composition
  • Urine volume should at least be 2L/day
  • HOW MUCH MORE THEY NEED TO DRINK
25
Q

Treatment and Prevention of CALCIUM OXALATE

RTC

A

1200 mg calcium with low salt and animal protein reduced subsequent stone formation

26
Q

Treatment and Prevention of CALCIUM OXALATE
THIAZIDE DIURETIC

A

Higher dose lowers urine calcium excretion (restrict Na also)

27
Q

Treatment and Prevention of CALCIUM OXALATE
RISK FACTORS

A
  • higher urine calcium and oxalate,
  • lower citrate
28
Q

Treatment and Prevention of CALCIUM OXALATE
VIT C

A

AVOID HIGH DOSE VITAMIN C: only strategy to reduce endogenous oxalate production

29
Q

Treatment and Prevention of CALCIUM OXALATE
for those with low bone density

A

biphosphonates

30
Q

Treatment and Prevention of CALCIUM OXALATE
Higher consumption of food rich alkali

A

increases urinary citrate excretion
- Supplemental alkali (K citrate or carbonate)
- Restriction of non dairy animal protein and reduce Na intake to <2.5 g/d
- Minimise sucrose and fructose

31
Q

Treatment and Prevention of CALCIUM PHOSPHATE

A
  • Higher urine calcium and lower urine citrate
  • Higher pH >6.5 and common in those with distal RTA and PHPT
  • Thiazide diuretics with Na restriction reduces calcium excretion
  • Alkali supplements for those with low citrate levels
  • Urine pH should be monitored as a higher pH potentially increases risk of stone formation
32
Q

Treatment and Prevention of URIC ACID
Main Factors

A
  • low urine pH
  • higher uric acid excretion
33
Q

Treatment and Prevention of URIC ACID

A
  • Mainstay in prevention is increasing urine pH (fruits and vegetables and reduce animal flesh intake)
  • Alkali supplementation preferably potassium basedvto reach ph goal of 6.5
  • allopurinol or febuxostat can reduce excretion by 40-50%
34
Q

Treatment and Prevention of STRUVITE

A
  • Infection or triple phosphate stones
  • Urease producing bacteria (proteus, Kleb, Providencia)
  • May grow quickly (stag horn calculi)
  • Complete removal by urologist
35
Q

Treatment and Prevention of CYSTINE

A
  • Focus on increasing solubility
  • Tip-ronin - binds to cystine and raises urine pH
  • K citrate or bicarbonate (sodium increases excretion)

IM NEPHRO (7 decks)

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