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Nephrology > Urolithiasis > Flashcards

Urolithiasis Flashcards

1
Q

Composition of stones

A
  • calcium oxalate (most common)
  • calcium phosphate
  • uric acid
  • struvite/ triple phosphate
  • cystine
  • other
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2
Q
  • most common stone type
  • mutiple etiologies, dehydration most common, forms in a wide range pH, radio-opaque, not dissolvable
A

calcium oxalate

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3
Q
  • dehydration (MC), hyperuricosuria
  • forms in ACIDIC URINE (pH < 6)
  • radiolucent
  • dissolves with urinary alkalinization
A

Uric acid

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4
Q

etio: Metabolic conditions such a renal tubular acidosis, migraines, medications

  • forms in ALKALINE URINE
  • Radio-opaque
A

Calcium phosphate

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5
Q

struvite and triple phosphate

  • Etio: UTI (MC)- bacteria produce ammonia that builds up in the urine
  • forms in ALKALINE urine
  • radio-opaque
  • dissolves with urinary acidification
A

Magnesium ammonium phosphate

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6
Q
  • etio: Cystinuria (hereditary genetic disorder)
  • typically form stones starting in childhood
  • cystine is a derivative of the amino acid cysteine
  • forms in ACIDIC urine
  • radio-opaque
  • dissolves with urinary alkalinization
A

cystine

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7
Q

etio: laxative abuse, UTI radioluscent

A

ammonium acid urate

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8
Q

etio: precipitated drug (ex: indinavir/HIV antivirals)

  • radiolucent & NOT visible on non-con CT
A

protease inhibitor stones

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9
Q

etiologies and risk factors for stones

A
  • anatomic- obstruction/stasis
  • urine composition- pH, hypercalcicuria, hypocitrauria, hyperoxaluria, hyperuricosuria, hypomagnesiuria
  • low urine volume (MC)
  • diet: sodium, low fiber, high oxalate, carbonated drinks
  • Hypokalemia
  • disease states- obesity, DM, HTN, gout, metabolic acidosis etc
  • UTI
  • sedentary lifestyle
  • medications
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10
Q

symptoms of stones

A
  • flank pain: colic/wave-like, sharp/severe (radiation to abdomen, testicles/labia
  • secondary to obstruction
  • Hematuria: gross or microscopic blood
  • GI: N/V
  • asymptomatic
  • LUTS: urgency/frequency/dysuria/pressue
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11
Q

obstructive vs non-obstructive stones

A
  • obstructing stones typically cause symptoms secondary to hydronephrosis (celiac ganglion compression)
  • non-obstructing stones are usually asymptomatic, incidentally notes
  • can have intermittent obstruction–> colic
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12
Q
  • presence of fluid in the kidneys as a result of obstruction
  • obstruction can be anywhere along urinary tract (meatus to kidney)
  • can be silent or symptomatic
  • obstruction can be from a stone (MC), strictures, BOO, BPH, extraureteral compression (think LAD/malignancy) trauma, edema, congenital anomalies, UPJ, blood clot, reflux
A

hydronephrosis

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13
Q

Complications of hydronephrosis?

A
  • UTI, pyelonephritis
  • urosepsis
  • renal atrophy
  • renal insufficiency/failure
  • urolithiasis
  • HTN
  • renal rupture–> peritonitis
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14
Q

labs to order for stones?

A
  • CBC
  • BPM
  • UA
  • Urine gram stain and C&s
  • pregnancy test
  • Mg
  • PO4
  • uric acid
  • PTH
  • TSH
  • 24h urine stone
  • calculus analysis
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15
Q

treatment of stones?

A
  • fluids, antiemetics, pain control
  • surviellance: small non-obstructing renal calculi
  • dissolution therapy: uric acid stone–> urinary alkalinization
  • medical expulsive therapy
  • surgical intervention
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16
Q
  • trial of spontaneous passage
  • hydration, strainer, pain control
  • alpha blocker, corticosteroids
  • follow up imaging
  • appropriate: passable stones, good pain control, no infection, appropriate renal function
A

Medical expulsive therapy

17
Q
  • historically done in tub bath
  • now done with gel pad under lower body & fluoroscopy
  • US waves utilized to break up stone +/- stenting
  • contraindications- pregnancy, coagulopathy, UTI, renal artery calcifications, AAA, radiolucent stones
  • stone favorable parameters: stone size * location, STSD, HUD
A

ESWL (extracorporeal shockwave lithotripsy)

18
Q

complications of ESWL

A
  • hematoma
  • skin ecchymosis
  • UTI
  • Pain
  • Steinstrasse (stone street)
  • lower stone clearance rate
19
Q
  • rigid and flexible
  • option for stone basketing
  • disadvantage- need for ureteral stent
  • good option for failed ESWL or non- ESWL candidate
  • cystolitholapaxy
  • complications- ureteral perforation, stricture
A

Ureteroscopy with laser lithotripsy

20
Q

Ureteral stone particularly distal ones

A

Rigid ureteroscopy

21
Q
  • Failed ESWL
  • Renal stones < 2cm
  • complex anatomy
  • proximal ureteral stone
A

flexible ureteroscopy

22
Q
  • removes renal calculi from the kidney through percutaneous access from back into the kidney
  • small hole for large stones? larger stones are laser fragmented before removed
  • disadvantages: 2-3 day admission, stent and/or nephrostomy tube
A

Percutaneous nephrolithotomy (PCNL)

23
Q

Large stones > 2.5cm
failed ESWL
complex anatomic cases
staghorn stones

A

PCNL

24
Q

complications of PCNL?

A
  • infection
  • pneumo/hemothorax
  • injury
  • extravasation of urine
  • rare- bowel injury
25
Q

indications of emergent treatment

A
  • Obstructing stone + infection
  • bilateral obstruction
  • solitary kidney
  • refractory pain
  • inability to tolerate oral intake d/t NV
  • goal is to drain the system: Stent & run, nephrostomy tube
26
Q

can be placed with ESWL, URS, PCNL and in the setting of infection, ureteral injury or ureteral surgery

A

ureteral stents

27
Q

prevention of stones?

A

complete evaluation

  • 24 hour urine for creatinine, Ca, Mg, Citrate, uric acid, oxalate
  • serum labs
  • dietary assesment
  • assess history for risk factors

Dietary managment
medical management

28
Q

what should you know about first time stone formers?

A
  • 50% recurrence within 5-10 years
  • recurrent stones can lead to renal impairment, infections, pain, multiple ER visits, surgeries
29
Q

non-medication managment of stones?

A
  • avoidance of stone-provoking drugs
  • weight loss in the obese
  • high fluid intake
  • dietary oxalate restriction
  • dietary sodium restriction
  • limit animal protein excess “fleshy foods”
  • low purine diet- uric acid
  • avoid extremes of calcium intake
30
Q

medical management of hypercalciuria?

A

Thiazide Diuretics

  • Decrease urinary calcium & correct acidosis
  • increases reabsorption of calcium in the proximal & distal tubules
  • inhibits sodium reabsorption in the distal tubule
  • monitor for hypokalemia
31
Q

medical management of hypcitrauria?

A

Potassium citrate

  • urinary alkalinizer, increases urinary citrate goal pH > 6/5
  • monitor for hyperkalemia (sodium bicarbonate, baking soda)
32
Q

medical management of hyperuricosuria?

A

Allopurinol

  • decreases urinary uric acid
  • works even if normal serum uric acid
33
Q

medical mangement of cytinuria?

A

Thiola

  • forms bond with cysteine to increase its urine solubility

Nephrology (12 decks)

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