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Fdnts 3 Exam 1 > urolithiasis > Flashcards

urolithiasis Flashcards

1
Q

Urolithiasis includes:

A 
“Kidney stones”
Nephrolithiasis
Ureterolithiasis
Cystolithiasis
Calculus/calculi
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2
Q

what are urolithiasis composed of:

A

MC = Calcium oxalate, calcium phosphate, uric acid (urate)

Less common:
Magnesium ammonium phosphate (struvite, triple phosphate, MAP)
Cystine
Matrix
Ammonium acid urate
Protease inhibitor stone
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3
Q

characteristics of calcium oxalate stones

A

MC type
radio-opaque
resistant to dissolution
MCly d/t dehydration

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4
Q

characteristics of uric acid (urate) stones

A

radiolucent, forms in acidic urine < 6.0, dissolves in alkalinized urine

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5
Q

characteristics of MAP or struvite stones

A

Cause = UTI
radio-opaque

forms in alkaline urine

can be dissolved with acidification of urine

composed of most staghorn calculi

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6
Q

characteristics of cystine stones

A

d/t genetic defect, autosomal recessive

homozygotes usu form stones

caused by cystinuria

dissolves in alkaline environment

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7
Q

characteristics of matrix stones

A

assoc. w/Proteus UTI

radiolucent

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8
Q

characteristics of ammonium acid urate

A

Assoc. w/ UTI and laxative abuse

Radiolucent

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9
Q

characteristics of protease inhibitor stone

A

precipitated drug (ie. Indinavir for HIV)

Radiolucent

Not visible on stone-protocol CT

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10
Q

etiology of urolithiasis

A

anatomic, urine characteristics, pt volume status, diet, metabolic, dz states, UTI, meds

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11
Q

examples of anatomic etiology for urolithiasis

A

obstruction

stasis

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12
Q

examples of urine characteristics etiology for urolithiasis

A

pH

Crystal inhibitors: citrate, urea

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13
Q

examples of pt volume status etiology for urolithiasis

A

Volume depletion
Low urinary output
Supersaturation of solute

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14
Q

examples of metabolic etiology for urolithiasis

A

hypercalciuria
hypocitraturia
hyperoxaluria
hyperuricosuria

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15
Q

examples of dz states that cause urolithiasis

A 
obesity
chronic diarrhea
metabolic acidosis
renal tubular acidosis
sarcoidosis
IBS
hyperparathyroidism
medullary sponge kidney
adult polycystic kidney dz
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16
Q

how can UTI’s cause urolithiasis and what are the responsible pathogens?

A

can decrease ureteral peristalsis

hypocitraturia

Urea-splitting organisms: proteus, klebsiella, pseudomonas, serratia, staph

Proteus –> matrix stones

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17
Q

examples of meds that can cause urolithiasis

A

Vitamin C
Vitamin D
Triamterene precipitation
Protease inhibitors (Indinavir)
Furosemide incr’s urinary calcium excretion
Acetazolamide (CAI)–> RTA state
Uricosuric agents (probenecid, salicylates)

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18
Q

presentation of urolithiasis

A

Pain (flank, radiation, colic)
N/V
Hematuria
Hyperkinetic

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19
Q

History Q’s for urolithiasis eval?

A 
Pain
prior hx/tx's
assoc. fv, n/v, hematuria
LUTS, UTIs
h/o narcotic-seeking
dietary hx, fluid intake
fam hx of stones/types
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20
Q

PE for urolithiasis eval

A

Fv
hyperkinetic
CVAT

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21
Q

labs for urolithiasis eval

A

UA: pH, specific gravity, hemoglobin, microscopy

CBC: WBC elevation

BMP: Cr, BUN, electrolytes

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22
Q

Imaging for urolithiasis eval

A

KUB

US abd/retroperitoneal/renal and bladder

Intravenous Urogram

CT Stone protocol (Abd/pelvis non-contrast)

CT Urogram (Abd/pelvis w/contrast, including delayed phase—urogram)

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23
Q

Indications for Acute Intervention

A

Complete/high grade urinary obstruction

B/L urinary obstruction

Urinary obstruction w/ urinary infx

Urinary obstruction in solitary kidney

Urinary obstruction with rising Cr

NPO d/t severe N/V

Severe pain uncontrolled by analgesics

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24
Q

Urolithiasis Tx

A

abx for infx

acutely, relieve obstruction: ureteral stent, nephrostomy tube, sepsis prevention, renal damage/loss of renal fx prevention

later proceed to definitive stone management under more controlled circumstances

25
Q

Tx options for lower tract stones (bladder, urethra)

A

Cystourethroscopy, cystolitholapaxy

Extracorporeal Shock Wave

Lithotripsy (ESWL)

Open stone removal

Dissolution

26
Q

Tx options for upper tract stones (kidney, ureter)

A

Trial of passage

Dissolution

Extracorporeal Shock Wave

Lithotripsy (ESWL)

Ureteroscopy w stone manipulation

Percutaneous

Nephrolithotomy (PCNL)

Open or laparoscopic

surgery

27
Q

who are candidates for trial of passage?

A 
good renal fx (Cr)
pain control
PO intake
no infx
stone size
28
Q

describe trial of passage tx option

A

Stones 5 mm or less

fluids and analgesics PO
alpha-blocker (tamsulosin) incr. passage %, decr time to passage, decr pain

filter urine

periodic imaging: assess for hydronephrosis

29
Q

Describe dissolution (chemolysis) tx option

A

for uric acid stones: alkalinze urine w/Na bicarb or K citrate

cystine stones: alkalinze urine w/ K citrate

struvite, Ca phos stones: irrigation w/acidic sol’n (Renacidin)

30
Q

advantages/disadvantages of Extracorporeal Shock Wave Lithotripsy (ESWL) tx option

A

(+) Outpt, non-invasive, sedation

(-) stone fragments not removed

31
Q

CI’s for Extracorporeal Shock Wave Lithotripsy (ESWL)

A

Pregnancy
Coagulopathy
UTI
Renal artery aneurysm, AAA

also: cystine/matrix stones, chronic pancreatitis, distal obstruction

32
Q

Size of stone for ESWL tx option? how can you visualize it?

A

Stone size <2 cm

Visible on fluoroscopy

33
Q

Describe ESWL tx option

A

Done under sedation/anesthesia w/ fluoroscopic imaging

Shock wave generator positioned against patient’s side

Table manipulated to put stone in cross-hairs

Shocks delivered 60-90/min

Gated w/ EKG, to avoid of inducing dysrhythmia

34
Q

ESWL for b/l and solitary kidney

A

B/L: may choose to do each kidney at separate settings

solitary: ureteral stent

35
Q

complications of ESWL tx

A 
Renal/retroperitoneal hematoma
Ecchymosis
UTI, sepsis
Steinstrasse
Ureteral stricture
Pain
36
Q

how does ESWL work?

A

Decr’s renal perfusion, function–up to 3 wks

37
Q

describe ureteroscopy w/stone manipulation

A

OR under general anesthesia

transurethral approach

Flexible scope placed up ureter

Energy delivered to calculus

Stone broken up

Fragments basketed out

Poss ureteral stent temporarily

38
Q

complications of ureteroscopy w/manipulation (endoscopy)

A 
Ureteral avulsion
Ureteral perforation
Submucosal tunnelling
Ureteral stricture (1%)
Extrusion of stone outside the lumen of ureter
UTI
Bleeding
Pain
39
Q

what is Percutaneous Nephrolithotomy (PCNL)

A

Removal of stones via a tract passing through flank to kidney

40
Q

when is Percutaneous Nephrolithotomy (PCNL) indicated?

A

Large stone burden (>2 cm), staghorn calculus

41
Q

CI for Percutaneous Nephrolithotomy (PCNL)

A

UTI
Coagulopathy
No percutaneous renal access

42
Q

describe PCNL tx option

A

Interventional Radiology or in OR

Access through skin, flank approach, needle placed under fluoroscopic guidance

Needle/catheter advanced to renal collecting system

Wire, tract dilation

Nephroscopy

Instruments passed under direct vision

Energy delivered to lithotripsy stone

Fragments grasped, removed

43
Q

complications of PCNL

A

Bleeding
Sepsis
Renal pelvis perforation
Pneumothorax/hydrothorax

44
Q

indications for open or laparoscopic surgery?

A

Failure of/contraindications to other modalities

45
Q

what procedures are done during open or laparoscopic surgery?

A

Cystolithotomy
Pyelolithotomy
Ureterolithotomy
Anatrophic nephrolithotomy

46
Q

Prevention of future stones?

A

metabolic eval: UA, stone analysis, serum labs, 24hr urine collection

fluid intake (esp. w/citrate)

low sodium diet, low animal protein intake

moderate calcium intake

avoid high doses of vit. C & D

reduce PRAL

47
Q

who is considered high risk for recurrent stones or complications

A

ped’s stone formers, solitary kidney, gout, bone and GI dz’s, nephrocalcinosis

staghorn, multiple, cystine, uric acid, struvite stones

48
Q

what is PRAL?

A

Potential Renal Acid Load (reduce!!)

High PRAL lowers urinary citrate
Animal protein
Limit intake of cheese and egg yolks
Fruits/vegetables: low PRAL

49
Q

medications used to prevent future stones

A 
Potassium citrate
Thiazide
Allopurinol
Pyridoxine (B6)
Cholestyramine
Thiols
50
Q

How does K citrate prevent future stones?

A

Corrects acidosis

inhibits calcium crystallization

51
Q

Side effects of K citrate?

A

Hyperkalemia, peptic ulcers

52
Q

be cautious when giving K citrate to…

A

Uncontrolled DM, renal insufficiency, delayed gastic emptying, K sparing diuretics

53
Q

how does thiazide prevent future stones?

A

Corrects acidosis

Increases reabsorption of calcium into kidneys, decreasing urine calcium excretion

54
Q

SE’s of thiazides?

A

hypokalemia - give w/potassium
weakness
fatigue

55
Q

how does allopurinol prevent future stones?

A

decreases uric acid levels but only decreases stone incidence if pt had been hyperuricosuric

56
Q

how does pyridoxine (B6) prevent future stones?

A

metabolism of oxalate

Pyridoxine deficiency –> hyperoxaluria

57
Q

how does cholestyramine prevent future stones?

A

Cholestyramine binds bile acids, decreasing colon wall permeability to oxalate

58
Q

how do thiols prevention of future stones?

A

tx for cystinuria
Increases solubility, prevention of cystine stones
(tiopronin, D-penicillamine)

Fdnts 3 Exam 1 (17 decks)

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