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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
Tx options for lower tract stones (bladder, urethra)
Cystourethroscopy, cystolitholapaxy Extracorporeal Shock Wave Lithotripsy (ESWL) Open stone removal Dissolution
26
Tx options for upper tract stones (kidney, ureter)
Trial of passage Dissolution Extracorporeal Shock Wave Lithotripsy (ESWL) Ureteroscopy w stone manipulation Percutaneous Nephrolithotomy (PCNL) Open or laparoscopic surgery
27
who are candidates for trial of passage?
``` good renal fx (Cr) pain control PO intake no infx stone size ```
28
describe trial of passage tx option
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
Describe dissolution (chemolysis) tx option
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
advantages/disadvantages of Extracorporeal Shock Wave Lithotripsy (ESWL) tx option
(+) Outpt, non-invasive, sedation (-) stone fragments not removed
31
CI's for Extracorporeal Shock Wave Lithotripsy (ESWL)
Pregnancy Coagulopathy UTI Renal artery aneurysm, AAA also: cystine/matrix stones, chronic pancreatitis, distal obstruction
32
Size of stone for ESWL tx option? how can you visualize it?
Stone size <2 cm Visible on fluoroscopy
33
Describe ESWL tx option
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
ESWL for b/l and solitary kidney
B/L: may choose to do each kidney at separate settings solitary: ureteral stent
35
complications of ESWL tx
``` Renal/retroperitoneal hematoma Ecchymosis UTI, sepsis Steinstrasse Ureteral stricture Pain ```
36
how does ESWL work?
Decr's renal perfusion, function--up to 3 wks
37
describe ureteroscopy w/stone manipulation
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
complications of ureteroscopy w/manipulation (endoscopy)
``` Ureteral avulsion Ureteral perforation Submucosal tunnelling Ureteral stricture (1%) Extrusion of stone outside the lumen of ureter UTI Bleeding Pain ```
39
what is Percutaneous Nephrolithotomy (PCNL)
Removal of stones via a tract passing through flank to kidney
40
when is Percutaneous Nephrolithotomy (PCNL) indicated?
Large stone burden (>2 cm), staghorn calculus
41
CI for Percutaneous Nephrolithotomy (PCNL)
UTI Coagulopathy No percutaneous renal access
42
describe PCNL tx option
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
complications of PCNL
Bleeding Sepsis Renal pelvis perforation Pneumothorax/hydrothorax
44
indications for open or laparoscopic surgery?
Failure of/contraindications to other modalities
45
what procedures are done during open or laparoscopic surgery?
Cystolithotomy Pyelolithotomy Ureterolithotomy Anatrophic nephrolithotomy
46
Prevention of future stones?
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
who is considered high risk for recurrent stones or complications
ped's stone formers, solitary kidney, gout, bone and GI dz's, nephrocalcinosis staghorn, multiple, cystine, uric acid, struvite stones
48
what is PRAL?
Potential Renal Acid Load (reduce!!) High PRAL lowers urinary citrate Animal protein Limit intake of cheese and egg yolks Fruits/vegetables: low PRAL
49
medications used to prevent future stones
``` Potassium citrate Thiazide Allopurinol Pyridoxine (B6) Cholestyramine Thiols ```
50
How does K citrate prevent future stones?
Corrects acidosis | inhibits calcium crystallization
51
Side effects of K citrate?
Hyperkalemia, peptic ulcers
52
be cautious when giving K citrate to...
Uncontrolled DM, renal insufficiency, delayed gastic emptying, K sparing diuretics
53
how does thiazide prevent future stones?
Corrects acidosis | Increases reabsorption of calcium into kidneys, decreasing urine calcium excretion
54
SE's of thiazides?
hypokalemia - give w/potassium weakness fatigue
55
how does allopurinol prevent future stones?
decreases uric acid levels but only decreases stone incidence if pt had been hyperuricosuric
56
how does pyridoxine (B6) prevent future stones?
metabolism of oxalate Pyridoxine deficiency --> hyperoxaluria
57
how does cholestyramine prevent future stones?
Cholestyramine binds bile acids, decreasing colon wall permeability to oxalate
58
how do thiols prevention of future stones?
tx for cystinuria Increases solubility, prevention of cystine stones (tiopronin, D-penicillamine)

Fdnts 3 Exam 1 (17 decks)

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