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Summer FDTN Exam 1 > Urolithiasis > Flashcards

Urolithiasis Flashcards

1
Q

What is urolithiasis

A

Kidney stones

further classified as nephro, uretero, or cystolithiasis

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2
Q

What are the different types of stones

A 
Calcium oxalate (MC)
Calcium phosphate 
Uric acid 
MAP (struvite)
Cystine
Matrix
Ammonium acid urate 
protease inhibitor stone
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3
Q

What do different stones look like on imaging

A 
Calcium oxalate- Opaque 
Calcium phosphate 
Uric acid- Lucent 
MAP (struvite)- Opaque
Cystine
Matrix- Lucent
Ammonium acid urate- Lucent 
protease inhibitor stone- Lucent
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4
Q

What is a calcium oxalate stone

A 
Radio opaque (WHITE) that is resistant to dissolution 
caused by DEHYDRATION!
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5
Q

What is a uric acid stone

A

Forms in acidic urine (<6) and dissolves in alkalinized urine

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6
Q

What is a MAP (struvite) stone

A

Magnesium, ammonium, phosphate
Forms in alkaline urine, dissolves with acidification of urine
Caused by UTI’s
Forms Staghorn calculi

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7
Q

What is a cystine stone

A

MCC by genetic defect, Autosomal recessive (so homozygous are stone formers)
Caused by cystinuria
Dissolves in alkaline environment

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8
Q

What is a matrix stone

A

Proteus UTI associated

it is gelatinous so shock wave lithotripsy is not a good Tx

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9
Q

What is an ammonium acid urate stone

A

Associated with laxative abuse (and UTI’s)

Talk to your patient about healthier ways to have bowel movements

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10
Q

What is a protease inhibitor stone

A

Usually 2/2 precipitated drug (ex. Indinavir- HIV drug)

Not visible on stone protocol CT

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11
Q

What are some causes of Urolithiasis

A

Anatomic (not draining- obstruction/stasis)
Urine charac. (pH, specific gravity, crystal inhibitors)
Volume status (depletion, low UO, supersat urine)
diet
metabolic (high Ca, oxalate, uric acid- low Citrate)
disease states
UTI (proteus- low citrate- low ureteral peristalsis)
Meds (Indinavir)

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12
Q

What are crystal inhibitors

A

Citrate (complexes with calcium)

Urea (increases solubility of uric acid)

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13
Q

What are some disease states that cause urolithiasis

A 
Obesity 
Metabolic acidosis (high urine Ca/phos, low citrate) 
RTA 
Sarcoidosis (hypercalcuria) 
Chronic diarrhea (volume depletion, acidosis)
Cystinuria 
IBD (high oxalate) 
Hyperparathyroid (hypercalcemia) 
Medullary sponge kidney
Adult PKD
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14
Q

What are urea splitting organisms

A 
Proteus (matrix stone) 
Klebsiella
Pseudomonas 
Serratia 
Staph
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15
Q

What happens when urea is split

A

Breaks down into ammonia and Bicarb (alkaline) = Struvite stone

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16
Q

What meds can cause UTI

A

Indinavir (protease inhibitor)
Vitamin C (inc. oxalate) and D (increase Ca absorption)
Triamterene
Furosemide (increase Ca excretion)
Acetazolamide (causes RTA stone)
Uricosuric agents (salicylates, probenecid)

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17
Q

What are common Sx of urolithiasis

A

flank pain
colic (waxing and waning)
radiation (to scrotum or vulva)
N/V, hematuria

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18
Q

What will labs show for urolithiasis

A

hematuria
BMP: high Creatinine, BUN
CBC: high WBC
UA: specific gravity, pH, Hgb

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19
Q

What will PE for urolithiasis show

A

fever
hyperkinetic (constantly walking around)
CVA ttp

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20
Q

What imaging can you get to evaluate Urolithiasis

A

KUB
US abdomen
CT stone protocol (A&P non con)
CT urogram (A&P w/ con)

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21
Q

What are indications for acute intervention

A 
complete/high grade obstruction 
b/l obstruction 
obstruction w/ infection, in solitary kidney, or w/ rising Cr
NPO 2/2 N/V
Severe pain uncontrolled by analgesics
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22
Q

How do you treat acute urolithiasis

A

ABX for infection
Obstruction relief: ureteral stent, nephrostomy tube
Later proceed to definitive stone management
-goal is to prevent sepsis and renal damage

23
Q

How can you treat a lower tract stone (bladder, urethra)

A

Cystourethroscopy
Extracorporeal shock wave lithotripsy
open stone removal
dissolution

24
Q

How do you treat upper tract stones (kidney, ureter)

A 
trial of passage (5mm or less) 
dissolution 
ESWL
ureteroscopy w/ stone manipulaiton 
percutaneous nephrolithotomy 
open or laparoscopic surgery
25
Q

Candidates for trial of passage are based on

A 
Renal function 
pain control 
PO intake 
No infection 
stone size (5mm or less)
26
Q

What do you give during a trial of passage

A 
Fluids po 
analgesics po 
Alpha blockers (Tamsulosin) 
Filter urine 
periodic imaging to assess hydronephrosis
27
Q

What is dissolution for uric acid stones

A

chemolysis using Sodium bicarb or Potassium citrate to make urine more ALKALINE (>6.5)
Can take up to 3 months to work
-Then irrigate the system via nephrostomy tube, sodium bicarb, and THAM

28
Q

What is dissolution for cystine stones

A

chemolysis usine Potassium citrate to make urine more ALKALINE (>7.5)
Irrigate the system with sodium bicarb, THAM, and NAC

29
Q

What is dissolution for Struvite and Calcium phosphate stones

A

Irrigate with ACIDIC solution (Renacidin)

30
Q

What is ESWL

A

IF <2mm, using a gel barrier between skin and laser, skock wave generator delivered for 60-90 min (manipulate table so lasers hit as cross hairs)
Gate w/ ECG to avoid inducing arrhythmia
Do with fluoroscopic imaging (real time XR)- may need to stent and inject dye if radiolucent
Must be sedated or under anesthesia
Decreased renal perfusion for up to 3 weeks

31
Q

What are ups and downs to ESWL

A

Outpatient, non-invasive, and sedated

But, stone fragments cant be removed

32
Q

What are CI to ESWL

A

CI: pregnancy, coagulopathy, UTI, aneurysm, AAA

relative CI: Cystine or Matrix stone, chronic pancreatitis, distal obstruction

33
Q

What are complications of ESWL

A 
Renal or retroperitoneal hematoma
Ecchymosis
UTI
sepsis
Ureteral stricture 
Pain
34
Q

What is Ureteroscopy with stone manipulation (upper Tx)

A

In OR (gen anesthesia) use transurethral approach to place flexible scope and deliver energy to calculus
can use laser, ultrasonic, or electrohydraulic lithotripsy, or pneumatic impactor (jack hammer)
Stone is broke up and fragments basketed out
+/- ureteral stent temp.

35
Q

What are complications of Ureteroscopy with stone manipulation

A 
ureteral avulsion/ perforation 
submucosal tunneling 
ureteral stricture 
stone goes outside of ureteral lumen 
UTI
bleeding
pain
36
Q

What is Percutaneous nephrolithotomy (upper Tx)

A

In IR or OR, needle placed into flank under fluoroscopic guidance, and advanced into renal collecting system (kidney)
Energy delivered to lithotripsy stone
Fragments grabbed and removed
Good for stones >2mm (STAGHORN)

37
Q

CI to PCNL include

A

UTI
Coagulopathy
No percutaneous renal access

38
Q

What are complications of PCNL

A

bleeding
sepsis
renal pelvis perforation
PTX, hydrothorax

39
Q

What is indication for open or laparoscopic surgery

A

Fail trial of passage, dissolution, ESWL, ureteroscopy with stone manipulation, and PCNL

40
Q

What are the ways urolithiasis surgery can be preformed

A

Cystolithotomy (large stone or concurrent surgery)
Pyelolithotomy
Ureterolithotomy
Anatrophic nephrolithotomy (Brodel’s avascular plane)

41
Q

Metabolic evaluation includes

A

H&P, UA, stone analysis, serum labs, 24 hr urine collection

42
Q

Who is at high risk for recurrent stones/ stone complications

A 
Peds stone formers 
solitary kidney
Staghorn 
Cystine, uric acid, Struvite stone formers 
Nephrocalcinosis 
gout
chronic UTI
FH stones 
Crohn's (GI dz) 
Osteoporosis (bone dz)
Profession where stone can endanger others (pilot)
43
Q

How can you prevent future stones

A 
Fluid intake (UO 2500 ml/d) 
Increase fluids with citrate (NO POP) 
Low sodium (<2300mg) 
Low animal protein intake 
Low oxalate (beets, strawberry, rhubarb, chocolate, spinach, liver, tea, peanuts, potatoes) 
Moderate Calcium intake (800-1000 mh/d) 
Avoid high dose vitamin C (causes increased oxalate)
44
Q

What is PRAL (stone prevention)

A

Porential Renal Acid Load
high PRAL= low Citrate
so keep PRAL low by limiting animal protein, cheese and egg yolks, and increasing fruits and veggies

45
Q

What meds can help prevent future stones

A 
Potassium citrate (alkalinize urine) 
thiazide 
allopurinol 
Pyridoxine, B6
Cholestyramine 
Thiols
46
Q

How does Potassium citrate work

A

Citrate binds calcium and stops crystallization
corrects acidosis= increase urinary citrate= decrease urinary calcium
Caution in: uncontrolled DM, renal insuff, delayed gastric emptying, K sparing diuretic

47
Q

ADE of potassium citrate include

A

hyperkalemia

peptic ulcers

48
Q

How do thiazides work

A

Increase reabsorption of Ca into kidneys= decreased urine calcium excretion= corrects acidosis
*Can worsen stone dz if it causes hypokalemia- give with K+

49
Q

ADE of thiazides are

A

Weakness, fatigue

50
Q

How does Allopurinol work

A

Decreases uric acid levels therefor decreasing stone incidence IF patient was hyperuricosuric

51
Q

How does pyridoxine work

A

Helps metabolize oxalate

Take to prevent B6 deficiency and prevent hyperoxaluria

52
Q

How does cholestyramine work

A

Bind bile acid and make colon wall less permeable= less oxalate gets into system
(bile acids normally increase permeability)

53
Q

How do thiols work

A

Treat and prevent cystinuria by increasing solubility

*Tiopronin, D-Penicillamine

Summer FDTN Exam 1 (12 decks)

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