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Renal 3 > Urology: Nephrolithiasis > Flashcards

Urology: Nephrolithiasis Flashcards

1
Q

What % of kidney stones are radio-opaue and can be seen on KUB or clean Abd. X-ray?

A

90%

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2
Q

What % of patients with stones have a metabolic abnormality (hypercalciuria- Excreting too much Ca)?

A

Over 95%

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3
Q

What is the most common type of stone in industrialized countries?

A

Calcium oxalate

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4
Q

What is the most common cause of urolithiasis?

A

Dehydration (spike in summer and fall…sweating)

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5
Q

Is there a family inheritance with stones?

A

Yes… there is a 3 fold increase among family members

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6
Q

Who gets more stones, men or women?

A

Men (1.3:1)

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7
Q

What is the peak age for stone formation?

A

30-60

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8
Q

Where is the stone belt?

A

In the southern US… hotter, more dehydrated, less fluids

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9
Q

Does body size obesity increase the risk of stones?

A

Yes

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10
Q

What kind of diet increases stones and why?

A

High in aminal protein: Nucleic acids lead to uric acid stones which are not seen on KUB X-ray

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11
Q

What season are more stones seen in and why?

A

Summer…there is an increase in insensible water loss (sweating) and an increase in light exposure which results in increased calcium absorption due to increased vitamin D production

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12
Q

What are 10 Etiologies of Stone Formation?

A
  1. Anatomic
  2. Urine composition
  3. Urine volume
  4. Diet
  5. Metabolic
  6. Disease states
  7. Medications
  8. UTI (Staghorn stones
  9. Sedentary lifestyle
    10, Supersaturation point (If decreased, need fluids)
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13
Q

What are the anatomic features associated with stone formation?

A

Stasis v. obstruction

  • Poor ureter drainage (kidney stones)
  • BPH: Can’t empty bladder…urine is stagnant and warm and it can crystallize
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14
Q

What are the urine composition features associated with stone formation?

A
  • pH, crystal inhibitors, stone forming substances
  • Ex. Uric acid stones can only form in acidic urine (pH 5.), so if you alkalize the urine to 6.5-7.0 you can dissolve the stone
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15
Q

What are the 2 stones you can dissolve?

A

Uric acid and cysteine

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16
Q

What are the urine volume features associated with stone formation?

A

Smaller urine volume, more likely to form stones (decrease suprasaturation of urine)
-2.5 L of urine per day = Stone former

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17
Q

What type of diet can decrease stone formation?

A

Vegetarian (decrease protein)

-High protein diets have lots of nucleic acid and can lead to uric acid stones

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18
Q

What are the metabolic features associated with stone formation?

A
  • Hypercalciuria
  • Hypocitraturia
  • Hyperoxaluria
  • Hyperuricouria
  • Hypomagnesuira
  • Hypokalemia
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19
Q

What disease states lead to stone formation?

A
  • DM
  • Type I RTA
  • Chronic diarrhea: Dehydrated
  • Medullary sponge kidney
  • Hyperparathyroidism: Increase Ca excretions (remove PTH, fixes stones)
  • PCKD
  • IBD
  • Sarcoidosis
  • Obesity
  • Metabolic acidosis
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20
Q

What medications lead to stone formation?

A
  • Vitamin C: Metabolized to oxalate (this binds to Ca and forms stones)…only need 500mg a day of C
  • Vitamin D: Increases calcium absorption (in kidney)
  • Triamterene: Precipitates in the urine (crystalizes)..This is an old BP medication
  • Protease Inhibitors: Used in HIV…crystallizes in urine
  • Lasix: Increases Ca++ excretion
  • Acetazolamide
  • Agents that increase uric acid in urine (i.e. salicylates and probenicid)
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21
Q

What are some organic inhibitors of stone formation?

A
  1. Citrate: Directly inhibits Ca crystalization*
  2. Urea
  3. Nephrocaclcin
  4. Tamm-Horsfall Protein (native)
  5. Glycosaminoglycans
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22
Q

What are some inorganic inhibitors of stone formation?

A
  1. Phosphate
  2. Mg
  3. Trace elements: Zinc?
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23
Q

What is the recurrence after 1st stone in year 1?

A

10-15%

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24
Q

What is the recurrence after 1st stone in year 5?

A

50-50%

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25
Q

What is the recurrence after 1st stone in year 10?

A

70-80%

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26
Q

What should we do about stones?

A

PREVENT THEM!

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27
Q

What are the 5 types of stones and their incidence?

A
  1. Calcium containing stones: 70%
    - Calcium Oxalate: 27%
    - Calcium Phosphate: 7%
    - Mixed: 36%
  2. Infection stones (Struvite, Magnesium ammonium phosphate, matrix): 15-20%
  3. Uric Acid Stones: 5-10%
  4. Cystine Stones: 1-5%
  5. Protease Inhibitor Stones (Indinavir): Rare
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28
Q

What is the number 1 type of stone?

A

Calcium oxalate

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29
Q

What is the only stone to form in alkaline urine (pH 6.7-7)?

A

Calcium Phosphate

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30
Q

Are uric acid stones radio-opaque?

A

NO…they are radiolucent

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31
Q

What type of urine does uric acid stones form in?

A

Acidic urine (pH 5.0)

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32
Q

What type of patient might get a lot of uric acid stones?

A

A diabetic one…. ketoacidosis, always in an acidotic state, leads to uric acid

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33
Q

Describe cystine stones

A

The are super hard and smell like sulfuric acid when you lazer then (because it release a disulfide bond)

  • They are seen in people with an aberhation in COLA AA metabolism
  • These patients need to drink a ton of fluids to keep suprasaturation really low
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34
Q

What is the only stone not visible on a non-contrast CT scan?

A

Protease inhibitor stones (indinavir)…from HIV meds

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35
Q

What is the gold standard for imaging stones?

A

Non-contrast CT

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36
Q

Are calcium oxalate stones radioopaque?

A

Yes

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37
Q

What type of urine do calcium oxalate stones form in?

A

Wide range of pH

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38
Q

What is the most common cause of calcium oxalate stones?

A

Idiopathic (besides dehydration)

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39
Q

What are some other causes of calcium oxalate stones?

A
  • Primary hyperparathyroidism: 5 %
  • Secondary hyperparathyroidism (Renal failure most common cause)
  • Bone disease- primary and metastatic leading to hypercalcuria and hypercalcemia- Steroids
  • Hyperoxaluria (primary and enteric)
  • Sarcoidosis
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40
Q

What does increase Ca in the blood and urine lead to?

A

Calcium oxalate stones

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41
Q

What are staghorn calculi due to?

A

Infection

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42
Q

What kind of urine do staghorn calculi form in?

A

Alkaline (pH of 7)

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43
Q

What are staghorn calculi usually composed of?

A

Magnesium-Ammonium-Phosphate (along with Ca phosphate)

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44
Q

What kind of bacteria form staghorn calcui?

A

Urea Splitting Bacteria: Proteus, Staphylococcus, Klebsiella, Pseudomonas, Ureaplasma, anaerobes

45
Q

Does E. Coli produce urease?

A

NO…it doesn’t cause staghorn calculi

46
Q

What is the treatment for staghorn caluli and why?

A

Complete stone removal

-These stones have little crannies in them that bacteria can hide in and antiobiotics can’t get to

47
Q

What drug inhibits urease and can prevent stone formation and infection?

A

Lithostat

48
Q

Are staghorn calculi branched?

A

Yes

49
Q

What are staghorn calculi associated with?

A

Recurrent UTI

50
Q

What kind of urine are uric acid stones post soluble in?

A

Urine pH of 7.0 or greater

51
Q

What is uric acid?

A

The end point of purine metabolism (there fore uric acid stones are associated with protein/meat intake)

52
Q

What % of stones are uric acid stones?

A

5-10%

53
Q

What 4 conditions/states were mentioned that are associated with uric acid stones?

A
  1. Gout
  2. Meloproliferative diseases
  3. Increased water and bicarbonate loss due to diarrhea diseases
  4. Chemotherapy: Lysed cells release nucleic acid (increase uric acid stones)
54
Q

Are uric acid stones radioopaque?

A

No…they are radiolucent (on plain XR… can be seen on CT)

55
Q

What are cysteine stones associated with?

A

Interited autosomal recessive defect in transport of COLA AA at the renal tubule

56
Q

What are COLA AAs?

A

Cystine, ornithine, lysine, and argine)

57
Q

What is the only known pathology of cystinuria?

A

Urolithiasis (there are no other clinical manifestations)

58
Q

What pH are cysteine stones more soluble in?

A

Urine pH greater than 7.5

59
Q

Describe cysteine stones?

A

They are radiodense stones with a hexagon shape

  • Looks like a stop sign
  • These are super hard stones (like a diamond)
60
Q

What is the level of urinary cystine associated with these stones?

A

Over 400mg/day

61
Q

What can be done to the urine to help dissolve these stones?

A

Alkalize the urine with oral K-citrate to a pH of greater than 7.5

62
Q

What is the presentation with an acute stone?

A
  1. Renal colic (waxing and waning of pain) - Unilateral flank pain on the side of the stone
  2. Nausea and vomiting
  3. Frequency with persistent urgency
  4. Hematuria
  5. Flank pain without peritoneal signs
63
Q

Where are the kidney and ureter located?

A

RETROPERITONEAL

64
Q

What are some imaging studies used for stones?

A
  1. Non-contrast CT scans
  2. US: Hydroneprosis and kidney swelling are + signs for a potential stone
  3. KUB
65
Q

What is the poor mans CT?

A

US and a KUB

66
Q

If you have increased suspicion of a stone, what will you do?

A

Urine, vitals, fever, imaging (go to CT)

67
Q

What are 8 things done in acute management of a kidney stone?

A
  1. Is the patient sick/toxic?
  2. Fever? Elevated WBC? Low BP?  Treat accordingly
  3. Send urine for UA and culture (BEFORE ANTIBIOTICS)
  4. Imaging
  5. Pain management
  6. IV Hydration
  7. Antibiotics?
  8. Management of Nausea
68
Q

When is urgent intervention for stones requires?

A

Stones associated with:

  1. Solitary kidney
  2. Infection
  3. Renal failure
  4. Unrelenting pain/nausea
  5. Children
69
Q

What can be given to help dilate the mid-distal ureter (and prostate) and help pass a kidney stone?

A

Alpha-blockers

70
Q

If a stone is equal to or less than 4mm how often will it pass?

A

90% of the time

71
Q

Stones 5-7mm pass what % of the time?

A

50%

72
Q

Do stones greater than 7mm pass on their own?

A

Rarely

73
Q

If waiting for a stone to pass, what do you need to do and how long do you wait?

A
  • You need to control pain and increase hydraion

- Wait 4-6 weeks if not febrile

74
Q

What are 2 form of acute treatment for stones?

A
  1. JJ Ureteral stent

2. Percutaneous nephrostomy tube

75
Q

What can a JJ ureteral stent and percutaneous neprostomy tube do for a patient?

A

Alleviate pain (it is usually colicky because of the intermittent blockage of the ureter)

76
Q

Describe the use of a JJ ureteral stent.

A
  • It is placed cystopically under sedation
  • You canulate a wire above the stone to unobstruct the kidney/ureter to move urine and relieve their symptoms
  • Also, it can help the stone to pass with the bolus of urine
77
Q

Desribe percutaneous nephrostomy tube

A

You place a tube in the back to the kidney to drain it (this is typically done by interventional radiology)

78
Q

What are the 3 definitive surgical managements used for stones?

A
  1. Percutaneous Nephrolitholomy (PCNL)
  2. Extracorproeal Shock Wave Lithotripsy (ESWL)
  3. Ureteroscopy (URS)
79
Q

What can mid-ureteral stones be treated by?

A

URS or ESWL

80
Q

What can distal ureteral stones be treated by?

A

URS or ESWL

81
Q

Describe percutaneous neprolithotomy (PCNL)

A

Treatment of choice for stone over 2cm in size

  • You go through the back to the kidney for the stone
  • This is typically done for staghorn stones because you need bore access
82
Q

Describe ureteroscopy

A

You put a scope through the ureter, the stone is surrounded by a basket and pulled out

  • If the stone is under 5mm you can pull it out
  • If it is too big, you can laser it to crack it and break it into little pieces, then you use a basket to pull the pieces out
83
Q

Is ureteroscopy better for stones in the upper pole or lower pole?

A

Upper pole (it is harder to get the scope into the lower pole because it has to curve around)

84
Q

Describe extracorporal shockwave lithotripsy

A
  • US shock waves crush stones: Break stones into sand-like particles
  • Smaller pieces pass out of body in urine
  • This is well tolerated and only requires light sedation
85
Q

If a stone is over 8mm what needs to be done before ESWL?

A

You need to place a pre-operative stent to keep the ureter open to pass particles and facilitate passage (this prevents Steinstrasse)

86
Q

Does ESWL cause damage?

A

Yes…it can cause tissue damage so you need to let it recover 4-6 weeks before the 2nd treatment if needed

87
Q

What is Steinstrasse?

A

A complication of extracorporeal shock wave lithotripsy for urinary tract calculi in which stone fragments block the ureter to form a stone sheet

88
Q

What is involved in chronic management of stones?

A
  1. H&P
  2. Stone composition analysis (NEED to analyze stones)
  3. UA & Urine culture (check for infection)
  4. Serum chemistries; PTH if serum calcium elevated (if Ca is elevated check for PTH increase)
  5. 24-hour urine collection
89
Q

What patients require 24-hour urine collection?

A

All high-risk patients: Young, multiple stones or 2+ stones in a short time

  • Pediatric population
  • Solitary kidney
  • Staghorns or multiple stones
  • Bone disease
  • GI disease
  • Professional such as pilots, truck drivers, etc
90
Q

How is 24-hour urine collection done?

A

The first pee of the day goes in the toilet, then you collect every other one for 24 hours and measure pH, volume, look for rist factors, ect.

91
Q

What is something that is good for stones that we want to be high?

A

Citrate

92
Q

What is the goal in medical management of stones?

A

Prevent new ones

93
Q

What 2 stones can be dissolved under certain circumstances?

A

Uric acid and cystine

94
Q

Is treatment for stones life-long?

A

Yes

95
Q

What is the hub of treatment of kidney stones?

A

To increase the super saturation point

96
Q

How can you increase the supersaturation point?

A
  1. Increase fluids (over 2.5L of urine per day)
  2. Change diet
  3. Adding stone inhibitors
97
Q

What else is important in medical management?

A

Recognizing and reversing other medical factors

98
Q

What drugs are used for management of stones?

A
  • Thiazide diuretics
  • Allopurinol
  • Antibiotics
  • Alkalinizing agents: K-citrate, sodium bicarbonate, sodium citrate
  • Lithostat® for survite stones
  • Thiola & D-penicillamine for cysteine stones
  • Water
  • B6
  • Mg
99
Q

What is example of a thiazide diuretic used for stones and what is the dose?

A

Hydroclorothiazide: Low dose of 12.5-25mg per day

100
Q

How should thiazide diuretic be given for stones?

A
  • 6 months on, 6 months off

- Low Na diet

101
Q

What do thiazide diuretic do to help prevent stones?

A
  1. Increase reabsorption of Ca in the proximal and distal tubules
  2. Inhibit sodium reabsorption (in proximal and distal tubule of kidney
102
Q

What does allopurinol do?

A

It decreases serum uric acid by inhibiting xanthine oxidase (so it’s used with increased levels of uric acid)

103
Q

What are antibiotics used for?

A

Struvite stones (infection)

104
Q

What are alkalinizing agents used for?

A

Uric acid stones…the increase the pH to dissolve stones

105
Q

What is lithostat used for?

A

Struvite stones… it is a urease inhibitor

106
Q

What are thiola and D-penicillamine used for?

A

Cysteine stones (but they aren’t well tolerated because they cause GI distress

107
Q

What does thiola do?

A

It forms a disulfide bond with cysteine

108
Q

What can you drink that is good for kidney stones?

A

Lemonade…because it has citric acid

Renal 3 (17 decks)

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