Renal 2- Wisnoff- Urolithiasis

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most common cause of flank pain.

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Nephrolithiasis

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Renal colic- severe intermittent flank pain that radiates to the

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groin, lower abdomen, or genitalia due to the passage of a stone through the urinary system.

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Nephrolithiasis symp:

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Often accompanied by nausea, vomiting, dysuria, and hematuria

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Nephrolithiasis gender, age, race, prevalance

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Lifetime prevalence is 5.2%, which is increasing.
Affect men 2-3 times more frequently than women.
Caucasians>Hispanics>Asians>Africans
Incidence rises after age 20; peaks between age 40-60(men)
Women have a bimodal peak with a second peak after 60

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What stones account for 75% of all kidney stones.

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Ca

CaP and Ca oxalate

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Sufferers usually have hypercalciuria

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Hyperparathyroidism
Hypercalcemia of malignancy
Sarcoidosis

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Risk factors to developing stones

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-Increased BMI
-animal protein
-supplemental calcium
-medications

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Are a result of infection
requires a combination of ammonia and alkaline urine
What kind of stone?

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Struvite Stones

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occur more in women and people with chronic catheters

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Struvite Stones

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They can grow very large and extend into the calyces.

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Struvite Stones

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Struvite Stones

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15% 0f all kidney stones
Are a result of infection
Formation of struvite stone requires a combination of ammonia and alkaline urine
Struvite stone occur more in women and people with chronic catheters
They can grow very large and extend into the calyces.

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15% 0f all kidney stones

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Struvite Stones

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6% of all stones

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Uric Acid Stones

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Uric Acid Stones

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6% of all stones
Formation influenced by low urine PH, low urine volume, and hyperuricosuria
DM, obesity, and hypertension my be risk factors for formation of uric acid stones along with myeloprolifertive disorders or chemotherapy

Front 15

Formation influenced by low urine PH, low urine volume, and hyperuricosuria

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Uric Acid Stones

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DM, obesity, and hypertension my be risk factors for formation of these stones along with myeloprolifertive disorders or chemotherapy

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Uric Acid Stones

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Kidney stones form when

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when urine becomes supersaturated with stone-forming salts.

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It has been shown to inhibit calcium oxalate and calcium phosphate stone formation.

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citrate

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are inhibitory factors for stone formation:

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Glycoprotein nephrocalin, Tamm-Horsfall mucoprotein and uropontin
citrate

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Stone compostion can be ____ and ____

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1. Calcareous, like CaP and Ca oxalate. 70-75% of stones. Radio opaque (white on plain film)

2. Non-calcareous, like Uric acid, Cystine, Struvate, Others(Xanthine, guaifenesin), 25-30% of all stones, radiolucent (poorly visualized on plain film, grey to black color)

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Colic pain

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Severe, intermittent or spasmodic pain
Typically begins abruptly in the flank and increases in severity rapidly.
As the stone migrates, the pain can radiate to the abdomen, pelvis and genitals.
SSStones within the bladder can cause frequency,
urgency and dysuria.

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There are 3 main areas that a stone can become lodged

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Ureteropelvic junction
Iliac vessels
Ureterovesical junction

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PMHX
of kindey stone pt

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Positive family historyhyperparathyroidism
RTA
Diabetes
Gout
Horseshoe Kidney
HIV Meds

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pt with flank pain PE

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First, review the vital signs
Hypertensive, tachycardic, pale, cool, clammy
May see CVA tenderness and mild lower abdominal pain
Be sure to include aortic examination and genital examination

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pt with flank pain Diagnostic study

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Urinalysis
CBC
Bun/Cr

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Urinalysis

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Can be used to look for the presence of red or white blood cells, protein and crystals.
RBCs do not have to be present
Other conditions can produce RBCs
Sensitivity 84%, Specificity 48%, PPV 72%, NPV 65%

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A comprehensive metabolic evaluation req on what pts?

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A comprehensive metabolic evaluation is not cost effective for all patients. This may include people with multiple recurrences, pediatric patients, or risk factors.
Stone composition
24 hour urine collection

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Radiographic studies:

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1. KUB-Kidney/Ureter/Bladder x-ray- Has been shown useful in following stones progression through the urinary tract.

2. Intravenous Pyelogram- 94% sensitivity, 90% specificity, which was within 5 % of the results for ct.
Antiquated study now with invention of ct.

3. Ultrasound- modality of choice in those who should avoid radiation,. Pregnant patients and children.
It can look for stones or for hydronephrosis as a secondary sign of the presence of a stone.

4. Non-enhanced Helical Computed Tomography is the test of choice for lithiasis.
Benefits are that it can diagnose kidney stones after they have passed. The secondary signs are indicative of a localized inflammatory reaction or irritation caused by the presence of passing ureteral stones.
Its sensitivity and specificity approach 100%
Can make alternate diagnosis
Limitations of CT are radiation dosages

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TX of patient with kidney stones

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NSAIDS- relieve pain through prostaglandin-mediated pain pathway inhibition and decreased ureteral contractility.
Study performed showed combination of morphine and NSAID showed better relief than either alone.

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Fuids in kidney stone pts:

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Increasing oral fluid intake(2 liters a day) can prevent supersaturation and stone formation.
During acute attack giving high rate IV fluids has fallen out of favor. Originally thought to flush the kidneys. Found to increase the pain of obstruction.
No role for diuretics
No role for anti-muscarinic drugs

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Medical Expulsive Therapy

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Alpha Blockers and Calcium Channel Blockers augment stone expulsion rates.
Steroids do the same, but not better. As a result, use limited secondary to side affects.

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Stones less than 5 mm

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usually pass spontaneously.
Distal stones more likely than proximal stones

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Stones larger than 7 mm

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probably require surgical intervention.

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Indication for pt admission

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- obstruction w infection
- urosepsis
-intraceable pain w refractory nausea and/or vomiting
-impending renal failure
-severe volume depletion
-obstruction in solitary or transplanted kidney and complete obstruction
-bilateral obstruction
-urinary extravasation

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what shown to reduce kidney stone recurrences by half.

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Increased fluid intake to at least 2.5 l/d is recommended as this level has been shown to reduce recurrences by half.

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Differential diagnosis for pt with acute flank pain
Serious/Life threatning causes

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- abdominal aortic aneurism
- PE
-appendicitis
- renal vein thrombosis
- renal malignancies and infarction
- ectopic pregnancy
-bowel obstruction
- pancreatitis
-cholecystitis

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Differential diagnosis for pt with acute flank pain
NON- Serious causes

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- MSK pain
-acute pyelonephritis
- renal cysts
- hepatitis
- varicella-zoster
-peptic ulcer
-diverticulitis/colitis