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90 Cards in this Set
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Urinary stone inhibitors |
1) GAG 2) Acid mucopolysaccharides 3) Glucosamine 4) Mg 5) Inorganic pyrophosphates 6) Citrate 7) Urinary prothrombin fragment 1 8) Nephrocalcin 9) Tamm-Horsfall protein 10) Bikunin 11) RNA fragment 12) Osteopontin |
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GU manifestations of sarcoidosis |
GU SARC Has Pulmonary Nodular Disease 1) Genital skin lesions 2) Urolithiasis (Ca stone) 3) Scrotal mass (epididymal or testicular) 4) Azospermia 5) RPF 6) CRF 7) Hematuria 8) Pseudotumour 9) Nephrocalcinosis 10) Detrusor areflexia, DSD, etc.. |
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Indications for full metabolic stone work-up |
1. Children <18 2. Bilateral or multiple stones 3. Recurrence stones (2 or more episodes) 4. Non-calcium stones (uric acid, cystine) 5. Ca Phosphate stones 6. Any stone episode that had sepsis 7. Stones in a solitary kidney 8. Renal insufficient 9. Diorders that increase risk of stones (gout, osteoporsis, bowel disease, etc...) 10. Occupation where public safety is at risk (pilots, police, etc... |
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Microscopic features of different stones? 1 - Ca Phosphate - apatite 2 - Ca PO4 dihydrate (brushite) 3 - COM 4 - COD 5 - Strivute 6 - Cystine 7 - Uric Acid |
1 - Amorphous 2 - Needle-shaped 3 - Hourglass/ dumbells 4 - Tetrahedral/ envelope 5 - Rectangular, coffin-lid 6 - Hexagonal 7 - Amorphous shards, plates |
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Causes of hypocitraturia |
HARD TIP 1) HypoK 2) Acidosis 3) RTA (distal) 4) Diarrheal states 5) Thiazides 6) Idiopathic 7) Protein rich diet |
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Indications to investigate for RTA |
ACID Paint BRUSH 1) Azotemia 2) CaPO4 stones 3) Infants with FTT 4) Decreased K 5) Pyelo (chronic) 6) Bilateral stones 7) Recurrent stone formers 8) Unexplained metabolic acidosis 9) Sponge kidney (MSK, medullary nephrocalcinosis) 10) Hypocitraturia |
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Causes of acquired distal RTA |
POST CLAAASHH 1) Pyelo (chronic) 2) Obstruction (chronic) 3) Sickle cell 4) Transplant (renal) 5) Cirrhosis 6) Lithium 7) Analgesic abuse 8) ATN 9) Autoimmune (thyroiditis, Sjorens, SLE) 10) Sarcoidosis 11) HyperPTH'ism 12) Hypercalciuria |
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Ways that citrate reduces Ca stone formation |
Complex SNAG protein 1) Complexes Ca 2) Sedimentation inhibition 3) Nucleation prevention 4) Agglomeration inhibition 5) Growth inhibition 6) Enhancement of Tamm-Horsfall protein |
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Risk factors for uric acid stone formation |
They Make GOLDD'N PeePee 1) Thalassemia 2) Myeoloproliferative disorders 3) Gout 4) Obesity 5) Lesch-Nyhan syndrome 6) DM 7) Dehydration 8) Neoplastic disease 9) Purine-rich diet 10) Pregnancy |
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Disorders associated with cystinuria |
MR MD PHD 1) Mental retardation 2) Retinitis pigmentosa 3) Muscular hypotonia 4) Down syndrome 5) Pancreatitis 6) Hemophilia 7) DMD |
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Risk factors for struvite stones |
Urine Can OFFEND people 1) Urinary diversion 2) Congenital GU tract malformation 3) Obstructed GU tract 4) Female 5) Foreign body (foley) 6) Elderly 7) Neurogenic bladder 8) DM 9) Premature infants |
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Bacteria that produce urease |
PACK PUSSY 1) Proteus 2) Aeruginosa (Pseudomonas) 3) Corynebacterium 4) Klebsiella 5) Providencia 6) Ureaplasma urealyticum 7) Staph. Aureus 8) Serratia 9) Yersinia |
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Stones that are radiolucent on KUB |
U Don't See The Xray IMAGE 1) Uric Acid 2) Dihydroxyadenenine 3) Silicate 4) Triamterine 5) Xanthine 6) Indinivir 7) Matrix 8) Ammonium acid urate 9) Guafenasin 10) Ephedrine |
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Medications that directly form stones |
Silicates GET u SIC 1) Silicate antacids 2) Guafenasin 3) Ephedrine 4) Triamterene 5) Sulfa 6) Indinivir 7) Cipro |
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Medications that promote stone formation |
Can PLATE FAST 1) Cytotoxic agents (tumour lysis -> hyperuricemia) 2) PO4 binding antacids 3) Laxatives 4) Acetozolamide 5) Thiazides 6) Excess Vit D 7) Furosemide 8) Allopurinol 9) Steroids 10) Topiramate |
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Causes of renal stones in neonates |
DUTTCH Stones in Really Little Suckers 1) Dehydration 2) Underweight 3) TPN 4) Theophylline 5) Cystinuria 6) HyperPTH'ism 7) Sepsis 8) RTA 9) Lasix 10) Lasix |
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Medications used for absorptive hypercalciuria |
Ty COB 1) Thiazides 2) Celllose PO4 3) Orthophosphates 4) Bran |
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Medications used for primary hyperoxaluria |
1) Hydration 2) K citrate 3) Dialysis 4) Thiazides 5) Elmiron 6) Mg Gluconate 7) Pyrodixine 8) Transplant (liver + kidney) |
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Medicaitons used for enteric hyperoxaluria |
1) Hydration 2) Oxalate restriction 3) Na restriction 4) K citrate 5) Mg supplements 6) Ca supplements 7) Iron 8) Cholestyramine |
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Medications used for cystinuria |
PACK MAB 1) Penicillamine 2) Thiola 3) Captopril 4) K citrate 5) Mucomyst 6) Acetazolamide 7) Bucillamine |
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Theories behind mechanisms of stone fragmentation |
SSS CAD 1) Shear stress 2) Spall fracture 3) Superfocusing 4) Compression 5) Acoustic cavitation 6) Dynamic fracture |
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Contraindications to SWL |
1) Habitus (obesity) 2) Coagulopathy 3) Obstructed distally 4) UTI 5) Calcified renal artery aneursym or AAA 6) HTN uncontrolled 7) Pregnancy |
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When is US for first choice when retrograde access? |
1. Kidneys above urinary diversion 2. Transplanted kidneys 3. Kidneys above a completely obstructed ureter 4. radiation exposure is a concern |
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Increased radiation dose is associated with? |
1. Increased BMI 2. Greater stone burden 3. Non-branched stones 4. Greater number of access sites 5. Use of air rather than contrast |
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When is no drainage tube reasonable after PCNL? |
1. Low-volume stones 2. Atraumatic single access 3. No hemmorhage 4. No perforation 5. No obstruction |
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Risk factors for hemorrhage during PCNL |
1. Multiple access sites 2. Supracostal access 3. Increasing tract size 4. Tract dilatation with methods other than balloon dilation 5. Prolonged OR time 6. Renal pelvis perforation 7. Patient characteristics |
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Risk factors for colon injury |
1. Lower pole access 2. Left kidney 3. Advanced patient age 4. Dilated colon 4. Previous colon surgery or disease 5. Thin body habitus 6. Horseshoe kidney |
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What are signs of a colon injury post PCNL? |
1. Unexplained fever 2. Prolonged ileus 3. Unexplained leukocytosis 4. Rectal bleeding 5. Evidence of peritonitis 6. Fecaluria 7. Pneumaturia |
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Venous gas embolism is indicated by? |
1. hypoxemia 2. evidence of pulmonary edema 3. increased airway pressure 4. hypotension, jugular venous distension 5. facialplethora 6. dysrhythmias 7. auscultation of a mill-wheel cardiac murmur and/orthe appearance of a widened QRS complex with right heart strain |
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Risk factor for fever post PCNL are? |
1. DM 2. Paraplegia 3. Indwelling ureteral stent ornephrostomy tube 4. previous PCNL 5. Multiple tracts 6. Infectious stone 7. Positive pre-operative urine culture 8. Larger stones 9. Hydronephrosis |
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Risk factors for infundibular stenosis? |
1. Large stone burden requiring multiple tracts 2. Prolonged procedures 3. Prolonged nephrostomy tube drainage 4. Open stone surgery 5. DM 6. Obesity |
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Should a first time stone former undergoing a full metabolic workup? |
No, but should undergo a limited metabolic evaluation to rule out potential systemic disorders, such as hyperPTH, and renal dysfunction |
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What does a full metabolic work-up consist of? |
1. Serum - Cr, Na, K, Cl, Ca, Albumin, Uric acid, Bicarb - PTH, if serum Ca is high normal or abnormally elevated - Vit D if low serum Ca or elevated serum PTH 2. 24-hour urine collection - volume, Cr, Ca, Na, K, Oxalate, Citrate, Uric Acid, Mg - Cystine 3. Spot urine - Urine pH - Urinalysis - Specific gravity |
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For new stone formers, do you need to keep sending stones for analysis? |
Yes, because stone composition changed in 21.2% of patients over time. |
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How much volume should stone-formers consume a day? |
Achieve a daily urine output of 2.5 L |
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What is the goal for dietary calcium intake? |
1000-1200 mg/day |
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If someone needs Calcium supplementation with a history of Ca Oxalate stones - when should they consume the Calcium? |
At meal times because this is the time of greatest Oxalate seqestration |
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Should Vitamin D be given in a patient with documented vitamin D deficiency and Calcium oxalate based stones? |
Yes, but 24-hour urine should be conducted after initiation to assess for hypercalciuria |
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What is the recommendation for Na intake? |
Aim for Sodium intake of 1500 mg OD and not exceed 2300 mg OD |
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Those a diet high in fiber, fruits and vegetables prevent kidney stones? |
Small protective effect |
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What is the recommended daily dose of Vitamin C and what can happen if exceeded? |
1000 mg OD Associated risk of hyperoxaluria and nephrolithiasis |
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What is the dose of HCTZ, chlorthalidone and indapamide? |
25 mg BID or 50 mg OD 25 mg OD 2.5 mg OD |
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Side effects of thiazides? |
1. hypoK 2. HyperGlycemia 3. Hyperlipidemia 4. Hyperuricemia 5. HypoMg 6. Hypocitraturia |
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What is the dose of allopurinol? |
200-300 mg in single or divided doses |
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Is allopurinol useful in patients with normal urinary uric acid levels |
No |
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What are the side effects of Allopurinol? |
1. Rash 2. GI upset 3. Abnormal LFTs 4. Prolonged elimination in renal dysfunction |
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What conditions predispose to calcium phosphate stones? |
1. Distal RTA 2. Primary hyperPTH 3. Chronic UTIs 4. HyperCalciuria and/or Hyperphosphatuia |
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Suggestive features of primary hyperPTH? |
1. Elevated and high normal serum Ca 2. Elevated or high normal serum PTH 3. Hypercalciuria 4. Ca Oxalate or Calcium phosphate stones 5. Decrease bone mineral density |
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Suggestive features of renal tubular acidosis? |
Urine pH >5.8 Decreased serum bicarb Decrease serum K Pure apatite stones HypoCitraturia |
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What pH level is the target for treatment of Uric Acid stones? |
Try to target 6.5 |
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What are all dietary and medical treatments available for treating cystine stones? |
1. Hyperdiuresis - 3L of U/O 2. Na restriction - <1500 mg OD 3. Protein restriction - <0.8 mg/kg OD 4. KCitrate - Target pH 7-7.5 5. Thiol binding agents - Penicillamine (1-2 g or tiopronin 800-1200 mg in divided doses) |
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At what pH does cystine solubility increase? |
Between 7-7.5 |
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Why should a urine pH above 7.5 be avoided? |
Increased risk of CaPhosphate stones |
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What can be used along with K Citrate to elevate urinary pH? |
Acetozolamide |
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Side effects of Penicillamine? |
Fever, arthalgias, rash, dysgeusia, leucopenia and proteinuria |
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What are the chances of a stone <5 mm in the distal ureter passing? |
90% |
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What is the role of medical expulsive therapy? |
Stones <10 mm in the distal ureter |
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What stone factors can be used to guide patients with respect to SWL success? |
Composition, density and skin-to-stone distance |
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What stones are better off treated with URS than ESWL? |
Ca Oxalate monohydrate, brushite and cystine |
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What stone density and skin-to-stone distance will likely fail ESWL? |
>1000 HU and >10 cm |
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Do alpha blockers help facilitate stone passage after ESWL? |
Yes |
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What investigations can suspect you that thre is a uric acid stone? |
1. Radiolucent on xray 2. Density <500 HU 3. Acidic urine 5.5 or less |
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What stones are non-infectious? |
Calcium oxalate Calcium phosphate Uric acid |
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What stones are infection stones? |
Magnesium ammonium phosphate Carbonate apatite Ammonium urate |
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Diseases associated with stone formation |
HyperPTH Metabolic syndrome Nephrocalcinosis PCKD Gastrointestinal diseases and bariatric surgery Sarcoidosis Spinal cord injury and neurogenic bladder |
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Genetically determined stone formation |
Cystinuria (type A, B and AB) Primary hyperoxaluria RTA Type 1 2,8 Dihydroxyadeniuria Xanthinuria Lesch-Nyhan Syndrome Cystic fibrosis |
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Anatomic abnormalities associated with stone formation |
Medullary sponge kidney UPJO Calyceal diverticulum Ureteral stricture Vesico-uretero-renal reflux Horseshoe Kidney Ureterocele |
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Why does stepwise progression in power prevent renal injury? |
Can achieve vasoconstriction during treatment which prevents renal injury |
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Contraindications to PCNL? |
1. Untreated UTI 2. Tumour in presumptive access tract area 3. Potential malignant tumour 4. pregnancy |
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When leave a nephrostomy tube at end of PCNL? |
1. presence of residual stones 2. Likelihood of 2nd look 3. Significant intra-operative blood loss 4. Urine extravasation 5. Ureteral obstruction 6. Persistent bacteruria 7. Solitary kidney 8. Bleeding diathesis 9. Planned percutaneous chemolitholysis |
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Calcium phosphate stones present in two completely different minerals: Which one is associated with UTI |
Carbonate apatite - assoc. w UTI Brushite |
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At what pH does carbonate apatite crystallize at? At what pH does Brushite apatite crystallize at? |
Carbonate apa - >6.8 Brushite 6.5-6.8, at high concentrations of calcium and phosphate |
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How do Granulomatous diseases cause hypercalcemia and hypercalciuria? |
By increasing calcitriol production and thus causing increased gut absorption of Ca And suppress PTH |
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How to treatment primary hyperoxaluria? |
1. Hyperdiuresis (intake 3.5-4L OD) 2. Pyridoxine 3. Alkaline citrates 4. Magnesium 5. Liver-kidney transplant |
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What 24-Hr urine abnormalities are associated with enteric hyperoxaluria? |
1. Hyperoxaluria 2. Low urine pH 3. Decrease citrate from GI loss 4. Low urine volume 5. Low urinary calcium |
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At what pH is RTA likely? |
Consistently >5.8 |
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What is the goal of RTA treatment? |
Restore normal acid-base equilibrium Alkalinisation using Alkaline citrates or Na Bicarb is key to normalising the metabolic changes responsible for stone formation Thiazides may be used to lower urinary calcium excretion |
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What is and what are risk factors for nephrocalcinosis? |
Increased crystal deposition within the renal cortex, or medulla, and occurs alone or in combination with renal stones 1. HPT - hyperPTH 2. PH - primary hyperoxaluria 3. RTA 4. Vitamin D metabolic disorders 5. Idiopathic hypercalciuria 6. Hypocitraturia 6. Genetic disorders - Dent's disease, Bartter's syndrome and Medullary Sponge Kidney |
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How does pH increase with infectious type stones? |
Urease-producing bacteria, which increase ammonia ions and develop alkaline urine Struvite precipitates at pH >7.2 |
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How to acidify urine? |
Methionine or ammonium chloride |
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What factors predispose to struvite stone formation? |
neurogenic bladder spinal cord injury/ paralysis continent urinary diversion ileal conduit foreign body stone disease indwelling catheter urethral stricture BPH bladder diverticulum cystocele calyceal diverticulum UPJ obstruction |
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What do medications target with respect to cysteine stones? |
The disulphide bond |
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At what pH do you need to solubilize cysteine? |
>7.5 |
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What drugs can cause drug stones? |
Allopurinol Amoxicillin Ceftriaxone Quinolones Ephredrine Indivavir MgTriscillcate Sulphonamides Triamterene Zonisamide |
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What is a basic metabolic stone evaluation? |
Urinalysis + culture Serum - Na, Cl, CO2, K, Ca, Cr |
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What patients are required to undergo a full metabolic evaluation? |
< 18 years old Bilateral stones Recurrent stone Stone requiring PCNL Stone requiring hospitalization Public safety at risk Pure Ca Phosphate stones Non Calcium stones (Uric acid etc...) Co-morbidites with increased risk of stones (IBD, Gout, osteoporsis, hyperPTH) Stone in a solitary kidney Patient with renal insufficiency |
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Does a patient with struvite stones require metabolic evaluation? |
no |
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What does an in-depth stone evaluation require? |
Serum - Na, Cl, K, CO2, Uric Acid, Ca, Mg, Albumin, PTH if high normal or high Ca, Vitamin D if low normal or low Ca 2x 24-urines - Na, K, Uric Acid, Oxalate, Calcium, Mg, Citrate, Cr, Volume, Cysteine if suspected Urine pH Urinalysis Specific gravity |
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What % of stone composition changes over time? |
21% |
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What are general dietary recommendations for stone formers? |
UO > 2.5 L/day Calcium 1000-1200 mg/day - if Ca supplementation - take at meal times Vitamin D - Take if required but re-do 24-hour urine Animal protein - Moderate animal protein intake Salt aim for 1500-2300 mg Vitamin C - not exceed 1000 mg |
