Renal stone disease @ medical

outpatient clinic

Mahesh Raj Sigdel

July 4, 2014

Why???
At least 10 per cent of the population in the
industrialized world
Recurrence
Significant pain
Loss

What do we generally do ?

What do surgeons generally do ?

Stone in the urinary tract:

What is this stone type ?
Why did this stone form?
Does the stone(s) require active removal and if
so, how should this procedure be carried out?
What is the risk of further stone problems for
this individual patient?
What can be done to prevent recurrent stone
formation?
Are there any systemic conditions beyond
kidney that need to be addressed ?

Stone types
Calcium containing stones
Calcium oxalate
Hydroxyapatite
Brushite

Non calcium containing

Uric acid
Struvite
Cystine

Xanthine
Ammonium acid urate
Matrix
Medication related eg acyclovir,
indinavir, triamterine, ciprofloxaxin, loop
diuretics, acetazolamide, silicate etc
Stones associated with Melamine
exposure

Radiolucent stones..
Uric acid
Xanthine
Indinavir

How does stone form ?

Formation of stones in the urinary tract is the result of a
pathological crystallization
Complex cascade of events occur as the glomerular
filtrate traverses the nephron.
It begins with urine that becomes supersaturated with
respect to stone-forming salts, such that dissolved ions or
molecules precipitate out of solution and form crystals or
nuclei.
Once formed, crystals are retained in the kidney at
anchoring sites that promote growth and aggregation,
ultimately leading to stone formation.

Major steps in calcium salt crystallization

 Inhibitors
Magnesium
Citrate
Pyrophosphate
Glycosaminoglycans (heparin, heparan sulfate, hyaluronic
acid, and chondroitin sulfate)
Nephrocalcin
Tamm-Horsfall mucoprotein
Uropontin
Bikunin

Other factors
Urine volume
Urinary pH

Calcium Stones
Hypercalciuria
Hyperoxaluria
Hypocitraturia
Hyperuricosuria

Hypocitraturia
Excessive protein intake
Hypokalemia
Metabolic acidosis
Exercise
Hypomagnesemia
Infections
Androgens
Starvation
Acetazolamide

Uric acid stone

Three major factors influence uric acid stone
formation:
low urine pH,
low urine volume, and
elevated urinary uric acid levels

Infection Stones
Struvite stone (magnesium ammonium phosphate) mainly
Infection with urease producing bacteria
Alkaline pH of urine
Predispositions to infection

Cystine Stones
Cystinuria is an autosomal recessive or
dominant
Tubular defect in dibasic amino acid transport
The main contributor to cystine crystallization
is supersaturation because there is no specific
inhibitor of cystine crystallization in the urine

Presentation
Asymptomatic/incidental
Pain
Hematuria
Lithuria
Infection/pyelonephritis
Obstruction
CKD

Clinical Evaluation of Stone Formers

All stone formers should have basic evaluation
All patients with recurrent nephrolithiasis
merit metabolic evaluation
Complete evaluation of patients with a single
stone is controversial because of the
undetermined cost-benefit ratio

Basic evaluation
RBS
KFT, Na, K
Uric acid
Ca, Phosphate, ALP, iPTH
Blood Bicarbonate, Chloride (ABG)
Urine R/M, Urine pH
Urine C/S
Stool analysis
USG abdomen
X-ray KUB (+/- IVU)
Helical CT plain

History
History serves to uncover a systemic etiology for nephrolithiasis:

Any disease that can lead to hypercalcemia

Malabsorptive gastrointestinal disorders, GI bypass surgery
Growth, bone health
Gout, insulin resistance, metabolic syndrome

Stone history:

Number and frequency of stones formed

Age of the patient at occurrence of the first stone
Size of stones
Stone type
whether the patient required surgical removal of the calculi
stone response to intervention
whether stones recur frequently in a single kidney

History ..
Dietary history: protein, purine, oxalate, calcium
restriction

Occupation: drinking water, perspiration, avoiding

going to toilet, ambient temperature

Family history
Medications- eg loop diuretics, salicylates, aciclovir,
sulphadiazene, indinavir, acetazolamide, topiramate,
steroids, calcium, vitamin D, allopurinol, vitamin C

Exposure to melamine

Uric acid crystals

Calcium oxalate crystals

Cystine crystals

Triple phosphate crystal

Management...

Medical management
Generic:
Fluids to make urine >2.5 liters/day
Low protein ( 0.8 to 1 gm/kg/day)
Low salt < 2 gm/day
Normal calcium

Treatment of primary disorder eg

sarcoidosis, hyperparathyroidism

Specific..
Calcium stones
Thiazides
Potassium citrate
Orthophosphate sts

Hyperoxaluria
Dietary and Enteric Hyperoxaluria
Dietary oxalate restriction
Calcium carbonate (1 to 1.5 g) may be added at each meal
and snack

Primary Hyperoxaluria
Pyridoxine
Potassium citrate and magnesium supplementation
Orthophosphate

Oxalobacter formigenes

Uric acid stones

Potassium citrate
Low purine diet
Allopurinol /Febuxosatat

Infection stones
Antibiotic
Surgical
Acetohydroxamic acid (Lithostat)

Cystine stones
d-Penicillamine
Tiopronin
mercaptopropyonyl glycine (thiola)
Captopril

Surgical management
ESWL
PCNL
Endourologic procedures
Surgeries- open/laparoscopic

Stones less amenable to ESWL

Cystine
Brushite
Calcium oxalate monohydrate

Management

What should we generally do ?

What only should not be done by surgeons?

Thank you !!!