Download Constituents of Kidney Stones

Urinary Stones
Urolithiasis
Kidney stones
nephrolithiasis
Kidney stones
Kidney stones (renal calculi)
Aadalah batu yang terbentuk di dlm tub ginjal
dan biasanya tersusun dari produk
metabolisme yang difiltrasi glomerulus yang
biasanya disebabkan karena konsentrasinya
mendekati ambang maksimumnya.
Kidney stones
Nephrolithiasis
: adanya batu di dalam
ginjal
Urolithiasis : adanya / ditemukannya batu di
dlm traktus urinarius
Stones form in the urinary tract
Ada tiga cara : 
1. terbentuknya kristalkristal 
2. kristal2 tsb beragregasi satu sama lain 
3. menjadi batu kristal yg ckp besar utk 
memblok saluran urinari
Location of Renal stones
Conditions favouring kidney
stones formation
1. Konsentrasi zat terlarut yang harus
melalui filtrasi di glomerulus di atas
ambang batasnya
2. Perubahan pH urine.
3. Menahan Urin
4. Kurangnya inhibitor/faktor penghambat
yg berperan dlm pembentukan batu ginjal
Conditions favouring kidney
stones formation
1. Konsentrasi urine meningkat
menyebabkan:
-  volume urine (dengan fungsi ginjal
normal)
- Restricted fluid intake -  meningkatan kehilangan cairan pada periode yang panjang
-  ekskresi metabolik menyebabkan
peningkatan pembtkan batu ginjal

*  volume plasma volume ( yang bs 
meningkatkan laju filtrasi glomerulus)
* reabsopsi tubulus dari hasil 
filtrasi
Conditions favouring kidney
stones formation
2- perubahan pH urine
- often due to bacterial infection
-  precipitation of different salts at
different pH:
* A persistently acidic urine  •
promotes uric acid precipitation •
* A persistently alkaline urine •
(due to upper urinary tract infection)
promotes Mg Ammonium Phosphate
crystals (Struvite stones)
Conditions favouring kidney
stones formation
3. Urinary stagnation:
- Due to obstruction of urinary outflow
4- Lack of normal inhibitors in urine
- Inhibitors of stone formation: e.g.:
Citrates
Pyrophosphate
Glycoproteins
Constituents of Kidney Stones
1. garam kalsium
2. asam urat
3. magnesium amonium fosfat
4. Batu kristal Cystine stones
5. lain2 (Xantihine,dll)
Stones – Chemical Constituents
Whewelite – Calcium Oxalate Monohydrate –
CaC2O4-H2O
Weddelite - Calcium Oxalate dihydrate –
CaC2O4-2H2O
Brushite – Calcium Hydrogen phosphate
dihydrate – CaHPO4 2H2O
Whitlockite - TriCalcium Phosphate –
Ca2(PO4)2
Struvite – Magnesium Ammonium hexahydrate
– MgNH4PO4-6H2O
Uncommon Stones
XANTHINE STONES
– (kelainan autosomal resesif, defisiensi
xanthine oxidase akan memicu
xanthinuria)
DIHYDROXYADENINE STONE
– ( Defisiensi enzim adenin fosforibosil
tranferase)
Uncommon Stones
SlLICATE STONES
– jarang terjadi pada manusia (kelebihan intake
antasida yang mengandung Mg trisilicat)
MATRIX
- Infeksi oleh Proteus
Uncommon Stones
TRIAMTERENE
- terapi untuk menjaga kadar Na tetap
rendah, diberikan utk mencegah penumpukan
cairan (edema) pada penderita gagal
jantung
– penggunaan anti hipertensi dengan
hidroklorotiazid – bagian potassium.
Umumnya ditemukan sebagai inti pada Ca
Uncommon Stones
Indinavir Stones
- Drug to treat AIDS (4 to13%)
Ephedrine or Guifenesin
– Cough medicine - Radiolucent
Constituents of Kidney Stones:
1-Stones of calcium salts
* 80% of pasien dengan nephrolithiasis
membentuk batu kalsium dari:
- paling srg: Ca-Oxalate 
- jarang dari: Ca-Phosphate 
* Type of salt depends on: 
- pH urin
- asupan oksalate 

Stones of Calcium Salts
e.g. Calcium Oxalate Stones
Constituents of Kidney Stones:
(cont.)
1-Stones of calcium salts
karakteristik:
- putih, keras dan radioopak
- Ca-Oxalate: lebih kecil, terkumpul di ureter
- Ca-Phosphate: staghorn, di renal pelvis
(besar)
Constituents of Kidney Stones:
(cont.)
1-Stones of calcium salts
Beberapa penyebab pembentukan batu ginjal
kalsium::
1- Hypercalciuria:
Defined as daily urinary Ca excretion >6.2
mmol in ♀ & >7.5 mmol in ♂
- due to hypercalcemia (most often
due
to 1ary hyperparathyroism)
- sometimes, Ca++ salts stones are
found with no hypercalcemia
2- Hyperoxaluria (more important )
- favours formation of calcium oxalates
(even with no hypercalciuria)
- causes:
* exogenous (diet rich in oxalate )
* absorption (in fat
malabsorption)
* 1ary hyperoxaluria: inborn errors ,
in childhood , urinary oxalates >
400 mmol/24 hours


Increased intestinal absorption of calcium
(absorptive hypercalciuria),
excessive hormone levels hyperparathyroidism

renal calcium leak (kidney defect that causes
excessive calcium to enter the urine)

Prolonged inactivity also increases urinary
calcium and may cause stones.

Renal tubular acidosis (inherited condition in
which the kidneys are unable to excrete acid)
significantly reduces urinary citrate and total
acid levels and can lead to stone formation.
Constituents of Kidney Stones:
(cont.)
1-Stones of calcium salts
Conservative lines of treatment:
* Treatment of primary condition (i.e.
Infection, hypercalcemia, hyperoxaluria)
* Reducing oxalates in diet (it is not
recommended to reduce calcium in diet)
* Fluid intake (if no glomerular failure).
*Acidification of urine (as ppt. is favoured by
alkaline conditions)
Constituents of Kidney Stones:
2-Uric acid stones
- ~ 8% of renal stones contains uric acid
- may be associated with hyperuricemia (with or without clinical gout) - Characteristics: * small, friable & yellowish
* may form staghorn (if big)
* radiolucent (can’t be seen be plain X-ray)
* visualized by ultrasonography or I.V.
Pyelogram
Uric acid stones
Uric Acid Stones

Digestion produces uric acid.

If the acid level in the urine is high or too
much acid is excreted, the uric acid may not
dissolve and uric acid stones may form.

They are not visible on X-rays.

Patients with gout often develop these stones.
- Uric acid stones are more often caused by
low urine pH.
- Even relatively high uric acid excretion will
not be associated with uric acid stone
formation if the urine pH is alkaline.
Therefore, prevention of uric acid stones
relies on alkalinization of the urine with
citrate. Potassium citrate Is also used in
kidney stone prevention-
Cont.

Genetics may play a role in the development
of uric acid stones, which are more common
in men.

Approximately 10% of patients with kidney
stone disease develop this type of stone.
Constituents of Kidney Stones:
2-Uric acid stones, (Cont.)
Treatment:
- Treatment of cause of hyperuricemia
-  purine-rich diet
- Alkalinzation of urine (e.g. by potassium
citrate)
- fluid intake
Constituents of Kidney Stones:
3- Magnesium ammonium phosphate
stones
* ~ 10% of all renal stones
* With chronic urinary tract infection (by urease
splitting organisms as Proteus species 
ammonia production from urea)
* Alkaline urine pH (> 7.0)
Mg ammonium phosphate
(struvite) stone
Struvite Stones

Also called an infection stone, develops
when a urinary tract infection (e.g., bladder
infection) affects the chemical balance of
the urine.

Bacteria in the urinary tract release
chemicals that neutralize acid in the urine,
which enables bacteria to grow more quickly
and promotes struvite stone development.
Cont.

They are capable of splitting urea into
ammonia, decreasing the acidity of the urine
and resulting in favorable conditions for the
formation of struvite stones.

Organisms which alkalinize the urine can
cause struvite stones to form.

Struvite stones are more common in women.
-The stones usually develop as jagged
structures called "staghorns" and can grow to be quite large.
-
Treatment:
* Aggressive prevention & treatment of the
cause (urinary tract infection)
* Urine acidification
*  Fluid intake
* It may require complete stone removal
(percutaneous nephrolithotomy)
* Aggressive prevention & treatment of •
future urinary tract infection •
Constituents of Kidney Stones:
4- cystine stones

Cystine is an amino acid.

Some people inherit a rare, congenital
condition that results in large amounts of
cystine in the urine (cystinuria)
causes cystine stones that are difficult to
treat and requires life-long therapy. *
Cystine Stones
* Rare
* occurs in cases of homozygous cystinuria
(inborn error of amino acid metabolism)
* Soluble in alkaline urine (precipitates
by
acidic urine) •
Treatment: -  fluid intake
- Alkalinzation of urine
- Penicillamine
•
Cystine stones
The key features to the
formation of stones






Family history,
Age of onset,
Fluid intake pattern,
Diet, medications,
History of infections.
Certain stone formation has a genetic
predisposition
- Some an autosomal recessive pattern,
including cystinuria and primary
hyperoxaluria,
- Some have an autosomal dominant pattern
such as renal tubular acidosis (RTA) or
the syndrome of idiopathic calcium oxalate
urolithiasis.
-
Causes and Risk Factors

A low level of citrate is a risk factor for
hypocitraturia.

Congenital kidney defect that may increase
urinary calcium loss and stone formation
(medullary sponge kidney)

Excessive parathyroid hormone, which causes
calcium loss (hyperparathyroidism)

Gout (caused by excessive uric acid in the
blood)

High blood pressure ( hypertension)

Inflammation of the colon that causes
chronic diarrhea, dehydration, and chemical
imbalances (colitis)

Sodium (hypernatremia)

Inherited condition in which the kidneys
are unable to excrete acid (renal tubular
acidosis)

Painful joint inflammation (arthritis)

Urinary tract infectious (affect kidney
function)
- A diet high in sodium, fats, meat, and sugar,
and low in fiber, vegetable protein, and
unrefined carbohydrates increases the risk
for renal stone disease.
- High doses of vitamin C (i.e., more than 500
mg per day) can result in high levels of
oxalate in the urine (hyperoxaluria) and
increase the risk for kidney stones.

Oxalate is found in berries, vegetables (e.g.,
green beans, beets, spinach, squash,
tomatoes), nuts, chocolate, and tea.

Stone formers should limit their intake of
cranberries, which contain a moderate
amount of oxalate.
Certain foods may increase the risk of stones
- spinach, rhubarb, chocolate, peanuts, cocoa,
tomato juice, grapefruit juice, apple juice,
soda (acidic and contains phosphorus),
and berries (high levels of oxalate).
Other drinks are associated with decreased
risk of stones,
- wine, lemonade and orange juice (rich in
citrate -- a stone inhibitor
Allopurinol reduces calcium stone formation
Thiazides are the medical therapy of choice
for most cases of hypercalciuria
Cellulose supplements have also shown
potential for reducing kidney stones caused
by hypercalciuria
lithotripsy