Survey
* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project
Download 9:45 AM Nephrolithiagis
Document related concepts
no text concepts found
Transcript
NEPHROLITHIASIS SCOPE OF THE PROBLEM • Incidence 0.10 – 0.5% population/yr • High cost in yearly health care dollars • High morbidity: pain, obstruction, bleeding, • infection, loss of work Males >>Females except for infection related stones COMMON STONES • Calcium oxalate • Calcium phosphate • Struvite-apatite • Cystine • Uric acid STONE EVALUATION • Stone History • Family History • Medications • Dietary Considerations • Urologic Procedures • Radiologic Studies • Urinalysis • Stone Analysis • Metabolic Evaluation STONE HISTORY • Total number of stones • Frequency of analgesic use • Time off work • Symptoms: renal colic, renal ache • History of UTI, gout, diarrhea, malabsorption, myeloproliferative disorders STONE EVALUATION • Stone History • Family History • Medications • Dietary Considerations • Urologic Procedures • Radiologic Studies • Urinalysis • Stone Analysis • Metabolic Evaluation STONE-PROVOKING MEDICATIONS MEDICATION STONE TYPE MECHANISMS Acetazolamide Ca ox, Ca phos Hypercalciuria Vitamin C Ca ox Hypocitraturia Calcium supplements Ca ox, Ca phos Hyperoxaluria Vitamin D Ca ox, Ca phos Hypercalciuria Antacids Ca ox Hypercalciuria Theophylline Ca ox, Ca phos Hypercalciuria Nifedipine Ca ox, Ca phos Hypercalciuria Probenecid, ASA Uric Acid Hyperuricosuria DIETARY CONSIDERATIONS IN NEPHROLITHIASIS • Fluids • Dairy products • Salt • Protein • • Animal Vegetable Oxalate Alcohol STONE EVALUATION • Stone History • Family History • Medications • Dietary Considerations • Urologic Procedures • Radiologic Studies • Urinalysis • Stone Analysis • Metabolic Evaluation UROLOGIC PROCEDURES • Anatrophic Nephrolithotomy • Percutaneus Nephrolithotomy • Extracorporeal shock lithotripsy • Ureteroscopy (laser) RADIOLOGIC APPEARANCE OF CALCULI Radiopaque Calculi Radiolucent Calculi Calcium Oxalate Uric Acid Calcium Phosphate Struvite-Apatite Cystine STONE EVALUATION • Stone History • Family History • Medications • Dietary Considerations • Urologic Procedures • Radiologic Studies • Urinalysis • Stone Analysis • Metabolic Evaluation URINALYSIS CRYSTALLURIA • Calcium Oxalate • Calcium Phosphate-Apatite, Brushite • Struvite—Magnesium Ammonium Phosphate • Uric Acid • Cystine STONE EVALUATION • Stone History • Family History • Medications • Dietary Considerations • Urologic Procedures • Radiologic Studies • Urinalysis • Stone Analysis • Metabolic Evaluation STONE ANALYSIS RADIOPAQUE STONES STONE TYPE METABOLIC ETIOLOGY Calcium oxalate Hypercalciuria, Hyperoxaluria Hyperuricosuria, Hypocitraturia Hypomagnesiuria Calcium phosphate Hypercalciuria, PHPT, Distal RTA Sodium Alkali Therapy Struvite or Carbonate-apatite UTI Cystine Cystinuria STONE EVALUATION • Stone History • Family History • Medications • Dietary Considerations • Urologic Procedures • Radiologic Studies • Urinalysis • Stone Analysis • Metabolic Evaluation METABOLIC CLASSIFICATION OF NEPHROLITHIASIS • Hypercalciuria • Hyperuricosuria • Hyperoxaluria • Hypocitraturia • Hypomagnesiuria • Altered urinary pH • Cystinuria • Low urinary volume • • • • METABOLIC EVALUATION OF NEPHROLITHIASIS Blood Chemistries CBC PTH Urine Urianalysis Culture & Sensitivity Cystine 24-Hour Urine Collections Random Diet Restricted Diet Fast and Calcium Load Test 24 HOUR URINE COLLECTIONS TOTAL VOLUME SODIUM pH Potassium Calcium Uric acid Phosphorus Oxalate Magnesium Creatinine Citrate Sulfate NEPHROLITHIASIS COEXISTENCE OF METABOLIC DERANGEMENTS N=1270 CATEGORY Hypercalciuria PERCENT 60 Hyperuricosuria Calcium Nephrolithiasis 36 Uric Acid Nephrolithiasis 10 Hyperoxaluria 7 Hypocitraturia 31 Hypomagnesiuria 7 Infection 6 Cystinuria <1 Low Urinary Volumes 15 No Metabolic Abnormality 4 Difficult to Classify 5 CYSTINE STONES • Decreased renal tubule absorption of cystine, ornithine, lysine and arginine (COLA) • Autosomal recessive • Large, radiopaque, often staghorn • Rx: thiola, D-penicillamine, captopril INFECTION – STRUVITE STONES • Urea urease CO2 + NH3 • NH4 + Mg2 + PO4 • Carbonate + PO4 NH4+ Struvite carbonate apatite INFECTION – STRUVITE STONES • Radiopaque, staghorn • Women > men • Associated with chronic infection with urease producing organisms • Poor prognosis: Rx: surgery, lithotripsy, antibiotics, acetohydroxamic acid URIC ACID STONES • Associated with gout, GI disease, neoplasm • Radiolucent • Fluids, diet, alkali, allopurinol DEFINITIONS OF HYPERCALCIURIA • 24 hour Urinary Calcium Excretion > 200 mg/day 1 week on Ca and Na restricted diet (40 mg Ca, 10 mEg Na) • 24 hour Urinary Calcium Excretion > 4 mg/kg/day • 24 hour Urinary Calcium Excretion > 250 mg/dayfemales, > 300 mg/day--males FAST AND CALCIUM LOAD TEST • Normal fasting value <0.11 mg Ca/mg Cr (GFR) • Normal postload value <0.20 mg Ca/mg Cr ABSORPTIVE HYPERCALCIURIA • Primary Defect – increased intestinal absorption of Ca • Location of Lesion – Jejunum • Inheritance – autosomal dominant • Animal Model – genetically Hypercalciuric rat • Skeletal Status – normal to increased cortical bone density • Calcium Balance - normal ABSORPTIVE HYPERCALCIURIA •Sodium Cellulose Phosphate Urinary Ca > 350 mg/day Side effects – hyperoxaluria, hypomagnesiuria •Thiazide + Potassium Citrate •Amiloride RENAL HYPERCALCIURIA • Primary Defect – impaired tubular • • • • • reasborption of Ca Location of Lesion - ? Proximal tubule No effect of Diet on Calcium Excretion 1,25-(OH)2D3 – increased Skeletal Status – decreased cortical bone density Calcium Balance - negative RENAL HYPERCALCIURIA • Thiazide • Potassium Citrate PRIMARY HYPERPARATHYROIDISM • Primary Defect – parathyroid glad adenoma or hyperplasia • 1,25-(OH)2D3 – PTH- dependent increased renal synthesis • Skeletal Status – decreased cortical bone density PRIMARY HYPERPARATHYROIDISM • Surgical Management • Medical Management Estrogen Orthophosphates RENAL PHOSPHATE LEAK ABSORPTIVE HYPERCALCIURIA TYPE III • Primary Defect – increased urinary phosphate • 1,25-(OH)2D3 – increased • Skeletal Status – decreased bone density • Calcium Balance – negative • Role of Diet RENAL PHOSPHATE LEAK TREATMENT • Orthophosphates MANIFESTATIONS OF THE HYPERCALCIURIAS FEATURE AH RH PHPT RPL Serum Ca Normal Normal High Normal Serum Phos Normal Normal Low Low PTH Normal/Low Enhanced High Normal Fasting Urinary Ca <0.11 >0.11 >0.11 <0.11 Postload Urinary Ca >0.20 >0.20 >0.20 >0.20 TREATMENT OF NEPHROLITHIASIS CONSERVATIVE MANAGEMENT • Fluids to maintain 3-8 L Urinary Volume/Day • Diet No Calcium Restriction Sodium Restriction Limited Purine Intake Oxalate Restriction
Related documents