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Nephrolithiasis/Urinary Tract Infections Jeffrey T. Reisert, DO University of New England Physician Assistant Program 21 JAN 2010 Nephrolithiasis and UTI’s 1 Contact Information Jeffrey T. Reisert, DO [email protected] 103 Boulder Point Rd., Suite 3 Plymouth, NH 03264 603-536-6355 603-536-6356 (fax) Nephrolithiasis and UTI’s 2 Case example A 55 y/o male smoker with history of hypertension presents to ED 10/10 sharp abdominal pain Otherwise negative review (fever, wt. loss, etc.) Nephrolithiasis and UTI’s 3 Case cont. Exam: Looks uncomfortable. Fidgety. Work up – Slightly elevated white cell count – 3+ blood in urine Nephrolithiasis and UTI’s 4 Case cont. What is differential dx? What are diagnostic considerations? Treatment? Nephrolithiasis and UTI’s 5 Introduction Kidney stones and UTI’s are a relatively common cause of emergency room visit Suspect when appropriate symptoms and lab findings May or may not be easily treated Nephrolithiasis and UTI’s 6 Agenda Nephrolithiasis – Epidemiology – Types – Treatments UTI’s – Ditto Nephrolithiasis and UTI’s 7 Kidney stones-Epidemiology Men more than women 3rd decade of life 60% 10 year recurrence rate Nephrolithiasis and UTI’s 8 Problems May or may not pass Pain – – – – – Severe Colic to sharp Oh My God!!! Can radiate to groin Often requires opiates to control Bleeding Infection Hospitalization Nephrolithiasis and UTI’s 9 Pathogenesis Materials in urine that have low solubility can increase Decreased urine flow results in saturation Precipitation into stones that can snowball May be affected by urine pH – Acidic urine-Uric acid stones – AlkaloticUrate or phosphate – Note Ca++ stones not affected by pH Nephrolithiasis and UTI’s 10 Types Calcium most common (75-85%) – Oxalate – Phosphate Uric acid – Radiolucent – Red or orange Cysteine – Yellow Struvite – See below Nephrolithiasis and UTI’s 11 Calcium stones Again, most common type, by far Often hypercalciuria General treatment may include: – – – – – – Hydration Sodium restriction, oxalate restriction Potassium citrate 2-30mEq bid Decease meat intake Increase citrus fruit Moderate calcium intake ok (Calcium in gut helps bind with oxalate and actually reduces calcium absorption) Nephrolithiasis and UTI’s 12 Calcium stones-Associations If serum Ca++ abnormal – Check serum parathyroid hormone (PTH) level – Also r/o malignancy, sarcoidosis, steroid use If Hypercalcuria – Try thiazides (decrease urine Ca++ levels) Hyperuricosuria – Lower intake of purines (meats) or – try Allopurinol (decreases uric acid production) Nephrolithiasis and UTI’s 13 Calcium stones-Associations If Distal RTA (Recall Type I RTA has higher incidence of stone formation) – Alkalinize urine (potassium bicarbonate or citrate) If Hyperoxaluria – Try cholestyramine (fat absorption may be the problem) or citrate supplement If Hypocitruria – Try alkali to increase urine citrate excretion (potassium citrate or potassium bicarbonate) Nephrolithiasis and UTI’s 14 Uric Acid Stones R/O tumors – Especially the lymphomas (high cellular turnover) Increase urine pH (Alkalinize urine) K+ Citrate Acetazolamide (alkalinizes urine) Low purine diet Allopurinol Nephrolithiasis and UTI’s 15 Cysteine stones Etiology: amino acid transport defect Fluids to 3L per 24 hours Alkalinize urine Low salt diet Nephrolithiasis and UTI’s 16 Struvite stone Magnesium ammonium phosphate or simply “Magnesium stones” Associated with chronic UTI’s and self catheterization – Urease from bacteria (Proteus) converts urea to NH3 and CO2. NH3 converted to ammonia which alkalizes urine to pH of 8 or 9. – Leads to space occupying stone in renal pelvis (Staghorn calculus) Requires removal +/- treatment of infection Nephrolithiasis and UTI’s 17 Evaluation of the stone patient Check serum lytes including Ca++, creatinine Urinalysis – Cheap, easy Nephrolithiasis and UTI’s 18 Evaluation of the stone patientcont. 24 hour urine collection – – – – – pH Calcium Uric acid Oxalate Citrate Stone analysis-Test all stones! Nephrolithiasis and UTI’s 19 Radiography Flat plate abdomen – Detects radiopaque stones – Not good for uric acid stones Intravenous pyelogram (IVP) – Dye reaction – May include tomogram – Formerly diagnostic test of choice CT – See next slide Nephrolithiasis and UTI’s 20 CT Scanning for stones Non-contrasted helical CT with 3-5mm cuts Has become “gold standard” – Safer than IVP – Faster – Readily available at most hospitals Slightly more expensive, but worth it Nephrolithiasis and UTI’s 21 Ultrasound for stones If can’t have radiation Misses small stones Will help r/o obstruction Safer if dye risk, etc. Nephrolithiasis and UTI’s 22 Treatment Fluid intake to 2-3 liters of urine flow Pain medications – Narcotic analgesics – NSAIDS Tamsulosin (Flomax®)-may relax ureter to facilitate passage of stone-Not FDA approved but often used regionally. Direct treatment if specific cause identified Oral phosphates may be helpful R/O obstruction and remove if needed Nephrolithiasis and UTI’s 23 Removal of stones Cystoscopy – Basket Lithotripsy – Extracorporeal shock wave treatment Formerly bathtub Now portable units, smaller Not without side effects (bruising) – Percutaneous ultrasonic – Laser Nephrolithiasis and UTI’s 24 UTI’s-Overview Common (70M office visits per year in US) – Younger sexually active females – If in men, older Require clean collection >100,000 colonies per ml – >100 if suprapubic collection or catheter collection Nephrolithiasis and UTI’s 25 UTI’s-Types Acute or chronic Catheter associated (nosocomial) or not (community acquired) Symptomatic or asymptomatic Nephrolithiasis and UTI’s 26 UTI’s-Associations Short urethra in women Urethra close to anus in woman Intercourse – Voiding before and after intercourse not PROVEN to be helpful Contraceptives may increase risk Antibiotics may change bacterial flora Obstruction Nephrolithiasis and UTI’s 27 UTI’s-Locations/Syndromes Lower – Cystitis – Urethritis Upper – Pyelonephritis Nephrolithiasis and UTI’s 28 UTI’s-Organisms Gram negative bacilli – – – – Escherichia coli (by far MC) Klebsiella Proteus Enterobacter Others – Staph saprophyticus – Enterococcus – Staph aureus Nephrolithiasis and UTI’s 29 UTI’s cont… Must be differentiated from asymptomatic bacturia S/S – – – – Dysuria Frequency Urgency Pain suprapubic or prostate on DRE Pyelonephritis – – – – Flank pain Fever/Chills Nausea and vomiting Sepsis (Increased HR, Decreased BP) Nephrolithiasis and UTI’s 30 UTI-Evaluation None needed in simple cystitis in woman Culture otherwise – May help if recurrent infections – May identify resistance strains and patterns in your geographical area – Young men should always be further evaluated Ultrasound or CT considered to rule out obstruction, anatomical problems, stone, etc. Nephrolithiasis and UTI’s 31 UTI’s-Treatment Simple cystitis in woman-3d – May not even need to see patient, if patient familiar with symptoms Otherwise 7-14 days Sulfa, nitrofurantoin, or quinolones are all good choices – No quinlones in pregnancy. Penicillin safer alternative – Ciprofloxacin (Cipro®) now available generic Take into account – – – – Resistance patterns Recent antibiotic use Drug allergies Outpatient vs. inpatient Nephrolithiasis and UTI’s 32 Urosepsis Sick UTI Shocky – – – – Tachycardia Hypotension High fever Elevated WBC count Treat with Cephalosporin (or PCN drug) and Aminoglycoside or perhaps quinolone (Regional variation, check antibiogram) Nephrolithiasis and UTI’s 33 UTI’s-Prevention May be difficult Voiding after intercourse-Not proven Preventative antibiotics – May lead to drug resistance Cranberry juice-Is proven, NEJM Nephrolithiasis and UTI’s 34 Case wrap-up Exam suggests stone Must r/o malignancy too (age of pt, tobacco use) CT scan Pain control, IV fluids ?Surgical eval Warn of recurrence rate Nephrolithiasis and UTI’s 35 Summary You will see (or have) kidney stones and urinary infections! Look for treatable causes of each Urological referral if indicated Nephrolithiasis and UTI’s 36 Where to Get More Information Harrison’s or Cecil’s Any urology text Nephrolithiasis and UTI’s 37