NEPHROLITHIASIS.

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NEPHROLITHIASIS.

• EPIDEMIOLOGY12 MEN 40-60YRS. 7 WOMEN
  20-30. 2X CAUCASIAN gt AA.MgtF
• STONE BELT SE USA.
• RECURRENCE 50 IN 5 YRS.

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PATHOPHYSIOLOGY.

• SUPERSATURATION LOW URINE VOLUME. HIGH CONC OF
  CA,OXALATE,URIC ACID
• PROMOTERS ABNORMAL PH URINE URIC ,CYSTINE PPT
  IN ACIDIC MEDIUM.CAPHOSPHATE IN
  ALKALINE. NIDUS URIC ACID,BACTERIAL
  DEBRIS
• INHIBITORS CITRATE BINDS CA MAGNESIUM BINDS
  OXALATE

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IDENTIFIABLE CAUSES.

• HYEPRCALCIURIA gt250MG/DAY IN FEMALES. gt300MG
  IN MALES. CAOXALATE IN LOW PH,CAPO4 IN HIGH
• HYPERCALCEMIA PTH,MALIGNANCY,SARCOID,HYPERTHYRO
  IDISM,CUSHINGS,PAGETS,VIT D EXCESS,RTA
• IDIOPATHIC HYPERCALCIURIA RENAL LEAK URINE CA
  MORE THAN INTESTINAL ABSORBTION.POLYGENIC
  FAMLIAL.
• HYPOPHOSPHATAEMIC HYPERCALCIURIARENAL P
  WASTING-PTH STI-CA INCREASE

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MULTIPLE BILATERAL STONES

• PRIMARY PTH
• DISTAL RTA
• MEDULLARY SPONGE KIDNEY
• PRIMARY HYPEROXALURIA

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HYPEROXALURIA

• PRIMARY HYPEROXALURIA,AR PH TYPE 1 SEVERE
  CHILDHOOD,NEPHROCALCINOSIS ESRD DEF OF ALANINE
  GLYOXYLATE AMINOTRANSFERASE.INCREASED
  GLYCOLATE.PH TYPE 2DEF OFGLYOXYLATE
  REDUCTASE.INCREASED L-GLYCERIC ACID
• SECONDARY FAT MALABSORPTION-CA BOUND OXALATE
  ABSORBED.EG BARIATRIC SURGERY,CROHNS PANCREATIC
  EXOCRINE DEF,CELIAC, URETEROINTESTINAL
  DIVERSION.VIT C INCREASED PRODUCTION
• URINE OXALATE gt90MG/DAY

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HYPOCITRATURIA.

• INCREASED ENDOGENOUS ACIDHIGH PROTEIN
  INTAKE,RTA,HYPOKALEMIA.
• LESS THAN 325MG/DAY
• BINDS CA,INHIBITS CRYSTALLIZATION,

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HYPERURICOSURIA.

• DEFINITIONgt800MG/D IN MEN 750MG/D IN FEMALES
• INCREASED ABSORPTION. ?
• INCREASED PRODUCTION
• DECREASED EXCRETION
• URIC ACID CRYTALS MAY FORM IN NORMAL EXCRETION PH
  DEPENDANT COMMON IN ARID HOT REGIONS.

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INFECTION.

• UREA SPILTTING BACTERIA PROTEUS,KLEB UREAHNH3
  HIGH PH MAGNESIUM AMMONIUM PHOSPHATE FORM
  STRUVITE RAPID CRYSTALLIZATION STAGHORN CALCULI
• CYSTINURIAINHERITED AMINOACIDURIA DEFECT IN
  DIBASIC REABSORPTION.CYSTINE POORLY
  SOLUBLE.(ORNITHINE,LYARGININE LYSINE SOLUBLE.)
• 2 GENES SLC3A1 IN CHROMSOME 2,SLC7A9 IN
  CHROMOSOME 19
• NEPHROLITIASIS BEFORE 30YRS OR RECURRENT NEED
  SCREENING SODIUMCYANIDENITROPRUSSIDE URINE
  TEST.CYSTINE-CYSTEINE NITROPRUSSIDE RED PURPLE
  COLOR SPECIFICITY 95 SENSITIVTY72.

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DRUGS CAUSING STONES

• TOPIRAMATE,ZONISAMIDE-IHIBIT CARBONIC
  ANHYDRASE-.RTA .(HIGH URINE PH,LOW CITRATE NORMAL
  BICARBONATE).
• PROTEASE INHIBITORS INDINAVIR,ATAZANIVIR.
• DIETSMETABOLIC SYNDROME- HIGH PROTEIN ACID LOAD
  LOW URINARY NH3 BECAUSE OF INSULIN RESISTANCEUA
  NEPHROLITHIASIS.
• ATKINS DIET
• HIGH CALIUM LOW OXALATE(SPINACH,COCOA) PROTECTIVE.

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CLINICAL FEATURES

• RENAL COLIC,DYURIA FREQUENCY,HEMATURIA INECTION
  PYELONEPHRITIS ,AKI IN SOLITARY KIDNEY,
  INCIDENTAL.
• FIRST KIDNEY STONECHEMISTRY-CA,CR,CO2,K,URINE
  PH,UA CRYTALS( ONLY CYSTINE HEXAGONALPLATES AND
  COFFIN LIDS OF STRUVITE DIAGNOSTIC),STONE FOR
  CRYSTALLOGRAHY, IMAGING SPIRAL NON CONTRAST CT.
• MULTIPLE STONES, CHILDREN,RECURRENT STONES PT
  WITH FAMILY HISTORY OF STONES AIRLINE PILOTS NEED
  24 HR URINE CHEMISTRY X2 FOR VOLUME CA CITRATE
  OXALATEURIC ACIDSODIUM UREA AMMONIUM POTASSIUM
  SCREENING FOR CYSTINE,SPIRAL CT R/O COGENITAL
  CONDTINS LIKE DUPLICATION OF URETERS MEDULLARY
  SPONGE KIDNEYS.

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MANAGEMENT OF NEPHROLITHIASIS

• ACUTEPAINCONTROL TORADOL,DEMEROL,IV FLUIDS
  ANTIBIOTICS IMAGING
• MEDICAL EXPULSIVE THERAPYHIGH VOLUME FLUIDS WITH
  CCB OR FLOMAX
• URGENT SURGICAL INTERVENTION SOLITARY KIDNEY
  WITH OBSTRUCTION,PERSISTANT FEVER,INTRACTABLE
  PAIN NAUSEA
• STONE SIZE lt5MM PASS IN 80-90,STONESgt6MM
  ONLY20
• UROLOGICAL METHODSESWL FOR STONES IN LOWER
  URETER NOT INDICATED IN MULTIPLE STONES,LARGE
  STONES,CYSTINE OR BRUSHITE OR IN KIDNEY.
• URETEROSCOPY WITH BASKET ,LASER LITHOTRIPTER AND
  STENTS
• PERCUTANEOUS NEPHROLITHOMYLARGE STONES STAGHORN
  CALCUI,CYSTINE MULTILE STONES.

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MANAGEMENT OF NEPHROLITHIASIS

• CHRONIC HIGH URINE VOLUMEgt2.5 LITRES,LOW SODIUM
  WITH NORMAL CALCIUM LOW OXALATEAND APPROPIATE
  PROTEIN 1GM/KG AVOID VIT CMORE THAN 100MG
  /DAY,LARGE TEA INTAKE.
• HYPERCALCIURIA-THIAZIDE DIURETCS WITH K
  SUPPLEMENTS
• HYPEROXALAURIALOW DIET CALIUM ?OXALOBACTER
  FORMEGENS.
• HYPOCITRATURIA POTASSIUM CITRATE
• HYPERURICOSURIAALLOPURINOL,ALKALI,DIET

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