Dwi Lestari PartiningrumNephrology and Hypertension Division,Nephrology and Hypertension Division,

Internal Medicine DepartmentMedical Faculty Diponegoro University/ Kariadi Hospital

Affects 5-10% of Americans in their lifetime Chance of recurrence is about 50% Men are more often affected than women Average age of onset is between 20 and 30 g g

years.

Calcium oxalate and phosphate: Account for about 70% of stones.Account for about 70% of stones. Causes include hypercalciuria, hyperuricosuria,

hyperoxaluria, etc

Magnesium Ammonium Phosphate: 15-20% of stones caused by urea-splitting bacteria Proteus and some

StaphStaph Form the Staghorn calculi

Uric acid: 5 10% of stones 5-10% of stones Predisposed with gout, leukemias, or ???

Cystine:Only 1 2% of stones Only 1-2% of stones

Caused by genetic defects in renal re-absorption of amino acidsabsorption of amino acids.

Hypercalciuria (40-60%) Hyperuricosuria (25%)y ( ) Hyperoxaluria Hypocitriuria Other (vitamin A deficiency, hot climates,

immobilisation, urinary tract anomalies

Acute flank pain Renal colic if passed into ureter or if

obstruction Urinary urgency or frequency Hematuria Nausea and vomiting Fever and chills Silent (1/3) if large because remain in renal

pelvis

History Physicaly Urinalysistolookforbloodandbacteria,etc

IMAGING STUDIESIMAGING STUDIES

CT Scan:Non contrast CT scans are now the modality of choiceAdvantages include..

1) elimination of contrast 2) no need for bowel prep 3) can see noncalcified stones3) can see noncalcified stones 4) less expensive than IVP 5) does not require experienced radiologic technician.5) does not require experienced radiologic technician.

Intravenous Pyelography:

Classic diagnostic test of choice Advantages include..g

1) Can document nephrolithiasis and upper-tract anatomy2) Oblique views can diff between gallstones and renal2) Oblique views can diff between gallstones and renal stones on the right.

Disadvantages include..g1) Bowel prep2) Reactions to contrast3) Can take a really long time3) Can take a really long time

Abdominal plain film

Will reveal calculus in up to 80% of casesp Disadvantages include

Stones must generally be at least 2mm in g ydiameterStones must contain calcium to be visible

Ultrasound Advantages include.

Useful if patient is pregnant or has contraindication to IVPWhen used with KUB can be as effective as IVP

Analgesia and hydration are most effective Analgesia and hydration are most effective treatments

Shockwave lithotripsy for stones

Increase fluid intake to maintain urine output of 2-3 l/day: increase in urine sodium as a result of yincreased sodium intake. (Higher fluid intake alone will not prevent recurrent stones in patients with h l i i )hypercalciuria)

Decrease intake of animal protein ( 52 g/day): Decrease intake of animal protein ( 52 g/day):Reduces production of metabolic acids, resulting in a lower level of acid induced calcium excretion; increases excretion of citrate that forms a soluble complex with calcium; and reduces supersaturation with respect to

l i l t d li it th ti f i idcalcium oxalate and limits the excretion of uric acid

Restrict salt intake ( 50 mmol/day of sodium Restrict salt intake ( 50 mmol/day of sodium chloride): Dietary and urinary sodium is directly correlated with urinary calcium excretion, and lower y ,urinary excretion of sodium reduces urinary calcium excretion N l l i i t k ( 30 l/d ) L l i Normal calcium intake ( 30 mmol/day): Low calcium diets increase urinary oxalate excretion, which may result in more stone formation and possibly a negativeresult in more stone formation and possibly a negative calcium balance

Decrease dietary oxalate: Reduce the intake of foods yrich in oxalatespinach, rhubarb, chocolate, and nuts

Cranberry juice: Decreases oxalate and phosphate ti d i it t tiexcretion and increases citrate excretion