Nephrolithiasis and UTI’s 1 Nephrolithiasis/Urinary Tract Infections Jeffrey T. Reisert, DO...

Nephrolithiasis and UTI’s1

Nephrolithiasis/Urinary Tract Nephrolithiasis/Urinary Tract InfectionsInfections

Jeffrey T. Reisert, DOUniversity of New EnglandPhysician Assistant Program21 JAN 2010


Contact InformationContact Information

Jeffrey T. Reisert, [email protected] Boulder Point Rd., Suite 3

Plymouth, NH 03264603-536-6355

603-536-6356 (fax)


Case exampleCase example

A 55 y/o male smoker with history of hypertension presents to ED

10/10 sharp abdominal painOtherwise negative review (fever, wt. loss,

etc.)


Case cont.Case cont.

Exam: Looks uncomfortable. Fidgety.Work up

– Slightly elevated white cell count– 3+ blood in urine


Case cont.Case cont.

What is differential dx?What are diagnostic considerations?Treatment?


Introduction 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


AgendaAgenda

Nephrolithiasis– Epidemiology– Types– Treatments

UTI’s– Ditto


Kidney stones-EpidemiologyKidney stones-Epidemiology

Men more than women3rd decade of life60% 10 year recurrence rate


ProblemsProblems 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


PathogenesisPathogenesis

Materials in urine that have low solubility can increase

Decreased urine flow results in saturationPrecipitation into stones that can snowballMay be affected by urine pH

– Acidic urine-Uric acid stones– AlkaloticUrate or phosphate– Note Ca++ stones not affected by pH


TypesTypes Calcium most common (75-85%)

– Oxalate– Phosphate

Uric acid– Radiolucent– Red or orange

Cysteine– Yellow

Struvite– See below


Calcium stonesCalcium 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)


Calcium stones-AssociationsCalcium 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)


Calcium stones-AssociationsCalcium 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)


Uric Acid StonesUric Acid Stones

R/O tumors– Especially the lymphomas (high cellular

turnover)Increase urine pH (Alkalinize urine)K+ CitrateAcetazolamide (alkalinizes urine)Low purine dietAllopurinol


Cysteine stonesCysteine stones

Etiology: amino acid transport defectFluids to 3L per 24 hoursAlkalinize urineLow salt diet


Struvite stoneStruvite 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


Evaluation of the stone patientEvaluation of the stone patient

Check serum lytes including Ca++, creatinine

Urinalysis– Cheap, easy


Evaluation of the stone patient-Evaluation of the stone patient-cont.cont.24 hour urine collection

– pH– Calcium– Uric acid– Oxalate– Citrate

Stone analysis-Test all stones!


RadiographyRadiography

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


CT Scanning for stonesCT 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


Ultrasound for stonesUltrasound for stones

If can’t have radiationMisses small stonesWill help r/o obstructionSafer if dye risk, etc.


TreatmentTreatment

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


Removal of stonesRemoval of stones

Cystoscopy– Basket

Lithotripsy– Extracorporeal shock wave treatment

Formerly bathtubNow portable units, smallerNot without side effects (bruising)

– Percutaneous ultrasonic– Laser


UTI’s-OverviewUTI’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


UTI’s-TypesUTI’s-Types

Acute or chronicCatheter associated (nosocomial) or not

(community acquired)Symptomatic or asymptomatic


UTI’s-AssociationsUTI’s-Associations

Short urethra in womenUrethra close to anus in womanIntercourse

– Voiding before and after intercourse not PROVEN to be helpful

Contraceptives may increase riskAntibiotics may change bacterial floraObstruction


UTI’s-Locations/SyndromesUTI’s-Locations/Syndromes

Lower– Cystitis– Urethritis

Upper– Pyelonephritis


UTI’s-OrganismsUTI’s-Organisms

Gram negative bacilli– Escherichia coli (by far MC)

– Klebsiella

– Proteus

– Enterobacter Others

– Staph saprophyticus

– Enterococcus

– Staph aureus


UTI’s cont…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)


UTI-EvaluationUTI-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.


UTI’s-TreatmentUTI’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


UrosepsisUrosepsis

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)


UTI’s-PreventionUTI’s-Prevention

May be difficultVoiding after intercourse-Not provenPreventative antibiotics

– May lead to drug resistanceCranberry juice-Is proven, NEJM


Case wrap-upCase wrap-up

Exam suggests stoneMust r/o malignancy too (age of pt,

tobacco use)CT scanPain control, IV fluids?Surgical evalWarn of recurrence rate


SummarySummary

You will see (or have) kidney stones and urinary infections!

Look for treatable causes of eachUrological referral if indicated


Where to Get More InformationWhere to Get More Information

Harrison’s or Cecil’sAny urology text

Nephrolithiasis and UTI’s 1 Nephrolithiasis/Urinary Tract Infections Jeffrey T. Reisert, DO...

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