Urolithiasis - Metabolic Evaluation, Management and Prevention
Transcript of Urolithiasis - Metabolic Evaluation, Management and Prevention
![Page 1: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/1.jpg)
Urolithiasis : Metabolic evaluation ,
management and Prevention
Presented by: Dr Charbel DABALModerator: Dr R. El Khoury
![Page 2: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/2.jpg)
The goals of metabolic evaluation are to provide a guide for treatment to reduce the risk of stone
formation and to identify systemic disease presenting as kidney stone disease
![Page 3: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/3.jpg)
![Page 4: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/4.jpg)
Stone Analysis
![Page 5: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/5.jpg)
![Page 6: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/6.jpg)
![Page 7: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/7.jpg)
![Page 8: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/8.jpg)
Specific metabolic evaluation• Serum: Creatinine, sodium, potassium, chloride,
calcium, albumin, uric acid, bicarbonate, PTH (if serum calcium is high), Vitamin D (if low or high serum calcium or elevated PTH)
• collection of two consecutive 24-hour urine samples in special containers
• Spot urine samples are an alternative method of sampling
• self-determined diet, ideally stone free for at least twenty days
![Page 9: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/9.jpg)
Follow up…
• The first follow-up (24-hour urine measurement) is suggested 8-12 weeks after starting pharmacological prevention
• enables drug dosage adjustment• Once yearly• new stones, new evaluation (Stone composition
changed in 21.2%)
![Page 10: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/10.jpg)
General preventive measures
![Page 11: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/11.jpg)
Diet
• mixed balanced diet with contributions from all food groups, without any excesses
• Fruits, vegetables and fibres: should be encouraged, alkaline content of a vegetarian diet also increases urinary pH
• Oxalate: excessive intake of oxalate-rich products should be limited or avoided to prevent high oxalate load
• Vitamin C: it seems wise to advise calcium oxalate stone formers to avoid excessive intake
• Animal protein: limited to 0.8-1.0 g/kg body weight
![Page 12: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/12.jpg)
• Calcium intake: should not be restricted, daily requirement for calcium is 1,000 to 1,200 mg.
• Sodium: the daily sodium (NaCl) intake should not exceed 3-5 g. High intake adversely affects urine composition
• Urate: intake of purine-rich food should be restricted in patients with hyperuricosuric, calcium oxalate and uric acid stones. Intake should not exceed 500 mg/day
![Page 13: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/13.jpg)
Recommendations for recurrence prevention
![Page 14: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/14.jpg)
Pharmacological recurrence prevention
Ideal drug should •halt stone formation•have no side effects•be easy to administer
![Page 15: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/15.jpg)
![Page 16: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/16.jpg)
![Page 17: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/17.jpg)
Calcium oxalate stones
• Diagnosis:• Blood analysis : creatinine, sodium, potassium,
chloride, ionised calcium, uric acid, • PTH and vitamin D in the case of increased
calcium levels.• Urinalysis: urine volume, urine pH, specific
weight, calcium, oxalate, uric acid, citrate, sodium and magnesium.
![Page 18: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/18.jpg)
1 2 3 45
![Page 19: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/19.jpg)
![Page 20: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/20.jpg)
![Page 21: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/21.jpg)
![Page 22: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/22.jpg)
![Page 23: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/23.jpg)
![Page 24: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/24.jpg)
• “Acidic arrest” (urine pH constantly < 5.8) may promote co-crystallisation of uric acid and calcium oxalate.
• Similarly, increased uric acid excretion (> 4 mmol/day in adults or > 12 mg/kg/day in children) can act as a promoter.
![Page 25: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/25.jpg)
Recommendations for pharmacological treatment of patients with specific abnormalities in urine composition
![Page 26: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/26.jpg)
Calcium phosphate stones• Two completely different minerals: carbonate
apatite and brushite. • Diagnosis:• Blood analysis : creatinine, sodium, potassium,
chloride, ionised calcium, uric acid, • PTH and vitamin D in the case of increased calcium
levels.• Urinalysis: urine volume, urine pH, specific weight,
calcium, oxalate, uric acid, citrate, sodium and magnesium.
• Urine culture
![Page 27: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/27.jpg)
Ca10(PO4)6.(OH)2Basic calcium phosphate
![Page 28: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/28.jpg)
CaHPO4.2H20 Calcium hydrogen phosphate
![Page 29: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/29.jpg)
Recommendations for the treatment of calcium phosphate stones
![Page 30: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/30.jpg)
Disorders and diseases related to calcium stones
![Page 31: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/31.jpg)
Hyperparathyroidism• 5% of all calcium stone formation• Renal stones 20% of patients with primary HPT• increase calcium turnover-> hypercalcaemia and
hypercalciuria• repeated measurements may be needed• calcium oxalate and calcium phosphate stones• If HPT suspected, neck exploration should be
performed to confirm the diagnosis. Primary HPT can only be cured by surgery.
![Page 32: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/32.jpg)
Granulomatous diseases
• May be complicated by hypercalcaemia and hypercalciuria secondary to increased calcitriol production -> increased calcium absorption in the gastrointestinal tract
• Treatment focusses on the activity of the granulomatous diseases - reserved for the specialist.
![Page 33: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/33.jpg)
Primary hyperoxaluria
• endogenous oxalate production is increased in patients with PH
• Should be referred to specialised centres, as successful management requires an experienced interdisciplinary team.
• Pyridoxine therapy
![Page 34: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/34.jpg)
Enteric hyperoxaluria• intestinal malabsorption of fat• usually present with hypocitraturia due to loss
of alkali • Urine pH is usually low, as are urinary
calcium and urine volume• All these abnormalities contribute to high
levels of supersaturation with calcium oxalate, crystalluria, and stone formation.
![Page 35: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/35.jpg)
Specific preventive measures are:•restricted intake of oxalate-rich food•restricted fat intake•calcium supplementation at meal times to enable calcium oxalate complex formation in the intestine •sufficient fluid intake to balance intestinal loss of water caused by diarrhoea •alkaline citrates to raise urinary pH and citrate.
![Page 36: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/36.jpg)
Renal tubular acidosis• Caused by severe impairment of proton or
bicarbonate handling along the nephron• Distal RTA type I • acquired or inherited • Reasons for acquired: obstructive uropathy,
recurrent pyelonephritis, acute tubular necrosis, renal transplantation, analgesic nephropathy, sarcoidosis, idiopathic hypercalciuria, and primary parathyroidism; it may also be drug-induced
![Page 37: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/37.jpg)
![Page 38: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/38.jpg)
![Page 39: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/39.jpg)
Uric acid and ammonium urate stones
• high risk of recurrence • form under completely different biochemical
conditions
• Blood analysis : creat, potassium, uric acid• Urinalysis: urine volume, urine pH, specific
weight, uric acid.• Urine culture is needed in the case of
ammonium urate stones.
![Page 40: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/40.jpg)
>
![Page 41: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/41.jpg)
![Page 42: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/42.jpg)
Struvite and infection stones
• 7%, F>M, high risk of recurrence • may originate de novo or grow on pre-
existing stones• Blood analysis : creat• Urinalysis: urine pH• Urine culture is needed
![Page 43: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/43.jpg)
![Page 44: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/44.jpg)
Predisposing factors to struvite stone formation
![Page 45: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/45.jpg)
![Page 46: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/46.jpg)
Most important species of urease-producing bacteria
![Page 47: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/47.jpg)
Specific treatment
![Page 48: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/48.jpg)
Cystine stones • 1-2% of all urinary stones in adults • high risk of recurrence• Cystinuria is a common genetic disorder • Blood analysis : creat• Urinalysis: urine volume, urine pH, specific weight, cystine
• no role for genotyping patients• Diagnosis is established by stone analysis -
Quantitative 24hour urinary cystine excretion• Levels above 30 mg/day are considered abnormal
![Page 49: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/49.jpg)
• Cystine is poorly soluble in urine and crystallises spontaneously within the physiological urinary pH range.
• Cystine solubility depends strongly on urine pH
![Page 50: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/50.jpg)
Specific treatment• fluid intake high level of diuresis, aiming for a
24-hour urine volume of > 3 L • maintain urine pH > 7.5, to improve cystine
solubility • A diet low in methionine may theoretically reduce
urinary excretion of cystine• Free cystine concentration can be decreased by
reductive substances, which act by splitting the disulphide binding of cysteine:
• Tiopronin
![Page 51: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/51.jpg)
![Page 52: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/52.jpg)
![Page 53: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/53.jpg)
2,8-Dihydroxyadenine stones and xanthine stones
• high risk of recurrence• Both stone types are rare• Diagnosis and specific prevention are similar to
those for uric acid stones. • Pharmacological intervention is difficult• general preventive measures
![Page 54: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/54.jpg)
Drug stones
Induced by pharmacological treatment Two types exist: •stones formed by crystallised compounds of the drug;•stones formed due to unfavourable changes in urine composition under drug therapy.
![Page 55: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/55.jpg)
Radiolucent even on CT
![Page 56: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/56.jpg)
References:
• EAU Guidelines on Urolithiasis 2017• CUA guideline on the evaluation and medical
management of the kidney stone patient – 2016 update
• Evaluation and Medical Management of Urinary Lithiasis – Campbell-Walsh 10th Edition
![Page 57: Urolithiasis - Metabolic Evaluation, Management and Prevention](https://reader031.fdocuments.us/reader031/viewer/2022012414/616ee353d542a128e32757fd/html5/thumbnails/57.jpg)
Thank You