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TYPES OF STONES: +

Calcium oxalate
Calcium phosphate - usually hydroxyapatite, less commonly brushite
75-85%:
Men
30-40 yo
50%- forms another stone w/in next 10 years
Stone formers: 1 stone/2-3 years
Calcium 1.
Men
Who have gout
Usually familia
Uric acid - 5-10% 2.
Cystine - 1%, uncommon 3.
Potentially dangerous
Women
Who require bladder catheterization
Urease-producing bacteria, PROTEOUS SPECIES
STAGHORN
Struvite - common 4.
MANIFESTATIONS OF STONE +
Stone passage:
May be asymptomatic, or -
Pain and bleeding -
Begins graually
In the flank
Increase over the next 20-60min - -> severe
May need narcotic drug for control
May localize, or
May radiate to: LOIN, TESTIS, VULVA
PAIN: -
Ureter
Frequency, urgency, dysuria -
Ureter within bladde wall
Ureteral stones <0.5cm WILL PASS SPONTANEOUSLY!
DIAGNOSIS
NEPHROLITHIASIS - IM
Saturday, October 08, 2011
1:04 PM
NEPHROLITHIASIS Page 1
Intravenous pyelography 1.
Advantage:
Detects uric acid stone - RADIOLUCENT
no exposure to radiocontrast agent
Possible Dx of underlying cause of pain
Helical CT without radiocontrast enhancement - PREFERRED! 2.
DIAGNOSIS +
Struvite 1.
Cystine 2.
Uric acid 3.
STAGHORN CALCULI 1.
Calcium stones -
Multiple papillary calcifications
x-ray: -
Papillary - hereditary distal RTA
Dilated distal collecting duct - Medullary sponge kidney disease
NEPHRROCALCINOSIS 2.
INFECTION 3.
OTHER SYNDROMES: +
SALT SOLUBILITY SALT PRECIPITATION
NORMAL:
Dehydration -
Overexcretion of calcium, oxalate, phosphate, cystine, uric acid -
Can be increased by:
pH:
SUPERSATURATION 1.
Nucleation: when supersaturation exceeds upper limit
Heterogenous nucleation: where cell debris and other crystals serve as template
for crystal formation

On renal papillae: begins in deep renal medulla in the basement


membrane ot the thin limb of loop of Henle spread through the
interstitium of the papillary urothelium
-
Where calcium oxalate would form, d/t exposure to urine when the
urothelium is damaged
-
Randall's plaques
Depends on duration:
CRYSTALLIZATION 2.
Inhibition: Calcium phosphate > calcium oxalate
Inorganic pyrophosphate a.
Citrate - via complex formation with calcium- soluble complex b.
Glycoproteins - inhibit calcium oxalate crystallization c.
INHIBITORS OF CRYSTAL FORMATION 3.
PATHOGENESIS OF STONES +
CALCIUM STONES +
Familial 1.
HYPERCALCIURIA
NEPHROLITHIASIS Page 2
Polygenic- most likely a.
Monogenic - Dent's ds : X-linked b.
Familial 1.
Idiopathic hypercalciuria 2.
High calcitriol -
Excess vit D receptor -
Vitamin D overactivity 3.
HYPERCALCIURIA - contributes to stone formation by raising urine saturation with
respect to calcium oxalate and calcium phosphate

Excessive intake of purine


Due to salting out calcium oxalate by urate
Rx: allupurinol 100mg bid
HYPERURICOSURIA
Plasma Ca + PTH
Rx: parathyroidectomy
PRIMARY HYPERPARATHYROIDISM
Minimum urine pH >5.5 despite systemic acidosis -
Ammonium loading test -
Pt with distal RTA will not lower urine pH below 5.5
Dx: +
Nephrocalcinosis -
Osteomalacia and rickets -
Renal damage -
GFR falls gradually -
Consequence:
Supplemental alkali: sodium bicarbonate 1.
Potassium citrate supplementation 2.
Thiazide treatment - incomplete distal RTA 3.
Rx:
Urine citrate
Urine pH
If urine pH increase w/o increase in citrate = => calcium phosphate
supersaturation increase

Monitor: W
DISTAL RENAL TUBULAR DISEASE
Spinach -
Nuts -
Chocolate -
Increase oxalate in diet 1.
Promote hyperoxaluria b/c there is less calcium available to bind oxalate in
intestine

Low calcium diet 2.


Small bowel ds
Jejunoileal bypass 1.
Pancreatic insufficiency 2.
Extensive small intestine involvement due to Crohn's disease 3.
Causes:
Enteric hyperoxaluria 3.
Fat malabsorption 4.
HYPEROXALURIA
NEPHROLITHIASIS Page 3
Fat malabsorption 4.
Type 1 - alanine:glyoxalateaminotransferase (peroxisomal enzyme)
Type 2 - D-glyceric dehydrogenase
Primary hyperoxaluria - AR 5.
Idiopathic hypocitraturia 1.
RTA -
Chronic diarrheal disease -
Hypokalemia -
Secondary to systemic disorders: 2.
HYPOCITRATURIA
High fluid intake, maintain sp gravity <1.005 1.
Thiazide diuretics 2.
Allupurinol 3.
Citrate 4.
Lower urine calcium
Increase urine pyrophosphate
Oral phosphate 2g 5.
May cause nausea and diarrhea
Orthophosphate 6.
Rx:
IDIOPAHIC CALCIUM LITHIASIS
Inherited disorder
Cysteine
Lysine
Arginine
ornithine
Defective proximal tubular and jejunal transport of dibasic amino acid
Have normal urine cystine excretion
AR
Type 1
Moderately elevated urine cystine excretion
AD with incomplete penetrance
Non-type 1
Homozygous cystinuria - typical hexagonal,platelike cystine crystals
Sediment for first morning urine specimen -
Sensitive -
For asymptomatic heterozygotes
Urine sodium nitruprusside test -
Diagnosis +
<300mg/day to prevent stone formation -
Measure daily cystine excretion W
CYSTINURIA AND CYSTINE STONES +
Proteous species
-degrades urea to NH3 and CO2
Urease enzyme
STUVITE STONES +
NEPHROLITHIASIS Page 4