Urolithiasis

Presented By :
Aamir Sharif
HO at Hijaz Hospital

Overview
Introduction
Conditions causing stone formation
Types of kidney stones
Calcium salts
Uric acid
Mg ammonium PO4
Cystine
Other (xanthine, etc.)
Laboratory investigations
Comparison Between Urosinal Syrup
& Zyloric Tablets

Urolithiasis
Urolithiasis is the condition where urinary stones are
formed or located anywhere in the urinary system
The term nephrolithiasis (or "renal calculus") refers to
stones that are in the kidney,
Ureterolithiasis refers to stones that are in the ureter.
The term cystolithiasis (or vesical calculi) refers to stones
which form or have passed into the urinary bladder.
Stones are Composed of metabolic products present in
glomerular filtrate
These products are in high conc.
Near or above maximum solubility

Conditions causing
kidney stone formation
High conc. of
metabolic products in
glomerular filtrate
Changes in urine pH
Urinary stagnation
Deficiency of stoneforming inhibitors in
urine

High conc. of metabolic products

in glomerular filtrate is due to:
Low urinary volume (with
normal renal function) due
to restricted fluid intake
Increased fluid loss from
the body
Increased excretion of
metabolic products forming
stones
High plasma volume
(high filtrate level)
Low tubular reabsorption
from filtrate

Changes in urine
pH
is due
to:
Bacterial
infection
Precipitation
of salts at
different pH
Urinary stagnation
is due to:
Obstruction of
urinary flow

Deficiency of stoneforming inhibitors:

Citrate, pyrophosphate,
glycoproteins inhibit growth of
calcium phosphate and calcium
oxalate crystals
In type I renal tubular acidosis,
hypocitraturia leads to renal
stones

Calcium salt stones

80% of kidney stones contain
calcium
The type of salt depends on
Urine pH
Availability of oxalate
General appearance:
White, hard, radioopaque
Calcium PO4: staghorn in
renal pelvis (large)
Calcium oxalate: present in
ureter (small)

Calcium oxalate stones

Calcium salt stones

Causes of calcium salt stones:
Hypercalciuria:

Increased urinary calcium excretion

Men: > 7.5 mmols/day
Women > 6.2 mmols/day
May or may not be due to hypercalcemia

Hyperoxaluria:

Causes the formation of calcium oxalates without

hypercalciuria
Diet rich in oxalates
Increased oxalate absorption in fat malabsorption

Primary hyperoxaluria:

Due to inborn errors

Urinary oxalate excretion: > 400 mmols/day

Calcium salt stones Treatment:

Treatment of primary causes such
as infection, hypercalcemia,
hyperoxaluria
Oxalate-restricted diet
Increased fluid intake
Acidification of urine (by dietary
changes)
Calcium salt stones are formed in
alkaline urine

Uric acid stones

About 8% of renal stones
contain uric acid
May be associated with
hyperuricemia (with or
without gout)
Form in acidic urine
General appearance:
Small, friable, yellowish
May form staghorn
Radiolucent (plain x-rays
cannot detect)
Visualized by ultrasound
or i.v. pyelogram

:
t
n
e
m
t
a
e
r
T
s
e
n
o
t
s
d
i
c
t
a
e
i
c
d
ri

y
d
b
e
(
t
c
e
i
r
n
t
i
r
s
e
u
r
f
o
e
n
n
i
Pur linizationges)
e
k
a
a
a
k
h
l
t
c
in
A tary
d
i
u
die ased fl
e
r
c
n
I

Mg ammonium PO4 stones

About 10% of all renal stones contain
Mg amm. PO4
Also called struvite kidney stones
Associated with chronic urinary tract
infection
Microorganisms (such as from
Proteus genus) that metabolize
urea into ammonia
Causing urine pH to become
alkaline and stone formation
Commonly associated with staghorn
calculi
75% of staghorn stones are of
struvite type

am
g
M

u
i
n
mo

O4
P
m

s
e
n
sto

m
t
a
Tre

:
t
n
e

f
o
t
n
e
m
t
n
a
o
e
i
n
r
t
a
e
T ectio
c
k
fi
a
i
t
d
n
i
i
inf
c
d
a
i
u
e
fl
n
i
r
d
e
U
s
a
e
r
c
In

Cystine stones
A rare type of kidney stone
Due to homozygous cystinuria
Form in acidic urine
Soluble in alkaline urine
Faint radio-opaque
Treatment:
Increased fluid intake
Alkalinization of urine (by dietary
changes)
Penicillamine (binds to cysteine to form
a compound more soluble than cystine)

Laboratory investigations
of kidney stones
If stone has formed and
removed:
Chemical analysis of stone
helps to:
Identify the cause
Advise patient on prevention
and future recurrence

Laboratory investigations
of kidney stones
If stone has not formed:
This type of investigation identifies causes
that may contribute to stone formation
Serum calcium and uric acid analysis
Urinalysis: volume, calcium, oxalates and
cystine levels
Urine pH > 8 suggests urinary tract
infection (Mg amm. PO4)
Urinary tract imaging:
Ultrasound and i.v. pyelogram

Comparison Between Urosinal Syrup &

Zyloric Tablet
Urosinal Syrup

Zyloric Tablet

Name of the product

Urosinal

Zyloric Tablets

Composition

Barley Salt 500 mg

Potassium Nitrate500 mg
Solanum nigrum
(Leaves)125 mg
Solanum nigrum Berries
62.5 mg
Preservatives
BaseQ.S

Allopurinol 100 mg ,
Excipents
Lactose
Maize Starch
Povidone
Magnesium Stearate
Purified Water

Pharmaceutical form

Syrup:120 ml

(Tablets) 100 & 300 mg

Indications

Urinary Bladder Ailments,

Kidney Disorders, Liver
Disorders, Urinary
Retention

indicated for reducing

urate/uric acid formation in
conditions where urate/uric
acid deposition has already
occurred (e.g. gouty
arthritis, skin tophi,
nephrolithiasis) or is a
predictable clinical risk (e.g.
treatment of malignancy
potentially leading to acute
uric acid nephropathy).

Name of the product

Urosinal

Zyloric Tablets

Pharmacodynamic

It lowers the level of uric

acid in the body, and
alleviates gout and
rheumatism.
Mechanism not known

Allopurinol is a xanthineoxidase inhibitor. Allopurinol

and its main metabolite
oxipurinol lower the level of
uric acid in plasma and urine
by inhibition of xanthine
oxidase, the enzyme
catalyzing the oxidation of
hypoxanthine to xanthine and
xanthine to uric acid. In
addition to the inhibition of
purine catabolism in some
but not all hyperuricaemic
patients, de novo purine
biosynthesis is depressed via
feedback inhibition of
hypoxanthine-guanine
phosphoribosyltransferase.
Other metabolites of
allopurinol include allopurinolriboside and oxipurinol-7
riboside.

Name of the
product

Urosinal

Pharmacokinetics

Not Known

Zyloric Tablets

Allopurinol is active when given orally and is rapidly

absorbed from the upper gastrointestinal tract.
Allopurinol is negligibly bound by plasma proteins and
therefore variations in protein binding are not thought to
significantly alter clearance.
Estimates of bioavailability vary from 67% to 90%.
Peak plasma levels of allopurinol generally occur
approximately 1.5 hours after oral administration of Zyloric,
but fall rapidly and are barely detectable after 6 hours.
Approximately 20% of the ingested allopurinol is excreted
in the faeces.
Elimination of allopurinol is mainly by metabolic
conversion to oxipurinol by xanthine oxidase and
aldehyde oxidase, with less than 10% of the unchanged
drug excreted in the urine.
Allopurinol has a plasma half-life of about 1 to 2 hours

Name Of The product

Urosinal

Zyloric Tablets

Dosage

Children:
2.5 ml (half a
teaspoonful) mixed
with milk or Sharbat
Bazoori in the
morning and in the
evening.
Adults:
5 ml (one
teaspoonful) mixed
with milk or sharbat
Bazoori in the
morning and in the
evening

Children:
Children under 15 years: 10 to 20
mg/kg bodyweight/day up to a
maximum of 400 mg daily.
Use in children is rarely indicated,
except in malignant conditions
(especially leukaemia) and certain
enzyme disorders such as LeschNyhan syndrome.
Adults:
In the absence of specific data,
the lowest dosage which
produces satisfactory urate
reduction should be used. i.e
100mg/day

Contraindications

Not Reported

Zyloric should not be

administered to individuals known
to be hypersensitive to allopurinol
or to any of the components of the
formulation.

Name Of The product

Urosinal

Zyloric Tablets

Interaction with other

medicinal products

Not Known

Salicylates and uricosuric

agents decrease its activity
Chlorpropamide
increased risk of prolonged
hypoglycaemic activity
Theophylline: Inhibition of
the metabolism of
theophylline
Frequency of skin rash
increases patients receiving
ampicillin or amoxicillin
concurrently with allopurinol

Side Effects

No side effects reported

Skin reactions are the most

common reactions and may
occur at any time during
treatment.
They may be pruritic,
maculopapular, sometimes