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Nephrolithiasis

Monday, August 15, 2016

Clinical Manifestations

11:48 AM

Etiology & Risk Factors

If in the renal parenchyma or renal pelvis, are usually


Asymptomatic unless they cause obstruction or infection.

Renal colic of varying intensity, but usually excruciating


And intermittent, often occurs cyclically and lasts 20-60 min

Nausea and vomiting

Hematuria, gravel or calculus in urine

Analgesia: renal colic can usually be relieved with opioids

Calculus removal: technique used depends on location and


Size of calculus. Techniques include shock wave lithotripsy,
Ureteroscopy, holmium laser lithotripsy, endoscopic techniques

85% of calculi are composed of Ca, mainly Ca oxalate


10% are uric acid
2% are cystine
Most of the remainder are struvite
Ca calculi: hypercalciuria, family history, hypocitruria, renal
Tubular acidosis, hyperoxaluria, taking high doses of vitamin C,
A Calcium restricted diet, mild hyperuricosuria, excess intake of
Purine
Uric acid: increased urine acidity, severe hyperuricosuria
Cystine: only in the presence cystinuria

Radiating pain may indicate an obstruction


Ashen color and diaphoresis
Unable to lie still, may pace, writhe, or constantly shift position
Abdomen may be tender with palpitation due to increased
Pressure, but peritoneal signs are absent

Symptoms of UTI: fever, dysuria, cloudy or foul smelling urine

Struvite: indicate presence of UTI caused by urea-splitting bacteria

Treatment

Other risk factors: increased age, male sex, urinary stasis, low fluid
Intake, tobacco/alcohol abuse, gouty arthritis, some medications
Diagnosis

Clinical differential diagnosis: signs and symptoms usually suggest


Diagnosis. Key is type and duration of pain

Urinalysis: macroscopic/microscopic hematuria, pyuria with/out


Bacteria present, calculus and crystalline substances in sediment

Imaging: non contrast helical CT can detect location of calculi as


Well as degree of obstruction, or may reveal other cause of pain

Medical expulsive therapy: patients with calculi <1cm with


No infection or obstruction can be treated at home with
Analgesics and alpha receptor blockers

Prevention

Determination of calculus composition: stone analysis, urine specimens


That show microscopic crystals are sent for crystallography

Modifiable risk factors:

Non-modifiable risk factors:

Age
Male sex

Diet
Urinary stasis

Drinking 8-10 10 oz glasses of water a day

Hypocituria: K citrate supplementation, normal Ca intake, avoid Ca


Restriction

Hyperoxaluria: varies, may respond to pyridoxine which increases the


transaminase activity, different treatment may be necessary for
Patients with small-bowel disease

Hyperuricosuria: restriction of animal protein intake, or administration


Of allopurinol, reducing uric acid

Urea-splitting bacteria: culture-specific antibiotics, complete removal


Of all calculi

Cystine calculi: any combination of increasing urine volume with reducing


Cystine excretion

Low fluid intake


Smoking and alcoholism
Gouty arthritis

Hypercalciuria: thiazide diuretics to lower urine Ca, increase fluid


Intake, a diet low in Na and high in K, supplementation with K to
Prevent hypokalemia, restriction of animal dietary animal protein

Certain medications

Uric acid, ammonia phosphate, and


Calcium oxalate stone material deposition
On proximal renal tubule

Super saturation of urine by stone


Forming constituents

Nephrocalcinosis on proximal tubule

Randall's plaque

Hyperkalemia

Nidation of crystals or foreign bodies


From the supersaturated urine

Urinary tract infection caused by


Urea splitting microorganism

Increased production of WBC

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Low back pain

Pyuria

Progression of stone to
Loop of Henle

Accumulation of stones and


Increase in size

Dysuria

Blood vessel wall surface


Attraction and erosion

Hematuria

Stone formation in kidneys

Proteinuria

Increased size of stones in kidneys

Stone matrix progression

Multiple urinary calculus

Huether, Sue, Kathryn McCance. Understanding Pathophysiology, 5th Edition. Mosby, 122011.
VitalBook file.
Preminger, G. M. (2014, July). Urinary Calculi. In Merck Manual: Professional Edition. Retrieved from
http://www.merckmanuals.com/professional/genitourinary-disorders/urinary-calculi/urinarycalculi

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