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outpatient clinic
Why???
At least 10 per cent of the population in the
industrialized world
Recurrence
Significant pain
Loss
What do we generally do ?
Stone types
Calcium containing stones
Calcium oxalate
Hydroxyapatite
Brushite
Xanthine
Ammonium acid urate
Matrix
Medication related eg acyclovir,
indinavir, triamterine, ciprofloxaxin, loop
diuretics, acetazolamide, silicate etc
Stones associated with Melamine
exposure
Radiolucent stones..
Uric acid
Xanthine
Indinavir
Inhibitors
Magnesium
Citrate
Pyrophosphate
Glycosaminoglycans (heparin, heparan sulfate, hyaluronic
acid, and chondroitin sulfate)
Nephrocalcin
Tamm-Horsfall mucoprotein
Uropontin
Bikunin
Other factors
Urine volume
Urinary pH
Calcium Stones
Hypercalciuria
Hyperoxaluria
Hypocitraturia
Hyperuricosuria
Hypocitraturia
Excessive protein intake
Hypokalemia
Metabolic acidosis
Exercise
Hypomagnesemia
Infections
Androgens
Starvation
Acetazolamide
Infection Stones
Struvite stone (magnesium ammonium phosphate) mainly
Infection with urease producing bacteria
Alkaline pH of urine
Predispositions to infection
Cystine Stones
Cystinuria is an autosomal recessive or
dominant
Tubular defect in dibasic amino acid transport
The main contributor to cystine crystallization
is supersaturation because there is no specific
inhibitor of cystine crystallization in the urine
Presentation
Asymptomatic/incidental
Pain
Hematuria
Lithuria
Infection/pyelonephritis
Obstruction
CKD
Basic evaluation
RBS
KFT, Na, K
Uric acid
Ca, Phosphate, ALP, iPTH
Blood Bicarbonate, Chloride (ABG)
Urine R/M, Urine pH
Urine C/S
Stool analysis
USG abdomen
X-ray KUB (+/- IVU)
Helical CT plain
History
History serves to uncover a systemic etiology for nephrolithiasis:
Stone history:
History ..
Dietary history: protein, purine, oxalate, calcium
restriction
Family history
Medications- eg loop diuretics, salicylates, aciclovir,
sulphadiazene, indinavir, acetazolamide, topiramate,
steroids, calcium, vitamin D, allopurinol, vitamin C
Exposure to melamine
Cystine crystals
Management...
Medical management
Generic:
Fluids to make urine >2.5 liters/day
Low protein ( 0.8 to 1 gm/kg/day)
Low salt < 2 gm/day
Normal calcium
Specific..
Calcium stones
Thiazides
Potassium citrate
Orthophosphate sts
Hyperoxaluria
Dietary and Enteric Hyperoxaluria
Dietary oxalate restriction
Calcium carbonate (1 to 1.5 g) may be added at each meal
and snack
Primary Hyperoxaluria
Pyridoxine
Potassium citrate and magnesium supplementation
Orthophosphate
Oxalobacter formigenes
Infection stones
Antibiotic
Surgical
Acetohydroxamic acid (Lithostat)
Cystine stones
d-Penicillamine
Tiopronin
mercaptopropyonyl glycine (thiola)
Captopril
Surgical management
ESWL
PCNL
Endourologic procedures
Surgeries- open/laparoscopic
Management