Transcript Nephrolith & UTIs

Nephrolithiasis/Urinary Tract
Infections
Jeffrey T. Reisert, DO
University of New England
Physician Assistant Program
21 JAN 2010
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Contact Information
Jeffrey T. Reisert, DO
[email protected]
103 Boulder Point Rd., Suite 3
Plymouth, NH 03264
603-536-6355
603-536-6356 (fax)
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Case example
A 55 y/o male smoker with history of
hypertension presents to ED
 10/10 sharp abdominal pain
 Otherwise negative review (fever, wt. loss,
etc.)

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Case cont.
Exam: Looks uncomfortable. Fidgety.
 Work up

– Slightly elevated white cell count
– 3+ blood in urine
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Case cont.
What is differential dx?
 What are diagnostic considerations?
 Treatment?

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Introduction
Kidney stones and UTI’s are a relatively
common cause of emergency room visit
 Suspect when appropriate symptoms and
lab findings
 May or may not be easily treated
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Agenda

Nephrolithiasis
– Epidemiology
– Types
– Treatments
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UTI’s
– Ditto
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Kidney stones-Epidemiology
Men more than women
 3rd decade of life
 60% 10 year recurrence rate
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Problems
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May or may not pass
Pain
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Severe
Colic to sharp
Oh My God!!!
Can radiate to groin
Often requires opiates to control
Bleeding
Infection
Hospitalization
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Pathogenesis
Materials in urine that have low solubility
can increase
 Decreased urine flow results in saturation
 Precipitation into stones that can snowball
 May be affected by urine pH
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– Acidic urine-Uric acid stones
– AlkaloticUrate or phosphate
– Note Ca++ stones not affected by pH
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Types
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Calcium most common (75-85%)
– Oxalate
– Phosphate
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Uric acid
– Radiolucent
– Red or orange
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Cysteine
– Yellow
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Struvite
– See below
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Calcium stones
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Again, most common type, by far
Often hypercalciuria
General treatment may include:
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Hydration
Sodium restriction, oxalate restriction
Potassium citrate 2-30mEq bid
Decease meat intake
Increase citrus fruit
Moderate calcium intake ok (Calcium in gut helps
bind with oxalate and actually reduces calcium
absorption)
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Calcium stones-Associations

If serum Ca++ abnormal
– Check serum parathyroid hormone (PTH) level
– Also r/o malignancy, sarcoidosis, steroid use
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If Hypercalcuria
– Try thiazides (decrease urine Ca++ levels)
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Hyperuricosuria
– Lower intake of purines (meats) or
– try Allopurinol (decreases uric acid production)
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Calcium stones-Associations
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If Distal RTA (Recall Type I RTA has higher
incidence of stone formation)
– Alkalinize urine (potassium bicarbonate or citrate)
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If Hyperoxaluria
– Try cholestyramine (fat absorption may be the
problem) or citrate supplement
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If Hypocitruria
– Try alkali to increase urine citrate excretion
(potassium citrate or potassium bicarbonate)
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Uric Acid Stones

R/O tumors
– Especially the lymphomas (high cellular
turnover)
Increase urine pH (Alkalinize urine)
 K+ Citrate
 Acetazolamide (alkalinizes urine)
 Low purine diet
 Allopurinol
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Cysteine stones
Etiology: amino acid transport defect
 Fluids to 3L per 24 hours
 Alkalinize urine
 Low salt diet
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Struvite stone
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Magnesium ammonium phosphate or simply
“Magnesium stones”
Associated with chronic UTI’s and self
catheterization
– Urease from bacteria (Proteus) converts urea to NH3
and CO2. NH3 converted to ammonia which
alkalizes urine to pH of 8 or 9.
– Leads to space occupying stone in renal pelvis
(Staghorn calculus)
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Requires removal +/- treatment of infection
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Evaluation of the stone patient
Check serum lytes including Ca++,
creatinine
 Urinalysis
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– Cheap, easy
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Evaluation of the stone patientcont.
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24 hour urine collection
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pH
Calcium
Uric acid
Oxalate
Citrate
Stone analysis-Test all stones!
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Radiography
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Flat plate abdomen
– Detects radiopaque stones
– Not good for uric acid stones
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Intravenous pyelogram (IVP)
– Dye reaction
– May include tomogram
– Formerly diagnostic test of choice
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CT
– See next slide
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CT Scanning for stones
Non-contrasted helical CT with 3-5mm
cuts
 Has become “gold standard”
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– Safer than IVP
– Faster
– Readily available at most hospitals
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Slightly more expensive, but worth it
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Ultrasound for stones
If can’t have radiation
 Misses small stones
 Will help r/o obstruction
 Safer if dye risk, etc.
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Treatment
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Fluid intake to 2-3 liters of urine flow
Pain medications
– Narcotic analgesics
– NSAIDS
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Tamsulosin (Flomax®)-may relax ureter to
facilitate passage of stone-Not FDA approved but
often used regionally.
Direct treatment if specific cause identified
Oral phosphates may be helpful
R/O obstruction and remove if needed
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Removal of stones

Cystoscopy
– Basket
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Lithotripsy
– Extracorporeal shock wave treatment
Formerly bathtub
 Now portable units, smaller
 Not without side effects (bruising)
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– Percutaneous ultrasonic
– Laser
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UTI’s-Overview
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Common (70M office visits per year in
US)
– Younger sexually active females
– If in men, older
Require clean collection
 >100,000 colonies per ml
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– >100 if suprapubic collection or catheter
collection
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UTI’s-Types
Acute or chronic
 Catheter associated (nosocomial) or not
(community acquired)
 Symptomatic or asymptomatic
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UTI’s-Associations
Short urethra in women
 Urethra close to anus in woman
 Intercourse
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– Voiding before and after intercourse not
PROVEN to be helpful
Contraceptives may increase risk
 Antibiotics may change bacterial flora
 Obstruction
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UTI’s-Locations/Syndromes
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Lower
– Cystitis
– Urethritis
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Upper
– Pyelonephritis
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UTI’s-Organisms
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Gram negative bacilli
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Escherichia coli (by far MC)
Klebsiella
Proteus
Enterobacter
Others
– Staph saprophyticus
– Enterococcus
– Staph aureus
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UTI’s cont…
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Must be differentiated from asymptomatic bacturia
S/S
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Dysuria
Frequency
Urgency
Pain suprapubic or prostate on DRE
Pyelonephritis
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Flank pain
Fever/Chills
Nausea and vomiting
Sepsis (Increased HR, Decreased BP)
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UTI-Evaluation
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None needed in simple cystitis in woman
Culture otherwise
– May help if recurrent infections
– May identify resistance strains and patterns in your
geographical area
– Young men should always be further evaluated
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Ultrasound or CT considered to rule out
obstruction, anatomical problems, stone, etc.
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UTI’s-Treatment
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Simple cystitis in woman-3d
– May not even need to see patient, if patient familiar with
symptoms
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Otherwise 7-14 days
Sulfa, nitrofurantoin, or quinolones are all good choices
– No quinlones in pregnancy. Penicillin safer alternative
– Ciprofloxacin (Cipro®) now available generic
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Take into account
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Resistance patterns
Recent antibiotic use
Drug allergies
Outpatient vs. inpatient
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Urosepsis
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Sick UTI
Shocky
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Tachycardia
Hypotension
High fever
Elevated WBC count
Treat with Cephalosporin (or PCN drug) and
Aminoglycoside or perhaps quinolone (Regional
variation, check antibiogram)
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UTI’s-Prevention
May be difficult
 Voiding after intercourse-Not proven
 Preventative antibiotics
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– May lead to drug resistance
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Cranberry juice-Is proven, NEJM
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Case wrap-up
Exam suggests stone
 Must r/o malignancy too (age of pt,
tobacco use)
 CT scan
 Pain control, IV fluids
 ?Surgical eval
 Warn of recurrence rate
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Summary
You will see (or have) kidney stones and
urinary infections!
 Look for treatable causes of each
 Urological referral if indicated
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Where to Get More Information
Harrison’s or Cecil’s
 Any urology text
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