Transcript ANALYSIS OF STONES

RENAL STONE DISEASE
ANALYSIS OF STONES
______________________________
Oxalate
504 (56.1%)
Triple phosphate
237 (26.4%)
Phosphate
119 (13.4%)
Uric acid
38 (4.2%)
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Total
898 (100%)
AGE DISTRIBUTION OF
OXALATE STONES
160
140
120
100
Number of
80
Patients
60
40
20
0
10
20
30
40
50
Age in Years
60
70
80
FORMATION OF STONES
Urine pH/infection
Renal damage
Calcium/oxalate
Tissue debris
Anatomical stasis
Fixed
Aggregation
Stone formation
particles inhibitors
FORMATION OF STONES
1.
2.
3.
4.
5.
6.
Calcium -
a) hypercalcaemia
b) hyperparathyroidism
c) hypercalciuria
Oxalate - G1, hyperoxalaturia
Cystine
Uric Acid
Infection - Urea-splitting organisms
Congenital / metabolic defects:
- medullary spone kidney
- renal tubular acidosis
CLINICAL PRESENTATION
1. Flank/loin pain, colicky + radiation
- haematuria
- nausea and vomiting
- chills/fever/frequency, if infected
2. Loin tenderness
3. Bilateral stones : renal failure
INVESTIGATIONS
1.
IVU and DTPA
2.
Serum creatinine calcium
3.
Urine pH
4.
24-hour urine
5.
Urine cultures
6.
Stone analysis
METABOLIC ABNORMALITIES
(N = 392)
Hypercalciuria
Hyperoxaluria
Hyperuricosuria
Cystinuria
Hyperparathyroidism
Primary oxalosis
Renal tubular acidosis
28%
16%
14%
0.5%
1%
0.25%
0.25%
INDICATIONS FOR TREATMENT
Presence of symptoms and / or obstructive
uropathy in a functioning kidney
Treatment of Renal Stones
Four Options
1) conservative
2) non-invasive: ESWL
3) minimal invasive : PCNL, URS
4) open surgery
New technology :  morbidity,  hospital stay,
 invasiveness
Electromagnetic Shockwave
MANAGEMENT OF RENAL
CALCULI by ESWL
< 2cm in diameter and/or surface area < 500 mm2
Treatment : ESWL monotherapy
> 2cm in diameter and/or surface area > 500 mm2
Treatment : PCNL +/- ESWL
Combination therapy
MANAGEMENT OF RENAL
CALCULI by ESWL
> 2cm in diameter and/or
surface area > 500 mm
J Stents + ESWL with repeated
treatments required
ESWL for Staghorn Stones
PCNL + ESWL as main option
ESWL monotherapy is discouraged
Open surgery has a place for large
complete staghorn calculi
Contra-indications to the
Use of ESWL
Absolute contra-indications
• Pregnancy
• Untreated urinary tract infection
• Distal obstruction to the stone that cannot be
bypassed by a stent
• Untreated bleeding diatheses
• Non-functioning kidney
PCNL
Percutaneous Nephroscope and Lithoclast
PCNL
Results of Percutaneous
Nephrolithotripsy PCNL
Indications :
High stone burden or failed ESWL
Success
Stones free
82%
Insignificant fragments
15%
Stones > 4cm in diameter
3%
Failure
:
:
Traumatic AV Fistula
after PCNL
MANAGEMENT OF URETERIC
STONES
-Stones < 0.5 cm in diameter doesn’t pass
spontaneously 4 to 6 weeks and /or causing
symptoms : ESWL monotherapy
-Stones > 0.5 cm in diameter & < 1 cm in
diameter : ESWL monotherapy
MANAGEMENT OF URETERIC
STONES
Stones > 1 cm in diameter : trial of ESWL
monotherapy
Patient counselled:
1. Repeat session may be necessary
2. URS/PCNL/ureterolithotomy
RESULTS OF URETROSCOPIC
LITHOTRIPSY (URS)
Achieved stone free status = 85% to 90%
Failures:
1.Access problems
2.Stone migration
Flexible URS for upper third ureteric calculi
especially in the male
Ureteric stone
suitable for ESWL
URS with
Guide wire
OPEN STONE SURGERY
2% incidence of all stone treatments
Indications:
1.Complex stone burden 38%
2.Non-functioning kidneys 20%
3.Failure of MIS
16%
4.Others
26%
Recurrent Rate
75% - 10 Years
100% - 20 Years
(Williams 1963)
PREVENTION OF STONES
1.
Treatment of causes
2.
Dietary manipulations
3.
Medications - indication duration
DIETARY ADVICE
1. Hydration
2. Avoid oxalate-rich food
3. Avoid calcium-rich food ?
4. Avoid refined carbohydrates
5. Increase crude fibres
MEDICATIONS
1.
2.
3.
4.
5.
6.
7.
Thiazides
Allopurinol
Antibiotics
Sodium bicarbonate
Potassium citrate
Magnesium salts
Pyridoxine
Cystine Stone
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1% of stone population
Autosomal recessive
Round stones in calyces
Large staghorn stones
Hexagonal crystals
Medical Treatment - Cystine
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Volume at 2.5 l/day
Increase pH to > 7.0
Decrease dietary protein
D-penicillamine, thiola
Side-effects : marrow / nephrotic
Indinavir Stone
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Protease inhibitor for HIV
Not radio-opaque
Cannot see on CT scan
Poor solubility
Prophylaxis – acidification of urine
Congenital Oxalosis
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Autosomal recessive
Dystrophic calcifications in blood vessels
Multiple nephrocalcinosis in young
Early renal failure
Disease recur in transplanted kidney
Treatment with high dose pyridoxine
Nanobacteria
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Small size 50-500 nm
Atypical, cytotoxic, filterable 0.22 ųm
Slow doubling time – 3 days
Present in 90% human stones?
Act as the nidus
Sensitive to tetracycline
T Jarrett 1999