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FA17 Nephrology > Kidney Stones > Flashcards

Kidney Stones Flashcards

(55 cards)

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1
Q

pathophys of kidney stones

A

dissolved salts in urine condense into solid and obstruct urtheral pathway

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2
Q

natural prevention of kidney stones

A

increasing amount of urine and decreasing amount of solute in urine

citrate and magnesium can block formation

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3
Q

types of stones (5)

A
  1. calcium
  2. struvite
  3. uric acid
  4. cystine
  5. miscellaneous
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4
Q

Calcium stones

occur when?

A

MC type of stone, occurs w/elevated Ca excretion

Hyperparathyroidism
resorptive hypercalcemia
renal hypercalciuria
immobilization syndrome

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5
Q

randall’s plaque

A

collection of subepithelilal calcification of renal papillae

serves as anchoring surface for calcium oxalate stones

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6
Q

diet restriction and calcium stones

A

diet that restricts calcium can increase calcium stone formation bc less Ca to bin to collate in lumen

this results in increased oxalate absorption in gut and recruitment of calcium in bones

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7
Q

struvite stones

A

typically in UTI infections caused by urea splitting bacteria

produce excess ammonia phosphate and elevate pH levels (decrease solubility of phosphate)

MC cause of stag horn calculi

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8
Q

urea splitting bacteria

A

UTI from these species cause struvite stones

Klebsiella, Proteus, Staphylococcal species

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9
Q

staghorn calculi

A

struvite stones MC cause

lg stones that form cast of renal pelvis

poor abx penetration, can lead to urosepsis

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10
Q

uric acid stones

A

10% of stones

radiolucent, urine is typically acidic

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11
Q

cystine stones

A

rare

founding pts with cystinuria (genetic disorder)

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12
Q

Misc. causes of stones

A 
Indinavir (HIV drug) 
trimterine (Abx) 
Acetazolamide (glaucoma drug) 
Xanthine (caffeine) 
silicate
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13
Q

why are kidney stones so painful?

A

obstruction of hollow viscus organ and hydronephrosis causing pressure against GEROTA’s fascia

migrating but non obstructive stones can cause pain

stones in the KIDNEY don’t cause pain

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14
Q

Cr levels in obstructive kidney stones

A

no rise in serum CR

other kidney can compensate 185% of baseline

if Cr rises, suggests kidney dysfunction

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15
Q

determining probability of passage of stone:

A

size
shape
location
degree of urinal obstruction

bizarre/irregularly shaped stones have lower spontaneous passage rate

complete obstruction = lower rate of spontaneous passage

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16
Q

common sites of obstruction

A

ureteropelvic junction (UPJ)
Pelvic brim
UVJ

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17
Q

probability of spontaneous passage of kidney stones in 4 weeks

A

98% <5mm
60% 5-7
39% >7

stone size on radiograph is larger, stone on CT is actually smaller

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18
Q

classical clinical feature of kidney stone

A

acute onset of crampy intermittent flank pain that radiates to the groin

visceral pain, n/v

unable to find comfort

tachycardia, HTN, diaphoresis

hematuria

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19
Q

location of pain

A

upper utter refer pain to plank

mid ureter radiate to lower quadrant of abdomen

distal ureter refers to pain in groin

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20
Q

3 important things to clarify in history

A

asses risk factors for stone development

prior stone related outcome

important mimickers

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21
Q

risk factors for poor outcome

A

renal function at risk

history of difficulty stones

infections

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22
Q

serious mimickers to consider in kidney stone

A

AAA
renal artery infarction
aortic dissection

AAA is often misdiagnosed as kidney stone

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23
Q

distinguishing AAA from kidney stone

Study These Flashcards
A

stones don’t usually present in men older than 60

stones dont cause hypotension

24
Q

distinguish renal artery thrombosis from stone

Study These Flashcards
A

swelling of infarcted kidney can cause hematuria BUT

non contrast CT can distinguish

25
patients with at risk renal function
``` DM HTN Renal insufficiency single kidney horseshoe kidney transplanted kidney ```
26
patient with difficult stones
extraction stent urterostomy tubes liphotripsy
27
diagnosis of urologic stone disease
clinical suspicions presence of hematuria imaging (not often)
28
lab eval (4)
1. pregnancy (ectopic consideration - all women = preg test) 2. UA (rule out infection) 3. renal function 4. hematuria
29
imaging in kidney stones
confirms presence r/o other diagnoses identifies complications defines stone location
30
who gets imaging in stone workup?
pts with first time stones CT scanning reveals alternative diagnosis 33% of patients
31
non contrast CT of A and P
images obtained from top of kidney to bladder base urterial dilation* perinephric fat stranding* dilation of collecting system enlargement faster, no need for contrast damage, an see other pathology
32
plan abdominal radiograph
90% of stones are radiopaque (density similar to bone) - calcium struvite and cystine less able to see uric acid stones are unable to be seen not good to diagnose but good to see if stone is passing
33
US in stones
good if pt can't use CT may miss stones <5mm, mid arterial stones information on size, renal blood and urine flow
34
ED tx
pain and n/v control antibiotics for those w/evidence of infection medical expulsion therapy IV fluids to correct electrolyte imbalance
35
NSAIDs
primary choice of analgesics, direct action on ureter by inhibiting prostaglandin synthesis avoid in its with high risk bleeding, DM, renal insufficiency, pregnancy
36
IV NSAID +dosing
ketorolac (Toradol) <55 w.o. PMH of DM, renal insufficiency or GI bleeding - 30 mg 60-63 no CI - 15mg >65 - avoid
37
narcotics use
good analgesic do not affect care of pain second line morphine, percocet
38
antiemetic agents
Odansteron (Zofran) Metoclopradmide (Reglan)
39
Metoclopramide (Reglan)
blocks dopaminergic receptors in CNS less sedating, can provide pain provide
40
medical expulsion therapy
alpha blockers are DOC benefit in stones of distal third of ureter (tamsulosin) Flowmax mc alpha blocker
41
surgical treatments used in kidney stones
Shock wave lithotripsy Ureterscopy Percutaneous nephrolithotomy open surgery
42
SWL
renal calculi <3 cm NOT recommended for stones >3 cm utilized high energy shock waves to stone and break it down, then pass small fragments in urine
43
success of SWL depends on
number and density of stones total number and rate of shocks stone size chemical composition
44
URS when is it used?
tx of choice for majority of middle and distal ureteral stones measuring > 3 cm used in management of stones that have failed SWL, stones in proximal ureter and intrarenal
45
URS process
breaks up stones to less than 1 mm, pass painlessly successful in 90% of cases can place stents after to help passage
46
when is stenting performed
urinary tract abnormalities solitary kidneys residual edema or inflammation secondary to stone or endoscopic removal
47
PNL
placement of small caliber nephrostomy catheter thru flank into renal collecting system -- cath is dilated and enter the kidney to grab and remove the stone
48
open stone surgery
used in management of complex renal and ureteral calculi <1% of pts
49
indications for open stone surgery y
failed other procedures complex (stag horn) complex anatomy morbid obesity
50
preventative treatment
thiazide diuretics (increased calcium reabsorption) allopurinol or potassium citrate (uric acid)
51
disposition
<6 mm stone w/o impairment discharged with follow up
52
indications for hospitalization
intractable pain stone > 6mm evidence of infection evidence of worsening renal impairment irregular or proximal stone return to ED
53
patients should return to ED if
fever vomiting intractable pain
54
urology follow up
w/in 7 days allows etiology of stone to be evaluated and prophylactic strategy should be arranged
55
pregnancy
1 in 1500 pregnancies, most often in secondary third trimester diagnostic study of choice: ultrasound can use CT or MRI with OBGYN consult NSAIDs can't be used - narcotics instead can use medical expulsive therapy

FA17 Nephrology (13 decks)

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