Urolithiasis - Thierfelder

Question 1

Patient reports with severe flank pain radiating to the lower abdomen, groin, testes. Patient also has hematuria. What are these symptoms for?

Answer 1

Kidney Stones- can be asymptomatic, cause restlessness, nausea, vomiting, ileus, “mirror pain”

Question 2

Renal Colic

Answer 2

• severe flank pain radiation to lower abdomen, groin, or testes
• restless, ambulatory
• nausea, vomiting, ileus
• mirror pain

Question 3

Urolithiasis Stone Presentation

Answer 3

• asymptomatic
• acute urinary obstruction - renal colic
• hematuria

Question 4

Stone Ingredients

Answer 4

Calcium
Oxalate
Phosphate
Uric Acid
Cystine
Struvite
Triameterne

Question 5

________ and _________ inhibit nucleation

Answer 5

Magnesium and Citrate

Question 6

Calcium Phosphate Stones form in acidic/alkaline urine?

Answer 6

Alkaline - as pH increases more phosphates exist in ionic form

Question 7

Uric Acid Stones form in acidic/alkaline urine?

Answer 7

Acidic - solubility of urate increases as pH increases

Question 8

Diagnosis of Urolithiasis

Answer 8

Urinalysis - hematuria, cystine and struvite crystals are diagnostic
Plain Abdominal Film
IVP
Ultrasound
** Spiral CT - no contrast - very sensitive and specific

Question 9

Most common stone ingredients

Answer 9

Calcium oxalate, calcium phosphate.

Ingredients can be: Calcium, oxalate, phosphate, uric acid, cystine, struvite(Urea broken down), triamterene

Question 10

What inhibits nucleation of kidney stones

Answer 10

Magnesium and citrate

Question 11

What inhibits nuclei or larger structures to adhere to one another

Answer 11

Tamm-Horsfall protein in ascending limb of henle

Question 12

Calcium phosphate stones form in ______ urine; uric acid stones form in _______ urine

Answer 12

Alkaline, acidic

Question 13

Struvite stones process

Answer 13

Magnesium ammonium phosphate. Normal urine is under saturated with ammonium phosphate, UTI with urease-producing organism (Klebsiella or proteus)> Alkaline urine forms struvite

Question 14

Colorless eight sided envelope crystal is

Answer 14

Calcium oxalate

Question 15

Yellow or reddish brown diamond shaped or six sided stone is

Answer 15

Uric acid

Question 16

Cystine crystals are

Answer 16

Colorless, hexagon shaped

Question 17

Diagnosis of Kidney stone

Answer 17

Urinanalysis, plain abdominal film, IVP, ultrasound, SPIRAL CT

Question 18

Abdominal flatplate: what stones are radiopaque and radiolucent

Answer 18

Radiopaque: Calcium oxalate, calcium phosphate, mix
Radiolucent: Uric acid, xanthine, hypoxanthine

Question 19

T/F: If stone is 10mm or more you normally need a urologist to take it out.

Answer 19

True

Question 20

How to treat stone passage

Answer 20

80-90% pass spontaneously.
Increase fluids.
Strain urine.
Analgesia (NSAID to normal creatinine levels)
Calcium channel blocker/alpha blocker (Nifedipine/tamsulosin- Flomax)

Question 21

When do you put someone in the hospital for kidney stone?

Answer 21

fever
UTI
oral analgesia ineffective
intractable vomiting 
dehydration

Question 22

Urologic management includes:

Answer 22

Shock wave lithotripsy (with stint)
percutaneous nephrostolithotomy
ureteroscopy
open stone surgery

Question 23

Risks for kidney stones

Answer 23

sweating
excessive sun exposure
recurrent UTI
neurogenic bladder
gout
chronic diarrhea
family hx (Renal Tubular Acidosis (RTA) and cystinuria)
medications

Question 24

Medications that may cause kidney stones

Answer 24

Carbonic anhydrase inhibitors (eventually drops pH)
triamterene
sulfadiazone
ascorbic acid
Indinavir (HIV med)
Topiramate (Topomax)
Acetazolamide (Diamox)

Question 25

What lab work could you order if someone had a kidney stone

Answer 25

``` Serum BUN Serum creatinine, calcium, PTH if hypercalcemic phosphorus, uric acid, Urinalysis (UTI, crystals, pH). Could do a 24 hour urine collection. ```

Question 26

Preventative therapy for kidney stones

Answer 26

Drink more fluids (produce 2 liters of urine, 8 8oz.) Reduce salt intake limit animal protein to 8 oz. daily

Question 27

Why would low calcium intake increase urinary oxalate

Answer 27

Less calcium is available in intestinal lumen to bind oxalate and prevent its absorption

Question 28

What drinks increase risk of stone

Answer 28

``` Apple juice, and grapefruit. Decrease risk: coffee, tea, beer, wine. Colas made no difference. Lemonade rich in citrate. OJ will increase urine pH and citrate ```

Question 29

What food will increase urine uric acid

Answer 29

Red meat, fish, poultry

Question 30

Foods rich in oxalate

Answer 30

Spinach, nuts, PB, strawberries, chocolate, rhubarb, brewed tea

Question 31

What inhibits sodium reabsorption in distal renal tubules?

Answer 31

Thiazides (hydrochlorothiazide). Give potassium citrate to replace potassium

Question 32

Medical management of uric acid stones

Answer 32

Alkalinize urine to pH 6 to 6.5. pH>7 is risk for calcium phosphate stones. Give potassium citrate. Increase fluids. Dietary restriction of purines. Allopurinol