Nephrolithiasis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Andrea Tamayo Soto [2]

Overview

Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.

Causes

Life Threatening Causes

  • Renal Obstruction
  • Renal Isquaemia
  • Renal Impairment

Common Causes[1]

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic approach to Nephrolithiasis based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.[2]

 
 
 
 
 
Characterize the symptoms:[3]

Abdominal Pain

Colic pain
❑ Irradiated to the lower abdomen and groin
❑ Acute, moderate to severe pain

Urinary urgency
Dysuria
Polyuria
Vomits
Nausea
Malaise

Fever and chills
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain a detailed history:

❑ History of kidney stones

❑ Personal and Family
❑ Treatment
❑ Stone analysis

❑ History of UTI or pyelonephritis
❑ Anatomic Features

❑ Horse shoe kidney
❑ Solitary kidney
❑ Obstruction of uteropelvic junction
❑ Previous Kidney or ureteral surgery

❑ Diseases such as:

Hyperparathyroidism
Renal tubular acidosis
Cystinuria
Gout
Diabetes mellitus type 2 or Insulin resistance
Inflammatory bowel disease
Renal insufficiency
Sarcoidosis
Gastro-intestinal pathology

❑ Drug treatments and regular intake:

❑ Carbonic anhydrase inhibitor
Ephedrine
Sulfadiazine
Calcium and Vitamin D
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

❑ Measure the blood pressure
❑ Measure the heart rate
❑ Measure the temperature
❑ Abdomen

❑ Tender
❑ Painful
Obesity
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order labs and tests:

Urinalysis

Microscopic hematuria
❑ Nitrates
Leucocytes
Crystalluria

Hemogram

Complete blood count
❑ Serum electrolytes
Urea
Creatinine

CT
Ultrasound if pregnant
Intravenous Pyelography
❑ 24 hour urine collection analysis

Calcium
Phosphorus
Magnesium
Uric acid
Oxalate
 
 
 
 


Therapeutic Approach

Shown below is an algorithm depicting the therapeutic approach to Nephrolithiasis[2][3]:

 
 
 
 
 
 
 
 
 
 
Initial Management

❑ Hydration

Water (2L/24h)
❑ 0.9% Normal saline
❑ 5% dextrose in water and 0.45% Normal saline

Analgesics

❑ Opioid Narcotics
Codeine / acetaminophen (1 or 2 tablets(5-10mg codeine / 325-500mg acetaminophen))
❑ Hydrocodone / acetaminophen (5-10mg/4-6hours)
NSAIDs
Diclofenac
Ibuprofen
Ketorolac

Antispasmodics

Alpha-blockers
Doxazosin (4mg/day)
Tamsulosin (0.4mg/day)
❑ Calcium channel blockers
Nifedipine (30mg/day)
Steroids
Corticosteroid
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Complications?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Size
 
 
 
 
Infection
 
Obstruction
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<5mm
 
 
 
>5mm
 
 
❑ Broad spectrum antibiotics include coverage for:

❑ Antibacterial treatment should be administer to the results of the urine culture

 
❑ Ureter Obstruction:
  • decresed glomerular filtration
  • decresed renal blood flow
  • Acute intervention is needed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Spontaneous passage
 
Elective intervention if the has not passed after 2 - 4 weeks
 
Intervention
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Spontaneous passage[1][2]

Kidney Stone Treatment and future prevention
Calcium Oxalate stones Thiazide Diuretics

Sodium restriction
Calcium supplements
Protein intake <30% of TCI
Vitamin D (if <30ng/ml)

Calcium Phosphate stones ❑Acidify urine

❑Perform a pregnancy test on women
❑Decrease dietary intake of phosphate

Cystine stones ❑Alkalize urine

❑Cystine-binding agents
❑Decrease methionine intake
❑If measures fail:

❑D-penicillamine OR
Tiopronin OR
Captopril
Struvite stones ❑Acidify urine

❑Avoid supplementary magnesium
Acetohydroxamic acid

Uric acid stones ❑Alkalize urine

Allopurinol
❑Reduce protein intake <30% of TCI
❑Reduce or eliminate alcohol intake
❑In patients with diabetes - increase tea and coffee intake

Indications
Acidify urine Betaine (650mg three times/day with meals)

❑Cranberry juice (16oz/day)

Alkalinize urine Potassium citrate (10-20mEq with meals

Calcium citrate (1g/day with meals)


Intervention[4]

Treatment Indications
Extracorporeal shock wave lithotripsy ❑Renal stones <2cm

❑Ureteral stones <1cm

Uteroscopy ❑Ureteral stones
Ureterorenoscopy ❑Renal stones <2cm
Percutaneous nephrolithotomy ❑Renal Stones >2cm

❑Proximal ureteral stones >1cm


Do´s[3]

  • Perform a metabolic evaluation in patients with risk factors for stone recurrence
    • Family history of nephrolithiasis
    • Presence of biliary stone disease
    • Nephrocalcinosis
    • Stones are formed from cysteine, uric acid or calcium phosphate
    • The patient is a child
  • Administer tamsulosin and corticosteroids to help stones pass quicker and with less analgesics.
  • Proceed intravenously in patients who are unable to take oral fluids or oral medications and with hypotension.
  • Perform


Don´ts[3][4]

  • Do not recommend calcium restrictions, as the may increase the urinary oxalate excretion.
  • Do not administer NSAIDs when extracorporeal shock lithotripsy is planned, as it may increase the risk of perinephric bleeding.
  • Do not perform extracorporeal shock lithotripsy in women who want to have children, percutaneous nephrolithotomy is a safer option.

References

  1. 1.0 1.1 Hall PM (2009). "Nephrolithiasis: treatment, causes, and prevention". Cleve Clin J Med. 76 (10): 583–91. doi:10.3949/ccjm.76a.09043. PMID 19797458.
  2. 2.0 2.1 2.2 Frassetto L, Kohlstadt I (2011). "Treatment and prevention of kidney stones: an update". Am Fam Physician. 84 (11): 1234–42. PMID 22150656.
  3. 3.0 3.1 3.2 3.3 Miller NL, Lingeman JE (2007). "Management of kidney stones". BMJ. 334 (7591): 468–72. doi:10.1136/bmj.39113.480185.80. PMC 1808123. PMID 17332586.
  4. 4.0 4.1 Portis AJ, Sundaram CP (2001). "Diagnosis and initial management of kidney stones". Am Fam Physician. 63 (7): 1329–38. PMID 11310648.


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