Nephrolithiasis resident survival guide: Difference between revisions

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{{CMG}} {{AE}} {{ATS}}
{{CMG}} {{AE}} {{ATS}}


==Definition==
==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.
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.


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❑Proximal ureteral stones >1cm
❑Proximal ureteral stones >1cm
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==Do´s<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586  }} </ref>==
*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<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586  }} </ref><ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648  }} </ref>==
*Do not recommend [[calcium]] restrictions, as the may increase the urinary oxalate excretion.
*Do not administer [[NSAID]]s 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==
==References==

Latest revision as of 00:24, 13 March 2014

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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