MEDICAL MANAGEMENT OF MEDICAL MANAGEMENT OF RENAL STONESRENAL STONES

KIDNEY STONES KIDNEY STONES IntroductionIntroduction

This disease is not This disease is not transmittable.transmittable.

Kidney stones can develop Kidney stones can develop when certain chemicals in when certain chemicals in urine form crystals that urine form crystals that stick together. stick together.

Stones may also develop Stones may also develop from a persistent kidney from a persistent kidney infection.infection.

Drinking small amounts of Drinking small amounts of fluids.fluids.

More frequent in hot More frequent in hot weatherweather

SYMPTOMSSYMPTOMS

Pain in the lower back part or in the lower Pain in the lower back part or in the lower abdomen, which might move to the groin. Pain abdomen, which might move to the groin. Pain may last from hours to minutes.may last from hours to minutes.

Nausea, vomitingNausea, vomiting Blood in urine Blood in urine Burning during urination, foul smell in urine, Burning during urination, foul smell in urine,

chills, weakness and fevers for urinary tract chills, weakness and fevers for urinary tract infection.infection.

EPIDEMIOLOGYEPIDEMIOLOGY

This disease can be This disease can be found anywhere.found anywhere.

This disease can This disease can strike on any age strike on any age group.group.

COMPARATIVE INCIDENCES OF FORMS OF COMPARATIVE INCIDENCES OF FORMS OF

URINARY LITHIASISURINARY LITHIASIS

Stone analysis in PercentageStone analysis in Percentage

Form of Lithiasis Form of Lithiasis India India USA USA Japan Japan UKUK

Pure Calcium OxalatePure Calcium Oxalate 86.186.1 3333 17.417.4 39.439.4

Mixed Calcium Oxalate andMixed Calcium Oxalate and 4.94.9 3434 50.850.8 20.220.2

PhosphatePhosphate

Magnesium Ammonium Magnesium Ammonium 2.72.7 1515 17.417.4 15.415.4

Phosphate (Struvite )Phosphate (Struvite )

Uric AcidUric Acid 1.21.2 8.08.0 4.44.4 8.08.0

CystineCystine 0.40.4 3.03.0 1.01.0 2.82.8

Cause of Stone DiseaseCause of Stone Disease

Supersaturation of urine is the key to stone Supersaturation of urine is the key to stone

formationformation

Intermittent supersaturation - Dehydration Intermittent supersaturation - Dehydration

Crystal aggregationCrystal aggregation

Anatomic Abnormailities – PUJ , MSKAnatomic Abnormailities – PUJ , MSK

Bacterial Infection* Bacterial Infection*

Defects in transport of Calcium and Oxalate by Defects in transport of Calcium and Oxalate by

Renal epitheliaRenal epithelia

*E.Coli infection increases matrix content in urine . Proteus makes urine alkaline

Inhibitors, Promoters of Stone Inhibitors, Promoters of Stone Formation Formation

INHIBITORSINHIBITORS

Inhibits crystal Growth - Inhibits crystal Growth - Citrate – complexes Citrate – complexes

with Cawith Ca Magnesium – complexes Magnesium – complexes

with oxalateswith oxalates Pyrophosphate - Pyrophosphate -

complexes with Cacomplexes with Ca ZincZinc

Inhibits crystal Inhibits crystal AggregationAggregation

GlycosaminoglycansGlycosaminoglycans NephrocalcinNephrocalcin

PROMOTERSPROMOTERS Bacterial InfectionBacterial Infection Matrix Matrix Anatomic Abnormalities – Anatomic Abnormalities –

PUJ obst., MSK PUJ obst., MSK Altered Ca and oxalate Altered Ca and oxalate

transport in renal epithelia transport in renal epithelia Prolonged immobilisationProlonged immobilisation Increased uric acid levels i.e Increased uric acid levels i.e

taking increased purine taking increased purine subs– promotes subs– promotes crystalisation of Ca and crystalisation of Ca and oxalate oxalate

?? Nanobacteria – seen in ?? Nanobacteria – seen in 97% of renal stones97% of renal stones

SOME DISEASES ASSOCIATED WITH SOME DISEASES ASSOCIATED WITH HYPERCALCAEMIA & HYPERCALCIURIAHYPERCALCAEMIA & HYPERCALCIURIA

HyperparathyroidismHyperparathyroidism LeukemiaLeukemia

SarcoidosisSarcoidosis LymphomaLymphoma

Multiple myelomaMultiple myeloma MyxedemaMyxedema

HyperthyroidismHyperthyroidism Adrenal Adrenal

InsufficiencyInsufficiency

Metastatic Malig. Neoplasm'sMetastatic Malig. Neoplasm's Vit. D IntoxicationVit. D Intoxication

TYPES OF KIDNEY / URETER TYPES OF KIDNEY / URETER STONESSTONES

OXALATE (CALCIUM OXALATE)OXALATE (CALCIUM OXALATE)

PHOSPHATEPHOSPHATE

URIC ACID & URATEURIC ACID & URATE

CYSTINECYSTINE

Uncommon StonesUncommon StonesXANTHINE STONESXANTHINE STONES

– – Autosomal Recessive – Def. of Xanthine Oxidase leading to Autosomal Recessive – Def. of Xanthine Oxidase leading to Xanthinuria Xanthinuria

DIHYDROXYADENINE STONEDIHYDROXYADENINE STONE

– – Def. of enzyme adenine phospo ribosyl transferase Def. of enzyme adenine phospo ribosyl transferase

SlLICATE STONES SlLICATE STONES

– – Rare in humans - excess intake of Antacid with Mg TrisilicateRare in humans - excess intake of Antacid with Mg Trisilicate

( Mostly in cattle due to ingestion of sand )( Mostly in cattle due to ingestion of sand )

MATRIX MATRIX

- Infection by Proteus - Radiolucent (all calculi have some - Infection by Proteus - Radiolucent (all calculi have some amt ( 3%) of matrix but matrix calculus has 65% Matrix amt ( 3%) of matrix but matrix calculus has 65% Matrix content in calculi)content in calculi)

Uncommon StonesUncommon Stones

TRIAMTERENE TRIAMTERENE

– – Anti-hypertensive used with hydroclorothiazide – spares Anti-hypertensive used with hydroclorothiazide – spares

potassium. Mostly found as a nucleus in Ca-oxalate or uric potassium. Mostly found as a nucleus in Ca-oxalate or uric

acid calculus acid calculus

Indinavir StonesIndinavir Stones

- Drug to treat AIDS (4 to13%)- Drug to treat AIDS (4 to13%)

Ephedrine or GuifenesinEphedrine or Guifenesin

– – Cough medicine - RadiolucentCough medicine - Radiolucent

Stones – Chemical Stones – Chemical ConstituentsConstituents

WheweliteWhewelite – – Calcium Oxalate Monohydrate – Calcium Oxalate Monohydrate – CaCCaC22OO44-H-H22OO

WeddeliteWeddelite - Calcium Oxalate dihydrate – - Calcium Oxalate dihydrate – CaCCaC22OO44-2H-2H22OO

Brushite Brushite – Calcium Hydrogen phosphate dihydrate – – Calcium Hydrogen phosphate dihydrate – CaHPOCaHPO44

2H2H22OO

WhitlockiteWhitlockite - - TriCalcium Phosphate – TriCalcium Phosphate – CaCa22(PO(PO44))22

Struvite Struvite –– Magnesium Ammonium hexahydrate – Magnesium Ammonium hexahydrate – MgNHMgNH44POPO44--

6H6H22OO

DD of Radiolucent filling defect on DD of Radiolucent filling defect on IVU IVU

Must KnowMust Know

Uric Acid CalculusUric Acid Calculus Matrix CalculusMatrix Calculus Sloughed PapillaSloughed Papilla Blood ClotsBlood Clots TCC TCC Renal CystsRenal Cysts Vascular LesionsVascular Lesions

Know For Brownie PointsKnow For Brownie Points

Xanthine CalculusXanthine Calculus Hydroxyadenine Hydroxyadenine

CalculusCalculus Ephedrine CalculusEphedrine Calculus Infection due to gas Infection due to gas

forming Org.forming Org. Fungal BallFungal Ball TuberculomaTuberculoma MalacoplakiaMalacoplakia Hypertrophied PapillaHypertrophied Papilla Renal pseudo-tumourRenal pseudo-tumour

OXALATE (CALCIUM OXALATE (CALCIUM OXALATE)OXALATE)

ALSO CALLED MULBERRY STONEALSO CALLED MULBERRY STONE

COVERED WITH SHARP PROJECTIONSCOVERED WITH SHARP PROJECTIONS

SHARP SHARP MAKES KIDNEY BLEED (HAEMATURIA)MAKES KIDNEY BLEED (HAEMATURIA)

VERY HARDVERY HARD

RADIO - OPAQUERADIO - OPAQUE

Under microscope looks like Hourglass or Dumbbell shape if monohydrate and Like an Envelope if Dihydrate

PHOSPHATE STONEPHOSPHATE STONE

USUALLY USUALLY CALCIUM PHOSPHATECALCIUM PHOSPHATE

SOMETIMES SOMETIMES CALCIUM MAGNESIUM CALCIUM MAGNESIUM

AMMONIUM PHOSPHATE OR TRIPLE AMMONIUM PHOSPHATE OR TRIPLE

PHOSPHATEPHOSPHATE

SMOOTH SMOOTH MINIMUM SYMPTOMSMINIMUM SYMPTOMS

DIRTY WHITEDIRTY WHITE

RADIO - OPAQUERADIO - OPAQUE

Calcium Phosphate also called ‘Brushite’ appears ‘needle-shaped’ under the microscope

PHOSPHATE STONESPHOSPHATE STONES

IN ALKALINE URINEIN ALKALINE URINE

ENLARGES RAPIDLYENLARGES RAPIDLY

TAKE SHAPE OF CALYCESTAKE SHAPE OF CALYCES

STAGHORN STAGHORN

Struvite can form ‘stag-horn’ and appear like coffin lid under microscope

CALCIUM PHOSPHATE CALCIUM PHOSPHATE STONESSTONES

Hyperparathyroidism Hyperparathyroidism Ca Ca PP

Renal Tubular AcidosisRenal Tubular Acidosis K K CO CO22

Medullary Sponge Kidney - Medullary Sponge Kidney -

PTH Hormone Promotes renal production of 1-25-dihyroxycholecalciferol – active Vit.D and also increases absorption of Calcium and decreases Phosphorus

absorption from Kidneys

URIC ACID & URATE STONEURIC ACID & URATE STONE

HARD & SMOOTHHARD & SMOOTH

MULTIPLEMULTIPLE

YELLOW OR RED-BROWNYELLOW OR RED-BROWN

RADIO - LUCENT (USE RADIO - LUCENT (USE

ULTRASOUND)ULTRASOUND)

Under microscope appear like irregular plates or rosettes

pKa of uric acid 5.75 – at this pH 50% of uric acid insoluble.If pH falls further - uric acid more insoluble

CYSTINE STONECYSTINE STONE

AUTOSOMAL RECESIVE DISORDERAUTOSOMAL RECESIVE DISORDER

USUALLY IN YOUNG GIRLSUSUALLY IN YOUNG GIRLS

DUE TO CYSTINURIA - DUE TO CYSTINURIA -

CYSTINE NOT ABSORBED BY TUBULESCYSTINE NOT ABSORBED BY TUBULES

MULTIPLEMULTIPLE

SOFT OR HARD – can form stag-hornsSOFT OR HARD – can form stag-horns

PINK OR YELLOW - RADIO-OPAQUEPINK OR YELLOW - RADIO-OPAQUE

Under microscope appears like hexagonal or benzene ring – ask for first morning sample

Surgical Conditions and Surgical Conditions and Stone DiseaseStone Disease

Regional ileitis and Ileal Bypass Regional ileitis and Ileal Bypass Surgery for Obesity can lead to Surgery for Obesity can lead to increased oxalate absorption and increased oxalate absorption and stone diseasestone disease

Ileostomies, in Chr. Diarrhoea with Ileostomies, in Chr. Diarrhoea with Bicarbonate loss – systemic Bicarbonate loss – systemic acidosis and acidic urine – acidosis and acidic urine – increases risk of Uric Acid stones increases risk of Uric Acid stones

HISTORYHISTORY

A.A. IS PATIENT DRINKING ENOUGH ?IS PATIENT DRINKING ENOUGH ?

B. PROFESSIONB. PROFESSION

C.C. ENQUIRE ABOUT UTI - STONESENQUIRE ABOUT UTI - STONES

D. FAMILY HISTORYD. FAMILY HISTORY

E.E. LONG ILLNESS - BEDRIDDEN - STONES LONG ILLNESS - BEDRIDDEN - STONES

MANAGEMENT OF MANAGEMENT OF STONESSTONES

HISTORY :HISTORY :

A.A. FIND OUT IF DRINKING ENOUGH LIQUIDSFIND OUT IF DRINKING ENOUGH LIQUIDS

(NOT DRINKING ENOUGH IMPORTANT (NOT DRINKING ENOUGH IMPORTANT

CAUSE OF STONE FORMATION & CAUSE OF STONE FORMATION &

GROWTH)GROWTH)

Urinary supersaturation of salts in concentrated urineAtleast drink 3 lts to avoid stone formation

HISTORY HISTORY (Cont...)(Cont...)

B. ASK ABOUT THEIR PROFESSIONB. ASK ABOUT THEIR PROFESSION

DEHYDRATION - STONES CAN FORM e.g. DEHYDRATION - STONES CAN FORM e.g.

MARATHON, NEAR A FURNACE,MARATHON, NEAR A FURNACE,

BRICK - LAYER, LABOURERS & WEAVERSBRICK - LAYER, LABOURERS & WEAVERS

TRUCK & BUS DRIVERSTRUCK & BUS DRIVERS

C.C. ENQUIRE ABOUT UTI ENQUIRE ABOUT UTI STONESSTONES

D. FAMILY HISTORYD. FAMILY HISTORY

E.E. LONG ILLNESSLONG ILLNESS BEDRIDDEN BEDRIDDEN STONES STONES

HISTORY HISTORY (Cont...)(Cont...)

Zero Gravity state – astronauts on long space flights more prone to stones

CLINICAL FEATURESCLINICAL FEATURES

11.. PAIN IN 75 % OF THE CASES PAIN IN 75 % OF THE CASES

“RENAL COLIC” IF SEVERE AND ACUTE“RENAL COLIC” IF SEVERE AND ACUTE

A)A) KIDNEY STONE KIDNEY STONE

FIXED PAIN IN THE LOIN FIXED PAIN IN THE LOIN

B)B) URETERIC STONEURETERIC STONE

PAIN RADIATES PAIN RADIATES LOIN TO GROIN LOIN TO GROIN

Both Stomach & Kidney supplied by celiac ganglion hence nausea & vomiting common in renal colic

CLINICAL FEATURES CLINICAL FEATURES (Contd....)(Contd....)

2)2) HAEMATURIAHAEMATURIA

CAN BE FRANKCAN BE FRANK

OR ONLY FOUND ON DIP - STICK OR LAB.OR ONLY FOUND ON DIP - STICK OR LAB.

3)3) PYURIA - IF INFECTION, CAN HAVE PUS IN PYURIA - IF INFECTION, CAN HAVE PUS IN

URINEURINE

ON EXAMINATIONON EXAMINATION

1.1. ACUTE PRESENTATIONACUTE PRESENTATION

ABDOMEN TENSE AND RIGIDABDOMEN TENSE AND RIGID

TENDERNESS PRESENT IN THE TENDERNESS PRESENT IN THE

LOINLOIN

2.2. IN ROUTINE PRESENTATIONIN ROUTINE PRESENTATION

NO FINDINGS IN ABDOMENNO FINDINGS IN ABDOMEN

INVESTIGATIONS INVESTIGATIONS

1.1. FULL BLOOD COUNT TO CHECK FOR FULL BLOOD COUNT TO CHECK FOR

ANAEMIA, IF GOING FOR SURGERYANAEMIA, IF GOING FOR SURGERY

2.2. SERUM ELECTROLYTES PLUS UREA / SERUM ELECTROLYTES PLUS UREA /

CREATININE / CALCIUM / URIC ACID / CREATININE / CALCIUM / URIC ACID /

PHOSPHATEPHOSPHATE

INVESTIGATIONS INVESTIGATIONS (Cont...)(Cont...)

3.3. 24-HOURS URINE FOR ELECTROLYTES 24-HOURS URINE FOR ELECTROLYTES

(Only if recurrent stone former)(Only if recurrent stone former)

CALCIUM / OXALATE / URIC ACID / CALCIUM / OXALATE / URIC ACID /

CYSTINE / CITRATECYSTINE / CITRATE

INVESTIGATIONS INVESTIGATIONS (Cont...)(Cont...)

4.4. PLAIN KUB X-RAY OF ABDOMEN (Mandatory)PLAIN KUB X-RAY OF ABDOMEN (Mandatory)

5.5. IVU (INTRA VENOUS UROGRAM) OR IVP IVU (INTRA VENOUS UROGRAM) OR IVP

6.6. ULTRASOUND (Mandatory)ULTRASOUND (Mandatory)

INVESTIGATIONSINVESTIGATIONS

IVU OR IVP - Not MandatoryIVU OR IVP - Not Mandatory

1 in 40,000 patients die due to anaphylactic 1 in 40,000 patients die due to anaphylactic reaction to contrastreaction to contrast

Useful for radio-lucent stones & to detectUseful for radio-lucent stones & to detect

Congenital Anomalies in Urinary tractsCongenital Anomalies in Urinary tracts

INVESTIGATIONS INVESTIGATIONS (Cont...)(Cont...)

7. CT – TO LOOK AT UNUSUAL ANATOMY OF THE KIDNEY7. CT – TO LOOK AT UNUSUAL ANATOMY OF THE KIDNEY

To differentiate cause of acute colic – stone or To differentiate cause of acute colic – stone or

anuria anuria suspected due to stone diseasesuspected due to stone disease

8.8. DMSA OR DTPA OR MAG3 RENOGRAM - TO STUDY DMSA OR DTPA OR MAG3 RENOGRAM - TO STUDY

FUNCTION OF EACH KIDNEY.FUNCTION OF EACH KIDNEY.

Bilateral Ureteric Calculus in a patient presenting with Anuria Bilateral Ureteric Calculus in a patient presenting with Anuria

Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows on Gantry. These are rapidly performed and do not require contrast agents for reconstruction.

MANAGEMENT OF MANAGEMENT OF UROLITHIASISUROLITHIASIS

Non-invasive approach to urinary calculus -Non-invasive approach to urinary calculus -HALLMARK for last 20 yrs.HALLMARK for last 20 yrs.

Lithotripters – Lithotripters –

1.Extra Corporeal Shock wave1.Extra Corporeal Shock wave

2.Intra Corporeal 2.Intra Corporeal

Better fiber optics – Miniaturisation of Better fiber optics – Miniaturisation of Telescopes Telescopes

Accessories - Innovative varietyAccessories - Innovative variety

Diet & Fluid AdviceDiet & Fluid Advice

High Fluid IntakeHigh Fluid Intake

Restrict Salt (Na)Restrict Salt (Na)

Oxalate RestrictOxalate Restrict

Avoid high intake of Purine foodAvoid high intake of Purine food

Increased citrus fruits may helpIncreased citrus fruits may help

If hypercalciuria restrict Ca intake If hypercalciuria restrict Ca intake

Role of Potassium Citrate in preventing Cal Oxalate stone ds – KCit lowers urinary calcium whereas Na Citrate does not lower Calcium due

to Sodium load

LIQUIDSLIQUIDS

Moderate Amounts : High Amounts :Moderate Amounts : High Amounts :

Apple JuiceApple Juice CocoaCocoa

BeerBeer Fresh TeaFresh Tea

CoffeeCoffee

ColaCola

FOODS :FOODS :

Almonds, Asparagus, Cashew Nuts, Currants, Almonds, Asparagus, Cashew Nuts, Currants,

Greens, Plums, Raspberries, SpinachGreens, Plums, Raspberries, Spinach

Principles of Medical Principles of Medical ManagementManagement

Monitor stone burden with periodic KUBMonitor stone burden with periodic KUB Instruct patient on adequate water Instruct patient on adequate water

consumption ( enough to produce 2L of consumption ( enough to produce 2L of urine in 24 hrs.)urine in 24 hrs.)

Instruct in low oxalate and modified Instruct in low oxalate and modified calcium dietcalcium diet

If hypercalcuric, treat with If hypercalcuric, treat with hydrochlorothiazide (monitor urinary hydrochlorothiazide (monitor urinary Ca)Ca)

Principles of Medical Principles of Medical Management 2Management 2

If hyperuricosuricIf hyperuricosuric– allopurinol if serum uric acid elevatedallopurinol if serum uric acid elevated– alkalinize urine if serum level is normalalkalinize urine if serum level is normal

If active Ca stone former not aided by diet, If active Ca stone former not aided by diet, HCTZ added to K-citrateHCTZ added to K-citrate

If magnesium ammonium phosphate stone, If magnesium ammonium phosphate stone, after reduction of burden treat aggressively after reduction of burden treat aggressively with antibioticswith antibiotics

Anatomic EvaluationAnatomic Evaluation

Necessary to decide on how to best treatNecessary to decide on how to best treat

– size and location of stonesize and location of stone

– number of stonesnumber of stones

– anatomy of kidney, ureteranatomy of kidney, ureter

– is stone overlying boneis stone overlying bone

– ““condition” of involved kidneycondition” of involved kidney

Principles of Stone Principles of Stone PreventionPrevention

Prevent supersaturationPrevent supersaturation– water! water and more water enough to make water! water and more water enough to make

2L of urine per day2L of urine per day– prevent solute overload by low oxalate and prevent solute overload by low oxalate and

moderate Ca intake and treatment of moderate Ca intake and treatment of hypercalcuriahypercalcuria

– replace “solubilizers” i.e... citratereplace “solubilizers” i.e... citrate– manipulate pH in case of uric acid and cystinemanipulate pH in case of uric acid and cystine

Flush! forced water intake after any dehydrationFlush! forced water intake after any dehydration

Urine citrateUrine citrate

Hypocitriuria is one of the most Hypocitriuria is one of the most remarkable Feature of renal remarkable Feature of renal tubular acidosis and kidney stone tubular acidosis and kidney stone FormationFormation

Hypocitriuria is a frequent finding in Hypocitriuria is a frequent finding in individuals with Recurrent stone individuals with Recurrent stone formation.formation.

Presence of citrate in urine is an Presence of citrate in urine is an inhibitor of stone formation.inhibitor of stone formation.

Emergency Department Emergency Department CareCare

Intravenous access - for analgesics and Intravenous access - for analgesics and antiemeticsantiemetics

Intravenous hydration is controversial. Intravenous hydration is controversial. – May hasten passage of the stone May hasten passage of the stone – Others feel exacerbates the pain of renal colic Others feel exacerbates the pain of renal colic – IV hydration should be given in dehydration IV hydration should be given in dehydration

or with a borderline serum creatinine level or with a borderline serum creatinine level who must undergo IVPwho must undergo IVP

– Strain urine for stone collection Strain urine for stone collection

Ref: J Endourol. Oct 2006;20(10):713-6Ref: J Endourol. Oct 2006;20(10):713-6

ED Care – Analgesics ED Care – Analgesics AntiemeticsAntiemetics

Analgesia should be provided promptly. Analgesia should be provided promptly. – The pain of renal colic is mediated by PGE2. The pain of renal colic is mediated by PGE2.

NSAIDs inhibit formation of this mediatorNSAIDs inhibit formation of this mediator– NSAIDs have been proven in multiple NSAIDs have been proven in multiple

studies to be as effective as opioid studies to be as effective as opioid analgesics, with fewer adverse effectanalgesics, with fewer adverse effect

– Opioid analgesics can be added in cases of Opioid analgesics can be added in cases of incomplete pain controlincomplete pain control

Antiemetics should be administered as neededAntiemetics should be administered as needed

Ref: Arch Intern Med. Jun 27 1994;154(12):1381-7 Ref: Arch Intern Med. Jun 27 1994;154(12):1381-7

Am J Emerg Med. Jan 1999;17(1):6-10Am J Emerg Med. Jan 1999;17(1):6-10

ED Care - Expulsive therapy ED Care - Expulsive therapy

o Multiple prospective randomized controlled Multiple prospective randomized controlled studies in the urology literature have studies in the urology literature have demonstrated that patients treated with oral demonstrated that patients treated with oral alpha-blockers have an increased rate of alpha-blockers have an increased rate of spontaneous stone passage and a spontaneous stone passage and a decreased time to stone passagedecreased time to stone passage

o The best studied of these is tamsulosin, 0.4 The best studied of these is tamsulosin, 0.4 mg administered dailymg administered daily

Ref: J Urol. Dec 2003;170(6 Pt 1):2202-5 Ref: J Urol. Dec 2003;170(6 Pt 1):2202-5 J Urol. Jul 2005;174(1):167-72 J Urol. Jul 2005;174(1):167-72

J Urol. Aug 2004;172(2):568-71J Urol. Aug 2004;172(2):568-71

ED Care - Expulsive ED Care - Expulsive therapytherapy

o CCBs in combination with oral steroids have also CCBs in combination with oral steroids have also proven efficacious in multiple studies. The most proven efficacious in multiple studies. The most common regimen is 30-mg slow-release common regimen is 30-mg slow-release nifedipine daily plus oral corticosteroid such as nifedipine daily plus oral corticosteroid such as prednisoloneprednisolone

o A systematic review found that medical A systematic review found that medical expulsive therapy using either alpha antagonists expulsive therapy using either alpha antagonists or CCBs augmented the stone expulsion rate for or CCBs augmented the stone expulsion rate for moderately sized distal ureteral stonesmoderately sized distal ureteral stones

Ref: Ref: Ann Emerg Med. Nov 2007;50(5):552-63Ann Emerg Med. Nov 2007;50(5):552-63

ED Care - Expulsive ED Care - Expulsive therapytherapy

– A systematic review found that A systematic review found that medical expulsive therapy with alpha medical expulsive therapy with alpha antagonists for 28 days increased the antagonists for 28 days increased the rate and decreased the time to stone rate and decreased the time to stone passage; decreased the rates of passage; decreased the rates of hospitalization and ureteroscopyhospitalization and ureteroscopy

Ref: Ref: Ann Pharmacother. Jul-Aug 2006;40(7-8):1361-8Ann Pharmacother. Jul-Aug 2006;40(7-8):1361-8

Ca-oxalate, ca-phosphate, Ca-oxalate, ca-phosphate, and ca-urate are associated and ca-urate are associated

with:with:

– Hyperparathyroidism - Treated surgically or Hyperparathyroidism - Treated surgically or with orthophosphates if the patient is not a with orthophosphates if the patient is not a surgical candidatesurgical candidate

– Increased gut absorption of calcium - The Increased gut absorption of calcium - The

most common identifiable cause of most common identifiable cause of hypercalciuria, treated with calcium binders hypercalciuria, treated with calcium binders or thiazides plus potassium citrate or thiazides plus potassium citrate

Ca-oxalate, ca-phosphate, Ca-oxalate, ca-phosphate, and ca-urate are associated and ca-urate are associated

with:with:

– Renal calcium leak - Treated with thiazide Renal calcium leak - Treated with thiazide diureticsdiuretics

– Renal phosphate leak - Treated with oral Renal phosphate leak - Treated with oral

phosphate supplements phosphate supplements

– Hyperuricosuria - Treated with allopurinol, Hyperuricosuria - Treated with allopurinol, low purine diet, or alkalinizing agents such low purine diet, or alkalinizing agents such as potassium citrate as potassium citrate

Ca-oxalate, ca-phosphate, Ca-oxalate, ca-phosphate, and ca-urate are associated and ca-urate are associated

with:with:

– Hyperoxaluria - Treated with dietary oxalate Hyperoxaluria - Treated with dietary oxalate restriction, oxalate binders, vitamin B-6, or restriction, oxalate binders, vitamin B-6, or orthophosphatesorthophosphates

– Hypocitraturia - Treated with potassium Hypocitraturia - Treated with potassium

citratecitrate

– Hypomagnesuria - Treated with magnesium Hypomagnesuria - Treated with magnesium

supplementssupplements

Struvite (magnesium Struvite (magnesium ammonium phosphate) ammonium phosphate)

stones stones

Struvite stones are associated with chronic UTI Struvite stones are associated with chronic UTI with gram-negative rods capable of splitting with gram-negative rods capable of splitting urea into ammonium, which combines with urea into ammonium, which combines with phosphate and magnesiumphosphate and magnesium

Underlying anatomical abnormalities that Underlying anatomical abnormalities that predispose patients to recurrent kidney predispose patients to recurrent kidney infections should be sought and corrected infections should be sought and corrected

Struvite (magnesium Struvite (magnesium ammonium phosphate) ammonium phosphate)

stonesstones

– Usual organisms include Usual organisms include Proteus, Proteus, Pseudomonas,Pseudomonas, and and KlebsiellaKlebsiella species species

– Escherichia coliEscherichia coli is not capable of splitting is not capable of splitting urea and, therefore, is not associated with urea and, therefore, is not associated with struvite stonesstruvite stones

– UTI does not resolve until stone is removed UTI does not resolve until stone is removed entirelyentirely

Urine pH is typically greater than 7 Urine pH is typically greater than 7

Uric acid stones Uric acid stones

Associated with urine pH less than 5.5, high purine Associated with urine pH less than 5.5, high purine intake (eg, organ meats, legumes, fish, meat intake (eg, organ meats, legumes, fish, meat extracts, gravies), or malignancy extracts, gravies), or malignancy

Approximately 25% of patients with uric acid stone Approximately 25% of patients with uric acid stone have gout - serum and 24-hour urine sample have gout - serum and 24-hour urine sample should be sent for creatinine and uric acid should be sent for creatinine and uric acid determinationdetermination

If serum or urinary uric acid is elevated, the patient If serum or urinary uric acid is elevated, the patient may be treated with allopurinol 300 mg dailymay be treated with allopurinol 300 mg daily

Patients with normal serum or urinary uric acid are Patients with normal serum or urinary uric acid are best managed by alkali therapy alone best managed by alkali therapy alone

Cystine stones Cystine stones

Treated with low-methionine diet (unpleasant), Treated with low-methionine diet (unpleasant), binders such as penicillamine or a-binders such as penicillamine or a-mercaptopropionylglycine, large urinary mercaptopropionylglycine, large urinary volumes, or alkalinizing agentsvolumes, or alkalinizing agents

A 24-hour quantitative urinary cystine A 24-hour quantitative urinary cystine determination helps to titrate the dose of drug determination helps to titrate the dose of drug therapy to achieve a urinary cystine therapy to achieve a urinary cystine concentration of less than 300 mg/L concentration of less than 300 mg/L

Drug-induced stone Drug-induced stone disease disease

A number of medications or their metabolites A number of medications or their metabolites can precipitate in urine causing stone formationcan precipitate in urine causing stone formation

These include indinavir; atazanavir; guaifenesin; These include indinavir; atazanavir; guaifenesin; triamterene; silicate (overuse of antacids triamterene; silicate (overuse of antacids containing magnesium silicate); and sulfa drugs containing magnesium silicate); and sulfa drugs including sulfasalazine, sulfadiazine, including sulfasalazine, sulfadiazine, acetylsulfamethoxazole, acetylsulfasoxazole, acetylsulfamethoxazole, acetylsulfasoxazole, and acetylsulfaguanidine and acetylsulfaguanidine

Ref: Urology. Oct 2003;62(4):748 Ref: Urology. Oct 2003;62(4):748

Urol Clin North Am. Feb 2003;30(1):123-31 Urol Clin North Am. Feb 2003;30(1):123-31

Urology. Jan 2004;63(1):175-6Urology. Jan 2004;63(1):175-6

Potassium-magnesium-Potassium-magnesium-citratecitrate

Potassium citrate reduces urinary Potassium citrate reduces urinary saturation of calcium by saturation of calcium by complexing with calcium in urine complexing with calcium in urine and thus reduces urinary calcium and thus reduces urinary calcium

Citrate also inhibits spontaneous Citrate also inhibits spontaneous nucleation of calcium oxalate and nucleation of calcium oxalate and calcium phosphatecalcium phosphate

Due to its alkalinising effect it Due to its alkalinising effect it increasesincreases

dissolution of uric acid and thus dissolution of uric acid and thus reduce uric acid stone formationreduce uric acid stone formation

MagnesiumMagnesium

It forms complex with oxalate and reduces It forms complex with oxalate and reduces supersaturation of urine with calcium oxalatesupersaturation of urine with calcium oxalate

It increases pH of urine and thus inhibit It increases pH of urine and thus inhibit stone Formationstone Formation

Magnesium has direct inhibitory influence on Magnesium has direct inhibitory influence on Calcium phosphate crystal growth. Calcium phosphate crystal growth.

Magnesium also prevents intestinal Magnesium also prevents intestinal absorption of Oxalate absorption of Oxalate 11

1. Am J Ther,2006 Mar-Apr ; 13(2) : 101-8

CONCLUSIONCONCLUSION

As compared to potassium citrate , As compared to potassium citrate , Potssium –magnesium citrate cause Potssium –magnesium citrate cause moremore

Rise in urinary pHRise in urinary pH

Rise in urinary citrate levelRise in urinary citrate level

Rise in urinary magnesium levelRise in urinary magnesium level

Reduction in undissociated uric acid levelReduction in undissociated uric acid level

Equally effective in correcting thiazide Equally effective in correcting thiazide induced hypokalemiainduced hypokalemia

Potassium magnesium citrate based Potassium magnesium citrate based medical prophylaxis is effective for medical prophylaxis is effective for preventing recurrence of urinary stones preventing recurrence of urinary stones like calcium oxalate, hypercalciuria, like calcium oxalate, hypercalciuria, hyperuricosuria and hypocitriuriahyperuricosuria and hypocitriuria

Regular prophylaxis effectively prevent Regular prophylaxis effectively prevent stone recurrence regardless of stone stone recurrence regardless of stone composition, metabolic abnormalities composition, metabolic abnormalities and stone –free status.and stone –free status.

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