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By Dr. Khalid Shakeel Babar (KSB). Uric Acid Nephrolithiasis -in a nutshell. Kidney stone types. Major Risk Factors for UA Stones. p H. Mechanisms for Uric Acid Stones. Purine RICH FOODS. Gout Uricosuric Drugs Uric Acid Overproduction Chronic Diarrhea DM and Metabolic Syndrome. - PowerPoint PPT Presentation
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Uric Acid Nephrolithiasis -in a nutshell
ByDr. Khalid Shakeel Babar (KSB)
KIDNEY STONE TYPES
MAJOR RISK FACTORS FOR UA STONES
•Low Urine Volume•Hyperuricosuria
•Low Urinary pH
•High Serum Uric Acid Level
H+Urate
Uric Acid
pH
lighter heavier
MECHANISMS FOR URIC ACID STONES
Dietary Ingestion
De Novo Purine Synthesis
Decrease in Elimination
PURINE RICH FOODS
PREDISPOSING CONDITIONS Gout Uricosuric Drugs Uric Acid Overproduction Chronic Diarrhea DM and Metabolic Syndrome
PRESENTATION1. PAIN IN MOST OF THE CASES
“RENAL COLIC” IF SEVERE AND ACUTE
A) KIDNEY STONE FIXED PAIN IN THE LOIN
B) URETERIC STONE PAIN RADIATES ® LOIN TO GROIN
C) BLADDER STONE
PAIN WITH LUTS
Both Stomach & Kidney supplied by celiac ganglion hence Nausea & vomiting common in renal colic
HISTORY
A. IS PATIENT DRINKING ENOUGH WATER?
B. PROFESSION
C. ENQUIRE ABOUT UTI ® STONES
D. FAMILY HISTORY
E. LONG ILLNESS ® BEDRIDDEN ®
STONES
ON EXAMINATION
1. ACUTE PRESENTATION
ABDOMEN TENSE AND RIGID
TENDERNESS PRESENT IN THE LOIN
Renal Punch positive
2. IN ROUTINE PRESENTATION
NO FINDINGS IN ABDOMEN
INVESTIGATIONS
1. FULL BLOOD COUNT
2. Abdominal Ultrasound
3. URINE R/E
INVESTIGATIONS (CONT...)
4. KUB Xray
5. Stone Analysis
6. Serum Uric acid,
Blood urea and serum creatinine
7. 24 hour urine for uric acid
INVESTIGATIONS (CONT...)
8. IVU OR IVP (INTRA VENOUS UROGRAM)
9. CT Scan
10. Renogram (DMSA / DTPA / MAG3)
TREATMENT Alkalinization of urine Increased fluid intake Xanthine oxidase inhibiters ( if 24hr
urinary uric acid excretion more than 6 mmol/day)
Dietary restriction of purine rich foods.
DDS Renal
Pyelonephritis. Obstruction of the ureter due to other
causes (such as a blood clot, stricture, papillary necrosis, or urothelial tumour).
Acute renal infarction. Renal rupture. Renal abscess (very rare, and in the UK
usually secondary to stones).
DDS Gynaecological
Ectopic pregnancy. Endometriosis. Ovarian cyst: rupture or torsion. Pelvic inflammatory disease. Salpingitis.
DDS Gastrointestinal
Appendicitis. Diverticulitis. Biliary colic. Bowel obstruction. Bowel ischaemia. Crohn's diseaseOthersAAA
PROGNOSIS Mortality and morbidity are not
increased with uric acid stones compared with other stones; however, the process that leads to excess uric acid production (eg, malignancy, Lesch-Nyhan syndrome) may cause death.
RECURRENCE Restrict purine rich diet to reduce
recurrence. Repeat Urine pH, serum uric acid,
abdominal ultrasound and CT scan for recurrence.
STONES IN PREGNANCY Rare event Normal physiology of pregnancy Factors favoring stones in pregnancy Most stones appear to be
predominantly composed of calcium phosphate
DIAGNOSIS Renal and pelvic ultrasound Transvaginal and doppler ultrasoundIf further diagnosis is required
MR urography Low dose CT. limited intravenous pyelogram (IVP)
TREATMENT Most (75 to 85 percent) stones pass
spontaneously Decompression of the kidney with
placement of a ureteral stent percutaneous nephrostomy tube, ureteroscopy to remove the stone may be required
in the patient who is septic, has persistent severe pain, or has persistent obstruction.
shock wave lithotripsy use during pregnancy is contraindicated
CASE PRESENTATION Presentation:On 17th November, 2012, 8:00 AM26 year old boy presented withSevere Radiating Right Lumbar PainAssociated with nausea and vomiting.On examination: Renal Punch +ve on Right Side.Ultrasound Abdomen Report: Normal exceptRight Kidney shows minimal hydronephrosis with
dilated proximal ureter raises the suspicion of distal ureteric obstruction.
Urine R/E Report: Normal , except Urine pH 5.0KUB xray: Normal, No stone seen.
Initially managed with Inj. Diclofenac Sodium i/mInj. Spasfan i/mInj. Gravinate i/v After the pain was relieved patient was
asked detailed history, he told about Family history of stones.
Serum uric acid level advised and it was 7.8 mg/dl (normal range 3.5 – 7.2).
Patient started on conservative treatment
Alkalinization of urine Increased fluid intake24hr urinary uric acid excretion test doneIt was less than 6mmol/day, so patient
did not start Xanthine oxidase inhibiters.
Video
Special Thanks to Dr. Kamran sahib for solving all my queries regarding stones and immensely helping me in preparing presentation.
Thanks to Dr. Qais Falah and Prof; Dr. Zahid Ahmed Hashmi for encouragement and help.