Nephrolithiasis Scope of The Problem

NEPHROLITHIASIS SCOPE OF
THE PROBLEM
• Incidence 0.10 – 0.5% population/yr

• High cost in yearly health care dollars
• High morbidity: pain, obstruction, bleeding,
infection, loss of work
• Males >>Females except for infection
related stones
COMMON STONES
• Calcium oxalate
• Calcium phosphate
• Struvite-apatite
• Cystine
• Uric acid
STONE EVALUATION
• Stone History
• Family History
• Medications
• Dietary Considerations
• Urologic Procedures
• Radiologic Studies
• Urinalysis
• Stone Analysis
• Metabolic Evaluation
STONE HISTORY
• Total number of stones

• Frequency of analgesic use
• Time off work
• Symptoms: renal colic, renal ache
• History of UTI, gout, diarrhea,
malabsorption, myeloproliferative
disorders
STONE EVALUATION
• Stone History
• Family History
• Medications
• Urinalysis
• Stone Analysis
STONE-PROVOKING
MEDICATIONS
MEDICATION STONE TYPE MECHANISMS
Acetazolamide Ca ox, Ca phos Hypercalciuria
Vitamin C Ca ox Hypocitraturia
Calcium supplements Ca ox, Ca phos Hyperoxaluria
Vitamin D Ca ox, Ca phos Hypercalciuria
Antacids Ca ox Hypercalciuria
Theophylline Ca ox, Ca phos Hypercalciuria
Nifedipine Ca ox, Ca phos Hypercalciuria
Probenecid, ASA Uric Acid Hyperuricosuria
DIETARY CONSIDERATIONS IN
NEPHROLITHIASIS
• Fluids
• Dairy products
• Salt
• Protein
Animal
Vegetable
• Oxalate
• Alcohol
STONE EVALUATION
• Stone History
• Family History
• Medications
• Urinalysis
• Stone Analysis
UROLOGIC PROCEDURES
• Anatrophic Nephrolithotomy
• Percutaneus Nephrolithotomy
• Extracorporeal shock lithotripsy
• Ureteroscopy (laser)
RADIOLOGIC APPEARANCE
OF CALCULI
Radiopaque Calculi Radiolucent Calculi
Calcium Oxalate Uric Acid
Calcium Phosphate
Struvite-Apatite
Cystine
STONE EVALUATION
• Stone History
• Family History
• Medications
• Urinalysis
• Stone Analysis
URINALYSIS
CRYSTALLURIA
• Calcium Oxalate
• Calcium Phosphate-Apatite, Brushite
• Struvite—Magnesium Ammonium Phosphate
• Uric Acid
• Cystine
STONE EVALUATION
• Stone History
• Family History
• Medications
• Urinalysis
• Stone Analysis
STONE ANALYSIS
RADIOPAQUE STONES
STONE TYPE METABOLIC ETIOLOGY
Calcium oxalate Hypercalciuria, Hyperoxaluria
Hyperuricosuria, Hypocitraturia
Hypomagnesiuria
Calcium phosphate Hypercalciuria, PHPT, Distal RTA
Sodium Alkali Therapy
Struvite or Carbonate-apatite UTI
Cystine Cystinuria
STONE EVALUATION
• Stone History
• Family History
• Medications
• Urinalysis
• Stone Analysis
METABOLIC CLASSIFICATION
OF NEPHROLITHIASIS
• Hypercalciuria
• Hyperuricosuria
• Hyperoxaluria
• Hypocitraturia
• Hypomagnesiuria
• Altered urinary pH
• Cystinuria
• Low urinary volume
METABOLIC EVALUATION OF
NEPHROLITHIASIS
• Blood
Chemistries
CBC
PTH
• Urine
Urianalysis
Culture & Sensitivity
Cystine
• 24-Hour Urine Collections
Random Diet
Restricted Diet
• Fast and Calcium Load Test
24 HOUR URINE COLLECTIONS
TOTAL VOLUME SODIUM
pH Potassium
Calcium Uric acid
Phosphorus Oxalate
Magnesium Creatinine
Citrate Sulfate
NEPHROLITHIASIS
COEXISTENCE OF METABOLIC DERANGEMENTS
N=1270
CATEGORY PERCENT
Hypercalciuria 60
Hyperuricosuria
Calcium Nephrolithiasis 36
Uric Acid Nephrolithiasis 10
Hyperoxaluria 7
Hypocitraturia 31
Hypomagnesiuria 7
Infection 6
Cystinuria <1
Low Urinary Volumes 15
No Metabolic Abnormality 4
Difficult to Classify 5
CYSTINE STONES
• Decreased renal tubule absorption of cystine,

ornithine, lysine and arginine (COLA)
• Autosomal recessive
• Large, radiopaque, often staghorn
• Rx: thiola, D-penicillamine, captopril
INFECTION – STRUVITE STONES
• Urea
urease
CO2 + NH3 NH4+
• NH 4 + Mg2 + PO4 Struvite
• Carbonate + PO 4 carbonate apatite

INFECTION – STRUVITE STONES
• Radiopaque, staghorn
• Women > men
• Associated with chronic infection with
urease producing organisms
• Poor prognosis: Rx: surgery, lithotripsy,
antibiotics, acetohydroxamic acid
URIC ACID STONES
• Associated with gout, GI disease,

neoplasm
• Radiolucent
• Fluids, diet, alkali, allopurinol
DEFINITIONS OF
HYPERCALCIURIA
• 24 hour Urinary Calcium Excretion > 200 mg/day

1 week on Ca and Na restricted diet (40 mg Ca, 10
mEg Na)
• 24 hour Urinary Calcium Excretion > 4 mg/kg/day

• 24 hour Urinary Calcium Excretion > 250 mg/day-
females, > 300 mg/day--males
FAST AND CALCIUM LOAD TEST
• Normal fasting value <0.11 mg Ca/mg Cr (GFR)
• Normal postload value <0.20 mg Ca/mg Cr

ABSORPTIVE HYPERCALCIURIA
• Primary Defect – increased intestinal absorption
of Ca
• Location of Lesion – Jejunum
• Inheritance – autosomal dominant
• Animal Model – genetically Hypercalciuric rat
• Skeletal Status – normal to increased cortical
bone density
• Calcium Balance - normal
ABSORPTIVE HYPERCALCIURIA
•Sodium Cellulose Phosphate

Urinary Ca > 350 mg/day
Side effects – hyperoxaluria, hypomagnesiuria
•Thiazide + Potassium Citrate
•Amiloride
RENAL HYPERCALCIURIA
• Primary Defect – impaired tubular

reasborption of Ca
• Location of Lesion - ? Proximal tubule
• No effect of Diet on Calcium Excretion
• 1,25-(OH)2D3 – increased
• Skeletal Status – decreased cortical bone
density
• Calcium Balance - negative
RENAL HYPERCALCIURIA
• Thiazide
• Potassium Citrate
PRIMARY
HYPERPARATHYROIDISM
• Primary Defect – parathyroid glad adenoma or

hyperplasia
• 1,25-(OH) D 2 3 – PTH- dependent increased renal

synthesis
• Skeletal Status – decreased cortical bone

density
PRIMARY
HYPERPARATHYROIDISM
• Surgical Management
• Medical Management
Estrogen
Orthophosphates
RENAL PHOSPHATE LEAK
ABSORPTIVE HYPERCALCIURIA TYPE III
• Primary Defect – increased urinary phosphate

• 1,25-(OH) D
2 3 – increased
• Skeletal Status – decreased bone density

• Calcium Balance – negative
• Role of Diet
RENAL PHOSPHATE LEAK
TREATMENT
• Orthophosphates
MANIFESTATIONS OF THE
HYPERCALCIURIAS
FEATURE AH RH PHPT RPL
Serum Ca Normal Normal High Normal
Serum Phos Normal Normal Low Low
PTH Normal/Low Enhanced High Normal
Fasting Urinary Ca <0.11 >0.11 >0.11 <0.11
Postload Urinary Ca >0.20 >0.20 >0.20 >0.20

TREATMENT OF NEPHROLITHIASIS
CONSERVATIVE MANAGEMENT
• Fluids to maintain 3-8 L Urinary Volume/Day

• Diet
No Calcium Restriction
Sodium Restriction
Limited Purine Intake
Oxalate Restriction

Nephrolithiasis Scope of The Problem

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Nephrolithiasis Scope of The Problem

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NEPHROLITHIASIS SCOPE OF

• Incidence 0.10 – 0.5% population/yr

• Total number of stones

Radiopaque Calculi Radiolucent Calculi

Calcium Oxalate Uric Acid

Calcium oxalate Hypercalciuria, Hyperoxaluria

Calcium phosphate Hypercalciuria, PHPT, Distal RTA

Sodium Alkali Therapy

Struvite or Carbonate-apatite UTI

Calcium Uric acid

• Decreased renal tubule absorption of cystine,

• NH 4 + Mg2 + PO4 Struvite

• Carbonate + PO 4 carbonate apatite

• Associated with gout, GI disease,

• 24 hour Urinary Calcium Excretion > 200 mg/day

• 24 hour Urinary Calcium Excretion > 4 mg/kg/day

• Normal fasting value <0.11 mg Ca/mg Cr (GFR)

• Normal postload value <0.20 mg Ca/mg Cr

•Sodium Cellulose Phosphate

• Primary Defect – impaired tubular

• Primary Defect – parathyroid glad adenoma or

• 1,25-(OH) D 2 3 – PTH- dependent increased renal

• Skeletal Status – decreased cortical bone

• Primary Defect – increased urinary phosphate

• Skeletal Status – decreased bone density

Serum Ca Normal Normal High Normal

Serum Phos Normal Normal Low Low

PTH Normal/Low Enhanced High Normal

Fasting Urinary Ca <0.11 >0.11 >0.11 <0.11

Postload Urinary Ca >0.20 >0.20 >0.20 >0.20

• Fluids to maintain 3-8 L Urinary Volume/Day

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