RENAL STONE DISEASE

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RENAL STONE DISEASE
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ANALYSIS OF STONES

• ______________________________
  
• Oxalate 504 (56.1)
• Triple phosphate 237 (26.4)
• Phosphate 119 (13.4)
• Uric acid 38 (4.2)
• ______________________________
• Total 898 (100)

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AGE DISTRIBUTION OF OXALATE STONES
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FORMATION OF STONES

• Urine pH/infection Renal damage Calcium/oxalate
• Tissue debris
• Anatomical stasis Fixed particles
  inhibitors
• Aggregation
• Stone formation

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FORMATION OF STONES

• 1. Calcium - a) hypercalcaemia
• b) hyperparathyroidism
• c) hypercalciuria
• 2. Oxalate - G1, hyperoxalaturia
• 3. Cystine
• 4. Uric Acid
• 5. Infection - Urea-splitting organisms
• 6. Congenital / metabolic defects
• - medullary spone kidney
• - renal tubular acidosis

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CLINICAL PRESENTATION

• 1. Flank/loin pain, colicky radiation
• - haematuria
• - nausea and vomiting
• - chills/fever/frequency, if infected
• 2. Loin tenderness
• 3. Bilateral stones renal failure

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INVESTIGATIONS

• 1. IVU and DTPA
• Serum creatinine calcium
• Urine pH
• 4. 24-hour urine
• 5. Urine cultures
• 6. Stone analysis

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METABOLIC ABNORMALITIES(N 392)

• Hypercalciuria 28
• Hyperoxaluria 16
• Hyperuricosuria 14
• Cystinuria 0.5
• Hyperparathyroidism 1
• Primary oxalosis 0.25
• Renal tubular acidosis 0.25

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INDICATIONS FOR TREATMENT

• Presence of symptoms and / or obstructive
  uropathy in a functioning kidney

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Treatment of Renal Stones

• Four Options 1) conservative
• 2) non-invasive ESWL
• 3) minimal invasive PCNL, URS
• 4) open surgery
• New technology ? morbidity, ? hospital stay,
• ? invasiveness

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Electromagnetic Shockwave
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MANAGEMENT OF RENAL CALCULI by ESWL

• lt 2cm in diameter and/or surface area lt 500
  mm2
• Treatment ESWL monotherapy
• gt 2cm in diameter and/or surface area gt 500
  mm2
• Treatment PCNL /- ESWL
• Combination therapy

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MANAGEMENT OF RENAL CALCULI by ESWL

• gt 2cm in diameter and/or
• surface area gt 500 mm
• J Stents ESWL with repeated
• treatments required

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ESWL for Staghorn Stones

• PCNL ESWL as main option
• ESWL monotherapy is discouraged
• Open surgery has a place for large
• complete staghorn calculi

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Contra-indications to the Use of ESWL

• Absolute contra-indications
• Pregnancy
• Untreated urinary tract infection
• Distal obstruction to the stone that cannot be
  bypassed by a stent
• Untreated bleeding diatheses
• Non-functioning kidney

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PCNL
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Percutaneous Nephroscope and Lithoclast
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PCNL
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Results of Percutaneous Nephrolithotripsy PCNL

• Indications High stone burden or failed
  ESWL
• Success Stones free 82
• Insignificant fragments 15
• Failure Stones gt 4cm in diameter 3

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Traumatic AV Fistula after PCNL
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MANAGEMENT OF URETERIC STONES

• -Stones lt 0.5 cm in diameter doesnt pass
  
• spontaneously 4 to 6 weeks and /or
  causing
• symptoms ESWL monotherapy
• -Stones gt 0.5 cm in diameter lt 1 cm in
• diameter ESWL monotherapy

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MANAGEMENT OF URETERIC STONES

• Stones gt 1 cm in diameter trial of ESWL
  monotherapy
• Patient counselled
• 1. Repeat session may be necessary
• 2. URS/PCNL/ureterolithotomy

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RESULTS OF URETROSCOPIC LITHOTRIPSY (URS)

• Achieved stone free status 85 to 90
• Failures
• 1. Access problems
• 2. Stone migration
• Flexible URS for upper third ureteric calculi
• especially in the male

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Ureteric stone suitable for ESWL
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URS with Guide wire
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Laser Lithotripsy
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OPEN STONE SURGERY

• 2 incidence of all stone treatments
• Indications
• 1.Complex stone burden 38
• 2. Non-functioning kidneys 20
• 3. Failure of MIS 16
• 4. Others 26

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Recurrent Rate 75 - 10 Years 100 -
20 Years(Williams 1963)

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PREVENTION OF STONES

• 1. Treatment of causes
• 2. Dietary manipulations
• 3. Medications - indication duration

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DIETARY ADVICE

• 1. Hydration
• 2. Avoid oxalate-rich food
• 3. Avoid calcium-rich food ?
• 4. Avoid refined carbohydrates
• 5. Increase crude fibres

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MEDICATIONS

• 1. Thiazides
• 2. Allopurinol
• 3. Antibiotics
• 4. Sodium bicarbonate
• 5. Potassium citrate
• 6. Magnesium salts
• 7. Pyridoxine

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Cystine Stone

• 1 of stone population
• Autosomal recessive
• Round stones in calyces
• Large staghorn stones
• Hexagonal crystals

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Medical Treatment - Cystine

• Volume at 2.5 l/day
• Increase pH to gt 7.0
• Decrease dietary protein
• D-penicillamine, thiola
• Side-effects marrow / nephrotic

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Indinavir Stone

• Protease inhibitor for HIV
• Not radio-opaque
• Cannot see on CT scan
• Poor solubility
• Prophylaxis acidification of urine

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Congenital Oxalosis

• Autosomal recessive
• Dystrophic calcifications in blood vessels
• Multiple nephrocalcinosis in young
• Early renal failure
• Disease recur in transplanted kidney
• Treatment with high dose pyridoxine

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Nanobacteria

• Small size 50-500 nm
• Atypical, cytotoxic, filterable 0.22 um
• Slow doubling time 3 days
• Present in 90 human stones?
• Act as the nidus
• Sensitive to tetracycline

T Jarrett 1999