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Flashcards

Renal Stone Disease

Anna Hogarth Met3B English 47 cards

Cards in this deck (47)

  1. 1Clinical features of renal calculi?1) Asymptomatic
    2) Pain
    3) Infection
    4) Hematuria
    5) Proteinuria
    6) Sterile Pyuria
    7) Anuria
  2. 2How does pain present in renal stones? How can it be differentiated from peritonitis?Excruciating spasms of renal colic 'loin to groin', with nausea/vomiting.
    Patients will rithe around, rather than presenting with 'board-like' rigidity
  3. 3How does pain in obstruction of the kidney present?Felt in the loin between the 12th rib and the lateral edge of lumbar muscles - unlike intercostal nerve irritation pain, it is colickly and it is not worsened by specific movement/pressure on the trigger spot
  4. 4What can obstruction of the mid-ureter mimic?Appendicitis/diverticulitis
  5. 5What does obstruction the lower ureter cause?Can cause bladder irritability, and pain in scrotum, penile tip, or labia majora
  6. 6What does obstruction of the bladder or urethra cause?Pelvic pain, dysuria, strangury (desire but inability to void) +/- interrupted flow
  7. 7What would you expect to find on examination?No tenderness - possibly renal angle tenderness, especially to percussion if there is retroperitoneal inflammation
  8. 8What are the main types of renal calculi?Calcium oxalate (75%)
    Magnesium ammonium phosphate (struvite/triple phosphate; 15%)
    Urate (5%)
    Hydroxyapatite (5%)
    Brushite, cystine (1%)
    Mixed
  9. 9What blood tests are done to investigate urine calculi?FBC
    U&Es
    Ca2+
    PO4-
    Glucose
    Bicarbonate
    Urate
  10. 10What urine tests are done?Urine dip - usually positive for blood
    MSU/MC&S
  11. 11What tests are done to find the cause the renal stones?Urine pH
    24h urine for calcium, oxalate, citrate, sodium, creatinine, stone biochemistry (sieve urine and send stone)
  12. 12What imaging is done for suspected renal stones?Non-contrast CT is first line (also good for excluding differentials of acute abdomen)
    KUB xray shows 80% of stones
    Look along ureters for calcification over transverse processes of the vertebral bodies. US an alternative for hydronephrosis or hydroureter
  13. 13Describe the initial management of renal stonesDiclofenac (analgesia, if CI, give opioids)
    IV fluids (if can't have PO)
    Antibiotics if concurrent infection (i.e. piperacillin/tazobactam)
  14. 14What is the cut off for whether a stone is likely to pass on its own?5mm: if < 5mm, 90-95% of stones pass spontaneously. Increase fluid intake in these patients
  15. 15What medical therapy is used for the expulsion of renal stones?Start on presentation if stone is greater than 5mm or pain is not resolving
    Nifedipine (10mg/8h PO) or alpha blockers (tamsulosin 0.4mg/d).
    Most will pass within 48 hours, >80% after 30 days
  16. 16What are the non-medical options for management of renal stones? What are the indications for each?If they do not pass:
    Extracorporeal shockwave lithotripsy (ESWL) if less than 1cm, or ureteroscopy using a basket
    Percutaneous nephrolithotomy (PCNL) - keyhole surgery to remove stones when large, multiple or complex.
  17. 17What are the potential SE ESWL?Renal injury, can also cause high blood pressure and DM
  18. 18What are the indications for urgent intervention?Presence of infection AND obstruction (may need percutaneous nephrostomy or ureteric stent)
    Urosepsis
    Intractable pain or vomiting
    Impending AKI
    Obstruction of one or both kidneys
  19. 19What are the predisposing factors for the development of renal stones?1) Recurrent UTIs - (proteus causes alkaline urine and calcium precipitation which leads to ammonium salt formation; magnesium ammonium phosphate calculi)
    2) Metabolic abnormalities:
    Hypercalcaemia/hypercalciuria
    Hyperuricosuria/high plasma urate +/- gout
    Hyperoxaluria
    Cystinuria
    Renal tubular acidosis
    3) Urinary tract abnormalities
    4) Foreign bodies e.g. stents/catheters
  20. 20What can cause hypercalcaemia/hypercalciuria?Hyperparathyroidism, sarcoidosis, malignancy, hyperthyroidism, Addison's, Cushings', lithium, vit D abnormalities
  21. 21What drugs can precipitate renal stone formation?Diuretics
    Antacids
    Acetazolamide (glaucoma, heart failure, epilepsy, altitude sickness)
    Corticosteroids
    Theophylline (COPD)
    Aspirin
    Allopurinol
    Vitamin C/D
    Indinavir (protease inhibitor; HIV/AIDS)
  22. 22How does family history of renal stones affect risk?3X increase
    There are also inherited conditions:
    x-linked nephrolithiasis
    Dent's disease (proteinuria, hypercalciuria, and nephrocalcinosis)
  23. 23What causes calcium oxalate stones to form? Radiological appearance?1) Metabolic or idiopathic
    2) Spiky, radio-opaque
  24. 24What causes calcium phosphate stones to form? Radiological appearance?1) Idiopathic or metabolic
    2) Smoth, may large, radio-opaque
  25. 25What causes magnesium ammonium phosphate stones to form? Radiological appearance?1) UTI - proteus causes alkaline urine and calcium precipitation and ammonium salt formation
    2) Large, horny, 'staghorn', radio-opaque
  26. 26What causes urate stones to form? Radiological appearance?1) Hyperuricemia
    2) Smooth, brown, radiolucent
  27. 27What causes cystine stones to form? Radiological appearance?1) Renal tubular defect
    2) Yellow, crystalline, semi-opaque
  28. 28What are the general lifestyle preventative recommendations for renal stones?Drink plenty of fluids
    Have normal dietary calcium intake - low calcium intake will lead to increase oxalate excretion into the urine, and increased risk of stones
  29. 29How are calcium stones managed?If hypercalciuria, use a thiazide diuretic to reduce calcium excretion
  30. 30How are oxalate stones prevented?Lower oxalate diet (maintain normal calcium): avoid tea, chocolate, rhubarb, strawberries, nuts, and spinach
  31. 31How are struvite (magnesium ammonium phosphate) stones prevented?Treat UTIs/infections promptly
  32. 32How are urate stones prevented?1) Reduce red meat intake and alcohol intake
    2) Give allopurinol (100-300mg/24h PO)
    3) Alkalise urine (urate more soluble at pH>6); can use sodium bicarbonate or potassium citrate
  33. 33How are cystine stones prevented?1) High fluid intake - urine output should be more than 3L/day
    2) Urinary alkalisation (sodium bicarbonate or potassium citrate)
    3) Penicillamine to chelate cystine (also give pyridoxine to prevent B6 deficiency)
  34. 34If a stone is at the ureteric-vesico junction, how is it managed?1) Watchful waiting/expulsive therapy (95% of stones under 10mm with medical expulsives)
    2) Semi-rigid ureteroscopy (URS)
    3) Lithotripsy (ESWL)
  35. 35If a stone is at the pelvic brim, how is it managed?1) Waiting/medical expulsion
    2) Semi-rigid ureteroscopy (URS)
  36. 36If a stone is at the ureteric-renal junction, how is it managed?1) Semi-rigid ureteroscopy
    2) Flexible utero endoscopy (FURS)
    3) Lithotripsy (ESWL)
    4) Percutaneous nephrolithotomy
  37. 37If a stone is within the kidney, how is it managed?1) Waiting/medical expulsive therapy
    2) Flexible ureteroscopy
    3) Percutaneous nephrolithotomy
    4) Lithotripsy (ESWL)
  38. 38When is metabolic testing indicated?1) Single kidney
    2) Multiple stones
    3) Bilateral stone disease
    4) Urate, calcium or cysteine stones
  39. 39What are the metabolic tests that are done?1) 24hr urine collection for calcium, urate, oxalate, sodium, volume and cystine
    2) Nitroprusside spot test for cystine
    3) Blood tests for urate, calcium, bicarbonate and U&Es
  40. 40General lifestyle prevention of stones?1) Increase urine output to more than 2L per day (lemonade not lucozade)
    2) Reduce sodium intake
    3) Increase potassium intake
    4) Reduce intake of high oxalate foods (O)
    5) Reduce intake of fatty foods (O)
    6) Supplement protein intake with calcium (O)
    7) Do not take more than 1 vitamin C tablet a day (O)
    8) Vit D and calcium supplements with meal (O)
    9) Reduce animal protein intake (U)
  41. 41Which drug can be used to reduce calciuria?Thiazides, but poor evidence
  42. 42Which drugs can be used to reduce the acidity of the urine?1) Potassium citrate (poorly tolerated)
    2) Sodium bicarbonate
  43. 43Which drug is used to help prevent urate stone formation?Allopurinol
  44. 44Which drugs are used to prevent cystinuria?Penicillamine and thiola
  45. 45How is preventative treatment monitored?24hr urine for calcium, urate, oxalate, cysteine (whichever is relevant to the type of stone). Urine volume
    Blood urate for users of allopurinol
  46. 46What is the chance another stone will occur in the next 10 years if there are no dietary changes? How much does increasing fluid intake reduce this risk by?1) 50%
    2) 40%
  47. 47What is the imaging follow up is someone had previously know asymptomatic stones? No previous stones?1) 6 monthly-yearly KUB
    2) 6 monthly-yearly USSKUB

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Met3B (Renal Medicine) Flashcards on Renal Stone Disease, created by Anna Hogarth on 04/03/2020.
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Anna Hogarth
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