Nephrolithiasis resident survival guide: Difference between revisions
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{{CMG}} {{AE}} {{ATS}} | {{CMG}} {{AE}} {{ATS}} | ||
== | ==Overview== | ||
Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever. | |||
==Causes== | ==Causes== | ||
Line 12: | Line 12: | ||
* Renal Impairment | * Renal Impairment | ||
===Common Causes=== | ===Common Causes<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref>=== | ||
*Hypercalciuria | *[[Hypercalciuria]] | ||
*Hyperoxaluria | *[[Hyperoxaluria]] | ||
*Hypernatruria | *Hypernatruria | ||
*Hypocitraturia | *[[Hypocitraturia]] | ||
*Gout | *[[Hyperuricosuria]] | ||
*Previous chemotherapy for Lymphoma and Leukemia | *[[Cystinuria]] | ||
* | *[[Gout]] | ||
*Drug related stones | *[[Metabolic acidosis]] | ||
*Previous [[chemotherapy]] for [[Lymphoma]] and [[Leukemia]] | |||
*Urine Infection | |||
*Drug related stones | |||
**[[Allopurinol]] | |||
**[[Triamterene]] | |||
**[[Indinavir]] | |||
==Management== | ==Management== | ||
Line 31: | Line 37: | ||
<div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;"> | <div style="float: left; text-align: left; height: 18em; width: 30em; padding:1em;"> | ||
❑ [[Abdominal Pain]] <br> | ❑ [[Abdominal Pain]] <br> | ||
:❑ [[Colic]] pain <br> | |||
:❑ Irradiated to the lower abdomen and groin <br> | :❑ Irradiated to the lower abdomen and groin <br> | ||
:❑ Acute pain | :❑ Acute, moderate to severe pain | ||
❑ [[Urinary urgency]] <br> | ❑ [[Urinary urgency]] <br> | ||
❑ [[Dysuria]] <br> | ❑ [[Dysuria]] <br> | ||
Line 93: | Line 100: | ||
❑ [[CT]] <br> | ❑ [[CT]] <br> | ||
❑ [[Ultrasound]] if pregnant <br> | ❑ [[Ultrasound]] if pregnant <br> | ||
❑ [[Intravenous]] [[Pyelography]] <br> | |||
❑ 24 hour urine collection analysis <br> | ❑ 24 hour urine collection analysis <br> | ||
:❑ [[Calcium]] | :❑ [[Calcium]] | ||
Line 100: | Line 108: | ||
:❑ [[Oxalate]]</div>}} | :❑ [[Oxalate]]</div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
===Therapeutic Approach=== | |||
Shown below is an algorithm depicting the therapeutic approach to [[Nephrolithiasis]]<ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref><ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>: | |||
{{familytree/start}} | |||
{{familytree | | | | | | | | | | | A01 | | | | | | | | A01= Initial Management <br> | |||
<div style="float: left; text-align: left; height: 40em; width: 30em; padding:1em;"> | |||
❑ Hydration <br> | |||
:❑ [[Water]] (2L/24h)<br> | |||
:❑ 0.9% [[Saline|Normal saline]] | |||
:❑ 5% [[Glucose|dextrose]] in water and 0.45% [[Saline|Normal saline]] | |||
❑ [[Analgesics]] | |||
:❑ Opioid Narcotics <br> | |||
::❑ [[Codeine]] / [[acetaminophen]] (1 or 2 tablets(5-10mg [[codeine]] / 325-500mg [[acetaminophen]])) | |||
::❑ Hydrocodone / [[acetaminophen]] (5-10mg/4-6hours) | |||
:❑ [[NSAID]]s | |||
::❑ [[Diclofenac]] | |||
::❑ [[Ibuprofen]] | |||
::❑ [[Ketorolac]] | |||
❑ [[Antispasmodic]]s | |||
:❑ [[Alpha blocker|Alpha-blockers]] | |||
::❑ [[Doxazosin]] (4mg/day) | |||
::❑ [[Tamsulosin]] (0.4mg/day) | |||
:❑ Calcium channel blockers | |||
::❑ [[Nifedipine]] (30mg/day) | |||
:❑ [[Steroids]] | |||
::❑ [[Corticosteroid]] </div> }} | |||
{{familytree | | | | | | | | | | | |!| | | | | | | | | }} | |||
{{familytree | | | | | | | | | | | B01 | | | | | | | | B01= Complications? }} | |||
{{familytree | | | | | | |,|-|-|-|-|^|-|-|-|-|.| | | | | }} | |||
{{familytree | | | | | | C01 | | | | | | | C02 | | | | C01= No | C02= Yes }} | |||
{{familytree | | | | | | |!| | | | | | |,|-|^|-|.| | | }} | |||
{{familytree | | | | | | D01 | | | | | D02 | | D03 | | D01= Size |D02=Infection |D03=Obstruction }} | |||
{{familytree | | | |,|-|-|^|-|-|.| | | |!| | | |!| | | }} | |||
{{familytree | | | E01 | | | | E02 | | | E03 | | E04 | | E01= | |||
<div style="float: left; text-align: left; padding:1em;"> <5mm | |||
</div> | |||
| E02= <div style="float: left; text-align: left; padding:1em;"> >5mm | |||
</div> | |||
| E03= <div style="float: left; text-align: left; padding:1em;">❑ Broad spectrum antibiotics include coverage for: | |||
*[[Gram-negative bacteria|Gram (-)]] bacili | |||
*[[Gram-positive|Gram(+)]] cocci | |||
❑ Antibacterial treatment should be administer to the results of the urine culture | |||
</div> | |||
| E04= <div style="float: left; text-align: left; padding:1em;">❑ Ureter Obstruction: <br> | |||
*decresed glomerular filtration | |||
*decresed renal blood flow | |||
*Acute intervention is needed </div> }} | |||
{{familytree | |,|-|^|-|.| | | |!| | | | | | | | | | | | }} | |||
{{familytree | F01 | | F02 | | F03 | | | | | | | | | | | F01= Spontaneous passage | F02= Elective intervention if the has not passed after 2 - 4 weeks| F03=Intervention }} | |||
{{familytree | |!| | | |`|-|v|-|'| | | | | | | | | | | | }} | |||
{{familytree | G01 | | | | G02 | | | | | | | | | | | | | G01= | G02= }} | |||
{{familytree/end}} | |||
Spontaneous passage<ref name="pmid19797458">{{cite journal| author=Hall PM| title=Nephrolithiasis: treatment, causes, and prevention. | journal=Cleve Clin J Med | year= 2009 | volume= 76 | issue= 10 | pages= 583-91 | pmid=19797458 | doi=10.3949/ccjm.76a.09043 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19797458 }} </ref><ref name="pmid22150656">{{cite journal| author=Frassetto L, Kohlstadt I| title=Treatment and prevention of kidney stones: an update. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 11 | pages= 1234-42 | pmid=22150656 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22150656 }} </ref> | |||
{|Class="wikitable" | |||
|- | |||
| '''Kidney Stone''' | |||
| '''Treatment and future prevention''' | |||
|- | |||
|Calcium Oxalate stones | |||
|❑[[Thiazide]] [[Diuretics]] <br> | |||
❑[[Sodium]] restriction <br> | |||
❑[[Calcium]] supplements <br> | |||
❑[[Protein]] intake <30% of [[TCI]]<br> | |||
❑[[Vitamin D]] (if <30ng/ml) | |||
|- | |||
|Calcium Phosphate stones | |||
|❑Acidify urine<br> | |||
❑Perform a pregnancy test on women<br> | |||
❑Decrease dietary intake of [[phosphate]] | |||
|- | |||
|Cystine stones | |||
|❑Alkalize urine<br> | |||
❑Cystine-binding agents<br> | |||
❑Decrease [[methionine]] intake <br> | |||
❑If measures fail: | |||
:❑D-penicillamine OR | |||
:❑[[Tiopronin]] OR | |||
:❑[[Captopril]] | |||
|- | |||
|Struvite stones | |||
|❑Acidify urine<br> | |||
❑Avoid supplementary [[magnesium]]<br> | |||
❑[[Acetohydroxamic acid]]<br> | |||
|- | |||
|Uric acid stones | |||
|❑Alkalize urine<br> | |||
❑[[Allopurinol]]<br> | |||
❑Reduce [[protein]] intake <30% of TCI<br> | |||
❑Reduce or eliminate [[alcohol]] intake<br> | |||
❑In patients with [[diabetes]] - increase [[tea]] and [[coffee]] intake | |||
|} | |||
{| Class="wikitable" | |||
|- | |||
| | |||
| '''Indications''' | |||
|- | |||
|Acidify urine | |||
|❑[[Betaine]] (650mg three times/day with meals) <br> | |||
❑Cranberry juice (16oz/day) | |||
|- | |||
|Alkalinize urine | |||
|❑[[Potassium citrate]] (10-20mEq with meals<br> | |||
❑[[Calcium citrate]] (1g/day with meals) | |||
|} | |||
Intervention<ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref> | |||
{| Class="wikitable" | |||
|- | |||
| '''Treatment''' | |||
| '''Indications''' | |||
|- | |||
|Extracorporeal shock wave lithotripsy | |||
|❑Renal stones <2cm <br> | |||
❑Ureteral stones <1cm | |||
|- | |||
|Uteroscopy | |||
|❑Ureteral stones | |||
|- | |||
| Ureterorenoscopy | |||
|❑Renal stones <2cm <br> | |||
|- | |||
| Percutaneous nephrolithotomy | |||
|❑Renal Stones >2cm <br> | |||
❑Proximal ureteral stones >1cm | |||
|} | |||
==Do´s<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref>== | |||
*Perform a metabolic evaluation in patients with risk factors for stone recurrence | |||
**Family history of nephrolithiasis | |||
**Presence of biliary stone disease | |||
**[[Nephrocalcinosis]] | |||
**Stones are formed from cysteine, uric acid or calcium phosphate | |||
**The patient is a child | |||
*Administer [[tamsulosin]] and [[corticosteroids]] to help stones pass quicker and with less analgesics. | |||
*Proceed intravenously in patients who are unable to take oral fluids or oral medications and with [[hypotension]]. | |||
*Perform | |||
==Don´ts<ref name="pmid17332586">{{cite journal| author=Miller NL, Lingeman JE| title=Management of kidney stones. | journal=BMJ | year= 2007 | volume= 334 | issue= 7591 | pages= 468-72 | pmid=17332586 | doi=10.1136/bmj.39113.480185.80 | pmc=PMC1808123 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17332586 }} </ref><ref name="pmid11310648">{{cite journal| author=Portis AJ, Sundaram CP| title=Diagnosis and initial management of kidney stones. | journal=Am Fam Physician | year= 2001 | volume= 63 | issue= 7 | pages= 1329-38 | pmid=11310648 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11310648 }} </ref>== | |||
*Do not recommend [[calcium]] restrictions, as the may increase the urinary oxalate excretion. | |||
*Do not administer [[NSAID]]s when extracorporeal shock lithotripsy is planned, as it may increase the risk of perinephric bleeding. | |||
*Do not perform extracorporeal shock lithotripsy in women who want to have children, percutaneous nephrolithotomy is a safer option. | |||
==References== | ==References== |
Latest revision as of 00:24, 13 March 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Andrea Tamayo Soto [2]
Overview
Nephrolithiasis is the presence of stones, in the kidneys or the ureters, formed by different substances. The common presentation is a severe colic type pain in the abdomen flanks, sometimes including nausea, vomits or even fever.
Causes
Life Threatening Causes
- Renal Obstruction
- Renal Isquaemia
- Renal Impairment
Common Causes[1]
- Hypercalciuria
- Hyperoxaluria
- Hypernatruria
- Hypocitraturia
- Hyperuricosuria
- Cystinuria
- Gout
- Metabolic acidosis
- Previous chemotherapy for Lymphoma and Leukemia
- Urine Infection
- Drug related stones
Management
Diagnostic Approach
Shown below is an algorithm depicting the diagnostic approach to Nephrolithiasis based on the 2014 Review of the Cleveland Clinic, urological and kidney institute.[2]
Characterize the symptoms:[3] | |||||||||||||||||||||||||
Obtain a detailed history: ❑ History of kidney stones
❑ History of UTI or pyelonephritis
❑ Diseases such as:
❑ Drug treatments and regular intake:
| |||||||||||||||||||||||||
Examine the patient: ❑ Measure the blood pressure
| |||||||||||||||||||||||||
Order labs and tests:
❑ Hemogram
❑ CT
| |||||||||||||||||||||||||
Therapeutic Approach
Shown below is an algorithm depicting the therapeutic approach to Nephrolithiasis[2][3]:
Initial Management ❑ Hydration
| |||||||||||||||||||||||||||||||||||||||||||
Complications? | |||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||
Size | Infection | Obstruction | |||||||||||||||||||||||||||||||||||||||||
<5mm
| >5mm
| ❑ Ureter Obstruction:
| |||||||||||||||||||||||||||||||||||||||||
Spontaneous passage | Elective intervention if the has not passed after 2 - 4 weeks | Intervention | |||||||||||||||||||||||||||||||||||||||||
Kidney Stone | Treatment and future prevention |
Calcium Oxalate stones | ❑Thiazide Diuretics ❑Sodium restriction |
Calcium Phosphate stones | ❑Acidify urine ❑Perform a pregnancy test on women |
Cystine stones | ❑Alkalize urine ❑Cystine-binding agents |
Struvite stones | ❑Acidify urine ❑Avoid supplementary magnesium |
Uric acid stones | ❑Alkalize urine ❑Allopurinol |
Indications | |
Acidify urine | ❑Betaine (650mg three times/day with meals) ❑Cranberry juice (16oz/day) |
Alkalinize urine | ❑Potassium citrate (10-20mEq with meals ❑Calcium citrate (1g/day with meals) |
Intervention[4]
Treatment | Indications |
Extracorporeal shock wave lithotripsy | ❑Renal stones <2cm ❑Ureteral stones <1cm |
Uteroscopy | ❑Ureteral stones |
Ureterorenoscopy | ❑Renal stones <2cm |
Percutaneous nephrolithotomy | ❑Renal Stones >2cm ❑Proximal ureteral stones >1cm |
Do´s[3]
- Perform a metabolic evaluation in patients with risk factors for stone recurrence
- Family history of nephrolithiasis
- Presence of biliary stone disease
- Nephrocalcinosis
- Stones are formed from cysteine, uric acid or calcium phosphate
- The patient is a child
- Administer tamsulosin and corticosteroids to help stones pass quicker and with less analgesics.
- Proceed intravenously in patients who are unable to take oral fluids or oral medications and with hypotension.
- Perform
Don´ts[3][4]
- Do not recommend calcium restrictions, as the may increase the urinary oxalate excretion.
- Do not administer NSAIDs when extracorporeal shock lithotripsy is planned, as it may increase the risk of perinephric bleeding.
- Do not perform extracorporeal shock lithotripsy in women who want to have children, percutaneous nephrolithotomy is a safer option.
References
- ↑ 1.0 1.1 Hall PM (2009). "Nephrolithiasis: treatment, causes, and prevention". Cleve Clin J Med. 76 (10): 583–91. doi:10.3949/ccjm.76a.09043. PMID 19797458.
- ↑ 2.0 2.1 2.2 Frassetto L, Kohlstadt I (2011). "Treatment and prevention of kidney stones: an update". Am Fam Physician. 84 (11): 1234–42. PMID 22150656.
- ↑ 3.0 3.1 3.2 3.3 Miller NL, Lingeman JE (2007). "Management of kidney stones". BMJ. 334 (7591): 468–72. doi:10.1136/bmj.39113.480185.80. PMC 1808123. PMID 17332586.
- ↑ 4.0 4.1 Portis AJ, Sundaram CP (2001). "Diagnosis and initial management of kidney stones". Am Fam Physician. 63 (7): 1329–38. PMID 11310648.