Nephrolithiasis resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Andrea Tamayo Soto [2]

Causes

Life Threatening Causes

• Renal Obstruction
• Renal Isquaemia
• Renal Impairment

Common Causes

• Hypercalciuria
• Hyperoxaluria
• Hypernatruria
• Hypocitraturia
• Hyperuricosuria
• Cystinuria
• Gout
• Metabolic acidosis
• Previous chemotherapy for Lymphoma and Leukemia
• Urine Infection
• Drug related stones
  • Allopurinol
  • Triamterene
  • Indinavir

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.

Characterize the symptoms: ❑ Abdominal Pain ❑ Colic pain ❑ Irradiated to the lower abdomen and groin ❑ Acute, moderate to severe pain ❑ Urinary urgency ❑ Dysuria ❑ Polyuria ❑ Vomits ❑ Nausea ❑ Malaise ❑ Fever and chills

Obtain a detailed history: ❑ History of kidney stones ❑ Personal and Family ❑ Treatment ❑ Stone analysis ❑ History of UTI or pyelonephritis ❑ Anatomic Features ❑ Horse shoe kidney ❑ Solitary kidney ❑ Obstruction of uteropelvic junction ❑ Previous Kidney or ureteral surgery ❑ Diseases such as: ❑ Hyperparathyroidism ❑ Renal tubular acidosis ❑ Cystinuria ❑ Gout ❑ Diabetes mellitus type 2 or Insulin resistance ❑ Inflammatory bowel disease ❑ Renal insufficiency ❑ Sarcoidosis ❑ Gastro-intestinal pathology ❑ Drug treatments and regular intake: ❑ Carbonic anhydrase inhibitor ❑ Ephedrine ❑ Sulfadiazine ❑ Calcium and Vitamin D

Examine the patient: ❑ Measure the blood pressure ❑ Measure the heart rate ❑ Measure the temperature ❑ Abdomen ❑ Tender ❑ Painful ❑ Obesity

Order labs and tests: ❑ Urinalysis ❑ Microscopic hematuria ❑ Nitrates ❑ Leucocytes ❑ Crystalluria ❑ Hemogram ❑ Complete blood count ❑ Serum electrolytes ❑ Urea ❑ Creatinine ❑ CT ❑ Ultrasound if pregnant ❑ Intravenous Pyelography ❑ 24 hour urine collection analysis ❑ Calcium ❑ Phosphorus ❑ Magnesium ❑ Uric acid ❑ Oxalate

Therapeutic Approach

Shown below is an algorithm depicting the therapeutic approach to Nephrolithiasis:

Initial Management ❑ Hydration ❑ Water (2L/24h) ❑ 0.9% Normal saline ❑ 5% dextrose in water and 0.45% Normal saline ❑ Analgesics ❑ Opioid Narcotics ❑ Codeine / acetaminophen (1 or 2 tablets(5-10mg codeine / 325-500mg acetaminophen)) ❑ Hydrocodone / acetaminophen (5-10mg/4-6hours) ❑ NSAIDs ❑ Diclofenac ❑ Ibuprofen ❑ Ketorolac ❑ Antispasmodics ❑ Alpha-blockers ❑ Doxazosin (4mg/day) ❑ Tamsulosin (0.4mg/day) ❑ Calcium channel blockers ❑ Nifedipine (30mg/day) ❑ Steroids ❑ Corticosteroid

Complications?

No

Yes

Size

Infection

Obstruction

<5mm

>5mm

❑ Broad spectrum antibiotics include coverage for: Gram(-) bacili Gram(+) cocci ❑ Antibacterial treatment should be administer to the results of the urine culture

❑ Ureter Obstruction: decresed glomerular filtration decresed renal blood flow Acute intervention is needed

References

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