Minitopic NEPHROLITHIASIS INTRODUCTION Calcium stone7585 Calcium oxalate Calcium

Minitopic NEPHROLITHIASIS

INTRODUCTION Calcium stone(75~85%) Calcium oxalate , Calcium phosphate Uric acid stone(5~8%) Cystein stones(1%) Struvite stones(10~15%)

Diagnosis

Acute treatment(1) Renal Colic: Treating Pain Double –blind RCT : Ketolac 60 mg IM vs meperidine 100 -150 mg : Ketolan better relief and quiclker discharge Opiates and NSAIDS - Ketorolac, meperidine, morphine • Ketolan provids effective pain relief with less sedation than opiates • Among Opiates. meperidine causes N/V & Contraindicated if Decreased renal fx Aid passage of renal stones Less than 10 mm in diameter - tamsulosin[a-antagonist] - nifedipine

Acute treatment(2) -when to hospitalize >5 mm , parenteral tx required for pain Meta-analysis of 327 studies Ureteral stones Clinical guidelinens: 98% of <5 mm stones passed spontaneously Obstructed and infected tract → Absolute Ix for emergent intervention → Can lead to urosepsis & irriversible injury Bilateral obsturction , obstruction in solitary kidney. decreased fuction

Acute treatment(3) For Larger stones Ureteroscopy more appropriate -when to consider intervention l ESWL must fragment stones into. Europian smaller pieces Ureteral Stones Clinical Guidelines Panel & l Lead better clearance of association of urology stone fragments → minimize ü Proximal ureter: 1 cm↓ → ESWL 1 st stone recurrence 1 cm ↑ → PCN or ureteroscopy ü Distal ureter: ESWL or ureteroscopy For Patients c ESWL: consider subsequent tx with tamsulosine Staghorn calculi ü Percutaneous nephrolithotomy should be 1 st treatment ü ESWL monotherapy should not be used

Preventive Treatment Pathogenesis Supersaturation High urinary solute concentration Urine Volume↓ Urinary PH Acid: uric acid. , cystein stone Alkali: Calcium phosphate, Mg. NH 4 PO 4 Nucleation Urinary inhibitors of crystal formation Citrate. , magnes’ium. , uropontin. , nephrocalcin, glycoprotein Preventive ?

Preventive Treatment -Role of fluid intake & Diet Advise at least 2~2. 5 L/d maintain urine volume at least 2 L Dilkution of poor soluable salts : calcium oxalate, calcium phosphate and cystein Diet Only 1 RCT with positive results: -Greater calcium intake have fewer stones -most likely d/t ability of dietary calcium to bind oxalate in the intestine and prevent absorption Uric acid stones, cystein stones: limit animal pro 8 te’in intalke-> urine alkalizatioin

Preventive 1) Thiazide Lower urinary Ca excretion Stimulating renal calcium absorption Chlorothalidone 12. 5 mg /day or hydrochlorothiazide 25 mg BID Can cause hypokalemia → Lower citrate excretion → Should be supplemented potassium citrate or given potassium sparing agents such as spironolactone

Preventive 2) Citrate Inhibitor of crystalization of calcium oxalate and calcium phosphate “Increase ‘in Ur’ine p. H: ‘increase I’n Calkc’ium pho 8 sphate sto 8 nes Adequate flku’id ‘intalke Th’iaz’ide use to 8 lo 8 wer ur’inary calkc’ium excret’io 8 n ‘if ur’ine p. H ‘increase o 8 r ‘if Calkc’ium pho 8 sphate sto 8 ne o 8 ccurs O*range ju’ice and lkemo 8 nade: c’itrate excret’io 8 n

Preventive-Uric acid stones/Hyperuricouria Uric acid: ↓solubility of calcium oxalate Hyperuricosuria(-),