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Stones: Evaluation and Medical Management: Difference between revisions

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** Availability
** Availability
** Cost (most expensive, 30x cost of KUB)[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5443345/ §]
** Cost (most expensive, 30x cost of KUB)[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5443345/ §]
== Acute management ==
* Renal colic pain management[https://smhs.gwu.edu/urgentmatters/content/alternatives-opioids-pain-management-ed]
** Toradol 30 mg IV
** Cardiac Lidocaine 1.5 mg/kg IV in 100 mL NS over 10 minutes (MAX 200 mg)
** Acetaminophen 1000 mg PO
** 1 L 0.9% NS bolus


== Diagnosis and Evaluation of Metabolic Stone Disease ==
== Diagnosis and Evaluation of Metabolic Stone Disease ==


* '''Goals of evaluation'''
=== UrologySchool.com Summary ===
**'''Identify potential associated metabolic disorders such as (5)'''
 
**#'''Distal renal tubular acidosis (RTA)'''
==== AUA ====
**#'''Primary hyperparathyroidism'''
**#'''Enteric hyperoxaluria'''
**#'''Cystinuria'''
**#'''Gouty diathesis'''
**'''Reduce risk of stone recurrence'''
***First-time stone formers have been estimated to have a 50% risk for recurrence within the subsequent 10 years
*** Patients at higher risk for repeat episodes:
**** Family history of stones
**** Intestinal disease (particularly when causing chronic diarrheal states)
**** Pathologic skeletal fractures
**** Osteoporosis
**** UTI
**** Gout


=== UrologySchool.com Summary ===
* '''<span style="color:#ff0000">Screening Evaluation</span>'''
* Screening evaluation
**'''<span style="color:#ff0000">History and Physical Exam</span>'''
**
**'''<span style="color:#ff0000">Laboratory (5)</span>'''**#'''<span style="color:#ff0000">Urinalysis +/- culture</span>'''
*Extended metabolic testing
**#'''<span style="color:#ff0000">Serum electrolytes (Na, K, Cl, HCO3)</span>'''
*'''Abbreviated protocol for low-risk single-stone formers'''
**#'''<span style="color:#ff0000">Serum calcium</span>'''
** History
**#'''<span style="color:#ff0000">Serum creatinine</span>'''
*** Screen for factors that predispose to calculi
**#'''<span style="color:#ff0000">Serum uric acid</span>'''
**** Chronic diarrhea that could be caused by inflammatory bowel disease (Crohn disease, ulcerative colitis) or irritable bowel syndrome
* '''<span style="color:#ff0000">Extended evaluation</span>'''
**** Gout may predispose the patient to hyperuricosuria or gouty diathesis with either uric acid calculi or calcium oxalate stone formers
** '''<span style="color:#ff0000">One or two 24-hour urine collections</span>'''
**** Surgical history should be obtained focusing particularly on bariatric surgery and surgeries of the intestinal tract. '''In contrast to gastric bypass surgery, restrictive bariatric surgeries such as gastric sleeve or gastric band do not seem to increase the risk for kidney stones'''
** Laboratory
*** Serum metabolic panel
**** Preoperative serum chemistries are important because they may provide clues to underlying serious diseases such as renal tubular acidosis or hypoparathyroidism or other metabolic derangements
**** '''Assessment of underlying renal function is necessary'''
*** Urinalysis +/- culture
**** '''Urinalysis should include pH'''
***** '''pH > 7.0 is suggestive of infection lithiasis or RTA'''
***** '''pH < 5.5 suggests uric acid lithiasis secondary to gouty diathesis'''
**** Urine culture
***** Many infected calculi will harbour bacteria even after treatment with broad-spectrum antibiotics
***** Half of infected calculi grow bacterial cultures that are different from the preoperative urine specimen
*** Urine microscopy for crystals may provide clues to diagnosis
****Insert urine microscopy table
***Stone composition, if available
****Can direct metabolic investigation or potentially obviate the need for a complete metabolic evaluation


* '''Extensive diagnostic evaluation'''
=== Goals of Evaluation ===
** Includes one or two 24-hour urine collections
*'''Identify potential associated metabolic disorders such as (5)'''
**Indications for a metabolic stone evaluation
*#'''Distal renal tubular acidosis (RTA)'''
**# Recurrent stone formers
*#'''Primary hyperparathyroidism'''
**# Strong family history of stones
*#'''Enteric hyperoxaluria'''
**# Intestinal disease
*#'''Cystinuria'''
**# Pathological skeletal fractures
*#'''Gouty diathesis'''
*'''Reduce risk of stone recurrence'''
**First-time stone formers have been estimated to have a 50% risk for recurrence within the subsequent 10 years
** Patients at higher risk for repeat episodes (6):
**# Family history of stones
**# Intestinal disease (particularly when causing chronic diarrheal states)
**# Pathologic skeletal fractures
**# Osteoporosis
**# Osteoporosis
**# History of UTI with calculi
**# UTI
**# Personal history of gout
**# Gout
**# Infirm health (unable to tolerate repeat stone episodes)
=== History and Physical Exam ===
**# Solitary kidney
**# Anatomic abnormalities
**# Stones composed of cystine, uric acid, and struvite
**# Children should generally be evaluated because of concerns about renal damage and long-term sequelae of stone recurrence
** '''Significant aberrations in total creatinine excretion from estimated volumes (males 20-25mg/kg and females 15-20mg/kg in 24 hours) imply incomplete collection, overcollection, greater than expected muscle mass, or less than expected muscle mass'''
*** For abnormally collected 24 hour urine collections, can divide metabolite excretion by creatinine excretion to compare collections
** The urinary constituents most commonly assayed in a 24 hours urine collection include calcium, oxalate, citrate, total volume, sodium, magnesium, potassium, pH, uric acid, and sulfate.
*** Sulfate is added to assess the volume of protein loading from animal meat.


== Acute management ==
==== History ====
* Screen for factors that predispose to calculi
** Chronic diarrhea that could be caused by inflammatory bowel disease (Crohn disease, ulcerative colitis) or irritable bowel syndrome
** Gout may predispose the patient to hyperuricosuria or gouty diathesis with either uric acid calculi or calcium oxalate stone formers
** Surgical history should be obtained focusing particularly on bariatric surgery and surgeries of the intestinal tract. '''In contrast to gastric bypass surgery, restrictive bariatric surgeries such as gastric sleeve or gastric band do not seem to increase the risk for kidney stones'''


* Renal colic pain management[https://smhs.gwu.edu/urgentmatters/content/alternatives-opioids-pain-management-ed]
=== Laboratory ===
** Toradol 30 mg IV
* Serum metabolic panel
** Cardiac Lidocaine 1.5 mg/kg IV in 100 mL NS over 10 minutes (MAX 200 mg)
** Preoperative serum chemistries are important because they may provide clues to underlying serious diseases such as renal tubular acidosis or hypoparathyroidism or other metabolic derangements
** Acetaminophen 1000 mg PO
** '''Assessment of underlying renal function is necessary'''
** 1 L 0.9% NS bolus
* Urinalysis +/- culture
** '''Urinalysis should include pH'''
*** '''pH > 7.0 is suggestive of infection lithiasis or RTA'''
*** '''pH < 5.5 suggests uric acid lithiasis secondary to gouty diathesis'''
** Urine culture
*** Many infected calculi will harbour bacteria even after treatment with broad-spectrum antibiotics
*** Half of infected calculi grow bacterial cultures that are different from the preoperative urine specimen
* Urine microscopy for crystals may provide clues to diagnosis
**Insert urine microscopy table
*Stone composition, if available
**Can direct metabolic investigation or potentially obviate the need for a complete metabolic evaluation


=== Extensive Diagnostic Evaluation ===
* Includes one or two 24-hour urine collections
*Indications for a metabolic stone evaluation
*# Recurrent stone formers
*# Strong family history of stones
*# Intestinal disease
*# Pathological skeletal fractures
*# Osteoporosis
*# History of UTI with calculi
*# Personal history of gout
*# Infirm health (unable to tolerate repeat stone episodes)
*# Solitary kidney
*# Anatomic abnormalities
*# Stones composed of cystine, uric acid, and struvite
*# Children should generally be evaluated because of concerns about renal damage and long-term sequelae of stone recurrence
* '''Significant aberrations in total creatinine excretion from estimated volumes (males 20-25mg/kg and females 15-20mg/kg in 24 hours) imply incomplete collection, overcollection, greater than expected muscle mass, or less than expected muscle mass'''
** For abnormally collected 24 hour urine collections, can divide metabolite excretion by creatinine excretion to compare collections
* The urinary constituents most commonly assayed in a 24 hours urine collection include calcium, oxalate, citrate, total volume, sodium, magnesium, potassium, pH, uric acid, and sulfate.
** Sulfate is added to assess the volume of protein loading from animal meat.
== Conservative management ==
== Conservative management ==


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* '''Obesity'''
* '''Obesity'''
** '''Increased BMI, larger waist size, and weight gain are correlated with an increased risk for stone episodes'''
** '''Increased BMI, larger waist size, and weight gain are correlated with an increased risk for stone episodes'''
*** '''The association of obesity and uric acid stone formation is primarily due to change in urinary pH'''
*** '''The association of obesity and uric acid stone formation is primarily due to change in urinary pH'''
*** '''The association of obesity with calcium oxalate stone formation is primarily due to increased excretion of promoters of stone formation''' (oxalate, uric acid, sodium, and phosphorus)
*** '''The association of obesity with calcium oxalate stone formation is primarily due to increased excretion of promoters of stone formation''' (oxalate, uric acid, sodium, and phosphorus)
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***# '''Directly stimulate calcium reabsorption in the distal nephron'''
***# '''Directly stimulate calcium reabsorption in the distal nephron'''
***# '''Promotes excretion of sodium causing extracellular volume depletion'''
***# '''Promotes excretion of sodium causing extracellular volume depletion'''
***** '''Long-term thiazide therapy results in volume depletion, extracellular volume contraction, and proximal tubular resorption of sodium and calcium.'''
***#* '''Long-term thiazide therapy results in volume depletion, extracellular volume contraction, and proximal tubular resorption of sodium and calcium.'''
*** Chlorthalidone (25-50 mg/day) or indapamide (2.5 mg/day) are preferred to hydrochlorothiazide since they are long-acting and are once a day dosing.
*** Chlorthalidone (25-50 mg/day) or indapamide (2.5 mg/day) are preferred to hydrochlorothiazide since they are long-acting and are once a day dosing.
**** Indapamide is technically not a thiazide but does share a successful hypocalciuric effect with the other agents.
**** Indapamide is technically not a thiazide but does share a successful hypocalciuric effect with the other agents.
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**#** CUA Guidelines only discuss allopurinol for hyperuricosuric calcium oxalate nephrolithiasis, not potassium citrate
**#** CUA Guidelines only discuss allopurinol for hyperuricosuric calcium oxalate nephrolithiasis, not potassium citrate
**# '''Decreasing the production of uric acid'''
**# '''Decreasing the production of uric acid'''
**** '''Allopurinol (300 mg/day) may be used'''
**#* '''Allopurinol (300 mg/day) may be used'''
***** MOA: blocks the ability of xanthine oxidase to convert xanthine to uric acid.
**#** MOA: blocks the ability of xanthine oxidase to convert xanthine to uric acid.
****** The resultant decrease in serum uric acid will ultimately lead to a decrease in urinary uric acid as well.
**#*** The resultant decrease in serum uric acid will ultimately lead to a decrease in urinary uric acid as well.
***** Allopurinol’s use in hyperuricosuria associated with dietary purine overindulgence also may be reasonable if patients are unable or unwilling to comply with dietary purine restriction.
**#** Allopurinol’s use in hyperuricosuria associated with dietary purine overindulgence also may be reasonable if patients are unable or unwilling to comply with dietary purine restriction.


* '''Enteric hyperoxaluria'''
* '''Enteric hyperoxaluria'''
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** '''Citrates are first-line therapy for the management of RTA, thiazide-induced hypocitraturia, and idiopathic hypocitraturia'''
** '''Citrates are first-line therapy for the management of RTA, thiazide-induced hypocitraturia, and idiopathic hypocitraturia'''
*** Potassium citrate therapy is able to correct the metabolic acidosis and hypokalemia found in patients with distal RTA
*** Potassium citrate therapy is able to correct the metabolic acidosis and hypokalemia found in patients with distal RTA


* '''Hypomagnesuric Calcium Nephrolithiasis'''
* '''Hypomagnesuric Calcium Nephrolithiasis'''
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