NEPHROLITHIASIS SCOPE OF

THE PROBLEM

• Incidence 0.10 – 0.5% population/yr

• High cost in yearly health care dollars
• High morbidity: pain, obstruction, bleeding,
infection, loss of work
• Males >>Females except for infection
related stones
 COMMON STONES

• Calcium oxalate
• Calcium phosphate
• Struvite-apatite
• Cystine
• Uric acid
 STONE EVALUATION

• Stone History
• Family History
• Medications
• Dietary Considerations
• Urologic Procedures
• Radiologic Studies
• Urinalysis
• Stone Analysis
• Metabolic Evaluation
 STONE HISTORY

• Total number of stones

• Frequency of analgesic use
• Time off work
• Symptoms: renal colic, renal ache
• History of UTI, gout, diarrhea,
malabsorption, myeloproliferative
disorders
 STONE EVALUATION
• Stone History
• Family History
• Medications
• Dietary Considerations
• Urologic Procedures
• Radiologic Studies
• Urinalysis
• Stone Analysis
• Metabolic Evaluation
 STONE-PROVOKING
MEDICATIONS
MEDICATION STONE TYPE MECHANISMS
Acetazolamide Ca ox, Ca phos Hypercalciuria
Vitamin C Ca ox Hypocitraturia
Calcium supplements Ca ox, Ca phos Hyperoxaluria
Vitamin D Ca ox, Ca phos Hypercalciuria
Antacids Ca ox Hypercalciuria
Theophylline Ca ox, Ca phos Hypercalciuria
Nifedipine Ca ox, Ca phos Hypercalciuria
Probenecid, ASA Uric Acid Hyperuricosuria
DIETARY CONSIDERATIONS IN
NEPHROLITHIASIS

• Fluids
• Dairy products
• Salt
• Protein
Animal
Vegetable
• Oxalate
• Alcohol
 STONE EVALUATION
• Stone History
• Family History
• Medications
• Dietary Considerations
• Urologic Procedures
• Radiologic Studies
• Urinalysis
• Stone Analysis
• Metabolic Evaluation
UROLOGIC PROCEDURES

• Anatrophic Nephrolithotomy
• Percutaneus Nephrolithotomy
• Extracorporeal shock lithotripsy
• Ureteroscopy (laser)
 RADIOLOGIC APPEARANCE
OF CALCULI

Radiopaque Calculi Radiolucent Calculi

Calcium Oxalate Uric Acid

Calcium Phosphate

Struvite-Apatite

Cystine
 STONE EVALUATION
• Stone History
• Family History
• Medications
• Dietary Considerations
• Urologic Procedures
• Radiologic Studies
• Urinalysis
• Stone Analysis
• Metabolic Evaluation
 URINALYSIS
CRYSTALLURIA

• Calcium Oxalate
• Calcium Phosphate-Apatite, Brushite
• Struvite—Magnesium Ammonium Phosphate
• Uric Acid
• Cystine
 STONE EVALUATION

• Stone History
• Family History
• Medications
• Dietary Considerations
• Urologic Procedures
• Radiologic Studies
• Urinalysis
• Stone Analysis
• Metabolic Evaluation
 STONE ANALYSIS
RADIOPAQUE STONES
STONE TYPE METABOLIC ETIOLOGY

Calcium oxalate Hypercalciuria, Hyperoxaluria

Hyperuricosuria, Hypocitraturia

Hypomagnesiuria

Calcium phosphate Hypercalciuria, PHPT, Distal RTA

Sodium Alkali Therapy

Struvite or Carbonate-apatite UTI

Cystine Cystinuria
 STONE EVALUATION
• Stone History
• Family History
• Medications
• Dietary Considerations
• Urologic Procedures
• Radiologic Studies
• Urinalysis
• Stone Analysis
• Metabolic Evaluation
 METABOLIC CLASSIFICATION
OF NEPHROLITHIASIS

• Hypercalciuria
• Hyperuricosuria
• Hyperoxaluria
• Hypocitraturia
• Hypomagnesiuria
• Altered urinary pH
• Cystinuria
• Low urinary volume
 METABOLIC EVALUATION OF
NEPHROLITHIASIS
• Blood
Chemistries
CBC
PTH
• Urine
Urianalysis
Culture & Sensitivity
Cystine
• 24-Hour Urine Collections
Random Diet
Restricted Diet
• Fast and Calcium Load Test
 24 HOUR URINE COLLECTIONS
TOTAL VOLUME SODIUM

pH Potassium

Calcium Uric acid

Phosphorus Oxalate

Magnesium Creatinine

Citrate Sulfate
 NEPHROLITHIASIS
COEXISTENCE OF METABOLIC DERANGEMENTS
N=1270
CATEGORY PERCENT
Hypercalciuria 60
Hyperuricosuria
Calcium Nephrolithiasis 36
Uric Acid Nephrolithiasis 10
Hyperoxaluria 7
Hypocitraturia 31
Hypomagnesiuria 7
Infection 6
Cystinuria <1
Low Urinary Volumes 15
No Metabolic Abnormality 4
Difficult to Classify 5
 CYSTINE STONES

• Decreased renal tubule absorption of cystine,

ornithine, lysine and arginine (COLA)

• Autosomal recessive
• Large, radiopaque, often staghorn
• Rx: thiola, D-penicillamine, captopril
INFECTION – STRUVITE STONES

• Urea
urease
CO2 + NH3 NH4+

• NH 4 + Mg2 + PO4 Struvite

• Carbonate + PO 4 carbonate apatite

INFECTION – STRUVITE STONES

• Radiopaque, staghorn
• Women > men
• Associated with chronic infection with
urease producing organisms
• Poor prognosis: Rx: surgery, lithotripsy,
antibiotics, acetohydroxamic acid
 URIC ACID STONES

• Associated with gout, GI disease,

neoplasm

• Radiolucent
• Fluids, diet, alkali, allopurinol
 DEFINITIONS OF
HYPERCALCIURIA

• 24 hour Urinary Calcium Excretion > 200 mg/day

1 week on Ca and Na restricted diet (40 mg Ca, 10
mEg Na)

• 24 hour Urinary Calcium Excretion > 4 mg/kg/day

• 24 hour Urinary Calcium Excretion > 250 mg/day-
females, > 300 mg/day--males
FAST AND CALCIUM LOAD TEST

• Normal fasting value <0.11 mg Ca/mg Cr (GFR)

• Normal postload value <0.20 mg Ca/mg Cr

ABSORPTIVE HYPERCALCIURIA
• Primary Defect – increased intestinal absorption
of Ca
• Location of Lesion – Jejunum
• Inheritance – autosomal dominant
• Animal Model – genetically Hypercalciuric rat
• Skeletal Status – normal to increased cortical
bone density
• Calcium Balance - normal
ABSORPTIVE HYPERCALCIURIA

•Sodium Cellulose Phosphate

Urinary Ca > 350 mg/day
Side effects – hyperoxaluria, hypomagnesiuria
•Thiazide + Potassium Citrate
•Amiloride
 RENAL HYPERCALCIURIA

• Primary Defect – impaired tubular

reasborption of Ca
• Location of Lesion - ? Proximal tubule
• No effect of Diet on Calcium Excretion
• 1,25-(OH)2D3 – increased
• Skeletal Status – decreased cortical bone
density
• Calcium Balance - negative
RENAL HYPERCALCIURIA

• Thiazide
• Potassium Citrate
 PRIMARY
HYPERPARATHYROIDISM

• Primary Defect – parathyroid glad adenoma or

hyperplasia

• 1,25-(OH) D 2 3 – PTH- dependent increased renal

synthesis

• Skeletal Status – decreased cortical bone

density
 PRIMARY
HYPERPARATHYROIDISM

• Surgical Management
• Medical Management
Estrogen
Orthophosphates
 RENAL PHOSPHATE LEAK
ABSORPTIVE HYPERCALCIURIA TYPE III

• Primary Defect – increased urinary phosphate

• 1,25-(OH) D
2 3 – increased

• Skeletal Status – decreased bone density

• Calcium Balance – negative
• Role of Diet
RENAL PHOSPHATE LEAK
TREATMENT

• Orthophosphates
 MANIFESTATIONS OF THE
HYPERCALCIURIAS
FEATURE AH RH PHPT RPL

Serum Ca Normal Normal High Normal

Serum Phos Normal Normal Low Low

PTH Normal/Low Enhanced High Normal

Fasting Urinary Ca <0.11 >0.11 >0.11 <0.11

Postload Urinary Ca >0.20 >0.20 >0.20 >0.20

TREATMENT OF NEPHROLITHIASIS
CONSERVATIVE MANAGEMENT

• Fluids to maintain 3-8 L Urinary Volume/Day

• Diet
No Calcium Restriction
Sodium Restriction
Limited Purine Intake
Oxalate Restriction