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CPC- differential dx of Nephrolithiasis

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Page 1: CPC- differential dx of Nephrolithiasis
Page 2: CPC- differential dx of Nephrolithiasis

A 65 year old Woman came in to a General practitioner with complaint of Hematuria for the past 6 months with Right Flank pain. NO Fever, dysuria and oliguria.

Urinalysis showed numerous red blood cells ( No Red cell Casts) with few white cells. Complete Blood count, Creatinine and Blood Urea Nitrogen are within normal range.

Page 3: CPC- differential dx of Nephrolithiasis

VISIBLE Bleeding ( Gross Hematuria)

Right Flank Pain

Page 4: CPC- differential dx of Nephrolithiasis

Gross HematuriaMicroscopic Hematuria No Fever, Dysuria, OliguriaNo Red Blood Cell CastFew white cellsCBC – Normal RangeBUN- Normal RangeCreatinine- Normal Range

Page 5: CPC- differential dx of Nephrolithiasis
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an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney

presents with dysuria (painful voiding of urine), abdominal pain (radiating to the back on the affected side) and tenderness of the bladder area and the side of the involved kidney (costovertebral angle tenderness)

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In many cases there are systemic symptoms in the form of fever, rigors (violent shivering while the temperature rises), headache, and vomiting. In severe cases, delirium may be present

characteristic colicky pain

Page 8: CPC- differential dx of Nephrolithiasis

Gross pathology often reveals pathognomonic radiations of hemorrhage and suppuration through the renal pelvis to the renal cortex

Chronic infections can result in fibrosis and scarring

Page 9: CPC- differential dx of Nephrolithiasis

Mechanical: any structural abnormalities to the kidneys and the urinary tract, vesicoureteral reflux (VUR) especially in young children, calculi (kidney stones), urinary tract catheterisation, urinary tract stents or drainage procedures (e.g. nephrostomy), pregnancy, neurogenic bladder (e.g. due to spinal cord damage, spina bifida or multiple sclerosis) and prostate disease (e.g. benign prostatic hyperplasia) in men

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Constitutional: diabetes mellitus, immunocompromised states

Behavioural: change in sexual partner,

spermicide usePositive family history (close family

members with frequent urinary tract infections)

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is the most common urologic trauma and occurs in 8-10% of patients with significant blunt or penetrating abdominal trauma. In most cases, major renal injuries are associated with injuries to other major organs.

Renal trauma accounts for approximately 3% of all trauma admissions and as many as 10% of patients who sustain abdominal trauma.

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Penetrating (eg, gunshot wounds, stab wounds)

Blunt (eg, pedestrian struck, motor vehicle crash, sports, fall)

Latrogenic (eg, endourologic procedures, extracorporeal shock-wave lithotripsy, renal biopsy, percutaneous renal procedures)

Intraoperative (eg, diagnostic peritoneal lavage)

Other (eg, renal transplant rejection, childbirth [may cause spontaneous renal lacerations])

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renal laceration renal contusion and renal vascular injury

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Grade Injury 1 Renal contusion; non-expanding

subcapsular hematoma 2 Laceration < 1 cm in depth sparing the

renal medulla and collecting system; non- expanding retroperitoneal hematoma

3 Laceration > 1 cm sparing the collecting system

4 Laceration > 1 cm involving the collecting system; renal vessel injury with hemorrhage

5 Shattered kidney or avulsed renal vessels

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Hematuriaother indicators include:

-seat-belt marks -diffuse abdominal

tenderness -flank contusions -lower rib fractures

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Perioperative complications may be specific to the kidney or more generalized. Those specific to the kidney may include urinoma, hematoma, or infection. General complications may include deep vein thrombosis, systemic inflammatory response syndrome, or acute renal insufficiency

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kidney cancer that originates in the lining of the proximal convoluted tubule, the very small tubes in the kidney that filter the blood and remove waste products.

most common type of kidney cancer in adults, responsible for approximately 80% of cases

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known to be the most lethal of all the genitourinary tumors.

resistant to radiation therapy and chemotherapy, although some cases respond to immunotherapy

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RENAL CARCINOMA

Clear cell carcinoma Papillary carcinoma Chromophobe carcinoma Collecting duct Carcinoma

- loss of 3p - trisomy 7 and 17- hypodiploid with loss

of chromosomes 1, 2, 6,

10, 13, 17, 21

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yellowish, multilobulated tumor in the renal cortex, which frequently contains zones of necrosis, hemorrhage and scarring

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tumor cells forming cords, papillae, tubules or nests, and are atypical, polygonal and large. Because these cells accumulate glycogen and lipids, their cytoplasm appear "clear", lipid-laden, the nuclei remain in the middle of the cells, and the cellular membrane is evident.

Some cells may be smaller, with eosinophilic cytoplasm, resembling normal tubular cells. The stroma is reduced, but well vascularized.

The tumor compresses the surrounding parenchyma, producing a pseudocapsule.

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1. Abnormal urine color (dark, rusty, or brown) due to blood in the urine (found in 60% of cases)

2. Loin pain (found in 40% of cases) 3. Abdominal mass (25% of cases) 4. Malaise, weight loss or anorexia (30%

of cases) 5. Polycythemia (5% of cases) 6. Anemia resulting from depression of

erythropoietin (5% of cases) 7. pathologic fracture of the hip due to a

metastasis to the bone

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8. Varicocele, the enlargement of one testicle, usually on the left (2% of cases). This is due to blockage of the left testicular vein by tumor invasion of the left renal vein; this typically does not occur on the right as the right gonadal vein drains directly into the inferior vena cava.

9. Vision abnormalities 10. Pallor or plethora 11. Hirsutism - Excessive hair growth (females) 12. Constipation 13. Hypertension resulting from secretion of renin by the tumour

(30% of cases) 14. Hypercalcemia 15. Paraneoplastic disease 16. Night Sweats 17. Severe Weight Loss

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Cigarette smoking and obesity

Hypertension Family history of the

disease Dialysis patients with

acquired cystic disease of the kidney showed a 30 times greater risk

Patients with certain inherited disorders such as von Hippel-Lindau disease, hereditary papillary renal cancer, a hereditary leiomyoma RCC syndrome and Birt-Hogg-Dubé syndrome, show an enhanced risk of RCC.

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Physical examination can provide information about

signs of kidney cancer and other health problems. The doctor checks general signs of health and tests for fever and high blood pressure and the doctor may be able to feel an abnormal mass when he or she examines your abdomen

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1. Urinalysis(Urine tests) - check for several indicators of the cancer such as blood, sugar, proteins, and bacteria.

2. Complete blood count - can detect findings sometimes seen with renal cell cancer.

3. Blood chemistry tests - usually done in people who may have kidney cancer, as it can affect the levels of certain chemicals in the blood

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Definition:Kidney stones result when urine becomes too concentrated and substances in the urine crystallize to form stones. Symptoms arise when the stones begin to move down the ureter causing intense pain. Often as small as grains of sand and pass out of the body in urine without causing discomfort. The deposits can be pea sized, marble sized or even larger.

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asymptomatic HematuriaFlank pain or back painon one or both sidesprogressiveseverecolicky (spasm-like)may radiate or move to lower in flank, pelvis, groin, genitals

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sometimes accompanied by intense visceral symptoms (i.e., nausea, vomiting, diaphoresis, light-headedness)

pyuria Hydronephrosis Staghorn calculi are associated with

recurrent UTI with urea splitting

organisms (Proteus, Klebsiella, Providencia, Morganella, and others).

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PATHOLOGIC True RENAL

Diseases such as:1.Pyelonephritis2.Renal Cell Ca3.Nephrolithiasis

NON- PATHOLOGIC

Strenuous exercise Due to Drugs like

Warfarin, Penicillin, Heparin, Cyclophosphamide

Ectopic Pregnancy Malingering Renal Trauma

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Page 38: CPC- differential dx of Nephrolithiasis
Page 39: CPC- differential dx of Nephrolithiasis

UTI - Burning sensation during urination - Strong smelling urine - 30 % Gross Hematuria Pyelonephritis- same with UTI - Flank pain describe as

“Colicky”

Enlarged prostate- pain and difficulty of urination

- BPH, Prostatitis

Page 40: CPC- differential dx of Nephrolithiasis

Cancer – Renal Cell Carcinoma - asymptomatic in early stages - Gross hematuria Kidney Injuries - bleeding due to blow to the kidney - 15-40 % of cases in Abdominal

trauma Nephrolithiasis - Gross Hematuria - flank pain - Inc. Incidence as age increases.

Page 41: CPC- differential dx of Nephrolithiasis
Page 42: CPC- differential dx of Nephrolithiasis

Affected by Certain Kidney dis., infections, Patient’s Habit and Diet

Hypercalciuria, Hyperuricosuria, Hypocitraturia,

Family history Hypertension Marathon runners High ingestion of Softdrinks, some

juices

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UTI caused by Proteus, Klebsiella High protein diet low water intake Gout

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Jalad, Ma. Shiril A.

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Page 46: CPC- differential dx of Nephrolithiasis
Page 47: CPC- differential dx of Nephrolithiasis

Kidney stones are made of salts and minerals in the urine that stick together, creating small "pebbles" formed within the kidney or urinary tract. They can be as small as grains of sand or as large as golf balls.

Kidney stones are a common cause of blood in the urine and often severe pain in the abdomen, flank, or groin. One in every 20 people develops a kidney stone at some point in their life

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Physical examination In patients with renal colic,

costovertebral angle and ipsilateral flank tenderness may be pronounced. Signs of sepsis, including fever, tachycardia and hypotension might indicate an obstructing stone with infection, warranting urgent urology referral.

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• A urinalysis may provide an enormous amount of information. Not only is blood detected, but pH of the urine may indicate the type of stone present.

• Calcium oxalate stones are found in acid urine with pH less than 6.0.

• Uric acid stones are found in acid urine with pH less than 5.5.

• Calcium phosphate and struvite stones develop in alkaline urine with a pH greater than 7.2.

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Calcium oxalate

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CALCIUM PHOSPHATE

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white blood cells

If bacteria and white blood cells are present in the urine, a urine culture may be obtained to identify the exact type of bacteria present and their susceptibility to antibiotics.

If white blood cells are noted in the urine, an infection may be indicated.

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Blood chemistry tests are usually done for calcium, phosphate, uric acid, sodium, potassium, chloride, bicarbonate, albumin, and creatinine. If the serum calcium level is elevated, then a test for hyperparathyroidism is performed by obtaining an intact parathyroid hormone test.

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A twenty-four hour urine collection is performed once the acute episode is over. This checks total urine volume, pH, calcium, oxalate, uric acid, citrate, magnesium, phosphate, sodium, and creatinine.

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• KUBA KUB is a plain film of the abdomen with the letters standing for Kidneys-Ureters-Bladder. Approximately, 85% of kidney stones can be identified with the KUB. Most kidney stones have a calcium component and can be seen on the KUB. Only uric acid is truly radiolucent, that is, can’t be seen on the KUB. It’s a quick, inexpensive x-ray that can often tell the size and number of stones present. Small stones less than 2mm may not be identified and uric acid stones definitely cannot be seen.

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Page 63: CPC- differential dx of Nephrolithiasis

IVP stand for intravenous pyelogram. IV contrast is injected and several films are obtained as the contrast moves through the kidneys and ureters to the bladder.

• An IVP is very reliable at detecting stones and obstruction. It can often identify uric acid stones or filling defects in the contrast and can also identify obstruction.

• It does have drawbacks in that some people are allergic to IV contrast and it shouldn’t be used in patients with poor renal function.

IVP

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Ultrasonography can be used in patients with an allergy to IV contrast, and is also useful in pregnancy, since there is no radiation to the patient or fetus. It is very good at picking up obstruction to the kidney. Small kidney stones, however, that are not obstructing may be missed.

Ultrasound

Page 65: CPC- differential dx of Nephrolithiasis

• CT renal protocol is now the procedure of choice to identify stones of all sizes and to determine the presence of obstruction. Renal protocol CT scans utilize helical or spiral cuts to scan the entire urinary tract. It requires no IV contrast and is a quick study to perform. Also, it’s the most accurate study of all those discussed, and can pick up non-urological conditions that may be mimicking stone discomfort

CT Scans

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Recurrence of stones Urinary Tract Infection Obstruction of the ureter, acute

unilateral obstructive uropathy Kidney damage, scarring Decreased/ loss of function of the

affected kidney

Page 67: CPC- differential dx of Nephrolithiasis

Kidney stones are painful but are usually excreted from the body without causing permanent damage.

Tend to return especially, if the cause is not found and treated.

First time stone formers- 50% at 5 yrs and 80% at 10 yrs.

Highest risk of recurrence for those who are not compliant with medical therapy and dietary lifestyle modifications or where underlying metabolic abnormalities exist.

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Page 69: CPC- differential dx of Nephrolithiasis

90% of stones 4 mm or less in size usually will pass spontaneously, however 99% of stones larger than 6 mm will require some form of intervention

Treatment of renal calculi is often empirical, based on clinical History.

Stone analysis is advisable, especially for pts with more complex presentations or recurrent disease.

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Hydration (at least 2.5–3 L/day reduces the risk of recurrent stone formation )

Caution in food with high concentrations of oxalate (e.g. starfruit)

diuretics to encourage urine flow and prevent further stone formation

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medication for infection and reducing pain (opioids, NSAIDS), and antiemetics

alpha adrenergic blocking agent (such as Flomax, Uroxatral, terazosin or doxazosin), acts to reduce the muscle tone of the ureter and facilitate stone passage.

The calcium channel blocker nifedipine relaxes ureteral smooth muscle and enhances stone passage

active medical expulsive therapy (MET)

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*uric acid and cystine calculi form in acidic environments

alkalinization of the urine with citrate [Shohl's solution (sodium citrate), sodium bicarbonate, potassium citrate, potassium bicarbonate or acetazolamide, a carbonic anhydrase inhibitor]▪ maintain the urinary pH between 6.5 and 7.0. Urinary pH of more than 7.5 should be avoided because of the potential deposition of calcium phosphate around the uric acid calculus, which would make it undissolvable

Allopurinol is reserved for patients in whom alkalinization is difficult

For cystine stone, Penicillamine and Tiopronin medications may be considered.

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Calgranulin: Crystallization of calcium oxalate (CaOx) appears to be reduced by molecules in the urine that retard the formation, growth, aggregation, and renal cell adherence of calcium oxalate

caffeine does acutely increase urinary calcium excretion, several independent epidemiologic studies have shown that coffee intake overall is protective against the formation of stones

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After treatment, the pain may return if the stone moves but re-obstructs in another location. Patients should strain their urine to collect the stone when it eventually passes for chemical composition analysis with a 24 hour urine chemical analysis test to establish preventative options

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smaller stone that is not symptomatic is often given up to four weeks to move or pass before consideration is given to any surgical intervention**

Immediate surgery may be required in certain situations such as in people with only one working kidney

Intractable pain or in the presence of an infected kidney blocked by a stone which can rapidly cause severe sepsis and toxic shock

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Surgery is necessary when the pain is persistent and

severe in renal failure and when there is a kidney

infection It may also be advisable if the stone fails to pass

or move after 30 days Finding a significant stone before it passes into

the ureter allows physicians to fragment it surgically before it causes any severe problems

**C/I in active, untreated UTI, Uncorrected bleeding diathesis, Pregnancy (a relative, but not absolute, contraindication)

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extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy are both recognized as first-line treatments for ureteral stones patient, under varying degrees of

anesthesia (depending on the type of lithotriptor used), is placed on a table or in a gantry that is then brought into contact with the shock head.

The shockwaves are focused on the calculus, and the energy released as the shockwave impacts the stone produces fragmentation. The resulting small fragments pass in the urine

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ureteroscopic fragmentation (or simple basket extraction if feasible) using laser, ultrasonic or mechanical (pneumatic, shock-wave) forms of energy to fragment the larger stones

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Percutaneous nephrolithotomy (a small tube placed through the skin of the flank directly into the kidney) or open surgery(rare), may ultimately be necessary for large or complicated stones or stones which fail other less invasive attempts at treatment.

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(a small tube between the bladder and the inside of the kidney) to provide immediate relief of a blocked kidney. This is especially useful in saving a failing kidney due to swelling and infection from the stone

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Drinking enough water A diet low in protein, nitrogen and sodium Restriction of oxalate-rich foods (chocolate,

nuts, soybeans, rhubarb and spinach), adequate intake of dietary calcium.

Taking drugs such as thiazides, potassium citrate, magnesium citrate and allopurinol, depending on the cause of stone formation.

**Potassium citrate increases urinary pH (alkaline), as well as increases the urinary citrate level, which helps reduce calcium oxalate crystal aggregation

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fruit juices (orange, blackcurrant, and cranberry), may be useful for lowering the risk factors for specific types of stones. Orange juice may help prevent calcium oxalate stone formation, black currant may help prevent uric acid stones, and cranberry may help with UTI-caused stones.

Avoidance of cola beverages

Avoiding large doses of vitamin C

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That’s all folks!!!


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