UROLITHIASIS. BACKGROUND Urinary stone disease continues to occupy an important place in everyday...

UROLITHIASISUROLITHIASIS

BACKGROUNDBACKGROUND Urinary stone disease continues to occupy an Urinary stone disease continues to occupy an

important place in everyday urological practice. important place in everyday urological practice. The average lifetime risk of stone formation has The average lifetime risk of stone formation has been reported in the range of 5-10%.been reported in the range of 5-10%.

A predominance of men over women (approx. A predominance of men over women (approx. 3:1) can be observed with an incidence peak 3:1) can be observed with an incidence peak between the fourth and fifth decade of life.between the fourth and fifth decade of life.

Recurrent stone formation is a common Recurrent stone formation is a common problem with all types of stones and therefore an problem with all types of stones and therefore an important part of the medical care of patients important part of the medical care of patients with stone disease. with stone disease.

Theories of Theories of Stone FormationStone Formation

A.A. Nucleation TheoryNucleation Theory B.B. Stone Matrix TheoryStone Matrix Theory C.C. Inhibitor of Crystallization Inhibitor of Crystallization

TheoryTheory

Most investigators acknowledge Most investigators acknowledge that these 3 theories describe the that these 3 theories describe the 3 basic factors influencing urinary 3 basic factors influencing urinary stone formation. It is likely that stone formation. It is likely that more than one factor operates in more than one factor operates in causing stone disease. A causing stone disease. A generalized model of stone generalized model of stone formation combining these 3 basic formation combining these 3 basic theories has been proposed.theories has been proposed.

RISK FACTORSRISK FACTORS ••Start of disease early in life: <25 yearsStart of disease early in life: <25 years••Stone containing brushiteStone containing brushite••Only one functioning kidneyOnly one functioning kidney••Disease associated with stone formationDisease associated with stone formation: : - hyperparathyroidism - hyperparathyroidism - renal tubular acidosis (partial/complete) - renal tubular acidosis (partial/complete) - jejunoileal bypass - jejunoileal bypass - Crohn’s disease - Crohn’s disease - intestinal resection - intestinal resection - malabsorptive conditions - malabsorptive conditions - sarcoidosis - sarcoidosis - hyperthyroidism- hyperthyroidism

RISK FACTORSRISK FACTORS ••Medication associated with stone formation: Medication associated with stone formation: - calcium supplements - calcium supplements - vitamin D supplements - vitamin D supplements - acetazolamide - ascorbic acid in megadoses ( > 4 g/day) - acetazolamide - ascorbic acid in megadoses ( > 4 g/day) - sulphonamides - triamterene - sulphonamides - triamterene - indinavir- indinavir••Anatomical abnormalities associated with stone formation:Anatomical abnormalities associated with stone formation: - tubular ectasia (medullary sponge kidney)- tubular ectasia (medullary sponge kidney) - pelvo-ureteral junction obstruction - pelvo-ureteral junction obstruction - calix diverticulum, calix cyst- calix diverticulum, calix cyst- ureteral stricture - ureteral stricture - vesico-ureteral reflux - vesico-ureteral reflux - horseshoe kidney- horseshoe kidney - ureterocele- ureterocele

Etiology (according Capital and I. Pogo Elko).Etiology (according Capital and I. Pogo Elko). A). A). Disorders of urinary tractDisorders of urinary tract:: congenital abnormalities those favor to congenital abnormalities those favor to

apostasies;apostasies; obstructive processes;obstructive processes; neurogenic duskiness of the urinary tract;neurogenic duskiness of the urinary tract; inflammative and parasitogenic damages;inflammative and parasitogenic damages; foreign bodies of urinary tract;foreign bodies of urinary tract; traumatic injuries.traumatic injuries. B) Liver and digestive tract disorders:B) Liver and digestive tract disorders: latent and manifested hepathopathiy;latent and manifested hepathopathiy; hepatogenic gastritis;hepatogenic gastritis; colitis, etc.colitis, etc. C) Endocrine diseasesC) Endocrine diseases hyperparathyreoidism;hyperparathyreoidism; hyperthyroidism;hyperthyroidism; hypopituitaric diseases; hypopituitaric diseases; D.) Infect focuses of the urogenital system.D.) Infect focuses of the urogenital system. E) Metabolism disorders.E) Metabolism disorders. essential hypercalciuria;essential hypercalciuria; disorders of membranes for colloid disorders of membranes for colloid

substances diffusion;substances diffusion; renal rickets, etcrenal rickets, etc

F) Injuries those leads to continuous F) Injuries those leads to continuous immobilizationimmobilization

fractures of the vertebral column and limbsfractures of the vertebral column and limbs osteomyelitisosteomyelitis diseases of the bones and jointsdiseases of the bones and joints chronic diseases of the visceral organs and chronic diseases of the visceral organs and

nervous system.nervous system. G) Climate and geographical causes.G) Climate and geographical causes. dry and hot climate with a high vaporizationdry and hot climate with a high vaporization decrease water supplydecrease water supply iodine deficiencyiodine deficiency H) Disorders of nutrition and vitamins H) Disorders of nutrition and vitamins

balance:balance: retinole and oscorbine acid deficiency in retinole and oscorbine acid deficiency in

food.food. Excessive amount of the ergocalciferole in Excessive amount of the ergocalciferole in

organism.organism.

Renal CalculiRenal Calculi

1 Coral calculus1 Coral calculus 2 Coral calculi fragment2 Coral calculi fragment 3 Calculi, which are impregnated with blood pigments3 Calculi, which are impregnated with blood pigments

Diagnostic imagingDiagnostic imaging

Medical HistoryMedical History

A personal as well as a A personal as well as a family history should be family history should be obtained for all patients.obtained for all patients.

A history of inflammatory A history of inflammatory bowel disease, recurrent bowel disease, recurrent urinary tract infection, urinary tract infection, prolonged periods of prolonged periods of immobilization, gout, or immobilization, gout, or familial occurrence of familial occurrence of certain inherited renal certain inherited renal diseases, eg, renal tubular diseases, eg, renal tubular acidosis or cystinuria, acidosis or cystinuria, should be sought. should be sought.

Clinical ManifestationsClinical Manifestations

Acute obstruction of Acute obstruction of the urinary tract may the urinary tract may cause renal colic, a cause renal colic, a form of severe form of severe abdominal pain often abdominal pain often accompanied by accompanied by nausea and vomiting nausea and vomiting due to celiac ganglion due to celiac ganglion stimulation. Onset is stimulation. Onset is sudden, often during sudden, often during the night or in the the night or in the early morningearly morning


Obstructing calculi in the upper urinary Obstructing calculi in the upper urinary tract cause an extreme crescendo like tract cause an extreme crescendo like pain in the flank that generally radiates pain in the flank that generally radiates laterally around the abdomen to the laterally around the abdomen to the corresponding groin and testicles in corresponding groin and testicles in males and labia major in females.males and labia major in females.

When the stone obstructs the When the stone obstructs the midureter, the pain tends to radiate to midureter, the pain tends to radiate to the lateral flank and abdominal region. the lateral flank and abdominal region.

However, when the obstruction is in the However, when the obstruction is in the distal ureter (near the ureterovesical distal ureter (near the ureterovesical junction), the patient exhibits symptoms junction), the patient exhibits symptoms of bladder irritation (frequency and of bladder irritation (frequency and urgency or genital pain).urgency or genital pain).


Fever is rarely present except when a urinary tract Fever is rarely present except when a urinary tract infection accompanies obstruction. infection accompanies obstruction.

Pulse rate and blood pressure, however, may be Pulse rate and blood pressure, however, may be elevated as a result of the pain and agitation caused by elevated as a result of the pain and agitation caused by the renal colic. the renal colic.

The patient's abdomen is generally flat and soft, with The patient's abdomen is generally flat and soft, with moderate deep tenderness on palpation where the moderate deep tenderness on palpation where the calculus is lodged. calculus is lodged.

Some patients also have extensive hyperesthesia of the Some patients also have extensive hyperesthesia of the abdominal wall, either anteriorly or posteriorly. abdominal wall, either anteriorly or posteriorly.

The costo-vertebral area may be tender to percussion.The costo-vertebral area may be tender to percussion.

Laboratry InvestigationsLaboratry Investigations

Stone analysisStone analysis: In every patient one stone should: In every patient one stone should be analysed.be analysed.

Blood analysisBlood analysis: Calcium Albumin Creatinine Urate: Calcium Albumin Creatinine Urate

Urinalysis: Urinalysis: Fasting morning spot urine sampleFasting morning spot urine sample Dip-stick test: pH, Dip-stick test: pH,

Leucocytes/BacteriaLeucocytes/Bacteria Cystine test, Ca, P, citrate, urateCystine test, Ca, P, citrate, urate

Urinalysis.Urinalysis. This test usually reveals either This test usually reveals either

gross or microscopic gross or microscopic hematuria. Although hematuria hematuria. Although hematuria may be absent in complete may be absent in complete obstruction, microhematuria obstruction, microhematuria may be present in may be present in symptomatic partial symptomatic partial obstruction.obstruction.

Pyuria, usually moderate, may Pyuria, usually moderate, may accompany obstruction even accompany obstruction even in the absence of identifiable in the absence of identifiable infecting organisms. If severe infecting organisms. If severe pyuria is present, infection pyuria is present, infection should be considered should be considered (especially in a female), since (especially in a female), since the stones may be secondary the stones may be secondary to infection. to infection.


Routine examination involves a plain abdominal film of the Routine examination involves a plain abdominal film of the kidneys, ureters and bladder (KUB) kidneys, ureters and bladder (KUB) At least 90% of all At least 90% of all renal stones are radiopaque and therefore readily visible renal stones are radiopaque and therefore readily visible on a plain film of the abdomenon a plain film of the abdomen


Excretory pyelography must Excretory pyelography must not be carried out in the not be carried out in the following patients - those: following patients - those:

With an allergy to With an allergy to contrast media contrast media

With S-creatinine level > With S-creatinine level > 200 µmol/L 200 µmol/L

On medication with On medication with metformin metformin

With myelomatosisWith myelomatosis


Special examinations that Special examinations that can be carried out can be carried out include: include:

Retrograde or antegrade Retrograde or antegrade pyelography pyelography

Retrograde pneumo-Retrograde pneumo-pyelography or pyelography or cystographycystography

Spiral (helical) Spiral (helical) unenhanced computed unenhanced computed tomography (CT) tomography (CT)

Scintigraphy. Scintigraphy.


UltrasonographyUltrasonography-- InIn patients in whom it is not patients in whom it is not

possible to obtain an possible to obtain an intravenous urogram, intravenous urogram, ultrasonic evaluation of the ultrasonic evaluation of the kidneys may aid in the kidneys may aid in the diagnosis of renal stones.diagnosis of renal stones.

In pregnant women with In pregnant women with flank pain in whom it is flank pain in whom it is desirable to limit radiation desirable to limit radiation exposure or in anuric exposure or in anuric patients or patients with patients or patients with chronic renal failure, the chronic renal failure, the presence of hydronephrosis presence of hydronephrosis on acoustic shadowing may on acoustic shadowing may be diagnostic.be diagnostic.


CCystoscopia shows swallowing of the ureter ystoscopia shows swallowing of the ureter orifice in lower location of the stone, it may orifice in lower location of the stone, it may also partially project out to the orifice. also partially project out to the orifice.

CystoscopyCystoscopy

TREATMENTTREATMENT

ConservativeConservative InstrumentalInstrumental SurgicalSurgical

Pain relief Pain relief Pain relief involves the administration Pain relief involves the administration

by various routes of the following by various routes of the following agents: agents:

Diclofenac sodium Diclofenac sodium Indomethacin Indomethacin Hydromorphone hydrochloride + Hydromorphone hydrochloride +

atropine sulphate atropine sulphate BaralginBaralgin No-spae + AnalgineNo-spae + Analgine TramadolTramadol

Pain reliefPain relief

Warm bath Warm bath Spasmolytic “cocktails” (with papaverine, spasmalgone, Spasmolytic “cocktails” (with papaverine, spasmalgone,

no-spanum, promedole) should be taken. no-spanum, promedole) should be taken. A high dosage of the cystenal or urolesan (20 drops on A high dosage of the cystenal or urolesan (20 drops on

the piece of sugar) is rather effective at the start of the the piece of sugar) is rather effective at the start of the renal colic.renal colic.

If ache doesn’t disappear the novocaine blockade of the If ache doesn’t disappear the novocaine blockade of the spermatic cord in males and round ligament in females is spermatic cord in males and round ligament in females is requiredrequired..

Physical method.Physical method.

Pain relief Pain relief For patients with ureteral For patients with ureteral

stones that are expected to stones that are expected to pass spontaneously, pass spontaneously, suppositories or tablets of suppositories or tablets of diclofenac sodium, 50 mg diclofenac sodium, 50 mg administered twice daily administered twice daily over 3-10 days, might be over 3-10 days, might be useful in reducing ureteral useful in reducing ureteral oedema and the risk of oedema and the risk of recurrent pain. The patient recurrent pain. The patient should be instructed to should be instructed to sieve the urine in order to sieve the urine in order to retrieve a concrement for retrieve a concrement for analysis.analysis.

Pain reliefPain relief

When pain relief When pain relief cannot be obtained cannot be obtained by medical means, by medical means, drainage by stenting drainage by stenting or percutaneous or percutaneous nephrostomy (PN) or nephrostomy (PN) or stone removal stone removal should be carried should be carried out.out.

Stone removal Stone removal The size, site and shape of the stone at the initial The size, site and shape of the stone at the initial

presentation influence the decision to remove the presentation influence the decision to remove the stone. Also, the likelihood of spontaneous stone. Also, the likelihood of spontaneous passage has to be evaluated. Spontaneous stone passage has to be evaluated. Spontaneous stone passage can be expected in up to 80% of patients passage can be expected in up to 80% of patients with stones not larger than 4 mm in diameter. For with stones not larger than 4 mm in diameter. For stones with a diameter exceeding 7 mm the stones with a diameter exceeding 7 mm the chance of spontaneous passage is very low. chance of spontaneous passage is very low.

The overall passage rate of ureteral stones is: The overall passage rate of ureteral stones is: Proximal ureteral stones: 25% Proximal ureteral stones: 25% Mid-ureteral stones: 45% Mid-ureteral stones: 45% Distal ureteral stones: 70% Distal ureteral stones: 70%

Indications for Active Indications for Active Stone removalStone removal

Stone removal is usually indicated Stone removal is usually indicated for stones with a diameter for stones with a diameter exceeding 6-7 mm. Active stone exceeding 6-7 mm. Active stone removal is strongly recommended removal is strongly recommended in patients fulfilling the following in patients fulfilling the following criteria: criteria:

Persistent pain despite adequate Persistent pain despite adequate medication medication

Persistent obstruction with risk of Persistent obstruction with risk of impaired renal function impaired renal function

Stone with urinary tract infection Stone with urinary tract infection Risk of pyonephrosis or urosepsis Risk of pyonephrosis or urosepsis Bilateral obstruction.Bilateral obstruction. Obstructing calculus in a solitary Obstructing calculus in a solitary

functioning kidneyfunctioning kidney

Stone removal Stone removal A test for bacteriuria should be carried out in all A test for bacteriuria should be carried out in all

patients in whom stone removal is planned. Screening patients in whom stone removal is planned. Screening with dipsticks might be sufficient in uncomplicated with dipsticks might be sufficient in uncomplicated cases. In others, urine culture is necessary. In all cases. In others, urine culture is necessary. In all patients with a positive test for bacteriuria, with a patients with a positive test for bacteriuria, with a positive urine culture or when there is suspicion of an positive urine culture or when there is suspicion of an infective component, treatment with antibiotics should infective component, treatment with antibiotics should be started before the stone-removing procedure. be started before the stone-removing procedure.

Bleeding disorders and anticoagulation treatment Bleeding disorders and anticoagulation treatment should be considered. These patients should be should be considered. These patients should be referred to an internist for appropriate therapeutic referred to an internist for appropriate therapeutic measures during the stone-removing procedure. measures during the stone-removing procedure. Treatment with salicylates should be stopped 10 days Treatment with salicylates should be stopped 10 days before the planned stone removal.before the planned stone removal.

Indications to surgical operationIndications to surgical operation

Frequent attacks of the renal colic or persistent pain that Frequent attacks of the renal colic or persistent pain that disables the patient.disables the patient.

Disorder of the urine outflow causing the hydronephrotic Disorder of the urine outflow causing the hydronephrotic degeneration of the kidney.degeneration of the kidney.

Obturative anuria.Obturative anuria. Frequent attacks of the acute pyelonephritis, progress of Frequent attacks of the acute pyelonephritis, progress of

the chronic pyelonephritis that causes renal insufficiency.the chronic pyelonephritis that causes renal insufficiency. Total hematuria.Total hematuria. Calculous pyonephrosis, apostematous pyelonephritis or Calculous pyonephrosis, apostematous pyelonephritis or

carbuncle of the kidney.carbuncle of the kidney. Stone at the sole kidney that causes obstruction.Stone at the sole kidney that causes obstruction. Stone in the ureter of the sole kidney that won’t pass Stone in the ureter of the sole kidney that won’t pass

away spontaneously.away spontaneously.

Stone removal Stone removal In patients with coagulation disorders In patients with coagulation disorders

the following treatments are contra-the following treatments are contra-indicated: extracorporeal shock wave indicated: extracorporeal shock wave lithotripsy (ESWL), percutaneous lithotripsy (ESWL), percutaneous nnephrolithotomy with or without ephrolithotomy with or without lithotripsy (PNL), ureteroscopy (URS) and lithotripsy (PNL), ureteroscopy (URS) and open surgery.open surgery.

In pregnant women, ESWL, PNL and URS In pregnant women, ESWL, PNL and URS are contra-indicated. In expert hands URS are contra-indicated. In expert hands URS has been successfully used to remove has been successfully used to remove ureteral stones during pregnancy, but it ureteral stones during pregnancy, but it must be emphasized that complications must be emphasized that complications of this procedure might be difficult to of this procedure might be difficult to manage.manage.

In such women, the preferred treatment In such women, the preferred treatment is drainage, either with a percutanous is drainage, either with a percutanous nephrostomy catheter, a doublenephrostomy catheter, a double -- J stent J stent or a ureteral catheter . or a ureteral catheter .

For patients with a pacemaker it is wise For patients with a pacemaker it is wise to consult a cardiologist before to consult a cardiologist before undertaking an ESWL treatment.undertaking an ESWL treatment.

Percutaneous ProceduresPercutaneous Procedures Percutaneous nephrostomy. Percutaneous nephrostomy.

Because of this technique, Because of this technique, urologists can now perform urologists can now perform operative procedures within the operative procedures within the kidney without using the standard kidney without using the standard large flank incisions and large flank incisions and mobilization of the kidney. mobilization of the kidney.

This technique, along with This technique, along with refinements in endoscopic refinements in endoscopic instruments and advances in instruments and advances in fiberoptics, allows endoscopic fiberoptics, allows endoscopic manipulation in the upper urinary manipulation in the upper urinary tract by the percutaneous tract by the percutaneous approach.approach.

PPercutaneous ercutaneous nnephrolithotomy with or ephrolithotomy with or without lithotripsy (PNLwithout lithotripsy (PNL) )

Closed Surgical ProceduresClosed Surgical Procedures

Cystoscopic technique Cystoscopic technique [[With the patient under anesthesia With the patient under anesthesia and with fluoroscopic control, and with fluoroscopic control, stones in the distal ureter can stones in the distal ureter can sometimes be removed with a wire sometimes be removed with a wire stone basket] stone basket]

Ureteropyeloscopy Ureteropyeloscopy [[Manipulation of small ureteral Manipulation of small ureteral stones under direct vision with a stones under direct vision with a ureteroscope is a major advance ureteroscope is a major advance in the management of ureteral in the management of ureteral calculi. With this technique, small calculi. With this technique, small stones can be easily trapped in a stones can be easily trapped in a stone basket and safely extracted stone basket and safely extracted

through the dilated ureter.through the dilated ureter.

Extracorporeal Shock Wave LithotripsyExtracorporeal Shock Wave Lithotripsy An extracorporeal noninvasive An extracorporeal noninvasive

technique that uses shock waves technique that uses shock waves to disintegrate urinary calculi while to disintegrate urinary calculi while the patient is immersed in a water the patient is immersed in a water bath has been tested extensively bath has been tested extensively and is now in clinical use. With and is now in clinical use. With this technique, calculi in the upper this technique, calculi in the upper urinary tract are reduced to urinary tract are reduced to fragments, which pass fragments, which pass spontaneously from the collecting spontaneously from the collecting system and bladder in most system and bladder in most patients.patients.

Size, location, and consistency of Size, location, and consistency of stone determine the number of stone determine the number of shocks needed for fragmentation. shocks needed for fragmentation. In general, between 500 and In general, between 500 and 2,000 shocks arc necessary to 2,000 shocks arc necessary to fragment and pulverize an fragment and pulverize an intrarenal calculus sufficiently for intrarenal calculus sufficiently for complete passage. complete passage.

Open Surgical ProceduresOpen Surgical Procedures

Pyelolithotomy:Pyelolithotomy: Simple Simple pyelolithotomy is used for pyelolithotomy is used for removal of calculi removal of calculi confined to the renal confined to the renal pelvis. Minimal dissection pelvis. Minimal dissection of the renal sinus is of the renal sinus is usually needed, and usually needed, and exposure of the entire exposure of the entire kidney is not re quired. kidney is not re quired. This procedure is not This procedure is not indicated for the removal indicated for the removal of entrapped caliceal of entrapped caliceal stones or large, branched stones or large, branched renal calculi.renal calculi.


Ureterolithotomy.Ureterolithotomy. There are There are retroperitoneal, retroperitoneal, transperitoneal and transperitoneal and combined surgical combined surgical accesses. It depends on accesses. It depends on stone location. To remove stone location. To remove stone from the superior stone from the superior ureter the Fedorov’s access ureter the Fedorov’s access is used, from medial ureter is used, from medial ureter – Cuckulidze’s or – Cuckulidze’s or Derev’yanko access is Derev’yanko access is performed, the inferior performed, the inferior ureter – Pyrogov’s access ureter – Pyrogov’s access is needed, the pelvic portion is needed, the pelvic portion of ureter may be accessed of ureter may be accessed through the suprapubic through the suprapubic arcuate incision.arcuate incision.


NephrectomyNephrectomy NephrolithotomyNephrolithotomy CystolithotomyCystolithotomy

Preventive treatment in calcium stone Preventive treatment in calcium stone disease disease

Preventive treatment in patients with calcium stone Preventive treatment in patients with calcium stone disease should be started with conservative disease should be started with conservative measures. Pharmacological treatment should be measures. Pharmacological treatment should be instituted only when the conservative regimen instituted only when the conservative regimen fails. Patients should be encouraged to have a fails. Patients should be encouraged to have a high fluid intake. This advice is valid irrespective high fluid intake. This advice is valid irrespective of stone composition. For a normal adult, the 24-h of stone composition. For a normal adult, the 24-h urine volume should exceed 2000 ml, but the urine volume should exceed 2000 ml, but the supersaturation level should be used as a guide to supersaturation level should be used as a guide to the necessary degree of urine dilution. The fluid the necessary degree of urine dilution. The fluid intake should be evenly distributed over the 24-h intake should be evenly distributed over the 24-h period, and particular attention should be paid to period, and particular attention should be paid to situations where an unusual loss of fluid occurs. situations where an unusual loss of fluid occurs.


Diet should be of a 'common sense' type - a mixed balanced Diet should be of a 'common sense' type - a mixed balanced diet with contributions from all food groups but without diet with contributions from all food groups but without excesses of any kind. The intake of fruits and vegetables excesses of any kind. The intake of fruits and vegetables should be encouraged because of the beneficial effects of should be encouraged because of the beneficial effects of fibre. Care must be taken, however, to avoid fruits and fibre. Care must be taken, however, to avoid fruits and vegetables that are rich in oxalate. Wheat bran is rich in vegetables that are rich in oxalate. Wheat bran is rich in oxalate and should be avoided. In order to avoid an oxalate and should be avoided. In order to avoid an oxalate load, the excessive intake of products rich in oxalate load, the excessive intake of products rich in oxalate should be limited or avoided. This is of particular oxalate should be limited or avoided. This is of particular importance in patients in whom high excretion of oxalate importance in patients in whom high excretion of oxalate has been demonstrated. The following products have a has been demonstrated. The following products have a high content of oxalate : high content of oxalate :

Rhubarb 530 mg oxalate/100 g Rhubarb 530 mg oxalate/100 g Spinach 570 mg oxalate/100 g Spinach 570 mg oxalate/100 g Cocoa 625 mg oxalate/100 g Cocoa 625 mg oxalate/100 g Tea leaves 375-1450 mg oxalate/100 g Tea leaves 375-1450 mg oxalate/100 g Nuts 200-600 mg oxalate/100 g. Nuts 200-600 mg oxalate/100 g.


Vitamin C in doses up to 4 g/day can be taken Vitamin C in doses up to 4 g/day can be taken without increasing the risk of stone formation. without increasing the risk of stone formation. Animal protein should not be ingested in Animal protein should not be ingested in excessive amounts. It is recommended that the excessive amounts. It is recommended that the animal protein intake is limited to approximately animal protein intake is limited to approximately 150 g/day. Calcium intake should not be restricted 150 g/day. Calcium intake should not be restricted unless there are very strong reasons for such unless there are very strong reasons for such advice. The minimum daily requirement for advice. The minimum daily requirement for calcium is 800 mg and the general calcium is 800 mg and the general recommendation is 1000 mg/day. Supplements of recommendation is 1000 mg/day. Supplements of calcium are not recommended except in cases of calcium are not recommended except in cases of enteric hyperoxaluria, in which additional calcium enteric hyperoxaluria, in which additional calcium should be ingested with meals. should be ingested with meals.


The intake of foodstuffs particularly rich in urate The intake of foodstuffs particularly rich in urate should be restricted in patients with should be restricted in patients with hyperuricosuric calcium oxalate stone disease , as hyperuricosuric calcium oxalate stone disease , as well as in patients with uric acid stone disease. well as in patients with uric acid stone disease. The intake of urate should not be more than 500 The intake of urate should not be more than 500 mg/day. Below are examples of food rich in urate : mg/day. Below are examples of food rich in urate :

Calf thymus 900 mg urate/100 g Calf thymus 900 mg urate/100 g Liver 260-360 mg urate/100 g Liver 260-360 mg urate/100 g Kidneys 210-255 mg urate/100 g Kidneys 210-255 mg urate/100 g Poultry skin 300 mg urate/100 g Poultry skin 300 mg urate/100 g Herring with skin, sardines, anchovies, sprats 260-Herring with skin, sardines, anchovies, sprats 260-

500 mg urate/100 g. 500 mg urate/100 g.

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