Kidney Stones (CMPP)

What roots connect to the renal sensory

T11 - L2

Why does upper ureteral distension induce nausea and vomiting

Common innveration with GI tract

What inneravates the lower ureter

Genitofemoral

Ilioingugla

What compounds are considered stone formers

Ca Oxalate

Ca Phosphate

Uric Acid

Cystine

What susbtances are considered stone inhibitors

Citrate

Magnesium

Pyrophosphate

What is a big factor into stone formatiuon

Water Intake

What UOP should we keep someone above to avoid stone

2L / day

Where do kidney stones form

Renal Calyces

When do S/S of kidney stones present

When the stone blocks the ureter

What are the types of kidney stones

Ca-Based

Sturvite

Uric Acid

Cystine

What is the most common renal stone type

Ca-Based

What causes Ca-based stones to form

Hypercaluria

Hyperparathyroidism

What differs the type of Ca stone that is formed

Urine pH

• Acidic = Oxalate

• Basic = Phosphate

What stones are visible on KUB

Ca Stones

Sturvite Stones

What is struvite made from

Magnesium

Ammonium

Phosphate

What triggers struvite stone to form

UTIs

What pathogens cause struvite stone

Proteus

Klebsiella

What are risk factors for sturvite stones

Women

Frequent cath

What stones favor acidic urine

Ca Oxalate

Uric Acid

Cystine

What stones favor basic urine

Ca Phosphate

Struvite

What can cause uric acid stones

Idiopathic

Gout

Myeloproliferative Disorder

What causes cystine stone

Gene

What prevents stones from forming

Hydration

Citrate

Magnesium

High Fiber Diey

Renal Colic

Severe pain that comes and goes due to ureteral dilation

Where will regions of the ureter refer pain to?

Upper ureteral = Flank + Upper Abdominal

Mid-Ureteral = Mid and Lower Abdominal

Lower Ureteral / Junction = Lower Pelvis / Groin/ Scrotal / Labial

How do kidney stones present?

Renal Colic

N/V

Restlessness

Gross Hematuria

Dysuria

Frequency

Tachycardia

HTN

Diaphoretic

CVA Tenderness

What PMH can increase risk of kidney stones

Paraneoplastic Syndrome = PTH and hypercalciuria

Tumor Lysis Syndrome = Hyperuricemia and Hyperuricosuria

Hyperparathyroidism = hypercalciuria

Sarcoidosis = hypercalciuria and hypercalcemia

Gout = Hyperuricosuria

Multiple Myeloma = Hyperuricosuria

IBD = Hyperoxaluria due to Malabsorption

Recurrent UTI = Risk of struvite stones

Previous stones

What medications can indicate higher proability of stones

Diuretics = Dehydration and Supersaturation

Chemo = Hyperuricosuria

Colchicine + Allopurinol + Probenecid = Gout Medications

What is the most concerning DDX that must be ruled out in the setting of kidney stones

AAA

Why does AAA and kidney stones get mixed up

Similar pain presentation (Upper Ureteral Stones)

Both present with hematuria

What are DDX for the pain pattern of upper ureteral stones

AAA

Cholecystitis

Pancreatitis

Gastritis

PUD

MSK Back Pain

What are DDX for the pain pattern of mid ureteral stones

Appendicitis

Diverticulitis

What are DDX for the pain pattern of lower ureteral stones

Ruptured Ectopic

Ovarian Torsion

Tubo-Ovarian Abscess

PID

Ruptured Ovarian Cyst

Testicular Torsion

Epididymitis

UTI

When do we typically use KUB in setting of stones

F/U after a stone is found on CAT

Dx Method of Choice for Kidney Stones

Spiral CT

Spiral CT

A non-contrast CT of the abdomen

When do we spiral CT for stones

First-Time Episode

Unclear Dx

Suspected Associated Pyonephrosis

Dx Method of Choice for Stones in Peds

U/S

IV Pyelography

A imaging study in which contrast is injected and XR are taken of the kidney

Contraindicated for IV Pyelography

CKD stage

What imaging studies can rule in stones and rule out AAA

Spiral CT

U/S

What lab findings are possible for kidney stones with urinalysis

Concomitant UTI

Mild WBC elevation (Stress Response)

Hypercalciuria

Hyperuricouria

Acidic or Alkaline Urine

Hematuria

Crystals on Microscopy

Indication for 24 hour Urine Collection for Stones

Recurrent stone

Presents < 30 years old

Severe AKI

What findings on 24 hours collection can indicate stones

Decreased UOP

Hypercalciuria

Hyperoxaluria

Hyperuricosuria

Hypocitrauria

Tx for Kidney Stone Inpatient

0.9 NS IV Fluid

IV Toradol 30mg

IV Morphine 4mg

IV Ondansetron (Zofran) 4mg

Ketorolac (Toradol)

An IV NSAID

Why is Toradol commonly given for stones

Effective Analgesia

Blocks prostaglandins and relaxes the smooth muscle of the ureter

Opiate of Choice for Tx of Inpatient Kidney Stone

Morphine Sykfate

Contraindication for Toradol

CKD

Pregnancy

Side Effects of Morphine

N/V

Respiratory Depression

AMS

Hypotension

Why are NSAIDs better treatment for stones than opiate

NSAIDs activaly treat the condition while giving pain relief

Admission Criteria for Kidney Stone

Intractable Pain

Intractable Vomiting

AKI

Urosepsis

Anuria

Indications for Surgery for Tx of Kidney Stone

Unremitting pain

High-grade obstruction w/ Increasing Cr and suspected post-renal AKI

B/L Obstruction or Single Kidney Obstruction

Obstruction + Urosepsis

Options for Surgical Tx of Kidney Stone

Ureteral Stent

Cystoscopy Stone Retrieval

Extracorporeal Shock Wave Lithotripsy (ESWL)

Percutaneous Nephrostomy (PCN)

Open Surgery (Open Nephrolithotomy / Pyelolithotomy)

Ureteral Stent

A long hollow tube that is passed from the bladder to the kidney through the ureter

Tx for Stone and Pyonephrosis

How long can a ureteral stent remain in

3 months

Complications from Ureteral Stent

Blockage

Dislodgement

Infection

Cystoscopy Stone Retriveal

A surgical tx for stones by sending an instrument through the bladder and up the ureter to manually remove the stones

What must be done after cystoscopy stone retriveal

Ureteral Stent

Indication for Ureteral Stent

Pyonephrosis

Obstructed Kidney

P/O Cystoscopy Retrieval

P/O ESWL

What sized stones should be treaed with cystoscopic removal

5-10 mm

What is the least invasive method to remove a kidney stone

ESWL

Extracorporeal Stone Wave Lithotripsy (ESWL)

A treatment for stones that uses sound waves to fragement stones to the point that they can be passed spontaneously

Percutaneous Nephrostomy (PCN)

A procedure where a scope is sent through the skin and directly into the kidney to remove stones

Indication for Open Surgery for Kidney Stone

Anatomic Difficulty with Other Tx Methods

Complex Stones

#1 complication of PCN for Stones

p/o bleed

Tx for Kidney Stone Outpatient

Hydration for adequate UOP

Analgesia (Opiate / NSAIDs)

Anti-emetic

Alpha 1 antagonist

Return if intractable pain, vomiting, fevel, chills, or decreased UOP

How much water should we tell a patient with a kidney stone to drink

(2-3 L / day or 8-12 8oz glasses)

Pain Management for Outpatient Kidney Stone

#1 Line = Oxycodone/Acetaminophen (Percocet)

2nd Line = Hydrocodone/Acetaminophen (Vicodin)

Anti-Emetic of Choice for Outpatient Kidney Stone

Ondansteron (Zofran)

What sized stones are likely to spontaneously pass

< 5mm

Tx Plan for Spontaneous Passing of Stones

Give analgesic, anti-emetic, and alpha-lbocker

F/U with serial KUBs

Alpha Blocker for Outpatient Kidney Stobne

Tamsulosin (Flomax)

Tamsulosin (Flomax)

An alpha-1 blocker

Side Effects of Tamsulosin

Orthostatic Hypotension

Syncope

When should tamsulosin for kidney stone be taken

Before bed

What is the usual pass time for kidney stone

4 weeks

What sized stones are treated with ESWL

5-20mm

What sized stones are treated with PCN

> 20 mm

Long-Term Tx for Ca-Based Stones

Normal Ca diet with no supplements

Avoid oxalate-rich food

Avoid high protein

Thiazide Diuretic

Hypocitraturia

Hypomagnesuria

What foods are rich in oxalate

( Spinach and Rhubarb)

Tx for Hypocitruria (Stone Long-Term)

Potassium Citrate

Tx for Hypomagnesuria (Stone Long-Term)

Mg Supplements

Long-Term Tx for Uric Acid Stones

Allopurinol

Avoid purine rich food

PO Alkali

What foods are rich in purine

ETOH

Organic Meat

Long Term Tx of Struvite Stones

Abx Coverage

Correct anatomy abnormalities

Complications of Kidney Stones

Pyonephrosis

Urosepsis

Calyceal Rupture w/ Urine Extravasation

AKI

Urinary Fistula

Ureteral Stenosis / Perforation / Scarring

HTN