renal calculli veeresh vg rn

RENAL CALCULI

OUTLINE OF THE CONTENT

DEFINITION OF RENAL CALCULI

INCIDENCE OF RENAL CALCULI

RISK FACTORS FOR RENAL CALCULI

CLASSIFICATION OF RENAL CALCULI

ETIOLOGY : PATHOPHYSIOLOGY

SITES OF IMPACTION

OUTLINE OF THE CONTENT

• SIGNS AND SYMPTOMS OF RENAL

CALCULI

• COMPLICATIONS OF RENAL CALCULI

• DIAGNOSIS OF RENAL CALCULI

• MANAGEMENT OF RENAL CALCULI

• VEDIO ON ESWL

INTRODUCTION

Kidney stones (called renal calculi (from

Latin renes, "kidney" and calculi, "pebbles")

are solid concretions or crystal aggregations

formed in the kidneys from dietary minerals.

DEFINITION OF RENAL CALCULI

Renal calculi a condition in which there is a

formation of stones within the renal system

that is kidney, urethra and bladder.

INCIDENCE OF RENAL CALCULI

Kidney stones are a significant source of

morbidity with an annual incidence of 1–2 per

1000 and a lifetime prevalence of 3–5%.

80% of those with kidney stones are men;

most stones in women are due to either

metabolic defects (such as cystinuria) or

infection.

INCIDENCE OF RENAL CALCULI CONT...

Recurrence rates are estimated at 50% over a

10 year period and 75% over 20 years, with

some experiencing ten or more episodes over

the course of a lifetime.

The incidence of urolithiasis increases to 20-

25% in the Middle East, partly due to the

increased risk of dehydration in hot climates.

INCIDENCE OF RENAL CALCULI CONT...

Men most commonly experience their first

episode between age 30- 40 years, while for

women the age at first presentation is

somewhat later.

RISK FACTORS OF RENAL CALCULI

Occupation

Family history (cystinuria inherited metabolic

disorder)

Dietary pattern of family diet high in

calcium, vitaminD, milk, protein, oxalate,

alkali.

Dehydration

Small bowel disease : Krohn’s disease

Medical conditions: Hypercalcuria

Hyperparathyrodism, and Gout

RISK FACTORS OF RENAL CALCULI CONT…

Urinary tract infection

Urinary stasis

Immobility

Urinary tract obstruction

Hypercalcemia

CLASSIFICATION OF RENAL CALCULI

Kidney stones are typically classified by their

1. Location

2. Chemical composition

CLASSIFICATION OF RENAL CALCULI…

1. Location

Urolithiasis

Nephrolithiasis

Calyceal

ureterolithiasis

cystolithiasis.


Urolithiasis refers to stones originating

anywhere in the urinary system, including the

kidneys and bladder.

Nephrolithiasis refers to the presence of such

calculi in the kidneys.


Calyceal calculi refers to aggregations in

either the minor or major calyx, parts of the

kidney which pass urine into the ureter.

The condition is called ureterolithiasis when a

calculus or calculi are located in the ureter.

Stones may also form or pass into the bladder,

condition referred to as cystolithiasis.



Calcium-containing stones

Struvite stones

Uric acid stones



Calcium-containing stones

Calcium-containing stones represent about

80% of cases.

These typically contain calcium oxalate either

alone or in combination with calcium

phosphate

The formation of calcium phosphate stones is

associated with conditions such as

hyperparathyroidism and renal tubular acidosis


Struvite stones

• 10-15% of urinary calculi are composed of

struvite (ammonium magnesium phosphate).

• Struvite stones (also known as "infection

stones“ “Staghorn stone”, urease or triple-

phosphate stones), form most often in the

presence of infection by urea-splitting bacteria.


Struvite stones cont…..

The enzyme urease, these organisms metabolize

urea into ammonia and carbon dioxide.

This alkalinizes the urine, resulting in favorable

conditions for the formation of struvite stones.

Proteus vulgaris

Klebsiella,

Enterobacter

Ureaplasma urealyticum are the most common

organisms


Struvite stones cont…..

These infection stones are commonly observed in

people who have factors which predispose them

to urinary tract infections, such as those with

spinal cord injury and other forms of neurogenic

bladder, ileal conduit urinar diversion,

vesicoureteral reflux, and obstructive uropathies.


Uric acid stones

About 5-10% of all stones are formed from uric

acid.

Uric acid stones may form in association with

conditions that cause hyperuricosuria (an

excessive amount of uric acid in the urine) with

or without high hyperuricemia (an excessive

amount of uric acid in the serum)


Uric acid stones cont…..

People afflicted with xanthinuria often produce

stones composed of xanthine

People with certain rare inborn errors of

metabolism have a propensity to accumulate

crystal-forming substances in their urine. For

example, those with cystinuriaform stones

composed of cystine

http://en.wikipedia.org/wiki/Cystinuria


Supersaturation of urine

Inhibitors of stone formation

Calcium

others


Supersaturation of urine

When the urine becomes supersaturated (when

the urine solvent contains more solutes than it

can hold in solution) with one or more crystal-

forming substances,

a seed crystal may form through the process of

nucleation.

Heterogeneous nucleation (where there is a

solid surface present on which a crystal can

grow) proceeds more rapidly than

homogeneous nucleation (where a crystal must

grow in liquid medium with no such surface),

because it requires less energy.

Adhering to cells on the surface of a renal

papillae, a seed crystal can grow and aggregate

into an organized mass.

• Depending on the chemical composition of the

crystal, the stone-forming process may proceed

more rapidly when the urine pH is unusually

high or low.

ETIOLOGY : PATHOPHYSIOLOGY CONT.

Inhibitors of stone formation

Normal urine contains chelating agents such as

citrate that inhibit the nucleation, growth, and

aggregation of calcium-containing crystals.


Inhibitors of stone formation:

Other endogenous inhibitors include

calgranulin(an S-100 calcium binding protein),

nephrocalcin (an acidic glycoprotein),

prothrombin F1 peptide, and bikunin (uronic

acid-rich protein).

When these substances fall below their normal

proportions, stones can form out of an

aggregation of crystals.


CalciumPeople who take supplemental calcium have a

higher risk of developing kidney stones

In the Women's Health Initiative,

postmenopausal women who consumed

1,000 milligrams of supplemental calcium and

400 IU of vitamin D per day for 7 years had a

17% higher risk of developing kidney stones

than subjects taking a placebo.


Calcium

This is perhaps related to the role of calcium in

binding ingested oxalate in the gastrointestinal

tract.

Unlike supplemental calcium, high intakes of

dietary calcium do not appear to cause kidney

stones and may actually protect against their

development


Role of dietary animal protein

Animal protein than the body needs, and as the

excess amino acids are broken down and

excreted, the sulfurous amino acids (typically

derived from animal rather than vegetarian

foods) cause calcium to be excreted in the

urine.


• Red meat also contains acids that need to be

excreted and this acidity constitutes another

risk factor for kidney stones

• High intake of animal protein also presents a

greater uric acid load to be excreted by the

kidney. This in turn acidifies the urine,

increasing the risk of uric acid stones.


Other

Water fluoridation may increase the risk of

kidney stone formation.

Ingestion of vitamin C supplements is

associated with an increased incidence of

kidney stones.


Other

Alcohol consumption, binge drinking can lead

to systemic dehydration, which can in turn lead

to the development of kidney stones.

Astronauts seem to show a higher risk of

developing kidney stones during or after space

flights of long duration.

UROLITHIASIS – SITES OF IMPACTION

SIGNS AND SYMPTOMS OF RENAL CALCULI

Obstruction of urine flow through one or both

ureters.

Oliguria (reduced urinary volume) caused by

obstruction of the bladder or urethra by a stone or

rarely, simultaneous obstruction of both ureters by

two separate stones.

Postrenal azotemia and

Hydronephrosis (distension and dilation of the

renal pelvis and calyces

SIGNS AND SYMPTOMS OF RENAL CALCULI…

Flank pain

Costovertebral

tenderness

Cool, moist skin

Pallor,

DiaphoresisDiagram showing the typical

location of renal colic, from below

the rib cage to just above the pelvis

http://en.wikipedia.org/wiki/File:Pos-renal.png

http://en.wikipedia.org/wiki/File:Pos-renal.png


Frequency and urgency in urination

dysuria,

Chills and fever

Hematuria

Nausea and vomiting


• Hallmark symptoms of

kidney stones include

renal colic, fever,

blood, pus in the urine,

and painful urination.

• Pain, most commonly

felt in the flank, lower

abdomen and groin (a

condition called renal

colic.


Renal colic, which typically comes in waves

lasting 20 to 60 minutes, is caused by peristaltic

contractions of the ureter as it attempts to expel

the stone.

It typically begins in the flank or lower back,

often radiating to the groin or in men, to the

testes.

Renal colic can be associated with nausea and

vomiting.

COMPLICATIONS OF RENAL CALCULI

Chronic Urinary Tract Infection

RENAL OBSTRUCTION

UTERO-VESICAL REFLUX

HYDRO NEPHROSIS

PYELO NEPHROSIS

Acute Renal Failure

Chronic Renal Failure

DIAGNOSIS OF RENAL CALCULI

Diagnosis of kidney stones is made on the basis

of information obtained from the

History,

Physical examination,

Urinalysis, and

Radiographic studies

DIAGNOSIS OF RENAL CALCULI…

History and physical examination

Clinical diagnosis is usually made on the basis of

the location and severity of the pain, which is

typically colicky in nature (comes and goes in

spasmodic waves).

Physical examination may reveal fever and

tenderness at the costovertebral angle on the

affected side.


Urinalysis

Provides excellent information about renal function and

condition relative to fluids and Electrolytes

Urinalysis – know normal (color, odor, consistency &

related teaching)

Clean catch – know teaching of method and purpose

Culture and Sensitivity – know teaching

Urine chemistry pyuria, proteinuria, hematuria, and

wbc’s count.


Urinalysis

pH: Indicates acidity or alkalinity

Normal range 4.5-8.0

Normal for urine 6.0 (acid)

Osmolality

pinpoints fluid balance

normal = 300-1200 mOsm/kg

example: as urine Osm. increases. urine

volume decreases (urine more concentrated)


Electrolytes

Not frequently measured

Requires 24-hour specimen

Changes in urinary electrolytes highly

suggestive of renal impairment

Sodium extremely suggestive of type of acute

renal failure

<20 mEq/L = pre-renal

Normal or high >20 mEq/L


Creatinine Clearance test

A direct measurement of glomerular

filtration rate

Best indicator of overall kidney function

Clearance expressed in ml/min

Normal: male 90-139mL/min

female 80-125mL/min

Measured by completing a 24 hr urine with

corresponding blood test.


Serum Creatinine

By-product of muscle metabolism

Appears in serum in amts. proportional to body

muscle mass

Fluctuates little – excreted entirely by kidneys

Normal about 0.7-1.5 mg/dL

• ↓ elderly and with low muscle mass

• Creatinine: >1.5 (>50% loss), >4.8 (75% loss)

and >10 (90% loss)


• BUN/Creatinine Ratio

Normal ratio = between 6:1 to 20:1

When both BUN and [Cr] levels increase at same

rate (ratio remains normal) – suggestive of renal

dysfunction

When BUN rises faster then [Cr] (ratio increased)

suggestive of dehydration, hypo perfusion,

protein catabolism, GI bleeds

DIAGNOSTICS: KUB

KUB (kidney, ureters,

bladder)

No preparation

No contrast

Shows:

• Stones

• Strictures

• Calcifications

• Obstructions

http://en.wikipedia.org/wiki/File:Kidney_stones_abdominal_X-ray.jpg

http://en.wikipedia.org/wiki/File:Kidney_stones_abdominal_X-ray.jpg

DIAGNOSTICS: INTRAVENOUS PYELOGRAM

IVP/ IVU

Series of x-ray after

dye injection

To measure size,

shape, etc of kidneys

Detect obstructions

Assess for masses

Client preparation and

teaching important

nursing function

DIAGNOSTICS: RENAL ARTERIOGRAM

Angiogram

Inject contrast into renal artery via femoral catheter

Visualize renal vascular abnormalities

Same prep as IVP

Monitor for bleeding after procedure

DIAGNOSTICS: MRI: ARTERIAL

New and thought to

be more useful than

other artery/venous

grams

Very expensive

DIAGNOSTICS: CYSTOGRAM

Cystogram

Contrast into

bladder

Evaluate bladder

and vesicoureteral

reflux

DIAGNOSTICS: RETROGRADE PYELOGRAM

RETROGRADE

PYELOGRAM

x-ray after contrast

into kidneys.

Done by

cystoscope and

urethral catheters

placed into renal

pelvis

DIAGNOSTICS OF RENAL CALCULI

• Ultrasound – differentiates between fluid and

mass, notes obstructions (no dye)

• Cystoscopy – direct visualization of bladder, can

be used for diagnosis or treatment (no dye)

• Biopsy – used for definitive diagnosis (no dye)

MANAGEMENT OF RENAL CALCULI

• Medical management

• Surgical management

• Nursing management

MANAGEMENT OF RENAL CALCULI

Medical management

• 85% of the time, it is possible to spontaneously

pass a kidney stone with urination

• Stones larger than 6 millimeters will almost

always require some form of intervention,

however.

• Assuming there is no high-grade obstruction or

associated infection in the urinary tract, and

symptoms are relatively mild, various non-

surgical measures can be used to encourage the

passage of a stone.

MANAGEMENT OF RENAL CALCULI…

Analgesia

requires intravenous administration of NSAIDs

or opioids in an emergency department setting.

Intravenous acetaminophen appears to be

effective.


Alpha adrenergic blockers

as tamsulosin (Flomax) may increase the

spontaneous passage of the stone by 30%.


Diuretics (dietary and medicinal)

One of the recognized medical therapies for

prevention of stones is the thiazide diuretics.

Thiazides inhibit the formation of calcium-

containing stones by reducing urinary calcium

excretion, an effect independent of their

diuretic properties.


Urine alkalinization

The mainstay for medical management of uric

acid stones is alkalinization (increasing the

pH) of the urine. Uric acid stones are among

the few types amenable to dissolution therapy,

referred to as chemolysis.

Acetazolamide (Diamox) is a medication that

alkalinizes the urine.


Allopurinol

For people with hyperuricosuria and calcium

stones, Allopurinol (Zyloprim) is one of the

few treatments.


Allopurinol interferes with the production of

uric acid in the liver.

The drug is also used in patients with gout or

hyperuricemia (high serum uric acid levels).

Dosage is adjusted to maintain a reduced

urinary excretion of uric acid.

Serum uric acid level at or below

6 milligrams/100 mL) is often a therapeutic

goal for patients with gout or hyperuricemia.


Diet for the calcium stones ( acid ash with limited

intake of calcium and milk products

for oxalates stones ( alkaline ash with limited intake of foods high in oxalates

for uric acid stones ( alkaline ash with limited intake of foods high in purine

A high fluid of 3000ml per day after episode of urolithiasis to produce urine output of 2L per day

Intravenous therapy (fluid replacement )

Activity as tolerated


Surgical management

Invasive management

Non invasive managements


Surgical management

Non invasive managements

Electro hydraulic lithotripsy

Ultrasonic lithotripsy

Laser impulse (holmium laser)

Extra corporeal shock wave lithotripsy


Electro hydraulic lithotripsy


Ultrasonic lithotripsy

Laser impulse

Extra corporeal shock wave lithotripsy

Extracorporeal shock wave lithotripsy (ESWL)

involves the use of a lithotriptor machine to

deliver externally-applied, focused, high-

intensity pulses of ultrasonic energy to cause

fragmentation of a stone over a period of

around 30–60 minutes.

http://en.wikipedia.org/wiki/File:Lithotriptor_machine.jpg

http://en.wikipedia.org/wiki/File:Lithotriptor_machine.jpg


Surgical management

Invasive managements

Percutaneous nephrostolithotomy

Cystolithophaxy

Pyelolithotomy (incision into renal pelvis)

Cystotomy(bladder calculi)

Nephrotomy

Ureteroscopic surgery


Nursing management

Maintain proper nutrition

Force fluids 3 Liter / day

Assess renal status

Monitor and record vital signs, urine output,

input and output, daily weight, specific gravity,

lab studies, and urine pH.

Administer medication as prescribed

Allay the patient anxiety


Continue straining urine and giving warm baths

and warm soaks to flanks to reduce pain

Instruct on home care

Increase fluid intake during hot

Weather, illness, and exercise

Void when urge is felt

Test urine PH

Increase fluid at night and void frequently

NURSING DIAGNOSIS

• Acute pain related to irritation of stone and inadequate pain control or comfort as manifested by complaints of pain, facial grimicing, restlessness.

• Ineffective therapeutic regimen management related to lack of knowledge about prevention, recurrence, diet, fluid requirement as manifested by questions that indicate lack of knowledge.

renal calculli veeresh vg rn

Health & Medicine

renal system

extra renal fluid loss

formation of stones

uric acid stones

annual incidence

incidence of urolithiasis

increased risk of dehydration

increased sweating