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Metabolic evaluation of stone

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Metabolic Evaluation, urolithiasis, kidney stone

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Metabolic evaluation of stone

  1. 1. Metabolic Evaluation & Prevention Strategies Presented by: Rojan Adhikari FCPS II Urology Resident SDNTCSpecific Metabolic evaluation Basic evaluation Stone Analysis
  2. 2. Stone disease profile: Recurrence • 52% in 10 years 1 • 100% if patients followed for more than 25 years 2 • 2-5% per year, the risk of recurrence increases with each new stone formed. 3 1. Uribarri et al, 2. Coe Fi et al, JAMA 3. Borghi L et al, 2002
  3. 3. Schneider et al, Urolithiasis etiology and diagnosis
  4. 4. GOALS OF Metabolic Evaluation • to prevent recurrent stone formation in high-risk stone producers, • to prevent extrarenal complications in associated systemic disorders
  5. 5. Why metabolic evaluation?? Renal stone and renal function loss R Todd Alexander et al. BMJ 2012;345:bmj.e5287
  6. 6. Diversity of etiology
  7. 7. Stone Recurrence Specific metabolic evaluation and metaphylaxis can lower the recurrence rate by 46% Nolde et al, Bonn team Walter et al, 2012
  8. 8. • Included 28 RCT of which 20 pharmacological and 8 diatery management . In the review 23 were of calcium stone , 2 struvite stone and 3 of other types • Treatment duration 1-5 years
  9. 9. Aim of Metabolic evaluation • Obtaining insight in dietary habits • Diagnosis of underlying systemic causes of urolithiasis • Determination of the risk for chronic kidney disease and metabolic bone disease
  10. 10. EAU 2020
  11. 11. Who should undergo stone analysis ? EAU 2020
  12. 12. FT-IR • Fourier Transformation – Infrared Spectroscopy
  13. 13. Risk classification • After stone passage, every patient should be assigned to a group • For correct classification, reliable stone analysis and basic evaluation of every patient are required. Low Risk High RIsk
  14. 14. General Preventive Measures
  15. 15. High risk stone formers
  16. 16. • Stone-specific metabolic evaluation
  17. 17. Urine sampling • two consecutive 24-hour urine samples. 1, 2 • Collecting bottles 5% thymol in isopropanol or boric acid (10 g powder per urine container) + stored at < 8°C during collection to prevent the risk of spontaneous crystallisation in the urine. 1 • Urine pH should be assessed during collection of freshly voided urine four times daily using sensitive pH-dipsticks or a pH-meter 1, 3 1. EAU 2020, 2. Elsheemy et al 2014 3. Ferraz et al 2006
  18. 18. • The container is colored to protect light sensitive preservatives • The preservative is added before the urine collection begins • On the morning of collection the patient empties his/her bladder • Collect all the urine even at the time of defecation • Collect the first urine passed next morning
  19. 19. TIM I NG • patient should be on self-determined diet under normal daily conditions and should ideally be stone free for at least 20 days 1, 2 1. EAU 2020 2. Norman et al, 1984
  20. 20. Calcium oxalate • Blood analysis: creatinine, sodium, potassium, ionised calcium (or total calcium + albumin), uric acid, and parathyroid hormone (PTH) (and vitamin D) in the case of increased calcium levels. • Urinalysis requires measurement of urine volume, urine pH profile, specific weight, calcium, oxalate, uric acid, citrate, sodium and magnesium. • 24 hour urine calcium citrate oxalate magnesium uric acid EAU 2020
  21. 21. Diagnostic and therapeutic algorithm for calcium oxalate stones EAU 2020
  22. 22. EAU 2020
  23. 23. Calcium phosphate • Blood analysis : creatinine, sodium, potassium, chloride, ionised calcium (or total calcium + albumin), and PTH (in the case of increased calcium levels). • Urinalysis includes measurement of: volume, urine pH profile, specific weight, calcium, phosphate and citrate. • 24 hour urine Calcium phosphate Citrate EAU 2020
  24. 24. Diagnostic and therapeutic algorithm for calcium phosphate stones EAU 2020
  25. 25. Diseases related to calcium stones Hyperparathyroidism • Stones occur in around 20% of patients with primary HPT • leading to hypercalcaemia and hypercalciuria • Stones of HPT patients may contain both calcium oxalate and calcium phosphate
  26. 26. Granulomatous diseases • Diseases, such as sarcoidosis, may be complicated by hypercalcemia and hypercalciuria • increased calcium absorption in the gastrointestinal tract and suppression of PTH
  27. 27. Renal tubular acidosis
  28. 28. Uric acid and ammonium urate stones • Blood analysis : creatinine, potassium and uric acid levels. • Urinalysis requires measurement of urine volume, urine pH profile, specific weight of urine, and uric acid level. Urine culture is needed in the case of ammonium urate stones. • 24 hour urine uric acid EAU 2020
  29. 29. Diagnostic and therapeutic algorithm for uric acid- and ammonium urate stones EAU 2020
  30. 30. Struvite stone • 24 hour urine not required URINE CULTURE EAU 2020
  31. 31. Diagnostic and therapeutic algorithm for infection stones EAU 2020
  32. 32. Factors predisposing to struvite stone formation
  33. 33. Cystine stones Blood analysis includes measurement of creatinine, and urinalysis includes measurement of urine volume, pH profile, specific weight, and cystine. • 24 hour urine cystine EAU 2020
  34. 34. Metabolic management of cystine stones EAU 2020
  35. 35. Xanthine stones • high risk of recurrence • Rare • Fluid intake and diet is recommended for general preventive measures
  36. 36. Summary of specific metabolic evaluation 24 hour urine Oxalate stone Phosphate stone Uric acid stone Struvite stone Cystine stone Calcium Oxalate Uric acid Citrate Magnesium Calcium Phosphate Uric acid - Cystine Total urine volume Urine pH Specific weight
  37. 37. Follow - up • first follow-up 24-hour urine evaluation is done after 8-12 weeks after initiation of therapy • 24 hour urine evaluation every 12 months is enough 1. EAU 2020 2. Norman et al, 1984
  38. 38. Summary • Kidney stones are preventable if we take an holistic approach • To maximize the efficacy of preventable regimens, appropriate data should be gathered through proper stone analysis and basic metabolic evaluation • Stone analysis should be done in every stone patients • All patients should be classified into a high risk or low risk group at the time of discharge • High risk patients should undergo evaluation and should be given opportunity for preventing recurrence
  39. 39. Thank You
  40. 40. 1. EAU 2. Assimos et al 2007 3. Hesse et al, 2002
  41. 41. Diagnostic classification of stones ? ? ? ? ? ? ? ? ? ? ? ?
  42. 42. Indications for a Metabolic Stone Evaluation • Recurrent stone formers • Strong family history of stones • Intestinal disease (particularly chronic diarrhea) • Pathologic skeletal fractures • Osteoporosis • History of urinary tract infection with calculi • Personal history of gout • Infirm health (unable to tolerate repeat stone episodes) • Solitary kidney • Anatomic abnormalities • Renal insufficiency • Stones composed of cystine, uric acid, struvite • Children
  • rohitnamdev6

    Mar. 7, 2021
  • ankurvarshneya8

    Jan. 15, 2021

Metabolic Evaluation, urolithiasis, kidney stone

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