I.

Introduction

Introduction

The Nephron

A kidney stone, also known as a renal calculus (from the Latin ren, "kidney" and calculus, "pebble") is a solid concretion or crystal aggregation formed in the kidneys from dietary minerals in the urine.

Urinary stones are typically classified by their location: in the kidney (nephrolithiasis), ureter (ureterolithiasis), or bladder (cystolithiasis), or by their chemical composition (calcium-containing, struvite, uric acid, or other compounds).

Kidney stones are a significant source of morbidity. 80% of those with kidney stones are men. Men most commonly experience their first episode between age 3040 years, while for women the age at first presentation is somewhat later.

Kidney stones typically leave the body by passage in the urine stream, and many stones are formed and passed without causing symptoms

If stones grow to sufficient size (usually at least 3 millimeters 0.12 in) they can cause obstruction of the ureter. Ureteral obstruction causes postrenal azotemia and hydronephrosis (distension and dilation of the renal pelvis and calyces), as well as spasm of the ureter

Definition

of Terms

Hydronephrosis Distension of the pelvis and calyces of the kidney by urine that cannot flow past an obstruction in a ureter. Calcium Oxalate A small colorless crystal that may be present in urine or may be component of renal calculi

Ph
A scale representing the relative acidity or alkalinity of a solution.

Calculi
Are masses of crystals, protein or other substance that are a common cause of urinary tract obstruction in adults.

Phosphate
A salt in phosphoric acid.

Struvite
Contain magnesium ammonium phosphate as varying levels.

Renal Colic
Moderate to severe pain often originating in the flank and radiating to the groin.

Idiopathic urolithiasis

Calcium

A condition whose exact etiology has not yet defined but hypercalciuria,hyperoxaluria, hyperurisucoria, hypercitaturia, are associated with calcium stones.

Cyrstalization
The process by which the crystals grows from a small nidus to a larger stones in the presence of supersaturated urine.

Matrix
Is an organic material that is formed in the presence of urea splitting pathogens.

Cystinuria
Disorder caused by an autosomal recessive trait that impairs cyctine reorption by the kidney tubules. In high concentration, cystine tends to precipitate in the urinary tract and form kidney or bladder stones.

Xanthinuria
Are genetic disorders of amino acid metabolism, and their excess in urine can cause stone formation ina presence of a low urine ph of 5.5 or less.

Lithotripsy
involves the use of a lithotriptor machine to deliver externallyapplied, focused, high-intensity pulses of ultrasonic energy to cause fragmentation of a stone over a period of around 3060 minutes

Common Diagnostic Exam

A.MRI shows stones B.Urinalysis shows red blood cells C.Ultrasound shows stones D.X-Ray shows stones E.CT Scan shows stones

Imaging Studies for the Evaluation of Nephrolithiasis (addindum)

Study
Abdominal radiography (kidney, ureter, and bladder)

Advantages
Easy to obtain Minimal radiation exposure Useful for following stone activity

Disadvantages
Sensitivity decreases without bowel preparation Provides no functional information Misses radiolucent stones Exposure to radiocontrast Radiation exposure Time-consuming

Intravenous urography

Good sensitivity and specificity Detects obstruction Diagnoses anatomic abnormalities of urinary tract Entire urinary tract visualized Easy to perform

Study
Ultrafast spiral computed tomography

Advantages
Excellent sensitivity and specificity Rapidly performed Detects all types of stones Helps diagnose other causes of symptoms Noninvasive and requires no contrast Noninvasive Can detect radiolucent stones Detects obstruction No radiation exposure

Disadvantages
Not universally available Expensive (although costs are decreasing) Radiation exposure

Ultrasonography

Decreased ability to detect mid- and lower ureteral stones Highly operatordependent

Factors that increase the cause of stone formation

Urinary Stasis
Increased Solute concentration occurs because of fluid depletion or an increased solute load.

Super saturation of urine

Increased concentration leads to the precipitation of crystals, such as calcium, uric acid and a phosphate.

Calcium
is one component of the most common type of human kidney stones, calcium oxalate. Some studies suggest that people who take supplemental calcium have a higher risk of developing kidney stones, and these findings have been used as the basis for setting the recommended daily intake (RDI) for calcium in adults

Other Electrolytes appear to influence the formation of kidney stones. For example, by increasing urinary calcium excretion, high dietary sodium may increase the risk of stone formation Fluoridation of drinking water may increase the risk of kidney stone formation by a similar mechanism, though further epidemiologic studies are warranted to determine whether fluoride in drinking water is associated with an increased incidence of kidney stones

Animal Protien
Diets in Western nations typically contain more animal protein than the body needs. Urinary excretion of excess sulfurous amino acids (e.g., cysteine and methionine), uric acid and other acidic metabolites from animal protein acidifies the urine, which promotes the formation of kidney stones.

The body often balances this acidic urinary pH by leaching calcium from the bones, which further promotes the formation of kidney stones. Low urinary citrate excretion is also commonly found in those with a high dietary intake of animal protein, whereas vegetarians tend to have higher levels of citrate excretion

Vitamins Despite a widely-held belief in the medical community that ingestion of vitamin C supplements is associated with an increased incidence of kidney stones, the evidence for a causal relationship between vitamin C supplements and kidney stones is inconclusive. While excess dietary intake of vitamin C might increase the risk of calcium oxalate stone formation,

The link between vitamin D intake and kidney stones is also tenuous. Excessive vitamin D supplementation may increase the risk of stone formation by increasing the intestinal absorption of calcium, but there is no evidence that correction of vitamin D deficiency increases the risk of stone formation

Inhibitor Substance
There are no conclusive data demonstrating a cause and effect relationship between alcohol consumption and kidney stones. However, some have theorized that certain behaviors associated with frequent and binge drinking can lead to systemic dehydration, which can in turn lead to the development of kidney stones

Risk Factors for stone formation causes either stasis or supersaturation

A.Immobility and a sedentary lifestyle which increase stasis B.Dehydration leads to dehydration C.Metabolic Disturbances result in increase in calcium or other ions in the urine D.Previous history of urinary calculi

A.High mineral content in water B.Diet high in purines, oxalates,. Calcium supplements and animal protiens C.UTI D.Prolonged indwelling catherization E.Neurologic Bladder F.History of female genital mutalition

Hallmark of sign and symptoms

A. Extreme flank pain that comes

slowly or quickly B. Hematuria C. Pain may radiate to lower abdomen, groin, scrotum, or labia

D.Nausea, vomiting and sweating associated with occurrence of pain E.Elevated blood pressure with pain

Nursing Interventions and Management

A. Dietary modifications needed based on content of stone. B. Monitor intake and Output C. Monitor pain level and response to pain medications D. Strain urine to obtain stone for analysis for laboratory

a)Adequate fluid intake b)Medications used to reduced chance of recurrence

Fluid Intake Drink at least 10 glasses of fluid/day and five glasses should be water Avoid grapefruit and apple juice Goal is urine output exceeding 2 L/day Sodium Intake Restrict to 2 to 3 g/day Animal Protien Restrict to 1g/kg body weight/day Oxalate-restricted dite( for hyperoxaluric pts) Avoid cocoa, beets, spinach, rhubarb, chard, kale, okra, sweet potatoes, endive, peanuts, chocolate Low Purine diet ( for hyperuricosuria pts) Avoid kidney, liver, sweetbreads, herring,salmon,sardines,mussels,scallops Limit all meat, poultry, seafoods, beans, lentils, spinach

Medical Management:

Increased Fluid
The most effective management strategy to facilitate passage of smallstones and to prevent the development of new ones.

Reduce Pain
Requires treatment with antispasmodic agnets. opiods and

Prevent Stone Recurrence

Diet modifications and medications may be required to prevent further calculus formation.

Implement Dietary Changes

Client with oxalate stones should avoid foods high in oxalate content

Administer Medication
Give thiazide diuretics such as hydrochlorothiazide. Allopurinol is prescribe only if a reduced purine diet fails and stones persist.

Selected Therapeutic Interventions for Nephrolithiasis (addindum)

Metabolic Abnormality Hypercalciuria Hyperoxaluria Hypocitraturia Hyperuricosuria Hyperuricosuria Acid urine Types of Therapeutic Intervention Stones Calcium Thiazide diuretics, amilaride, moderate daily calcium intake Calcium Adequate dietary calcium intake, avoid oxalate rich foods, magnesium supplements Calcium Oral citrate supplements (potassium citarte, sodium citrate Calcium Low-purine diet, allopurinol Uric acid Uric acid Low-purine diet, allopurinol Urinary alkalinization, oral citrate supplements, sodium bicarbonate, acetazolamide

Surgical Treatment for Nephrolithiasis

Lithotripsy shock waves are used to break the stone into very small pieces

Complications of Extracorporeal Shock-Wave (ESWL) Ecchymosis Perinephric hematoma (may result in hypertension) Pancreatitis (rarely) Renal colic Ureteral obstruction Sepsis

Stent placement to allow free flow of urine and passage of small stones or stone pieces

Stent Placement

A.Surgical removal of the stone. B.Ureteroscopic surgery C.Anatrophic nephrolithotomy

Percutaneous Nephrolithotomy

Nursing DX

 Acute pain related to irritation and spasm from stone movement in the urinary tract.

Interventions:
During acute phase, offer pain medication, antispasmodic and antiemetic. Force fluid intake and ambulate. Assist comfortable position

 Effective Therapeutic Regimen Management related to prevention of recurrent calculi

Increase fluid intake to 3 to 4L to flush the urinary system. Encourage client to drink full glass of water every hour Reach client for diet modification. Decreased intake of stone forming solutes in the diet , oxalates, purines and animal protiens.