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Kidney Stones (Nephrolithiasis) Audrey Ward - Coggle Diagram
Kidney Stones (Nephrolithiasis)
Audrey Ward
Pathogenesis
1.) Begins with supersaturation (lots of salt compared to fluid) of the urine and the salts turn into crystals through precipitation
Supersaturation could occur from dehydration, diuretics, after eating
Intake of too many crystal forming substances such as calcium, struvite, or uric acid outweighs the amount of fluid and crystal inhibitors in the body causing the development of crystals because the fluid and inhibitors cannot dilute or fight off the large amount of substances
2.) Crystals formed from precipitation get bigger through process of crystallization/aggregation
Majority of crystals can leave through micturition
Size of stone impacts ability to leave
Smaller than 5mm will be painful
Size of 1cm most likely will not pass on their own
Inability to pass urine or inflammation of urinary tract
What is aggregation of crystals?
Crystal forming substances begin to stick together and create bigger crystals
Due to their increasing size, they will not be able to be excreted through micturition (urination) if they are not stopped and treated
Can also be formed by the renal tubules attracting crystalline nidus (Randall Plaques) and combining it with matrix to make a stone
Stones cause the clinical manifestations if they are unable to pass through the urinary tract, usually caused by stretching of urinary tract due to blockage from stones
Most common types of stones
Calcium oxalate stones
Calcium phosphate stones
Struvite stones
Uric acid stones
Causes of kidney stones
Dehydration due to a low amount of fluids to dilute crystal forming substances and cannot produce enough urine without fluids to flush out the crystal forming substances
High levels of calcium in the body
Low levels of magnesium and citrate (crystal growth inhibiting substances) that help block stone formation
Diuretic use such as thiazides because they spare calcium with urination causing more calcium to build up in the body which is a common type of substance that forms kidney stones
Onset of renal colic pain
Stretching and spasms of the site of the obstruction from a kidney stones causes pain that radiates to the lower side of the back called renal colic pain
The level of pain is not determined by a big or small stone size but rather depends on the location of the obstruction
Onset of renal edema (swelling)
Renal edema is a response to the obstruction caused by kidney stones to help reduce pain but causes the kidney to get bigger
Complete Urethral Obstruction
Once the urethra is completely blocked due to the kidney stones, renal blood flow decreases continuously for weeks. The kidneys can become deprived of blood and nutrients leading to kidney injury.
Risk Factors
Alkaline urine can cause calcium phosphate and struvite stones to form
Acidic urine can cause uric acid stones to form
Inability to pass urine due to conditions such as BPH because the stones cannot pass easily through the urinary tract
Family history of kidney stones increases likeability of Nephrolithiasis
Already having kidney stones in the past increases your risk for having more kidney stones in the future
Being male
Due to the higher calorie diet with more protein and salt increases their risk for kidney stone formation
Easier for females to pass stones because of a shorter urethra creating less room to get stuck
Dehydration because fluids can help pass clumps of minerals through the urinary tract to reduce risk of stone formation
Most common in Caucasians
A diet high in sodium or calcium causing the kidneys having to filter out more electrolytes
Food items that are high in sodium
Canned meats or vegetables, frozen pizzas, soup, fast food, crackers, pretzels, processed cheeses, chips, soy sauce, TV dinners or frozen meals
Foods items that are high in calcium
Milk, spinach, broccoli, vanilla ice cream, green leafy vegetables, fish with bones in it, and soybeans
Obesity or having a high body mass index
Digestive issues such as surgery or IBD can affect absorption process of substances that are likely to cause stone formation
Excessive use of supplements or medicine such as antacids that contain calcium can increase the risk of Nephrolithiasis
Seasonal factors such as summer and hot weather creates an environment that promotes dehydration
References
Chirag N Dave, M. D. (2020, February 28). Nephrolithiasis. Practice Essentials, Background, Anatomy.
https://emedicine.medscape.com/article/437096-overview#a6
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Huether, S. E., & McCance, K. L. (2020). Understanding pathophysiology (7th ed.).
St. Louis, MO: Elsevier. Doi:9780323639088
Mayo Foundation for Medical Education and Research. (2020, May 5). Kidney stones. Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/kidney-stones/symptoms-causes/syc-20355755
.
Omudhome Ogbru, P. D. (2019, February 28). 22 pain Medication withdrawal Symptoms, side effects & uses.
https://www.medicinenet.com/narcotic_analgesics-oral/article.htm#what_are_narcotic_pain_medications_opioids_analgesics
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Incidence/Prevalence
Most patients can pass the stones without needing hospitalization
Seen more commonly in males compared to females
Rarely seen in children
At risk the most of developing kidney stones is from ages 35-45 years old
Commonly developed from ages of 20-49 years old
Caucasians have a higher incidence of getting kidney stones than African Americans
Those of a lower economic status are at a lower risk of developing Nephrolithiasis
Probability of a Caucasian male in the United States getting Nephrolithiasis by 70 years old is 1 in 8
Clinical Manifestations
Renal colic pain (lower side of the back)
Burning while voiding
Pain while voiding
Intermittent pain that radiates through abdomen and pelvic region
Unusual urine color such as brown or pink
Frequent urination
If an infection occurs with the kidney stones then a fever is likely to be noted
Nauseous
Vomiting
Suprapubic pain
Diagnostics
Assessing the clinical manifestations is initially used to narrow down options of diagnosing
Urinary sediment test is used to determine if any blood cells or microorganisms are present in the urine
Microscopic Urinalysis is used to identify any crystals, blood cells, and bacteria
Blood tests identify if there is a build up of stone-forming factors such as uric acid
24 hour urine collection can show how many stone-forming factors are present in the urine and can determine any issues with voiding
Tests to assess the patient's renal function
Serum Creatinine, if high it means the kidneys are struggling to clear it
Urinary pH, if abnormal it can indicate the kidneys are struggling with acid-base balance
CT scan is a form of medical imaging that can be used to view the abdominopelvic region and can show small or large kidney stones
Intravenous Pyelogram (IVP) which is an x ray that can be used to show the kidneys and urinary tract in a more focused format to clearly diagnose the issue
Renal Ultrasound is a medical imaging tool that uses sound waves to produce an image of the kidneys and urinary bladder
Plain abdominal radiograph is an x-ray of the abdomen that shows foreign objects such as kidney stones and their shape and size
After passing some or all of the stones an analysis of the stones is used to determine what the stone is made of to prevent further stones in the future
Treatments
Drinking plenty of fluids will help prevent the formation and help pass a kidney stone
IV fluids might be given to help pass a stone
Decrease intake of substances that cause stone formation such as foods high in calcium or struvite
Small Stones
Hydration
NSAIDs for pain relief
Will likely pass spontaneously
Uterescope can be used to find the stone and can be broken down even smaller if necessary to pass through the urine
Large Stones
Extracorporeal Shock Wave Lithotripsy is a medical procedure that breaks up larger stones into smaller pieces to be excreted through the urine
Percutaneous Nephrolithotomy is a medical procedure to remove larger stones by making an incision to remove the stone
Medications that support the passing of stones and/or relieve pain
NSAIDs
Assist in pain relief by decreasing pain and inflammation. Inhibit COX that makes prostaglandins that cause pain.
Ibuprofen, Meloxicam, Ketorolac Intranasal, Aspirin
Side Effects
Abdominal pain, diarrhea, indigestion, nausea, belching, vomiting, flatulence
Acetaminophen
Tylenol, Ofirmev, Mapap
Non-opioid analgesic for pain relief with no anti-inflammatory properties but used for moderate relief of pain
Side Effects
Blood, tarry stools, bloody urine, nausea, GI upset
Narcotic Analgesics
Help relieve renal colic pain by acting on the Central Nervous System's (CNS) opioid receptors
Side Effects
Constipation, nausea, sedation, dizziness, respiratory depression, headache, abdominal pain
Codeine, Hydrocdone, Butorphanol, Oxycodone-acetaminophen, Meperidine, Nalbuphine
Alpha blockers
Tamsulosin and Terazosin
Relax smooth muscles to help stones pass through the urethra
Side Effects
Difficulty urinating, lower back pain, fever, chills, chest pain, dizziness, irregular heartbeat
Antibiotics
Ampicillin, Gentamicin, Ciprofloxacin, Levofloxacin, Ofloxacin
Treats hydronephrosis (common complication in Nephrolithiasis due to an obstruction of urine flow from the kidney stones), infections are common with this condition and antibiotics help fight off the infection
Side Effects
Nausea, vomiting, diarrhea, bloating, indigestion, stomach cramping, fever
Corticosteroids
Prednisone and Prednisolone
Decrease inflammation of the urethra to decrease pain and help stones be able to pass through easier
Side Effects
Agitation, aggression, irritability, headaches, weight gain, dizziness, mood changes, irregular heartbeats
Calcium Channel Blockers
Nifedipine
Block calcium channels to induce smooth muscle relaxation to help the passage of stones
Side Effects
Swelling of the arms/legs, headache, muscle cramps, weakness, shortness of breath, cough
Medications used to prevent the formation of kidney stones
Xanthine Oxidase Inhibitors
Allopurinol
Reduces the production of uric acid to help prevent the production of uric acid kidney stones
Side Effects
Joint pain common in ankles/knees/toes, joint stiffness, rash, dizziness, drowsiness, constipation, joint inflammation
Surgical procedures to remove stones
Stent in the kidney to drain urine and remove the stone
Possible parathyroid gland removal if caused by hyperparathyroidism causing extra calcium to be in blood and urine creating kidney stones