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Renal Stones DR. Gehan Mohamed

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about kidney stones aimed at primary care md ... DR. Gehan Mohamed pyonephrosis Pyonephrosis,pyoureter pyonephrosis pyonephrosis Medical Treatment for renal stones ... – PowerPoint PPT presentation

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Title: Renal Stones DR. Gehan Mohamed


1
Renal Stones DR. Gehan Mohamed
2
Learning objectives
  • 1- define renal stones and know the alternative
    names.
  • 2- understand the causes and risk factors for
    the formation of nephrolithiasis.
  • 3- mention the Inhibitors of Spontaneous
    Crystallization in urine.
  • 4- list the different types of renal stones
  • 5- understand cause , site of the renal colic.
  • 6- mention the important investigations needed
    for diagnosis of nephrolithiasis.
  • 7- list complications and methods of treatment
    for renal stones.

3
How is Urine formed? 1- blood filteration through
glomeruli 2- tubular reabsorption 3- tubular
secretion
4
Kidney Stones
  • Definition are hard deposits of mineral and
    acid salts on the inner surfaces of the kidneys
  • Alternative names include
  • Renal Lithiasis
  • Nephrolithiasis (Kidney Stone Disease)
  • Renal Calculi
  • Stones are classified by
  • - Their location in the urinary system
  • - Their composition of crystals.
  • - Their size either small or large.

5
Inhibitors of Spontaneous Crystallization
  • Normal urine contains chelating agents(i.e agents
    have ability to make bonds with another
    substances) such as citrate that inhibit the
    nucleation, growth, and aggregation of
    calcium-containing crystals.
  • Other endogenous inhibitors include calgranulin
    (an S-100 calcium binding protein), Tamm-Horsfall
    protein

6
Causes of Stone formation
  • 1-Supersaturation of urine either due to
    Dehydration or due to increase level of minerals
    in urine such as (Ca,oxalate) ,uric acid lead
    to Crystal aggregation
  • 2- Bacterial Infection
  • - E.Coli infection increases protein matrix
    content in urine
  • - Proteus makes urine alkaline as it split
    urea into amonia making alkaline urine so
    fascilitate deposition of magnesium ammonium
    phosphate crystals (struvite stone).
  • 3-Imbalance of pH in urine
  • Acidic Uric acid,calcium oxalate Stones
  • Alkaline Calcium phosphate Stones
  • 4-Anatomic Abnormalities as Pelviureteric
    junction stenosis leading to urine stasis.

7
Risk Factors for renal stones
  • 1-family history is a factor in certain forms of
    stone disease such as cystinuria which is an
    inherited metabolic disorder.
  • 2- Occupation activities that keep people out in
    hot weather and increased sweating as in
    construction work, farming .
  • 3- Diet
  • - Low fluid intake lead to
    supersaturation of urine
  • - high dietary intake of
  • - animal protein produce purine
    which change to uric acid
  • - refined sugars, fructose
  • - grapefruit juice rich in vitamen C
    (ascorbate) which have the ability to change to
    oxalate.
  • 4- drugs as diuretics can cause dehydration.

8
Risk Factors
  • 5- crohns disease are associated with
    steattorhea, The fatty acids in the gut bind with
    intraluminal calcium leaving the oxalate to be
    absorbed by blood. net effect is hyperoxaluria.
  • 6- HYPERCALCAEMIA HYPERCALCIURIA either due to
  • - some diseases associated with
    hypercalcemia as hyperparathyroidism,sarcoidosis
    ,hyperthyroidism,myeloma,Vit. D
    Intoxication,Metastatic Malignant Neoplasms.
  • - while excessive supplemental calcium in
    diet do not appear to cause kidney stones and may
    actually protect against their development.This
    is perhaps related to the role of oral calcium in
    binding ingested oxalate in the gastrointestinal
    tract and prevent its reabsorption by blood so
    prevent hyperoxaluria and stone formation.

9
structure of Renal Stones
  • all urinary stones are composed of
  • crystalline material 98 which have a very
    limited solubility in urine .
  • mucoprotein 2 (matrix)
  • N.B The stone with branches formed within calyxes
    and pelvis is termed stag horn-like or
    coral-like stone

10
Stag horn stone is the stone with branches
formed within calyxes and pelvis is termed
stag horn-like or coral-like stone
11
Types of Renal Stones (cont.)
  • 1- calcium oxalate (75) need acidic urine.
  • 2- calcium hydroxyl phosphate (15) need
    alkaline urine.
  • 3- struvite magnesium ammonium phosphate
    10 is found mostly in women because of their
    increase chance of having chronic pyelonephritis.
  • 4- Uric acid stone (5 )
  • - occur in acidic urine with PH
    below 7 leading to crystal formation.
  • - common in patients with gout,high
    protein diet ,chemotherapy treatment.
  • - It is the only type that is truly
    radiolucent (can not be seen on a plain abdominal
    film.
  • 5- Cystine stones ( 1) of stones due to
    genetic abnormality in its metabolism leading to
    its leak through the kidneys and into the urine
    to form crystals.
  • .

12
Calcium oxalate stones
13
Stained and unstained microscopic image of a
calcium oxalate stone in urine
14
Calcium phosphate stones
15
Uric acid stone and shape of its crystals in urine
16
Cystine stones and shape of its crystals in urine
17
Commonest Site of Stone Development
  • Question Where in the Urinary Tract does urine
    reach its maximal concentration and can get
    stuck in the lumen?
  • Answer at the collecting duct in the renal
    papilla serves as the uterus for stone
    formation. It is here that urine has achieved
    its maximum concentration and hence is most
    likely to be supersaturated. Clumps of crystals
    become impacted in the opening of a collecting
    duct so that some of the crystals are now exposed
    to the urine in that calyx that comes from other
    collecting ducts

18
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19
Excretion of urine from body is essential to get
rid of excess body fluids, excess electrolytes
and waste products
20
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22
Diagnosis of renal calculi
  • Clinical pictures.
  • urine analysis
  • radiographic studies

23
Clinical Features
  • Asymptomatic if the stone donot cause any
    obstruction.
  • Severe flank pain colicky in nature (comes and
    goes in spasmodic waves). Pain in the back occurs
    when calculi produce an obstruction in the kidney
    or pain caused by peristaltic contractions of the
    ureter as it attempts to expel the stone
  • flank pain referred to genitalia
  • nausea, vomiting may mislead
  • Microhematuria if stone have rough surface.

24
Clinical picture of renal calculi
25
investigations
  • Urine analysis hematuria, infection,type of
    crystals.
  • X - Ray most of renal stones are radiopaque due
    to calcification except uric acid stones are
    radiolucent so not seen.
  • Intravenous urography(IVU) will show delayed
    function, hydronephrosis and ureteral dilatation
    to point of stone
  • Ultrasound can show hydronephrosis, stones.

26
Struvite crystals found on microscopic
examination of the urine
27
X- Ray showing radio opaque stone
28
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29
Complications of renal stones
  • 1- Calcular pyelonephritis
  • 2-obstructive uropathy with Reflux nephrosis
  • in the form of
  • - Hydronephrosis - dilatation of renal
    pelvis ,calyces with atrophy of renal parenchyma
    due to lower obstruction . Then
    Hydronephrosis lead to 2ry infection due to
    stasis of urine producing Pyonephrosis
  • So Pyonephrosis Hydronephrosis (dilatation)
    infection (pus)
  • 3-Kidney damage, scarring leading to Postrenal
    azotemia, renal failure .

30
Hydronephrosis
31
hydronephrosis
32
Hydronephrosis Hydroureter
33
pyonephrosis
34
pyonephrosis
35
Pyonephrosis,pyoureter
36
pyonephrosis
37
pyonephrosis
38
Medical Treatment for renal stones
  • Adequate water intake to reach urine level per
    day about 2 litres as Drinking enough water
    helps keep urine diluted and flushes away
    materials that might form stones that is the most
    important thing a person can do to prevent kidney
    stones.
  • Increase citrate intake present in lemon and
    orange juice . but citrus drinks may be helpful
    in preventing calcium oxalate stones and uric
    acid stones but they might be harmful for people
    who form calcium phosphate stones.
  • limit vitamen C,sodium ,animal protein,excess
    flouride in water.
  • Reducing salt intake is preferred to reducing
    calcium intake because Salt is made up of sodium
    and chloride. The sodium in salt, when excreted
    by the kidneys, causes more calcium to be
    excreted into the urine. High concentrations of
    calcium in the urine combine with oxalate and
    phosphorus to form stones.

39
  • Limit oxalate intake present in nuts, spinach,
    strawberries, nuts, dark chocolate, coffee and
    tea.
  • Change PH of urine to increase solubilty of the
    solutes.
  • Antibiotic intake with struvite type

40
Surgical Treatment
  • Surgery is usually needed if
  • The stone is too large to pass on its own
  • The stone is growing
  • The stone is blocking urine flow and causing an
    infection or kidney damage
  • The pain cannot be controlled

41
treatment for renal stones
  • 1- ESWL Extracorporeal shock-wave lithotripsy is
    used with stones smaller than a half an inch . It
    uses sound or shock waves to break up stones.
    Then, the stones leave the body in the urine.
  • 2- Percutaneous nephrolithotomy using endoscope
    is used for large stones. The stone is removed
    with tube that is inserted into the kidney
    through a small surgical cut.
  • 3- Ureteroscopy may be used for stones in the
    lower urinary tract.
  • 4- open surgery (nephrolithotomy) may be needed
    if other methods do not work or are not possible.

42
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