Objectives. Evaluation and treatment of kidney stones for the primary care provider. Disclosures. Presentation. Background. None

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1 Evaluation and treatment of kidney stones for the primary care provider Jason Bylund, MD University of Kentucky Division of Urology Objectives Review basic principles of evaluation of the patient with suspected kidney stone event Describe urgent or emergent clinical scenarios associated with stones Discuss medical and surgical treatment options for patients with stones 2 Disclosures None 3 Background Urinary tract stones, urolithiasis, will affect approximately 5-10% of American adults in their lifetime 1 Renal colic accounts for over a million ER visits annually 2 Rates higher in Stone Belt Presentation Acute stone episode vs incidental finding Common presenting symptoms: Flank pain radiating to groin (renal colic) Nausea/vomiting Hematuria Voiding symptoms (frequency, urgency, dysuria) Writhing or pacing 1

2 Obstructing ureteral stone Diagnosis History History of stones, risk factors, comorbidities, medications Physical exam Abdomen, CVA (no peritoneal signs) GU and rectal exam to rule out other causes Labs CBC, BMP, UA Imaging CT (low dose) stone protocol gold standard KUB radiopacity, monitoring Renal U/S select cases IVP useful for functional evaluation and anatomical mapping

3 Red flags Fever Evidence of UTI Solitary kidney Acute kidney injury Uncontrolled pain, nausea, vomiting Perinephric stranding Hydronephrosis Treatment? Pain control NSAIDs, narcotics, abx Emergent renal drainage? Stent vs percutaneous nephrostomy tube Medical expulsive therapy Alpha-blockers, IVFs? Elective surgical treatment Shockwave lithotripsy Ureteroscopy, laser lithotripsy Percutaneous surgery Laparoscopic/open surgery Percutaneous nephrostomy tube PCNT PCNT Cystoscopy with stent placement 3

4 Medical expulsive therapy If no indication for acute intervention, trial of passage is an option Likelihood of passage is inversely related to stone size and proximity to kidney 2 Likelihood of stone passage by size 3 : <5mm: roughly 2/3 5-10mm: less than half Alpha-blockers efficacy recently called into question Surgical options Shockwave lithotripsy Ureteroscopy Percutaneous nephrolithotomy Open or laparoscopic surgery Shockwave lithotripsy Clearance rates 74%, 73%, 82% for distal, mid, and proximal stones overall 3 Non-invasive Stone fragments pass on their own (hopefully) Ureteroscopy Clearance rates of 94%, 86%, and 81% for distal, mid, and proximal stones overall 3 Lasers and other lithotripters can be used with a variety of baskets and graspers to fragment and extract the stones 4

5 PCNL Most invasive Most effective for large stone burden Typically requires hospital stay Complications include: Bleeding Bowel injury Lung injury PCNL Stone analysis Calcium oxalate most common Calcium phosphate distal RTA Struvite associated with infection Uric acid associated with gout and other conditions Cystine metabolic disorder Metabolic evaluation Stone analysis Blood work BMP, Calcium, PTH, uric acid 24h urine Volume, electrolytes, stone inhibitors 5

6 31 32 Preventive measures Based on the results of the metabolic evauation, a variety of possible preventive measures can be implemented Lifestyle modifications Increased fluid intake (does not impact inhibitory substances) Decreased sodium intake Normal calcium intake Decreased red meat intake Medications Potassium citrate Hypocitraturia Alkalinization Chlorthalidone or hydrochlorothiazide Hypercalciuria Case #1 Healthy 34 year old with no history of stones presents with flank pain, nausea, and microscopic hematuria. Evaluation? Refer? 36 6

7 Case #2 52 year old with long history of stones presents with her typical renal colic Evaluation? Refer? (If fever?) Case #3 46 year old with long history of stones, no current symptoms, worried about future episodes Evaluation? Refer? Questions? UKMDs: 1 (800) References 1 Kraft KH and Pattaras JG. Medical management of Urolithiasis, AUA Update Series, Vol 26 #36, Pearle, MS. Management of the Acute Stone Event, AUA Update Series, Vol 27 #30, Preminger, et al Guideline for the Management of Ureteral Calculi, EAU/AUA Nephrolithiasis Guideline Panel,

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