Nephrolithiasis and Pyelonephritis

kidney stones and uti

1. NEPHROLITHIASIS ROD PRASAD GROUP 3A

2. INTRODUCTION Nephrolithiasis, or kidney stone disease, is a common, painful, and costly condition . Although nephrolithiasis is rarely fatal, patients who have had renal colic report that it is the worst pain they have ever experienced. Nephrolithiasis is a global disease. Data suggest an increasing prevalence, likely due to Westernization of Iifestyle habits (e.g. dietary changes, increasing BMI) . U p to 19% of men and 9% of women will develop at least one stone during their lifetime . The prevalence is -50% lower among black individuals than among whites . The incidence of nephrolithiasis also varies by age, sex, and race.

3. TYPES OF CALCULI It is clinically important to identify the stone type, which informs prognosis and selection of the optimal preventive regimen. There are various types of kidney stones : Calcium oxalate stones are most common(- 75 %) calcium phosphate ( - 1 5 %) uric acid (-8 %) struvite (-1 %) and cystine (<1 %) Many stones are a mixture of crystal types ( e.g. calcium oxalate and calcium phosphate) and also contain protein in the stone matrix. Rarely, stones are composed of medications, such as acyclovir, indinavir , and triamterene.

4. TYPES OF CALCULI

5. PATHOGENESIS

6. RISK FACTORS DIETARY Calcium Sodium Oxalate Animal protein High potassium intake Vitamin C supplementation Decreased fluid intake NON DIETARY Age Race Body size Environmental factors (hot, dry) Occupational factors Ethnicity URINARY Decreased urine volume Hypercalciuria High urine oxalate excretion Low urine citrate Urine uric acid levels Urine pH level ≤ 5.5 ( ≥ 6.5 for phosphate stones)

7. CLINICAL MANIFESTATIONS Severe pain (abdominal or flank) Pain in groin, labia or testicles Nausea and vomiting Fatigue Fever or chills Cloudy or foul smelling urine Dysuria, polyuria and hematuria High BP and respiration

8. RENAL COLIC PAIN When a stone moves into the ureter, the discomfort often begins with a sudden onset of unilateral flank pain . The intensity of the pain can increase rapidly, and there are no alleviating factors . The pain may radiate depending on the location of the stone. If the stone lodges in the upper part of the ureter, pain may radiate anteriorly. I f the stone is in the lower part of the ureter, pain can radiate to the ipsilateral testicle in men or the ipsilateral labium in women.

9. DIFFERENTIAL DIAGNOSIS OF PAIN LOCATION DIAGNOSIS Right ureteral pelvic junction Acute cholecystitis If the stone blocks the ureter as it crosses over the right pelvic brim Acute appendicitis Blockage at the left pelvic brim Acute diverticulitis Ureterovesical junction Patient may experience urinary urgency and frequency. Bacterial cystitis in women Other conditions Muscular or skeletal pain, herpes zoster, duodenal ulcer, AAA, ureteral stricture or foreign body obstruction

10. DIAGNOSIS HISTORY Number and frequency of episodes of kidney stones UTIs, bariatric surgery, gout, hypertension, and diabetes mellitus. A family history of stone disease may reveal a genetic predisposition. A complete list of prescriptions and over the counter medications as well as vitamin and minerals is essential. Dietary habits and fluid intake. PHYSICAL EXAMINATION Weight BP Costovertebral angle tenderness Lower extremity edema Signs of primary hyperparathyroidism and gout.

11. DIAGNOSIS LABORATORY EVALUATION Electrolyte, calcium, creatinine and uric acid PTH levels for exclusion Urinalysis for RBC and WBC 24-h urine samples while consuming their usual diet and usual volume of fluid . The following factors should be measured: Total volume, calcium, oxalate, citrate, uric acid, sodium, potassium, phosphorus, pH, and creatinine.

12. DIAGNOSIS IMAGING Helical CT scan Abdominal X ray Ultrasound Retrograde pyelogram Cystoscopy

13. TREATMENT INITIAL MANAGEMENT  fluids and analgesics Most stones < 5 mm will pass spontaneously Strain urine for stones STONE REMOVAL Intractable pain Severe obstruction Serious bleeding Infection Stones > 10 mm

14. METHODS OF REMOVAL Retrograde intrarenal surgery Pyelolithotomy and ureterolithotomy Lithotripsy Extracorporeal intracorporeal

15. PYELONEPHRITIS

16. INTRODUCTION I nflammation of the parenchyma and lining of renal pelvis of kidney. It causes the kidneys to swell and may permanently damage them . Pyelonephritis can be life-threatening . When repeated or persistent attacks occur, the condition is called chronic pyelonephritis. The chronic form is rare, but it happens more often in children or people with urinary obstructions.

17. RISK FACTORS Female : Shorter urethra Male : uncircumcised infant Bacterial colonization inside prepuce and urethra Catherization DIRECT : Bacteria carried directly into bladder during insertion INDIRECT: Facilitation of bacterial access via lumen of catheter Tracking up between outside catheter and urethral wall

18. RISK FACTORS Structural renal abnormalities, including vesicoureteric reflux (VUR). Calculi and urinary tract catheterisation. Stents or drainage procedures. Pregnancy. Diabetes. Primary biliary cirrhosis. Immunocompromised patients. Neuropathic bladder. Prostate enlargement.

19. ETIOLOGY GRAM NEGATIVE E.coli (common) Proteus mirabilis, Citrobacter , klebsiella , enterobacter , proteus pseudomonas aeruginosa GRAM POSITIVE Staph.saprophyticus , Staph . Epidermidis enterococcus, Corynebacteria L actobacilli The uropathogens causing pyelonephritis vary by clinical syndrome but are usually enteric gram-negative rods that have migrated to the urinary tract . The susceptibility patterns of these organisms vary by clinical syndrome and by geography.

20. ETIOLOGY VIRAL Rare Polyomaviruses , JC and BK strains Cytomegalovirus and rubella Korean hemorrhagic fever virus Mumps and HIV Recovered in urine in absence of UTI PARASITIC Fungi : candida and histoplasma capsulatum Protozoa : trichomonas vaginalis Helminth : schistosoma haematobium

21. PATHOGENESIS  Normal urine flow disruption ( obstruction ) Incomplete bladder emptying > 2-3ml residual urine infection ascent of infection pyelonephritis.

22. CLINICAL FEATURES Mild P yelonephritis : low-grade fever with or without lower-back or costovertebral -angle pain S evere P yelonephritis : High fever “picket-fence” 72hr Nausea vomiting flank and/or loin pain

23. FORMS OF PYELONEPHRITIS Emphysematous pyelonephritis: exclusively in diabetic patients production of gas in renal and perinephric tissues bilateral papillary necrosis rise in the serum creatinine level Xanthogranulomatous pyelonephritis: chronic urinary obstruction (often by staghorn calculi) chronic infection Suppurative destruction of renal tissue

24. LABORATORY DIAGNOSIS The Urine DipstickTest : Rapid diagnostic test Appearance of WBC in urine test for nitrite & leukocyte esterase Urinalysis : WBC in c ast shape due to of pyelonephritis No WBC, no infection Urine Culture Significant bacteriuria = 105 cfu /ml symptoms : 1 + ve cuture = infection Symptoms : 102 cfu /ml = propable infection Asymptomatic : 2 + ve cultures = infection False negative : antibiotics, antiseptics, renal TB , diuresis.

25. MICROSCOPY OF URINE Assessed with Gram-stained uncentrifuged urine Microscopic bacteriuria is found in >90% of specimens with colony counts of at least 105 / mL The detection of bacteria by urinary microscopy constitutes firm evidence of infection, but the absence of microscopically detectable bacteria does not exclude the diagnosi s Pyuria (WBC > 5/HPF) is demonstrated in nearly all acute bacterial UTIs Look also for RBCs, WBC casts Associated hematuria may indicate urinary calculi.

26. IMAGING Contrast-enhanced helical/spiral CT (CECT) scan is the best investigation in adults where diagnosis is in doubt, improvement does not occur after 72 hours of treatment, or deterioration occurs. Non-contrast helical/spiral CT scans will pick up moderate-to-severe disease but may be normal in milder cases. In pregnant women, ultrasound or MRI is preferred .

27. TREATMENT Fluoroquinolones the first- line therapy for acute uncomplicated pyelonephritis. Oral TMP-SMX (one double-strength tablet twice daily for 14 days) also is effective for treatment of acute uncomplicated pyelonephritis if the uropathogen is known to be susceptible. If the pathogen's susceptibility is not known and TMP SMX is used as an initial IV 1 g dose of ceftriaxone is recommended. Options for parenteral therapy for uncomplicated pyelonephritis include fluoroquinolones an extended- spectrum cephalosporin with or without anaminoglycoside

28. REFERENCE Wiener, C. (2008).  Harrison's principles of internal medicine . New York: McGraw-Hill, Medical Pub. Division. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672131 / https:// msdmanuals.com/professional/genitourinary-disorders/urinary-tract-infections-utis/chronic-pyelonephritis https:// patient.info/doctor/pyelonephritis

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