Renal calculi

RENAL CALCULI

1. Renal calculi Presented by Ms Jinumol Jacob 2 nd Year M.sc Nursing Student NUINS

2. INTRODUCTION Kidney stones (renal lithiasis, nephrolithiasis) are hard deposits made of minerals and salts that form inside in the kidneys. Kidney stones have many causes and can affect any part of urinary tract from kidneys to bladder . stones form when the urine becomes concentrated, allowing minerals to crystallize and stick together. Passing kidney stones can be quite painful, but the stones usually cause no permanent damage if they're recognized in a timely fashion.

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4. definition Renal Calculi or Nephrolithiasis is the formation of stone in the kidney. ( Ignatavicius) Kidney stones (renal lithiasis, nephrolithiasis) are hard deposits made of minerals and salts that form inside in the kidneys . ( Mayo clinic) A kidney stone is a hard object that is made from chemicals in the urine. The stone-forming chemicals are calcium, oxalate, urate, cystine, xanthine, and phosphate. (National kidney foundation )

5. INCIDENCE In the United States, kidney stone affects 1 in 11 people . it is estimated that 600,000 Americans suffer from urinary stones every year. In Indian population, about 12% of them are expected to have urinary stones and out of which 50% may end up with loss of kidney functions

6. ETIOLOGY Exact etiology is unknown. High urine acidity. Increased urine alkalinity. Obstruction with urinary stasis UTI with urea – splitting bacteria ( proteus , klebsiella , pseudomonas.)

7. Risk factors Metabolic factors such as increased urine level of calcium , oxalate, uric acid or citric acid etc. Climatic factors such as warm climates that cause increased fluid loss, low urine volume and increased solute concentration in urine. Dietary factors such as excessive amount of tea or fruit juices that elevate urinary oxalate level. Low fluid intake that increases urinary concentration. Genetic factors such as family history of stone formation, cystinuria etc. Life style factors .

8. Location of stones Kidney Ureter Bladder Urethra

9. TYPES OF STONES Calcium stone Oxalate stone Cysteine stone Struvite stone

10. Calcium stone Mainly include calcium oxalate and calcium phosphate stone Most stones (75%) are composed mainly of calcium oxalate crystals. Increased calcium concentrations in blood and urine promote precipitation of calcium and formation of stones. Causes of hypercalcemia (high serum calcium) and hypercalciuria (high urine calcium) includes Hyperparathyroidism ,Renal tubular acidosis , Excessive intake of vitamin D , Excessive intake of milk etc.

11. Uric acid stones 5 % to 10% of all stones Gout, acidic urine leads to formation of uric acid stone Diet high in purines such as Alcoholic beverages, seafood and shellfish, including anchovies, sardines , mussels etc. abnormal purine metabolism.

12. Struvite stones 15% of urinary calculi form in persistently alkaline, ammonia-rich urine caused by the presence of urease splitting bacteria such as Proteus, Pseudomonas, Klebsiella, Staphylococcus, or Mycoplasma species. Predisposing factors for struvite stones ( commonly called infection stones) include neurogenic bladder, foreign bodies, and recurrent UTIs .

13. Cystine stones 1 % to 2% of all stones occur in patients with a rare inherited defect in renal absorption of Cystine (an amino acid) and those who with acidic urine.

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15. CLINICAL FEATURES A kidney stone usually remains symptomless until it moves into the ureter. When symptoms of kidney stones become apparent, they commonly include : Sharp severe pain in the groin and/or side which results from the stretching, dilating and spasm of the ureter. Hematuria vomiting and nausea W hite blood cells or pus in the urine R educed amount of urine excreted B urning sensation during urination P ersistent urge to urinate F ever and chills if there is an infection

16. Pain Stones in the renal pelvis may be associated with an intense , deep ache in the costovertebral region. Pain originating in the renal area radiates anteriorly and downward toward the bladder in the female and toward the testis in the male. i f the pain suddenly becomes acute, with tenderness over the costovertebral area, and nausea and vomiting appear termed as renal colic

17. Continue.. Stones lodged in the ureter (ureteral obstruction) cause acute , excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia .It is called ureteral colic . Colic is mediated by prostaglandin E, a substance that increases ureteral contractility and renal blood flow and that leads to increased intraureteral pressure and pain. If the stone present in the bladder and obstruct the urine flow , produces the pain at suprapubic region along with bladder distension.

18. Hematuria Hematuria is often present because of the abrasive action of the stone. Dysuria Painful micturition is termed as dysuria. Obstruction in urine flow tend to cause the dysuria . Edema When the stones block the flow of urine, obstruction develops , producing an increase in hydrostatic pressure and distending the renal pelvis and proximal ureter . Thereby GFR decreases leads to sodium and water retention and gives rise to edema.

19. Pyuria Obstruction in urine flow, urinary retention and urinary stasis may cause the UTI and featured as pyuria . Associated symptoms Nausea , vomiting, diarrhea, abdominal discomfort. Features of infection Chill high grade fever dysuria

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21. DIAGNOSTIC MEASURES History collection General physical examination Urine culture Urine analysis Intravenous pyelography Ultra sound or CT Scan Blood investigations

22. Continue.. Urine analysis H aematuria and pyuria pH lesser 5.5 indicates uric acid stone pH greater 7.5 indicates struvite stone urine culture and drug sensitivity should done to detect infection . 24-hour urine test for measurement of calcium, uric acid , creatinine, sodium , citrate and oxalate.

23. CONTINUE.. Blood studies Hyperuracemia Hypercalcemia Neutrophilia Elevated serum parathyroid hormone

24. CONTINUE.. Stone chemistry Collection of stone through a strainer is useful. Analyze the stone chemically to find out the composition which helps in therapeutic management .

25. MANAGEMENT General Principles If small stone (< 4 mm) will be able to treat as outpatient,80 % will pass stone spontaneously with hydration . Hospitalized for intractable pain, persistent vomiting, high-grade fever, obstruction with infection . Medical management Surgical management Nursing management

26. Medical management Goal- Immediate goal- To relieve the pain until its causes can be eliminated. Long term goal (basic goal )- To eradicate the stone To determine the stone type To prevent nephron destruction To control infection To relieve any obstruction

27. CONTINUE.. Opioid analgesics or NSAIDs are administered to prevent shock and syncope that may result from the excruciating pain.eg Tramadol NSAIDs provide specific pain relief because they inhibit the synthesis of prostaglandin E . Most stones are 4mm or less in size and probably pass spontaneously. Hot baths or moist heat to the flank areas may also be useful.

28. CONTINUE… Fluids are encouraged. This increases the hydrostatic pressure behind the stone, assisting it in its downward passage. A high, around-the-clock fluid intake reduces the concentration of urinary crystalloids , dilutes the urine , and ensures a high urine output. Calcium stone Cellulose sodium phosphate ( Calcibind ) may be effective in preventing calcium stones. It binds calcium from food in the intestinal tract, reducing the amount of calcium absorbed into the circulation.

29. CONTINUE… Restrict calcium in diet Therapy with thiazide diuretics may be beneficial in reducing the calcium loss in the urine and lowering the elevated paratharmone levels . The urine may be acidified by use of medications such as ammonium chloride or aceto-hydroxamic acid. Sodium and protein restriction diet.

30. CONTINUE… Uric acid stone P urine diet such as shellfish, anchovies, asparagus , mushrooms, and organ meats are avoided. Allopurinol may be prescribed to reduce serum uric acid levels and urinary uric acid excretion. Proteins may be limited in diet

31. CONTINUE… Cystine stone Low-protein diet Penicillamine is administered to reduce the amount of cystine in the urine. Struvite stones . Control of infections by using antibiotic therapy. Eg Acetohydroxamic acid

32. others Tamsuloin or terazosin , - adrenergic blockers is administered (that relax the smooth muscle in the ureter can be used to facilitate the stone passage.) Adequate hydration should be maintained d ietry changes changes should be made ( sodium , potassium, calcium, purines should be limited in cusines )  

33. Surgical management Indications Stones are too large for spontaneous passage. ( usually greater than 7mm). Stones associated with bacteruria or symptomatic infections. Stones causing impaired renal functions. Stones causing persistent pain , nausea . Inability of patient to treat medically. Patients with only one kidney.

34. CONTINUE…. Nephrolithotomy – Incision into the kidney to remove the stone. Pyeloilthotomy - Incision on the renal pelvis for the stone removal. Ureterolithotomy - Removal of stone from the ureter, Cystotomy - Indicated for bladder calculi Cystolitholapaxy - an instrument is inserted through the urethra into the bladder, and the stone is crushed in the jaws of this instrument

35. Percutaneous Nephrolithotomy This is the removal of stone in the kidney through the skin. Patient lies in prone position Urologist identifies the ideal entry point with fluoroscopy and then passes a needle into the collecting system of the kidney. Once tract has been made in the kidney, other equipment such as an intracorporeal ultrasonic or laser lithotriptor can be used to break up and remove the stone.

36. Non surgical management Ureteroscopy Lithotripsy Endoscopic procedures Electrohydrolic lithotripsy Chemolysis

37. Ureteroscopy Ureteroscopy involves visualizing the stone and then destroying it. Access to the stone is accomplished by inserting a ureteroscope into the ureter and then inserting a laser, electrohydraulic lithotriptor, or ultrasound device is inserted through the ureteroscope to fragment and remove the stones. A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent.

38. LITHOTRIPSY Lithotripsy is a procedure used to eliminate calculi from the urinary tract. Lithotripsy technique includes Laser Lithotripsy. Extracorporeal shock – wave lithotripsy ( ESWL). Percutaneous ultrasonic lithotripsy. Electrohydraulic lithotripsy.

39. Laser lithotripsy Used to fragment urethral and large bladder stones. To access urethral stones , a ureteroscope is used to get close to the stone. A small fiber is inserted up the ureteroscope( tip which emit laser energy) can come in contact with stone. The intense energy break the stone into small pieces which can excreated or flushed out. Usually done under general anaesthesia.

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41. Extracorporeal shock – wave lithotripsy (ESWL ). ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney In ESWL, a high-energy amplitude of pressure, or shock wave, is generated by the abrupt release of energy and transmitted through water and soft tissues. When the shock wave encounters a substance of renal stone, a compression wave causes the surface of the stone to fragment. Repeated shock waves focused on the stone eventually reduce it to many small pieces. These small pieces are excreted in the urine, usually without difficulty .

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43. PERCUTANEOUS ULTRASONIC LITHOTRIPSY An ultrasonic probe is placed in the renal pelvis via a percutaneous nephroscope inserted through a small incision in the flank and is then positioned against the stone. The patient is given general or spinal anaesthesia for this procedure. The probe produces ultrasonic waves , which break the stone into sandlike particles.

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45. Electrohydraulic lithotripsy A n electrical discharge is used to create a hydraulic shock wave to break up the stone. A probe is passed through the cystoscope, and the tip of the lithotripter is placed near the stone. This procedure is performed under topical anesthesia. Continous saline irrigation flushes out the stone particles and all of the outflow drainage is strained, so that the particles can be analyzed. The calculi can also be removed by basket extraction.

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47. Chemolysis Chemolysis,is the stone dissolution using infusions of chemical solutions ( eg , alkylating agents, acidifying agents ) A percutaneous nephrostomy is performed, and the warm irrigating solution is allowed to flow continuously i nto the stone

48. NURSING DIAGNOSIS Acute pain related to effect of stones and inadequate pain relief measures INTERVENTIONS Determine and note location, duration, intensity (0–10 scale), and radiation. Document nonverbal signs such as elevated BP and pulse, restlessness. Implement comfort measures (back rub, restful environment ). Encourage use of focused breathing, guided imagery, divertsional activities . Apply warm compresses to back . Check and sustain patency of catheters when used.

49. CONTINUE… Impaired urinary elimination related to trauma or obstruction of ureters or urethra. INTERVENTIONS Determine patient’s normal voiding pattern and note variations . Record I&O and characteristics of urine. Promote sufficient intake of fluids . Encourage the patient to walk if possible. Irrigate with acid or alkaline solutions as indicated . Check laboratory studies (electrolytes, BUN, Cr ). Obtain urine for culture and sensitivities.

50. CONTINUE… Deficient knowledge related to unfamiliarity with information resources and lack of experience with urinary stones. Interventions Recall and analyze disease process and future expectations. Emphasize importance of increased fluid intake of 3–4L a day or as much as 6–8 L a day . Encourage patient to notice dry mouth and excessive diuresis and diaphoresis and to increase fluid intake whether or not feeling thirsty . Review dietary regimen, as individually appropriate. Promote regular activity and exercise program . Avoid the use of OTC drugs . Identify signs and symptoms requiring medical evaluation (recurrent pain, hematuria, oliguria ). Demonstrate proper care of incisions and catheters if present.

51. conclusion Renal calculi are a common cause of blood in the urine (hematuria) and pain in the abdomen, flank, or groin. They occur in one in 11 people at some time in their lifetimes with men affected 2 to 1 over women. Development of the stones is related to decreased urine volume or increased excretion of stone-forming components such as calcium, oxalate, uric acid, cystine , xanthine, and phosphate.

52. Research study A case–control study on environmental and biological risk factors for renal calculi persisting in a coastal Union Territory, India. RESULTS Study conclude that in costal union territories of India, female gender, illiteracy, high BMI, high sodium in drinking water, inadequate water consumption, borewell drinking water, soft-drink consumption, sedentary work, and family history of renal stones can lead to a significant increase in the risk of renal stone disease.

53. BIBLIOGRAPHY Ignatavicius , L inda workman ,Text book of “ Medical Surgical Nursing”Elsevier Publications,united states,7 th edition, 2 nd Volume, Pg no : 1508 -1510. Lewis,Chintamani , “ Text book of Medical Surgical Nursing” Elsevier Publications , New Delhi,3 rd Edition, 2 nd Volume , Pg no : 1003 -1008. B.T Basuvanthappa,Text book of “Medical surgical Nursing” Jaypee Publications , New Delhi , 3 rd Edition, volume – II , Pg no : 1152 -1154.