Renal stones ayman mohamed faculty of nursing minia university

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Renal stones

Out lines:-1-Introduction to the Urinary Tract

2-Definition ofRenal stones.

3-Causes Renal stones.

4-Types of renal stones:

5-Risk factors.

6-Symptoms of kidney stones include.

7-Diagnosis of renal stones.

8-Medical Therapy.

9-Surgical Treatment.

10-Prevention of stone formation.

11-nursing care.

A-patient teatching

B-nursing process.

C- prevention of recurence stone formation.

12-Complications list for Kidney stones.


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1-Introduction to the Urinary Tract

The urinary tract, or system, consists of the kidneys, ureters, bladder,and urethra. The kidneys are two bean-shaped organs located belowthe ribs toward the middle of the back, one on each side of the spine.The kidneys remove extra water and wastes from the blood,producing urine. They also keep a stable balance of salts and othersubstances in the blood. The kidneys produce hormones that help

build strong bones and form red blood cells.

The urinary tract.

Narrow tubes called ureters carry urine from the kidneys to thebladder, an oval-shaped chamber in the lower abdomen. Like aballoon, the bladders elastic walls stretch and expand to store urine.They flatten together when urine is emptied through the urethra to

outside the body.

2-Definition ofRenal stones:

Kidney stones (renal lithiasis) are small, hard deposits of mineral andacid salts on the inner surfaces of your kidneys. Normally, thesubstances that make up kidney stones are diluted in the urine. Whenurine is concentrated, though, minerals may crystallize, stick togetherand solidify. The result is a kidney stone. Most kidney stones contain

calcium.


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3-CausesRenal stones

Kidney stones can be due to underlying metabolic conditions, such asrenal tubular acidosis,[7]Dent's disease[13], Hyperparathyroidism[14] andmedullary sponge kidney.[15] Many health facilities will screen for suchdisorders in patients with recurrent kidney stones. This is typicallydone with a 24 hour urine collection that is chemically analyzed fordeficiencies and excesses that promote stone formation. Kidneystones are also more common in patients with Crohn's disease.[16]

There has been some evidence that water fluoridation may increasethe risk of kidney stone formation. In one study, patients withsymptoms ofskeletal fluorosis were 4.6 times as likely to developkidney stones.[17] However, fluoride may also be an inhibitor of urinarystone formation.[18]

There is a longstanding belief among the mainstream medicalcommunity that vitamin C causes kidney stones, which may be basedon little science.[19] Although some individual recent studies havefound a relationship[20] there is no clear relationship between excessascorbic acid intake and kidney stone formation. [21]

4-Types of renal stones:

Calcium oxalate stones

The most common type of kidney stone is composed ofcalciumoxalate crystals, occurring in about 80% of cases,[7] and the factorsthat promote the precipitation of crystals in the urine are associatedwith the development of these stones.

Common sense has long held that consumption of too much calciumcould promote the development of calcium kidney stones. However,current evidence suggests that the consumption of low-calcium dietsis actually associated with a higher overall risk for the development ofkidney stones.[22] This is perhaps related to the role of calcium inbinding ingested oxalate in the gastrointestinal tract. As the amount ofcalcium intake decreases, the amount of oxalate available forabsorption into the bloodstream increases; this oxalate is then

excreted in greater amounts into the urine by the kidneys. In the
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urine, oxalate is a very strong promoter of calcium oxalateprecipitation, about 15 times stronger than calcium.

Uric acid (urate)

About 510% of all stones are formed from uric acid.[7] Uric acidstones form in association with conditions that cause hyperuricosuriawith or without high blood serum uric acid levels (hyperuricemia); andwith acid/base metabolism disorders where the urine is excessivelyacidic (low pH) resulting in uric acid precipitation. A diagnosis ofuricacid nephrolithiasis is supported if there is a radiolucent stone, apersistent undue urine acidity, and uric acid crystals in fresh urinesamples.[23]

Other types

Other types of kidney stones are composed ofstruvite (magnesium,ammonium and phosphate); calcium phosphate; and cystine.

The formation of struvite stones is associated with the presence ofurea-splitting bacteria, most commonly Proteus mirabilis (but alsoKlebsiella, Serratia, Providencia species). These organisms arecapable of splitting urea into ammonia, decreasing the acidity of the

urine and resulting in favorable conditions for the formation of struvitestones. Struvite stones are always associated with urinary tractinfections.

The formation ofcalcium phosphate stones is associated withconditions such as hyperparathyroidism and renal tubular acidosis.

Formation of cystine stones is uniquely associated with peoplesuffering from cystinuria, who accumulate cystine in their urine.

Urolithiasis has also been noted to occur in the setting of therapeuticdrug use, with crystals of drug forming within the renal tract in somepatients currently being treated with Indinavir, Sulfadiazine orTriamterene[24].

5-Risk factors:

These factors may increase your risk of developing kidney stones:

Lack of fluids. If you don't drink enough fluids, especially water,your urine is likely to have higher concentrations of substances
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that can form stones. That's also why you're more likely to formkidney stones if you live in a hot, dry climate or exercisestrenuously without replacing lost fluids.

Family or personal history. If someone in your family has

kidney stones, you're more likely to develop stones too. And ifyou've already had one or more kidney stones, you're atincreased risk of developing another.

Age and sex. Most people who develop kidney stones arebetween 20 and 70 years of age. Men are more likely todevelop kidney stones than are women.

Diet. A high-protein, high-sodium and low-calcium diet mayincrease your risk of some types of kidney stones.

Limited activity. You're more prone to develop kidney stonesif you're bedridden or very sedentary for a long period of time.That's partly because limited activity can cause your bones torelease more calcium.

Obesity. High body mass index (BMI), increased waist sizeand weight gain have been linked to kidney stones in long-termstudies of large populations. The relationship is strongest inwomen.

High blood pressure. Having high blood pressure doublesyour risk of forming kidney stones.

Gastric bypass surgery, inflammatory bowel disease orchronic diarrhea. Changes in the digestive process affectyour absorption of calcium and increase the levels of stone-forming substances in your urine.

6 -Symptoms of kidney stones include:

Localization of Kidney stone pain Colicky pain: The pain is 'loin to groin'. The pain may be felt

over back or side, radiates to the groin, scrotum in men and thelabia in women. It is often described as 'the worst pain' everexperienced, even more painful than gunshot, surgery, fracturedbones and so on.

Hematuria: blood in the urine, due to minor damage to inside

wall of kidney, ureter and/or urethra. Pyuria: pus in the urine.
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Dysuria: burning on urination when passing stones (rare). Moretypical of infection.

Oliguria: reduced urinary volume caused by obstruction of thebladder or urethra by stone, or extremely rarely, simultaneousobstruction of both ureters by a stone.

Abdominal distention. Nausea/vomiting: embryological link with intestine stimulates

the vomiting center. Fever and chills. Hydronephrosis[26] Postrenal azotemia: when kidney stone blocks ureter[27] frequency in micturation: Defined as an increase in number of

voids per day (>than 5 times), but not an increase of total urineoutput per day (2500ml). That would be called polyuria.

dribbling of urine loss of appetite loss of weight

7 -Diagnosis of renal stones:

Star shaped bladder urolith on an X-ray of the pelvis.

Bilateral kidney stones on abdominal X-ray. Not to be confused withphleboliths seen in the pelvis.

Clinical diagnosis is usually made on the basis of the location andseverity of the pain, which is typically colic in nature (comes and goesin spasmodic waves). Pain in the back occurs when calculi producean obstruction in the kidney.[3]

Imaging is used to confirm the diagnosis and a number of other testscan be undertaken to help establish both the possible cause andconsequences of the stone.

A- X-rays:
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The relatively dense calcium renders these stones radio-opaque andthey can be detected by a traditional X-ray of the abdomen thatincludes the Kidneys, Ureters and BladderKUB.[5] This may befollowed by an IVP (Intravenous Pyelogram; (IntraVenous Urogram(IVU) is the same test by another name)) which requires about 50 mlof a special dye to be injected into the bloodstream that is excreted bythe kidneys and by its density helps outline any stone on a repeatedX-ray. These can also be detected by a Retrograde pyelogram wheresimilar "dye" is injected directly into the ureteral opening in thebladder by a surgeon, usually a urologist.

About 10% of stones do not have enough calcium to be seen onstandard x-rays (radiolucent stones).

B- Computed tomography:

Computed tomography without contrast is considered the gold-standard diagnostic test for the detection of kidney stones. All stonesare detectable by CT except very rare stones composed of certaindrug residues in the urine.[5] If positive for stones, a single standard x-ray of the abdomen (KUB) is recommended. This gives a clearer ideaof the exact size and shape of the stone as well as its surgicalorientation. Further, it makes it simple to follow the progress of the

stone by doing another x-ray in the future.

Draw back of CT scans include high radiation exposure and cost.

C- Ultrasound:

Ultrasound imaging is useful as it gives details about the presence ofhydronephrosis (swelling of the kidneysuggesting the stone isblocking the outflow of urine).[5] It can also be used to detect stones

during pregnancy when x-rays or CT are discouraged. Radiolucentstones may show up on ultrasound however they are also typicallyseen on CT scans.

Some recommend that US be used as the primary diagnostictechnique with CT being reserved for those with negative US resultand continued suspicion of a kidney stone. This is due to its lessercost and lack of radiation exposure.[28]

D- Other:

Other investigations typically carried out include:[5]
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If struvite stones cannot be removed, a doctor may prescribe amedicine called acetohydroxamic acid (AHA). AHA is used with long-term antibiotic medicines to prevent the infection that leads to stonegrowth.

People with hyperparathyroidism sometimes develop calcium stones.Treatment in these cases is usually surgery to remove the parathyroidglands, which are located in the neck. In most cases, only one of theglands is enlarged. Removing the glands cures the patients problemwith hyperparathyroidism and kidney stones

9-Surgical Treatment:

Treatment for kidney stones varies, depending on the type of stoneand the cause. You may be able to move a stone through your urinarytract simply by drinking plenty of water as much as 2 to 3 quarts(1.9 to 2.8 liters) a day and by staying physically active.

Stones that can't be treated with more-conservative measures either because they're too large to pass on their own or because theycause bleeding, kidney damage or ongoing urinary tract infections may need professional treatment. Procedures include:

Extracorporeal shock wave lithotripsy (ESWL). {non

invasive procedure}.

uses highly focused impulses projected and focused fromoutside the body to pulverize kidney stones anywhere in theurinary system. The stone usually is reduced to sand-likegranules that can be passed in the patient's urine. Large stonesmay require several ESWL treatments. The procedure should notgenerally be used for struvite stones, stones over 1 inch indiameter, or in pregnant women.

Percutaneous nephrolithotomy.

When ESWL isn't effective, or the stone is very large, your

surgeon may remove your kidney stone through a small incisionin your back using an instrument called a nephroscope.


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Ureteroscopic stone removal.

This procedure may be used to remove a stone lodged in aureter. The stone is snared with a small instrument(ureteroscope) that's passed into the ureter through your bladder.Ultrasound or laser energy also can be directed through thescope to shatter the stone. These methods work especially wellon stones in the lower part of the ureter.

Parathyroid surgery.

Some calcium stones are caused by overactive parathyroidglands, which are located on the four corners of your thyroidgland, just below your Adam's apple. When these glands

produce too much parathyroid hormone, your body's level ofcalcium can become too high, resulting in excessive excretion ofcalcium in your urine. Most often, this is the result of a smallbenign tumor in one of your four parathyroid glands. A doctor cansurgically remove the tumor.

10-Prevention of stone formation.

Preventive strategies include dietary modifications and sometimesalso taking drugs with the goal of reducing excretory load on thekidneys:[35][22]

Drinking enough water to make 2 to 2.5 liters of urine per day. A diet low in protein, nitrogen and sodium intake. Restriction ofoxalate-rich foods, such as chocolate, nuts,

soybeans,[36]rhubarb and spinach, plus maintenance of anadequate intake of dietary calcium. There is equivocal evidencethat calcium supplements increase the risk of stone formation,though calcium citrate appears to carry the lowest, if any, risk.

Taking drugs such as thiazides, potassium citrate, magnesiumcitrate and allopurinol, depending on the cause of stoneformation.

Some fruit juices, such as orange, blackcurrant, and cranberry,may be useful for lowering the risk factors for specific types ofstones.[37][38]

Avoidance ofcola beverages.[39][40] Avoiding large doses ofvitamin C.[41]
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celery, bell peppers, beans, asparagus, beets, soda, and alltypes of teas and berries).

Reduce uric acid by eating a low-protein diet. Reduce salt; higher amounts may raise the level of calcium

oxalate in your urine.

Avoid vitamin D supplements, which can increase calciumoxalate levels.

Renal stones ayman mohamed faculty of nursing minia university

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