Urinary stone evaluation in laboratory and clinical significance
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Dr. Sanjeev Mehta MDDr. Sanjeev Mehta MD
Ahmedabad, INDIAAhmedabad, INDIAwww.urolab.net
Metabolic Evaluation&Stone Analysis
Practical implications
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Role of laboratory
• What lab can not tell you, you will not know.• What it tells you in error, you will not
correct by using your instincts, your medical experience or your art.
• Misdirected treatment : unreasonable expenses.
• The Kidney Stone Handbook; Gail Savitz & co auth.
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Stone : Supersaturation of Urine
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Stone Promoting and Inhibiting Factors
PROMOTORS INHIBITORS
Calcium Inorganic : Magnesium
Sodium Phosphorus
Oxalate Citrate
Urate Organic : Nephrocalcin
Cystine Tomm-Horsfall Protein
Low Urine Ph Urinary Prothrombin fragment.
Tomm-Horsfall Protein
Bacterial products
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Evaluation of Stone Disease
ROUTINE BLOOD AND URINE TESTSSTONE ANALYSIS.24 HRS URINE METABOLIC PROFILE
New advances in Stone analysis, Blood and Urinary Chemical analysis can find out 90-95% cause.
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Clinical usefulness
1.Identify treatable metabolic abnormality2.Identify underlying medical disease that
predisposes to stone formation.3.Outline a treatment plan.
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A. Routine Tests
BLOOD low K, and HCO3- RTA High Uric acid - Uric acid
diathesisHigh Calcium- pri
hyperparathyroidism Low phosphorus- renal
phosphorus leak. Parathyroid ; sos
URINEpH > 7.5 – infection
lithiasis pH < 5.5 – Uric acid lithiasisSediments for crystalluriaUrine cultureQualitative cystine
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Renal Stone Analysis
• Essential step in the examination and initial treatment of Urolithiasis.
• Yields fundamental information about ;- Metabolic abnormality.- Presence of infection.- Possible artifacts.- Drug metabolism.
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Technique
Integrated analysis with Infra-red spectrometryXenthene and Ca.oxalate Dihydrite
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INTEGRETED ANALYSIS ;Mixed Stone
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11
Actually up to 65 different chemical compounds are found in urinary calculi.
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Clinical significance of Stone analysis• Three categories :1.Composition and hardness of Renal
Stones.2.Composition and its predictive value.3.Composition and related metabolic
abnormalities. Kourambas J, Aslan P, Teh CL, Mathias BJ, Preminger GM.J Endourol. 2001
Mar;15(2):181-6
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Clinical Significance: Hardness pattern in Stone.• Useful in describing consistency in individual.• Formulation of treatment strategies. - Number of re-treatments. - Number of Shock waves. • Energy index (KV x number of shock waves).
Ringdén I, Tiselius HG, Scand J Urol Nephrol. 2007;41(4):316-23
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Hardness Factor of Stone
Calcium Oxalate Dihydrate 1.0Calcium Oxalate Monohydrate 1.3Hydroxy-peptite 1.1Brushite 2.2Uric Acid/ Urate 1.0Cystine 2.4Carbonate Apatite 1.3Struvite 1.0Mixed Stone 1.0* Ringden I, Scand J Urol Nephrol.2007;41(4):316-23
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Clinical value : Calcium
• Present in approximately 80% stones.• Combines with phosphate or oxalate or both.• Risk factors : hypercalciuria, Hyperoxaluria. hyperuricosuria. predominantly acid or alk urine. hypocitraturia. low urine volume.
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Calcium Stones …..
Pure calcium Stones
• More Acid urine• Low Urine volume• High Oxalate
excretion
Mixed Stone formers
• pH is higher• High Calcium • High Calcium
excretion• High recurrence rate
* Schroeppel j Smith et all ; J Am Soc Nephrol 1997;8:568A
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Calcium Stone…..
Ca-oxalate Monohydrate
• Hypo- megnesuria• Acidic Urine• Low Urine volume• Hardness +
• Ca-ox Dihydrate
• Hyper-calciuria• Alkaline Urine• Hypo-citraturia• Hardness ; less
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Renal tubular acidosis
Carbonate apattite
• Consider RTA• Increases with amount • (5-39%)
Brushite Stones
• Consider RTA
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Struvite Stone Magnesium Ammonium Phosphate
• Mixed Stone : Infection. ‘Proteus’ • Strains of staphylococci, pseudomonas and
kelbsiella. • Rarely; E.coli.• Urine Ph. Is < 7.5
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Ammonium Urate
• Calcium oxalate – containing calculi, may start hyperuricosuria.
• Elders : associated with infection.• Children : May as result of hyperuricosuria,
but No UTI
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Brushite : Amm. Calcium Phosphate
• Sizable stone burden. Increasing trend • High recurrence rate , 3 yrs• Familial tendency• Hypercalciurea and underlying metabolic
abnormality. • Extreme Alkaline Urine.
J Urol. Oct 2010; 184(4): 1367–1371.
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Dahilite ( Carbonate apatite)
• Phosphate stone• Infection in body.• May not accompanying sign of disease.• RTA• Disorder of phosphate metabolism. • Rare in pure form ( 2-3%).
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Uric Acid
URIC ACID• Hyperuricemia, hyperuricosuria.• Low Urine Ph. < 6.2• Causes: - Gout. - Myeloproliferative dis. - Chemotherapy and Radiotherapy.
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Cystine
CYSTINE• Cysteinuria.• Autosomal recessive
disorder.• Occurs predominantly
in pure form.
• XENTHENE Most frequent causes:- Xanthinuria. - Absence of Xanthene
oxidase.• Genetic autosomal
hereditary recessive enzyme disorder.
• Trigger : Allopurinol Treating Gout.
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Urine: Metabolic Evaluation24 hrs Urine collections: multiple parameters Stone risk factors : Quantitation Volume and pH Calcium Oxalate Citrate Uric acid. Creatinine
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Metabolic Evaluation: 24 hrs Urine
• Dietary risk factors: Sodium, Potassium Magnesium Urinary analysts : phosphorus, sulphate, Urea Children : state sample Repeat 24 hrs Urine collection 4-6 weeks post
interventi
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GOLD STANDARDSupersaturation value.
•High risk parameter can be monitored.
Graphic presentation
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Super-saturation : Gold standard….
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Conclusion
• Advancement in laboratory can now diagnose cause of stone formation uo tp 90% cases.
• By appropriate Stone analysis and metabolic
evaluation can effectively treat impact of Nephrolithiasis and prevent recurrence .
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Conclusion: Significance
• Advancement in laboratory can diagnise cause of Stone disease up to 90%
• Impact mitigated by appropriate metabolic evaluation.
• Identify risk factor.• Focused medical treatment • Significantly reduces recurrence• Social and financial burden. • Batter quality of life
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Thank you !
For further details contact:
Phone: +91 79 40380380