During the five year follow-up after the initial intervention, all patients received individualized and specific nutritional guidance appropriate to their specific metabolic changes. All patients received specific pharmacological treatment according to their individual metabolic alterations Table 1. During the five years of follow-up, drug treatments were individually modified to suit changes in metabolic profiles.
The pre-treatment urolith recurrence rate Rp was considered to be the average yearly number of uroliths eliminated from the time of disease onset until treatment as reported by clinical questionnaire. At the initial consultation, the number of uroliths present NI was determined by imaging. During follow-up, the number of uroliths spontaneously eliminated NE was assessed, and imaging tests were repeated to allow diagnosis of possible new urolith formation. The urolith recurrence rate during the intervention period R I was calculated by summing NE with those observed at the end of the five year follow-up NEnd and then subtracting NI.
This result was divided by five to obtain the average number of uroliths formed per year Figure 2.
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Data were analyzed using SPSS. The periods before and during the intervention were compared using exploratory inferential analysis. In the presence of Gaussian distribution the paired t test was used and, when the data were not normally distributed, the nonparametric Wilcoxon test was used. The patients had a mean age of On average, There were no statistically significant differences in mean BMI or urinary volume when the pre- and post-treatment periods were compared.
The concentrations of calcium, sodium and uric acid in the 24h urine samples were significantly lower during the post-treatment period. A concomitant increase in citrate in the 24h urine sample post-treatment was also observed Table 2. The number of stones during the 5-year follow-up period decreased significantly relative to the pre-treatment period Table 3. Recent epidemiological studies have shown an increasing prevalence of urolithiasis in both sexes This increase has been greater in women than in men, resulting in a decrease in the male:female ratio from 1.
This change may be related to increased body weights and changes in lifestyle among women 13 , In this study we observed a similar trend; the male:female ratio of the patients in this study was 1. Many of the patients in this study were overweight and there was a positive relationship between BMI and urolith formation. Some authors 15 , 16 have shown that being overweight or obese is a risk factor for urolithiasis. Weight gain may also be related to the formation of kidney stones 17 , and weight reduction can decrease the excretion of lithogenic salts in the urine In this study, significant weight gain was not observed during the follow-up period.
The dietary guidance provided to the patients probably prevented weight gain during the 5-year follow-up, which may have contributed to the reduced urolith recurrence rate. Identification and correction of the metabolic disorders that may cause urolithiasis is critical to preventing its recurrence In our patients, diet change coupled with specific pharmacological treatments had an important influence on urolith recurrence.
The relationship between sodium intake and increased urinary calcium excretion is well established In another study, dietary salt intake was significantly higher in patients with idiopathic hypercalciuria 9. We observed a direct relationship between urinary calcium and sodium in the pre-treatment period, demonstrating that salt intake is an important lithogenic factor.
Increasing fluid intake is an important first intervention in the general treatment of urolithiasis 1. Although all patients in this study were advised to increase their fluid intake, few complied with this recommendation. This demonstrates the difficulty of using only this increased fluid intake as a strategy for the prevention of urolithiasis. There was a significant decrease in urolith recurrence, as well as in urinary calcium and uric acid concentrations, over the five years follow-up period.
This suggests that our intervention decreased the excretion of these solutes, thus preventing urolith formation and recurrence. Parks and Coe 21 also reported a long-term reduction in urolith recurrence and urine calcium excretion in patients receiving dietary guidance and drug treatment. Other authors also found similar results in a controlled study Preventing urolith recurrence may decrease the costs associated with urolithiasis and have an important economic impact.
However, there are few studies similar to this one available in the literature. This suggests that there is a need for greater involvement of different professionals in the prevention of urolithiasis. Individual dietary guidance combined with specific drug treatment significantly reduces long-term recurrence of uroliths. An update and practical guide to renal stone management. Nephron Clin Pract. Clinical practice. Calcium kidney stones. N Engl J Med.
Highlights from the 6th International Alliance of Urolithiasis annual meeting - BJUI
Lotan Y. Economics and cost of care of stone disease. Adv Chronic Kidney Dis. The financial effects of kidney stone prevention. Kidney Int. J Bras Nefrol. Diet and fluid prescription in stone disease. Pharmacotherapy of urolithiasis: evidence from clinical trials. Urinary lithiasis and idiopathic hypercalciuria: the importance of dietary intake evaluation.
Int Braz J Urol. The role of salt abuse on risk for hypercalciuria. Nutr J. Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized prospective study. J Urol. Garrow JS, Webster J. Int J Obes. World Health Organization.
Urolithiasis: Therapy · Prevention (Handbook of Urology)
Obesity: preventing and managing the global epidemic. Geneva: World Health Organization [ cited jan 10], Report of a WHO Consultation. Prevalence of kidney stones in the United States. This can result in catastrophic gram-negative sepsis, often requiring intensive care admission and occasionally causing death.
sketrefoljohnpred.ga Occasionally, urine dipstick may be negative because of complete obstruction of infected urine. In any patient with fevers, tachycardia or hypotension, the diagnosis of infection must be considered. Patients with evidence of complete urinary obstruction — those with a single kidney ie congenitally, postoperatively , bilateral obstructive stones or anuria — should not trial conservative management. Patients with minimal renal reserve — those with pre-existing kidney disease — should also be sent to hospital for treatment. Most urolithiasis, even symptomatic, can initially be managed conservatively.
The majority of stones will pass within six weeks. The likelihood of spontaneous passage decreases with increasing size and with more proximal stones.
What are Kidney Stones Made of?
All patients undergoing conservative management should be told to present to the emergency department if they develop symptoms of a UTI, or if the pain is unbearable despite analgesia. Renal colic can be intensely painful, as ureteric peristalsis increases back pressure behind an obstructing stone and dilates the renal capsule.
Effective analgesia is important. Nonsteroidal anti-inflammatory drugs NSAIDs provide the most effective available pain relief in renal colic. NSAIDs reduce the prostaglandin-mediated pain response, and decrease the transient increase in glomerular blood flow that accompanies acute urinary obstruction. NSAIDs can be given by oral, rectal, intramuscular and intravenous routes, with the latter providing the most rapid onset of analgesia in renal colic. For outpatient management, oral and rectal routes provide equivalent analgesia; however, given the nausea that frequently accompanies renal colic pain, many patients find it beneficial to have NSAID suppositories available.
Despite recent controversy with a large randomised control trial showing that alpha-adrenoceptor antagonists have no benefit 15 as an expulsive therapy, many other studies, including meta-analyses, have shown benefit, specifically with the alpha-1a-selective antagonist tamsulosin. Alpha-1a antagonists are contraindicated in patients with end-stage hepatic or renal failure, and patients with severe orthostatic hypotension.
Patients who are trialling conservative management should be advised to strain urine, to avoid unnecessary imaging if the stone has passed. Patients should be given a specimen jar and asked to bring the stone in to be verified; the stone should then be sent for analysis. The stone should be palpated as, occasionally, small blood clots may appear to be calculi on cursory inspection.
Follow-up scans X-ray KUB if the stone is definitely seen on initial X-ray, or CT KUB if it is not seen should be organised for four weeks after the initial visit, unless a stone has been collected and verified by the GP or urologist. Some patients with urolithiasis do not require emergency treatment, but are likely to experience ongoing pain and potentially have kidney damage if they are not offered surgical management. These patients should be referred to a urologist at diagnosis, rather than conservatively managed or sent straight to hospital.
Patients who have ongoing pain despite adequate oral analgesia should also be referred to a urologist, and those with unbearable pain despite oral analgesia should be sent to the emergency department. Lastly, patients who have passed stones but have ongoing blood in the urine should be referred to a urologist for investigation of haematuria, preferably with three urine cytology tests and a CT IVP.
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In Australia, there are three main surgical options for the management of urolithiasis. Availability varies, particularly in more remote areas. All procedures except percutaneous nephrolithotomy PCNL are usually performed as day cases. Laser lithotripsy can be used to treat calculi anywhere in the urinary tract, and is the most commonly performed procedure for the management of urolithiasis.