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Wednesday, 29 February 2012

Diagnosis and management of kidney stone (Nephrolithiasis)

To commemorate the fallen world kidney day on March 1, it is reviewed on a case Nefrolithiasis is one of the causes of the destruction of the kidneys, so we need to know and understand about the mechanism of occurrence of stones in the urinary tract, especially the kidneys so that we can anticipate and prevent (lower morbidity) of nefrolithiasis which may indirectly increase the quality of kidney health.

In Indonesia, cases of urinary tract stone disease is common. In Asian countries such as Indonesia, the Middle East, China and India is mentioned in the literature as the countries with the number of cases of urinary tract stones are high.
Urinary tract stones are common in the urine is sterile. It is estimated that the increased incidence of stones associated with plant-based diet low in protein and phosphate. The change of lifestyle to a modern style, which among other marked by increasing consumption of animal protein, the incidence of urinary tract stones tend to increase. Foods that affect stone formation is a variety of foods that contain calcium, but low.
Urinary tract stones is actually nothing more than the minerals in the water that had precipitation and compact. Dehydration due to weather, the hot tropical climate and circumstances diarrhea can complicate kidney stones or urinary tract stones that have previously occurred. In addition, urinary tract stones often recur, so have the nature of the threat of a lifetime for patient.
In developing countries, many found bladder stone patients, whereas in developed countries the disease is more prevalent upper urinary tract stones, because of the influence of nutritional status and daily activities of patients Kidney stones or nefrolithiasis hari.2 affects about 4% of all population, the ratio of male: female is  4: 1, and nefrolithiasis illness accompanied by greater morbidity due to pain. 3

Definition Nefrolithiasis
Nefrolithiasis or kidney stones are solid objects that occur in the kidney is formed through a process fisikokimiawi of substances contained in the urine. Kidney stones are formed endogenously from the smallest elements, mikrolith-mikrolith and can grow to be large. Mass is soft at first, for example jendalan blood, can also experience.

Etiology Nefrolithiasis

Formation of kidney stones in suspected something to do with urine flow disorders, metabolic disorders, urinary tract infection, dehydration and other circumstances that remain unclear (idiopathic)
Epidemiologically, there are several factors that facilitate the occurrence of kidney stones. These factors are two:
A. Intrinsic factor
Which is the state that comes from a person's body. Intrinsic factor and idiopathic factors are generally difficult to be corrected, so as to have a tendency to relaps.
Intrinsic factors that include:
a. Hereditair and Ras
Disease thought to be derived from the nefrolithiasis tuanya2 and apparently more nefrolithiasis family members have the opportunity to suffer from the same disease in others. For example, genetic factors in familial hipersistinuria, primary hypercalciuria and hyperoxaluria primer5. Urinary tract stones are also more commonly found in Africa and Asia, while the Americans and Europeans rarely be found.
b. Age.
Nefrolithiasis disease most often obtained at the age of 30 to 50 years
c. Gender
The number of male patients are three times more than patients perempuan2 and more common in men ureter stones and a jar while women are more often found in kidney stones or stone chalice kidney
2. Extrinsic factors
Namely the influence that comes from the surrounding environment. Extrinsic factors, when the cause is known to take steps to change the environmental factors or daily habits so that recurrence can be avoid. Several extrinsic factors, such as:
a. Geography
In some areas showed a higher incidence of stones than other regions, and became known as the stone belt
b. Climate and temperature
Hot spot temperature, eg in the tropics, in the engine room, causing a lot of sweat that would reduce urine production and facilitate the formation of stones. Whereas in the cold, will cause a lack of water intake on the community.
c. Water intake
Lack of water intake causes the levels of all substances in the urine will increase and will facilitate the establishment of batu5 and high levels of calcium in mineral water can increase the incidence batu2 consumed.
d. Diet
Many purine diet, facilitate the formation of calcium oxalate and batu2. On the people who ate more animal protein, reduced morbidity stone while in social groups with low socio-economic conditions more frequently increases morbidity. Vegetarian population who ate less egg whites more often suffer from bladder stones and urethral and few are found to suffer from kidney stones or stone chalice kidney
e. Work
Nefrolithiasis disease often found in people who work a lot less sitting or sedentary activity or a life
f. Infection
Urinary tract infections can cause kidney and tissue necrosis will be the core of stone formation. Infection by bacteria that breaks down urea (urea splitting organisms) and the ammonium form will change the pH of urine to be alkaline and will precipitate the phosphate salts that will accelerate the formation of stones that have been exist.
g. Obstruction and urinary stasis
Urinary tract obstruction, for example by a tumor, stricture and prostatic hyperplasia, will lead to stasis of urine, while the urine itself is a substance that contains bacteria that facilitate the occurrence of infection and stone formation.
In addition to the above factors there are other factors that influence, such as metabolic disorders. Metabolic disorder in question is that can lead to increased levels of products that can settle and become stones. For example, hypercalcemia caused by hyperparathyroidism, milk alkali syndrome, multiple myeloma, metastases Ca and sarcoidosis. Hyperuricaemia and therapy with diuretics sitostatika or old, and hipersistinemia caused by renal tubular acidosis.

Pathophysiology Nefrolithiasis
Theoretically, the stones can be formed on the entire urinary tract, especially in places that are experiencing barriers to the flow of urine (urine stasis), namely the system of renal calices or jar. Pelvikalises congenital abnormalities (stenosis uretero pelvis), diverticulum, chronic intravesical obstruction such as benign prostatic hyperplasia on, stricture and neurogenic bladder are the circumstances that facilitate the formation of stone.
Kidney stones are formed in the renal tubule, then located in the kidney Calix, pielum, infundibulum, renal pelvis and can even fill the renal pelvis and the entire Calix. Pielum stone fill and more than two kidneys Calix provides an overview so as to resemble antlers are called staghorn stones. Abnormalities or obstruction on renal systems pelvikalises (narrowing of the infundibulum and stenosis uteropelvik) will facilitate the occurrence of kidney stones.

Derived from kidney stones and walked down the ureter, most likely lodged in one of three locations, namely in connection uteropelvik, at the point of the ureter crosses the iliac vessels, or in connection ureterovesika6. Stones are not too large, driven by a peristaltic pelvikalises system and down to the ureter into the ureter stones. Ureteral peristalsis energy trying to remove the rock to drop into a jar. The size of small stones (<5 mm) in general can come out spontaneously, whereas larger stones often remain in the system pelvikalises and ureter, and capable of causing obstruction and urinary tract structural abnormalities.
A. The theory of Stone Formation
Calcium salts can be precipitated in the form of stones or calculi in the duct system of various organs. Calculi formed from various substances, which are available locally, the ingredients of the secretions of certain organs. Thus, although calculi-calculi that often contain calcium, but in the beginning, many of these calculi-calculi that do not contain calcium. Some calculi are formed as a result of the destruction of necrotic debris in the channel, while others are formed from an imbalance of certain elements such that secretion occurs deposition of elements that usually absorbed.
A rock composed of crystals composed of organic materials and inorganic dissolved in the urine. The crystals remain in a permanent state of dissolved (metastable) in the urine in the absence of particular circumstances which caused the precipitation of crystals. The crystals are held together to form the core of the stone precipitation (nucleation) which would then hold the aggregation, and other interesting materials so that a larger crystal. Although the size is large enough, aggregate crystals are fragile and not quite able to block the urinary tract. To that end, the crystal aggregates attached to the epithelium of the urinary tract, forming a crystal retention, and from other materials deposited on the stone aggregate to form large enough to clog the channels.
Conditions remain dissolved affected by temperature, pH, presence of colloids in the urine, the concentration of solutes in the urine, urine flow rate in the urinary tract or the corpus alienum in the urinary tract that acts as the core batu2. Persistent urinary acidic metabolic acidosis may occur in the state and pyrexia, while the urine is alkaline continually suggested a urinary tract infection, renal tubular acidosis, potassium deficiency and the syndrome Fanconi.
Formed or whether the stone in the urinary tract, determined by a balance between stone-forming substances and inhibitors, ie substances that can prevent the occurrence of stones. Known for some substances that can inhibit the formation of stones in the urinary tract, which works from the reabsorption of calcium in the intestine, the formation of stones or crystal nuclei, crystal aggregation process, to crystal retention. Magnesium ions are known to inhibit the formation of stones as if to bind with oxalate, magnesium oxalate will form a salt, so that the amount of oxalate binds to calcium to form calcium oxalate stones decreased. Similarly, the citrate, if it binds to calcium ions, to form calcium citrate salt, so the amount of calcium binds to oxalate and phosphate is reduced. This causes crystals of calcium oxalate or calcium phosphate dwindling. Several proteins or other organic compounds able to act as inhibitors by inhibiting crystal growth, inhibit crystal aggregation, and inhibit crystal retention. Compounds that include glycosaminoglycans, Tamm Horsfall protein or uromukoid, nefrokalsin, and osteopontin. Deficiency of substances which function as inhibitors of stone is one of the causes of duct stones.
B. Stone composition
A. Calcium stones
This type of stone, most often found, which is about 70-80% of all urinary tract stones. The content of this type of stone, composed of calcium oxalate, calcium phosphate or a mixture of both elements. Calcium oxalate stones are usually formed in the atmosphere of acid urine. Calcium forms a jagged stone that rarely come out spontaneously. Factors of calcium stone .
a. Hiperkalsiuri
Namely the level of calcium in the urine> 250-300 mg/24 hours. There are three kinds of causes of hypercalciuria, among others:
• absorbtif hypercalciuria: a state of absorbtif hypercalciuria is due to increased absorption of calcium through the gut
• Hiperkalsiuri Renal: renal hypercalciuria situation can occur because of an impaired ability renal tubular reabsorption of calcium through
• resorptif hypercalciuria: a state of resorptif hypercalciuria is due to the increase in bone calcium resorption. Many occur in primary hyperparathyroidism or parathyroid tumors.

b. Hiperoksaluri
Urinary oxalate excretion is exceeding 45 g / day. Hyperoxaluria situation often found in patients with disorders of the colon after undergoing intestinal surgery and in patients who consume lots of oxalate-rich foods such as tea, instant coffee, soft drinks, cocoa, strawberry, orange, lemon, and green vegetables, especially spinach.
c. Hyperuricosuria
Is the level of uric acid in urine exceeds 850 mg/24 hours. Excessive uric acid in urine, act as the core rock / nidus for calcium oxalate stone formation. Source of uric acid in the urine comes from many foods contain purines such as meat, fish, poultry and derived from endogenous metabolism.
d. Hipositraturia
Can occur in renal tubular acidosis, malabsorption syndrome, or the use of thiazide diuretics group in the long term
e. Hipomagnesiuria
The most common cause is hipomagnesiuria inflammatory bowel disease (inflammatory bowel disease) followed malabsorption disorders.
2. Stone struvit
Also called infection stones, because struvit stone formation caused by urinary tract infection. Germs that cause infections are bacteria-breaking class of urea that can produce the enzyme urease and change the atmosphere of the urine becomes alkaline by hydrolysis of urea into ammonia. Alkaline conditions facilitate the salts of magnesium, ammonium, phosphate and carbonate rocks to form magnesium ammonium phosphate and carbonate apatite. Because it consists of three cations, known as triple phosphate stones. Germs which include urea solvers include Proteus spp, Klebsiella, Serratia, Enterobacter, Pseudomonas, and Staphylococcal
3. Uric acid stones
Is 5-10% of all urinary tract stones. Largely made up of pure uric acid stones, the rest is a mixture of calcium oxalate. Uric acid stone disease affects many patients with gout, myeloproliferative, patients with anticancer therapy, and many use Obet urikosurik, among others sulfinpirazole, thiazide, and salicylate. Obesity, alcohol consumption, and high-protein diet most likely to get the disease. Uric acid stones are round and smooth so often out spontanous.
Source of uric acid from purine-containing diet and endogenous metabolism in the body. Purines in the body inosinat degraded by acid, converted into hipoxanthin,. With the help of xanthin oxidase enzyme, converted into xanthin hipoxanthin eventually converted into uric acid. In humans, because they do not have the enzyme urikase, the uric acid is excreted into the urine in the form of free uric acid and urate salts. Urate salts more often bind to the sodium to form sodium urate, which is more soluble in water as compared uric acid-free. Relatively free of uric acid dissolved in the urine, so that in certain circumstances is easy to form crystals of uric acid and uric acid stones form the next. Several factors influence the formation of uric acid stones are:
• Urine that is too acidic (urine pH <6)
• The volume of urine with small amounts (<2 liters / day) or dehydration
• hyperuricosuria or high uric acid levels

Clinical Nefrolithiasis
Complaints submitted by patients, depending on the position of the stone, stone size and the complications that have occurred. The complaint most felt by the patient is pain in the waist, either colicky and non colicky. Colicky pain caused by the peristaltic activity of smooth muscle increases calices system in an attempt to remove the stones from the urinary tract. Increased peristalsis causing increased intraluminal pressure resulting in stretching of the nerve terminal that give the sensation of pain. While non-colicky pain due to stretch the renal capsule because of hydronephrosis or infection of the kidney due to stasis urine.2, 4,6,7
Hematuria is often complained by the patient due to trauma to the mucosa of the urinary tract because of the stone. Sometimes urinalysis hematuria obtained from the examination of microscopic hematuria. If you get a fever, should be suspected of a urosepsis.2
On physical examination, may get pain in the area of ​​word-vertebral kosto, palpable kidney on the side of the hurt caused by hydronephrosis, visible signs of kidney failure, and the retention urine.2
On urine sediment examination, showed a leukosituria, hematuria, and found the stone-forming crystals. Culture examination of urine may indicate a growth of bacteria breaking urea.2
Diagnosis can be established through anamnesis and physical examination, but it needs to be supported by laboratory, radiological, and with imaging to determine the possibility of impaired renal function.
Examination Support Nefrolithiasis to establish the diagnosis include:
A. Urine
- PH of urine
- Calcium stones, uric acid and cystine stones are formed in urine with low pH (pH <7).
- Stone struvit formed in urine with high pH (pH> 7)
• Sediment
- Blood cells increased (90%), the infection of white blood cells will increase.
- Found a crystal, such as oxalate crystals
- Cultures of urine to see what kind of microorganisms that cause infections of the urinary tract
2. Blood
- Hemoglobin, the presence of chronic renal dysfunction can occur anemia
- Leukocytes, urinary tract infections because of the stone causes leukocytosis
- U creatinine, this parameter is used to look at kidney function
- Calcium and uric acid.

A. Plain photo abdomen
Aims to look at the possibility of radioopak stones in the urinary tract. Types of calcium oxalate stones and calcium and phosphate are the most common radioopak, while uric acid stones are radiolusen.
2. Intra Venous Pielografi
Aims to assess the anatomy and renal function. It also can detect the presence of semi-opaque stone or non-opaque stone that can not be seen by plain photo abdomen. If pielografi intra venous (hereinafter referred to as PIV) have not been able to explain the state of the urinary system due to a decrease in renal function, but instead is an examination of pielografi retrograde.
3. Ultrasonography
May be performed if the patient does not undergo PIV, which is in a state of allergy to contrast material, decreased renal physiology and in women who are pregnant. Ultrasound can assess the presence of stones in the kidney or bladder (which is shown as echoic shadow), hydronephrosis, pionefrosis, or the shrinkage ginjal.5

Management Nefrolithiasis
Management objectives of the kidney stones is to remove the obstruction, treat infection, relieve pain, prevent the occurrence of renal failure and reduces the likelihood of rekurensi3. To achieve these objectives, the measures can be taken are as follows :
• Correct diagnosis of the presence of rock, stone location and size of
• Determine the result of stones such as pain, obstruction is accompanied by changes in the kidneys, the infection and the presence of impaired renal function
• Eliminate obstruction, infection and pain
• Analysis of rock
• Finding the background of a stone
• Pursue the prevention of recurrence
Management actions that can be done is :
A. Medical
Medical treatment intended to rock the size of less than 5 mm, because the stone is expected to come out spontaneously. Given therapy is more symptomatic, that aims to reduce pain, facilitate the flow of urine by giving diuretikum, and drink a lot in order to push the stone out
2. ESWL (Extracorporeal Shockwave Lithotripsy)
ESWL tool can break up kidney stones without invasive and without anesthesia. Stone broken into small fragments that easily excreted through the urinary tract. Not infrequently, the fragments of stone which induce a feeling of being out of colicky pain and cause hematuria.
3. Endourology
Endourology action is minimally invasive techniques to remove the stone, the action consists of breaking rocks, and then remove it from the urinary tract through a device that is inserted directly into the urinary tract. Such a device is inserted through the urethra or through a small incision in the skin (percutaneous). Stone-solving process can be done mechanically, using hidroulik energy, energy sound waves, or with laser energy. Some action to remove endourology kidney stones are:
a. PNL (Percutaneous Nephro Litholapaxy)
Ie remove stones in the bile duct by inserting an endoscope into the system tools calices kidney through an incision in the skin. Stone is then removed or broken down first into small fragments.
b. Uretero or Uretero-renoskopi
Which include tools ureteroskopi per uretram to see kedaan pielokaliks ureter or renal system. By using a particular energy, the stone inside the ureter and the system can be broken down through the guidance pelvikalises ureterorenoskopi.

4. Open Surgery
In the clinics that do not have adequate facilities for the actions of endourology, and ESWL laparaskopi, stone retrieval is still performed through open surgery. The surgeries include nefrolitotomi pielolitotomi or to take stones in the bile duct. Not infrequently the patient must undergo nefrektomi action because his kidneys are not functioning and there has been pionefrosis, korteksnya have very thin or having a cause shrinkage due to stone obstruction and chronic infection

Prevention Nefrolithiasis
Further action is no less important after spending a stone is an attempt to avoid the onset of recurrence. Prevention is done is based on the content of the elements that make up the stone obtained from the analysis batu3. In general, prevention is the form of 2.7:
• Avoid dehydration by drinking enough and sought the production of urine as much as 2-3 L / day
• Daily activities are quite
• Diet to reduce levels of substances rock-forming components

Prognosis Nefrolithiasis
Prognosis of stone in the urinary tract, and kidneys in particular depends on factors of stone size, stone location, presence of infection and obstruction. The greater the size of a rock, the bad prognosis. Location of stones that can cause obstruction to facilitate the occurrence of infection. The greater the tissue damage and the presence of infection because of the obstruction will cause decreased kidney function, so the prognosis becomes bad.

Complications Nefrolithiasis
Ureteric obstruction and hydronephrosis can cause hidroureter. Stone in pielum may cause hydronephrosis, stones can cause major Calix Calix kaliekstasis in question. If accompanied by a secondary infection, can cause pionefrosis, urosepsis, renal abscess, abscess perinefrik, or pyelonephritis. In the situation further, kidney damage can occur, and if on both sides can result in kidney failure permanent.

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2.     Purnomo B., 2003, Batu Ginjal dan Ureter dalam Dasar-Dasar Urologi, hal ; 57 – 68, Sagung Seto, Yogyakarta
3.     Raharjo J. P., 1996, Batu Saluran Kencing dalam Ilmu Penyakit Dalam, ed 3, hal ; 337 – 340, Fakultas Kedokteran Universitas Indonesia, Jakarta
4.     Sabiston C. D. Jr, MD., 1997, Batu Ginjal dan Ureter dalam Buku Ajar Bedah 2, hal ; 472 – 3, EGC, Jakarta
5.     Sjahriar dkk, 2000, Nefrolitiasis, Radiologi Diagnostik, Bagian Radiologi Fakultas Kedokteran Universitas Indonesia, Jakarta
6.     Sjamsuhidrajat R, 1 W. Buku Ajar Ilmu Bedah. Edisi ke-2. Jakarta : Penerbit Buku Kedokteran – EGC. 2004. 756-763.
7.     Tanagho EA, McAninch JW. Smith’s General Urology. Edisi ke-16. New York : Lange Medical Book. 2004. 256-283.
8.     Stuart J., Nefrolithiasis,www.eMedicine.com, 2005

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