Lithiasis, renal

Use sulindac with caution in patients with a history of renal lithiasis and keep patients well hydrated while receiving the drug. 

Nonneoplastic forms Prostatic hypertrophy Renal tuberculosis Renal lithiasis Calculi of the bladder Cystic diseases Urethral stricture Hypospadias Neurogenic bladder Nephritis... 

Approximately 10% of the human population (with regional differences indicating both genetic and environmental factors [33]) is affected by the formation of stones or calculi in the urinary tract. Urolithiasis is not only a painful condition, but also causes annual costs to the health system in the order of billions of dollars in the USA alone [34, 35]. Based on their composition, structure and location in the urinary tract, renal stones have been classified into 11 groups and their formation mechanisms have been discussed together with alterations in urinary parameters and metabolic risk factors for renal lithiasis [35]. Approximately 70% of these stones contain calcium oxalate monohydrate (COM) and dihydrate as major components, while other calculi are composed of ammonium magnesium phosphate (struvite), calcium phosphates (hydroxyapatite and brushite), uric acid and urates, cystine and xanthine. An accurate knowledge of the solubilities of these substances is necessary to understand the cause of renal or bladder calculi formation and find ways towards its prevention and treatment [36]. 

In general, renal lithiasis is rare in early age, but its incidence increases to reach a maximum in the 6th and 7th decades. It is slightly more common in men than in women, and in 30% of the cases it is bilateral. 

Lonsdale [87, 88] has reviewed the epidemiology of urinary lithiasis and concludes that bladder stones have become rare in adult man. The bladder stones Lonsdale found were urate stones and were believed to result from faulty diet. Bladder stones, composed of urate and oxalates, are seen in young people, rarely in the West, but commonly in India, Turkey, and Thailand. In contrast, kidney stones are a relatively frequent ailment in the West (200,000 new cases a year in the United States). Kidney stones are usually made of calcium oxalate, calcium phosphate, or MgNH4 phosphates. The incidence seems to be highest among those with sedentary professions, and renal lithiasis is said to constitute an occupational hazard among airplane pilots. 

Even within the United States, the distribution of renal lithiasis varies from place to place. The incidence of stones is approximately 20% in Tampa and 29% in Miami, but it is only 4% in Cleveland and 2.4% in New York. The environmental factors that influence this variation in incidence are not known. 

Many conditions result in the increased concentration of special solutes in the urine, and many of these have been or will be described in more detail in other chapters. For example, primary or secondary hyperparathyroidism releases calcium from bone and leads to its precipitation in kidneys. In some inborn errors of metabolism, metabolites accumulate in the blood, are excreted in the kidney, and under the appropriate conditions are precipitated in the excretory system. Gout, cysteinuria, and oxaluria are among those diseases that cause renal lithiasis. 

Maybe one of the reasons why the pathogenesis of renal lithiasis is so poorly understood is because we know so little about changes in the composition of the urine—with time, diet, effort, and other factors. Most of the studies on urolithiasis have been done on urine collected from the bladder and sometimes the pelvis. It is unlikely that the composition of the urine at a given time is representative of its composition at all other times, and it is quite possible that if kinetic analysis of urine in the tubules, pelvis, ureter, and bladder were available, transient conditions would be discovered which favor lithiasis. Studies of this kind have resulted in a better understanding of lithiasis in the gall bladder. 

No relationship between renal lithiasis (either in general or uric acid lithiasis) and high blood pressure was found (12). 

The survey of cases of gout with renal involvement in relation to blood pressure (Table IV) revealed, in the hypertensive secondary renal gout, an earlier age of onset a higher incidence of females a predominance of the acute clinical type and a higher incidence of gouty attacks caused by the admin Istration of diuretic drugs. On the contrary. In the normotensive group, uric acid renal lithiasis and diabetes were more frequent, which confirms the non-specificity of these parameters. 

Almeria (Spain) flor de piedra ( stone flower ) Decoction used as diuretic to treat renal lithiasis. One cup taken daily until patient is better (Gonzalez-Tejero et al. 1995 Martmez-Urola et al. 1996)... 

Guitard J, Kamar N, Mouzin M, Borde JS, Tran-Van T, Durand D, et al. Sulfadiazine-related obstructive urinary tract lithiasis an unusual cause of acute renal failure after kidney transplantation. Clinical nephrology. 2005 May 63(5) 405-7. 

In conclusion, the kidney protects itself against calcium oxalate nephrocalcinosis/lithiasis at different levels. Failure or saturation of these protection mechanisms, might explain why patients develop renal and/ or urinary tract calcifications. 

CT imaging is progressively gaining an important role in the management of patients with suspected lithiasis of the urinary tract. An unenhanced scan of the entire abdomen performed in a single breath-hold, at high resolution, allows the depiction of calcifications in the urinary tract (Tublin et al. 2002). In difficult cases where the position of calcification cannot be precisely defined, the use of intravenous contrast helps in delineating the entire urinary map (Fig. 23.5) and also allows calculi located in the renal... 

Oxaluria is a rare disease occuring mainly between one and four years of age and most often in white males. The patient is usually afflicted with a chronic renal disease associated with normal blood pressure. Renal failure results from the deposition of pure calcium oxalate calculi into the pelvis and calices. The lithiasis causes chronic inflammation of the kidney with parenchymal involution, fibrosis, and formation of thick capsules that strip off with difficulty. Microscopic examination of the kidney demonstrates the presence of oxalate calculi in the tubules. Calcium oxalate is also frequently found in the arterial walls, but usually the glomeruli remain free of salt. Histologically, the calculi appear as globular or rhomboidal crystals they are slightly yellowish and doubly refrac-tile under polarized light [98-104]. 

Although most of this discussion concerns stones originating in the kidney, lithiasis may be primary to the bladder or the ureters. Whereas phosphate and oxalate stones develop more frequently in the kidney, bladder stones are usually of the urate type. The geographical distribution of urinary lithiasis varies considerably. The disease is common in central Russia, China, Canton, and India. However, in India and China bladder stones are the type seen most often, whereas renal stones are more common in America. 

A substance with similar immunological properties has been found in the kidney, where it is more abundant in the cortex than in the medulla. According to Boyce and King [90, 91], the mucoprotein is consistently found in the kidneys of patients with recently formed stones, but is rarely present in patients with other kidney diseases in which stones are not formed (e.g., renal carcinoma and severe renal arteriosclerosis). The mucoprotein has not been detected in normal kidneys or in patients with pyelonephritis, and the compound cannot be immunologically detected in blood serum, human saliva, or bone matrix. The only other tissue where this matrix substance has been detected is the intestine. (Boyce and King think that this is not a coincidence and that the reason for its presence in kidney and intestine is that both these organs are involved in calcium absorption.) But most important to the pathogenesis of lithiasis are the mucopolysaccharides found in urine. 

Becker et al recently reported a variant of the purine synthetic enzyme phosphoribosylpyrophosphate (PP-ribose-P) synthetase (EC 2.7.6.1) in a patient with symptoms characteristic of the Lesch-Nyhan syndrome at three years of age, but with normal HGPRT enzyme levels. The clinical manifestations of this X-linked disorder in three previous families in which it had been described had been restricted to gout, uric acid lithiasis and/or renal insufficiency and had not developed until early adulthood. ... 

Renal Disease and Uric Acid Lithiasis in Urate Overproduction... 

Mouth Sialolithiasis A case of sialolithiasis with obstruction of the parotid duct in a patient without any previous occurrence of renal or biliary lithiasis is reported [278 ]. 

A calyceal diverticulum is an eventration of a calyx into the renal parenchyma that is filled with urine. Most of the diverticula are small and asymptomatic. Complications include the development of milk of calcium and lithiasis and rarely hematuria infection is unusual. The relation between diverticulum and isolated renal cyst is unclear. The diverticulum is usually detected by US as an isolated cystic structure. However, the connection with the pyelocaly-ceal system is usually not visualized on US it can be demonstrated on IVU or on CT (Fig. 5.1). Treatment is necessary only when complications such as hemorrhage or lithiasis occur (Siegel and McAllister 1979 WuLFSOHN 1980 Ulchaker et al. 1996). 

Lithiasis may develop in association with a UTI it can develop either with no other favoring factor (the pathogen involved is often Proteus mirabilis) or when there is any cause favoring renal stasis (Kraus et al. 1999) (Figs. 15.1, 15.18). The work-up must differentiate a metabolic and/or genetic origin from a specifically infectious origin (infectious stones). These stones are often poorly calcified and may appear stratified on CT. 

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