The problem of kidney stones today

With the onset of the XXI century urolithiasis (ICD) continues to be an urgent problem of modern medicine because it has a widespread distribution throughout the world and occupies a leading place in the structure of surgical diseases of the urinary system. In the majority of cases of urolithiasis complicated with secondary pyelonephritis, is characterized by a long latent period, a tendency to rapid recurrence and development of renal failure. Among the total range of causes of disability in urological practice, the incidence of ICD is in third place, with 82% of disabled people of working age. A well-known fact that kidney stones have a marked tendency to recurrence in 50% of cases over 10 years from the moment of occurrence of first episode of illness.

The prevalence

Urolithiasis is widely distributed throughout the world. In developing countries it is endemic, the incidence ranges from 5% to 15%, the disease is detected already in the first year of life in developed country the incidence is in the range of 1-5%.

The etiology of stone formation

Risk factors:

• early onset (before 25 years);
• stones containing will brusic (calcium hydroxyphosphate);
• indicate the incidence of IBC in the family;
• the only functioning kidney (this fact in itself does not increase the risk of stone formation; should be taken to prevent recurrence).

Diseases associated with stone formation:

• hyperparathyroidism;
• renal tubular acidosis;
• cystinuria;
• primary hyperoxaluria;
• Euro-idealny anastomosis;
• Crohn's disease;
• resection of the small intestine;
• sarcoidosis;
• the hyperthyroidism;
• malabsorption syndrome.

Drug-induced stone formation (rocks containing calcium):

• calcium supplements;
• preparations containing vitamin b;
• ascorbic acid (in doses over 4 g/day);
• sulfonamides;
• triamterene;
• indinavir (a drug for treatment of AIDS).

Anatomical abnormalities (communication with stone formation):

• spongy kidney;
• obstruction of the ureteropelvic segment;
• diverticula and cysts of the cups;
• stricture of the ureter;
• vesicoureteral reflux;
• L-, S-, and distopian horseshoe kidneys;
• ureterocele.

Thus, the most common causes of stone formation include: anomalies of the kidneys and urinary tract, chronic pyelonephritis, and various metabolic disorders. It is established that in some countries the predominant influence on those or other factors of the Genesis of the ICD. In most European countriesthe formation of stones in 50-70% of cases associated with urinary tract infection. At the same time in the United States and Scandinavian countries based on Genesis nephrolithiasis more frequently detected metabolic disorders. Children's stones often are secondary, arising on the background malformations of the upper and lower urinary tract, tubulopathy, chronic pyelonephritis, the so-called "idiopathic" nephrolithiasis occurs in 10-15% of children surveyed.

Clinical manifestations

In the most General form of manifestation of the ICD include the following symptoms:

• pain;
• nausea and/or vomiting;
• fever;
• discharge of ureteral stones;
• paresis of the intestine.

Clinical manifestations of ICD in children. Pain is the most common symptom, occurs in 40-75% of cases. Unlike adults, in children the pain is mostly manifested not in the form typical of renal colic, and often is in the nature of diffuse pain in the abdomen, which in some cases complicates the diagnosis. Micro or gross hematuria occurs in 25-40% of patients.

Diagnosis

History:

• indication of any clinical manifestations in the past;
• the discharge of stones;
• various conservative and surgical benefits;
• the pattern of scarring in the lumbar region on the front side wall;
• the fact of the incidence of urolithiasis in their relatives.

Physical examination:

• restless behavior of the patient (forced posture does not lead to relief of pain symptom);
• lumbar scoliosis in the direction opposite to the location of pain;
• frequent, painful urination (dysuria), especially evident in the stones of the terminal segment of the ureter;
• tenderness to palpation of the kidney;
• muscle tension anterior abdominal wall on palpation of the lumbar region;
• varying degrees of tenderness to effleurage lumbar region (symptom pasternatskogo).

Special research methods

Routine investigations patients with ICD as the importance and the recommended sequence would include the following:

• review urography;
• Ultrasound;
• excretory urography;
• x-ray computed tomography;
• radioisotope methods;
• ante- (retro-) gradney pielografia.

Indications for performing excretory urography:

• fever;
• a single kidney.

Contraindications to performing excretory urography:

• the presence of pain attack;
• 10-14 days after the last episode of colic;
• Allergy to radiopaque preparation;
• serum creatinine exceeding 200 µmol/l;
• multiple myeloma;
• menses (suspended).

Risk factors of oppression renal functions for determining indications for performing excretoryurography:

• elevated serum creatinine level (more than 150-170 mmol/ml);
• dehydration of the body;
• patient age greater than 70 years;
• diabetes mellitus;
• congestive heart failure;
• the concomitant use of nephrotoxic drugs (e.g. nonsteroidal anti-inflammatory drugs, some antibiotics and aminoglycosides during the last 24 h);
• multiple myeloma (requires pre-hydration or alternative methods of research).

Radiopaque dosage of the drug in determining the dose of the contrast agent to perform the excretory urography is necessary to consider following circumstances:

• criteria renal function: plasma creatinine must be in the range of 140 mmol/l, and the level of glomerular filtration (KF) should not exceed 70 ml/min;
• when KF 80-120 ml/min the dose should not exceed 80-90 g;
• when KF 50-80 ml/min the dose is determined as the level of KF, expressed in ml/min, equivalent to 1.73 m2;
• to prevent nephropathy if serum creatinine over 140 mmol/l recommended hydration both before and after I/V administration of the drug.

Diagnosis: acute phase

Laboratory:

• urinalysis;
• leukocytosis of the blood;
• serum creatinine level;
• the level of C-reactive protein;
• urine on the microbial flora and antibiotic susceptibility;
• determination of the levels of potassium and sodium in the plasma (especially with vomiting and dehydration).

In the diagnosis of IBC along with clinical methods of investigation the overwhelming importance of ultrasound (including Doppler imaging) and x-ray methods, includes review and excretory urography.

To clarify the functional ability of the kidneys used dynamic neprezentare. In recent years, along with clinical research methods the study used 24-hour urine samples, which explores the daily content levels of calcium, phosphorus, citrate, uric acid, which helps in further evaluation of the etiology and Genesis of nephrolithiasis.

Renal colic

Treatment:

• diclofenac (first-line drug, with no effect – the use of alternative products);
• indomethacin;
• ibuprofen;
• of that hyrdromorphone hydrochloride + atropine sulfate (increased risk of vomiting);
• Metamizole sodium;
• tramadol.

Prevention of new episodes of renal colic:

• diclofenac 50 mg 3 R/day for 7 days (minimum 4 days);
• at stones in the ureter with a tendency to discharge – diclofenac in the form of suppositories or tablets in doses of 50 mg 2 p/day for 3-10 days;
• with no effect from medication treatment are showninternal (stent), external (percutaneous nephrostomy) drainage or removal of calculus (the question of whether drainage is solved individually during operation).

Indications for active removal of stones (General provisions):

• size, localization and shape of the stone, the possibility of arbitrary discharge affect the choice of indications for its removal;
• spontaneous discharge is possible in 80% of patients with stones 7 mm, the chance of divergence is minimal.

The average parameters of spontaneous expulsion of ureteral stones:

• the upper third to 25%;
• the middle third of 45%;
• lower third – 70%.

Conclusion

ICD representative in all age groups, both men and women, is characterized by polymorphism of the etiological factors and the variety of clinical manifestations. The diagnostic algorithm at the present stage has a clearly delineated framework. The technological revolution at the turn of the century significantly transformed the therapeutic possibilities in patients with different clinical forms of ICD.