Treatment for Kidney Stones - Case Study Example

RENAL STONE CASE STUDY Introduction Kidney stones are hardened crystal deposits that occur in the kidney. The stones form from acid salts and mineral. They start as crystals or microscopic particles and eventually progress into stones. The kidneys separate waste substances from the blood and pass them as urine produced by the kidneys. When these waste materials do not dissolve wholly, crystals and kidney stones may result. Often, kidney stones form when urine becomes concentrated, a situation that lets minerals to crystallize and cluster together. The medical word for this situation is renal stone disease, or nephrolithiasis (Rosette, et al. 2011). There are several causes of kidney stones and they can occur in the kidneys or the urinary tract. A brief case history A 37-year-old man presented with 2 hours of painful in left femur. The patient has experienced a few cramps over past 2 months, presents with a KUB that appears normal, but with blood in urine. The patient is referred to urology, and the IVU indicated two small calculi, of about 4 mm and 5 mm, located in left mid-ureter. There are no signs of hydronephrosis dilatation identified. Clinical diagnosis A number of different tests can be conducted to determine the presence of a kidney stone. The simplest test is a physical examination which may disclose pain in the lower back by the kidneys and the femur and is often the warning signs of the ailment. An examination of the urine will indicate the presence of blood in the urine and the possibility of a subsequent infection. Blood tests can also be conducted to find complications that may arise because of a kidney stone and validate prior diagnosis (Daugirdas 2011). However, imaging modalities are the most effective methods of clinically diagnosing kidney stones. In this regard, a Computed Tomography (CT) scan is the most thorough method of diagnosing kidney stones. A CT scan will determine the state of the kidneys, bladder and ureter, which will assist in the determination of whether or not a stone exists. Additionally, a CT scan will determine the kidney stone's precise location, and size. It will also determine whether a blockage exists, and the condition of the other organs such as the pancreas, appendix, and aorta. However, to avoid unnecessary radiation pregnant women receive an ultrasound, as opposed to a CT scan. Moreover, once a patient is diagnosed with a kidney stone, simple x-rays is used to check the stone's movement through the urinary system (Sital 2011). Anatomy of the kidney Both kidneys are retroperitoneal organs that are usually located between the T12-L3 vertebral column with the right kidney placed a little lower than the left kidney to accommodate the liver. The upper poles of the kidney are usually oriented more posteriorly and medially than the lower poles. The kidneys serve significant functions, including separation and elimination of metabolic waste products, regulation of essential electrolytes, acid-base and fluid balance; and stimulation of the production of red blood cells. According to Rao (2011) kidneys also assist in the regulation of blood pressure through the renin-angiotensin-aldosterone structure, maintaining intravascular volume and controlling reabsorption of water. The kidneys also reabsorb amino acids and glucose and have hormonal roles through erythropoietin, calcitriol, and activation of vitamin D.Although kidneys are always paired, many people can live with only a single functioning kidney. Because of its dynamic functions and the toxins they encounter, the kidneys are weak to various problems including kidney stones. Source :( Renal resources center 2013) Pathology The pathology of kidney stones can be defined into three stages. The first stage is the inclinations toward calculi in the urinary system, a condition where the normal elimination process is breaking down often with its origin in the kidneys. The second stage is the severe or semi-acute stage, where the stones have occurred and are in the process of elimination or causing chronic trouble. The third stage is where the system has come to a balance and succeeds in maintaining a homeostasis despite the presence of one or more stones in the kidney. At this stage, the stone may deteriorate at and cause difficulty and acute pain as it begins to pass out of the ureter (Schrier 2008). On the other hand, it is possible to live with a stone without any problem. The intervention is aimed at easing pain, soothing mucous membranes in the urinary tract, and either passing the stone or removing it surgically. Aetiology Kidney stones regularly do not have definite or single cause but dehydration it the leading risk factor. Several other elementscan increase the risk of kidney stones. This condition occurs when there is insufficient fluid in the urine to dilute crystal forming substances such as oxalate, calcium and uric acid. These stones can also be triggered by an imbalance in the rate of metabolism resulting in the collection of unusually high levels of mineral salts in the urine. Kidney stones are classified according to its cause and therefore it is easy to identify the causes of kidney stones. Calcium stones are caused by calcium oxalate and are the most common type of stones. An oxalate is a natural compound including some vegetables, fruits, chocolates and nuts. The liver also generates oxalate (Abratt and Reid 2010). Calcium stones can also arisefrom the formation of calcium phosphate. Another type of kidney stones is the struvite stones, which forms because of an infection in the urinary tract. Struvite stones can enlarge rapidly, often without symptoms. Uric acids stones are also a type of kidney stones that form in people who lose excessive fluids or who do not consume sufficient fluids. Uric acid stones also result from the consumption of high-protein diets, chronic dehydration and diseases such as gout, and some cancers. The risk of developing stones can also be attributed to genetic factors. Cystine stones occur in individuals with genetic disorders that make the kidneys to produce large amounts of cystinuria. Hyperparathyroidism, a disorder that renders the parathyroid gland overactive, can also be associated to kidney stones. Additionally, certain bowel and intestinal disorders as well as acute infection of the urinary system can cause kidney stones (Miller and Lingeman 2007). Epidemiology The occurrence of kidney stone is around 2-3 % across the entire population. The projected life risk is around 10-15%, but the risk is higher in areas with hot climates. A substantial number of patients with kidney stones have reoccurrences within 10 years. However, some people experience multiple episodes of kidney stones over the course of their lifetime. There is a higher prevalence of kidney stones in men than in women with about 65-80% of cases of kidney stones affecting men. Most occurrences of in women are as a result of either infections or metabolic deficiencies for instance cystinuria. It is important to note that men experience their first episode at the age of between 30- 40. Conversely, the women experience a little later between the age of 35 and 55 years. These stones occur more frequently in adults than in agedpeople and more often-in aged people than in children (Pincus, et al. 2010). There is a greater prevalence of kidney stones in white people than those of the Asian ethnicity or blacks. In addition, kidney stones occur more often in hot, arid areas than in moderate regions. Some drugs, including acetazolamide, indinavir and Triamterene, are also linked to kidney stones. Role of imaging modalities in the diagnosis Imaging has a crucial role in the diagnosis and intervention of people with kidney stones. A range of imaging modalities is available for the diagnosis of kidney stones, and they include intravenous urography (IVU), conventional radiography (KUB), ultrasound, computed tomography (CT) scans and magnetic resonance urography (Richmond 2007). The intravenous Urography is used to identify the shape and the size of the kidney. It is also essential in the assessment of ureters and the pelvis. The results of an ordinary x ray may not provide a clear picture of the kidneys and it is possible to see the shape of the kidney, and whether a stoner exists. However, x rays do not give the details of the internal structure of the kidney and as such; it is difficult to ascertain how well the kidneys are functioning. With an injection of a contrast medium, there is a much better view of the kidneys. With intravenous urogram it is possible to get more detail of the kidney and assess how well the kidneys are functioning. According to Akbar, Reinus & Khurana (2010) there are slight risks associated with the injection of contrast material and from ionizing radiation. All X-ray techniques involve exposure to radiation and this procedure is prone to this risk. Additionally, every use of the dye or contrast medium, there is a possibility of a reaction. It is common for patients to feel warm as the contrast dye flows through the body. Some individuals may develop a mild asthma attack or a rash because of the contrast material. Even though the risk is reduced by the availability of non-ionic contrasts, there is still the risk of such complications occurring (Geary and Schaefer 2008). However, this modality has been replaced by computed tomography scans. Ultrasound is the most invasive procedure in the diagnosis of kidney stones because it does not involve radiation. Therefore, ultrasound is an appropriate imaging modality in children and pregnant women. This procedure can measure the size and project the appearance of the kidneys (Hechtman 2012). Ultrasound can also detect congenital anomalies, tumors, blockage and swelling. A newer technique termed Color Doppler is also effective in assessing pseudo-aneurysms, clots and narrowing of the arteries and veins of the kidneys. The ultrasound technique allows a quick visualization of the kidneys and related organs from outside the body. The process is comparatively cheaper to the other imaging modalities used in the diagnosis of kidney stones. However, certain factors may interfere with the interpretation of the results and these factors include severe obesity, intestinal gas and barium in the intestines used from a barium procedure (Greenberg & Cheung 2005). A computed tomography or CT scan, which is a noninvasive digital x-ray modality used to portray the internal organs such as the kidneys or the urinary tract. A CT scan is more sensitive than x-ray or ultrasound and is the best modality in the diagnosis of kidney stones and can detect all kidney stones. This modality is used in the reconstruction of several x-ray data samples. This scan gathers X-ray pictures from various positions of the body and generates thorough cross-sectional and solid images of the organs. Dhar & Denstedt (2009) argues that the technique can assess most details that can be assessed by an ultrasound. A contrast substance is not required with CT scans. However, the examination may require a CT urogram after a plain CT scan. This later procedure employs a contrast medium to provide a better visualization of the kidney and the urinary tract. Though a CT scan can sometimes fail to detect indinavir stones it can detect both non-calcium and calcium stones. The procedure is however more expensive than an x-ray and entails more radiation. Since a CT scan scans many organs, it is possible to detect causes of severe pain that are not related to kidney stone. This procedure is however not without risk such as the exposure to radiation and, occasionally, where contrast dye is used; there is the risk of allergic reactions to the contrast material used (Demertzis & Menias 2007). Because of its high sensitivity and accurateness in the detection of kidney stones, computed tomography is the preferred modality in the initial diagnosis of suspected kidney stones. The use of this modality reveals the presence, size and location of the stones. This information is important in the selection of the suitable therapeutic approach. However, Poletti et al. (2007) posits that the use of this modality increases exposure to ionizing radiation, which can affect the patient. With the increased use of computed tomography there is the concern of this risk, thus the preference to use low or ultra-low dose protocol. While the standard protocol is at 100mAs the low dose protocol is at 30mAs and this significantly reduces the risk of exposure to radiation. In contrast to the standard computed tomography protocol, the low radiation CT protocol provides comparatively similar sensitivity and accurateness in the detection of kidney stones and is, therefore, preferred (Sung, Singh, & Kalra 2011). Another imaging modality that can be employed in the diagnosis of kidney stones is magnetic resonance imaging. This technique uses hydrogen ions found in the body to get images of the kidney. MRI scanning uses radio waves, magnetism, and a computer to create images of the body organ. An MRI scan is painless and does not involve x-ray radiation but gives similar information as a computed tomography scan (Yuhico and Ko 2008). Metallic materials, chips, surgical clips, or foreign materials such as metallic bone plates, artificial joints or prosthetic devices, can substantially distort the images created by an MRI scanner. Gadolinium is a contrast dye used with MRI scans to obtain clearer images. An MRI does not involve radiation and there is no risk of radiation. However, gadolinium, which is the contrast material used in MRI scans, has been associated with nephrogenic systemic fibrosis, which is a potentially terminal skin disease in persons with reduced kidney function (Shah 2013). Moreover, gadolinium may decrease the rate of glomerular filtration, just like other contrast dyes. Additionally the powerful magnetic fields created during the scan can cause implants to malfunction. These magnetic fields can also result in the shift of metallic implants in the body. Post treatment imaging of kidney stone patients is recommended to guarantee complete disintegration and clearance of kidney stones. Plain radiography is recommended for post treatment with ultrasound and intravenous urography reserved for these sessions to reduce exposure to radiation from repetitive CT scan. Source: (Jaffe et al.2006). A CT scan of a patient with kidney stones. (Jaffe et al.2006) Treatment and prognosis The treatment of kidney stones is focused primarily on symptom management. Where a patient has a history of stones, home treatment can be appropriate; however, patients who have never passed stones should opt for professional medical assistance. Passing, a kidney stone, can be painful, but the pain can be treated with prescription pain drugs, bed rest, and consumptionof lots fluids to avoid dehydration. Hospital treatment may involve hydration through the use of an intravenous tube and anti-inflammatory drugs (Rule et al. 2009). Additionally narcotics are effective in relieving the pain of passing the stone while anti-emetic drugs can controlnausea and vomiting. Eventually most kidney stones are excreted naturallywithin a few weeks, but some requireeither be broken up into smaller pieces or surgically removed. Stones can be broken up using techniques such as extracorporeal shock wave lithotripsy, percutaneous lithotripsy or cystoscopy.In an extracorporeal shock wave lithotripsy, high intensity ultrasound waves pass through water sacks placed on the skin and are focusedon the stone. These waves break down the stones into small pieces that can get through the ureter (Srisubat et al. 2009). If the stone is located in the higher section of the ureter or the bladder, it can be broken using cystoscopy. This procedure involves passing a crushing device and a viewing tube into the lower ureter or bladder. This crushing device can be used to extract the stone, or it can break the stone up with electric or laser energy.Stones, which are too large to be removed as a whole, can be crushed using percutaneous lithotripsy, which involves the insertion of a viewing tube into the body through an incision. Ultrasound or electric energy is then used to break up the stone. The use of surgery in the treatment of kidney stones is only used in circumstances where the other techniques have failed often because the stones are large or hard to reach (Stoller and Meng 2007). Where the stones are because of issues in metabolism, medications and dietary prescription can be used. The occurrence of stones can also be prevented by drinking plenty of fluids and reducing excessive proteins and salts Summary and conclusion A kidney stone forms in a kidney because of high levels of some substances in the urine. At lower levels, these substances do not cause problems. The stones may result from high levels of oxalate, phosphorus and calcium in the urine. Symptoms of kidney stones include pain when passing urine, sharp pain in the back or lower abdomen and blood in urine. The diagnosis of kidney stones includes physical examination, medical history and urine, blood tests. However, complete diagnosis of kidney stones can be achieved by use of imaging.Treatment for kidney stones is determined from its composition and size. Pain relievers are used to reduce the pain associated with passing the stones. Where the stones are considerably large and cannot be excreted naturally, the stones can be broken down or removed surgically. Taking plenty of fluids and a dietary change can significantly assist in the prevention of kidney stones. References: Abratt, Valerie R., and Sharon J. Reid. 2010. "Oxalate-degrading bacteria of the human gut as probiotics in the management of kidney stone disease." Advances in applied microbiology 7 (2): 63-87. 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