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    treatment for kidney stone by guomanman and chenya

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    guomanman

    Posts : 30
    Join date : 2009-06-23
    Age : 34
    Location : China

    treatment for kidney stone by guomanman and chenya

    Post  guomanman on Wed 24 Jun 2009, 10:58 am

    Dyad 6 guomanman and chenya

    Idiopathic hyperuricosuria, hypercalciuria and infantile renal stone disease: new association and therapeutic approach
    Aamir Jalal Al-Mosawi


    Urolithiasis in association with idiopathic hypercalciuria (IHC) plus idiopathic hyperuricosuria (IHU) has been reported in older children and adult patients only. IHU plus IHC in association with progressive infantile bilateral renal stone disease has not been previously reported during the first year of life.The aim of this paper is to report the novel association of IHU, IHC and progressive infantile bilateral renal stone disease and also to report our therapeutic approach for this new association, combining traditional treatments of hyperuricosuria (HU) and hypercalciuria (HC) with recently used essential oil terpenes in the management of childhood and infantile urolithiasis.

    An 8.5-month old boy was referred with bilateral multiple stone disease. He initially presented with excessive crying and irritability since early infancy. The first renal stone was detected using ultrasound and intravenous pyelogram (IVP) at the age of 4 months. On referral, he showed signs of colic with excessive crying. Renal ultrasound showed bilateral multiple stones. 24-h urine examination revealed concomitant significant HU (1.7 g/day) and HC (15 mg/kg/day). 24-h urine oxalate excretion was also mildly elevated (2.9 mg/kg/day). Due to the serious nature of infantile progressive stone disease, the boy was treated with triple therapy consisting of hypocalciuric diuretics, allopurinol and essential oil terpenes with the aim of achieving a stone-free state and preventing renal damage.

    results

    Early symptomatic relief was achieved during the first week of therapy. A stone-free state was achieved after 3 months of treatment without the occurrence of any side effects.

    summary

    IHC and IHU have rarely been association with progressive infantile bilateral renal stone disease. Therapy for this new association with a combination of the traditional treatments of HU and HC with essential oil terpenes may be beneficial.

    reference

    La Manna‌ A, Polito C, Marte A, Iovene A, Di Toro R. Hyperuricosuria in children: clinical presentation and natural history. Pediatrics107(1),86–90 (2001). [CrossRef] [Medline]
    2 Polito‌ C, La Manna A, Nappi B, Villani J, Di Toro R. Idiopathic hypercalciuria and hyperuricosuria: family prevalence of nephrolithiasis. Pediatr. Nephrol.14(12),1102–1104 (2000). [CrossRef] [Medline]
    3 Andres‌ A, Praga M, Bello I. Hematuria due to hypercalciuria and hyperuricosuria in adult patients. Kidney Int.46,96–99 (1989). [CrossRef]
    4 Levy‌ FL, Kemp RD, Breyer JA. Macroscopic hematuria secondary to hypercalciuria and hyperuricosuria. Am. J. Kidney Dis.24,515–518 (1994). [Medline]
    5 Terzani‌ G. The remedies of the terpenes series. Gazetta Internazionale Di Medicine E Chirugia (International Journal of Medicine and Surgery) LIX (1954).
    6 Kanstein‌ K. Clinical experiences with new drugs containing terpenes. Medizinsche Monatschrift10(4),254–257 (1956). [Medline]
    7 Barrat‌ TM, Duffy PG. Nephrocalcinosis and urolithiasis. In: Pediatric Nephrology (4th Edition). Barrat TM, Avner ED, Harmon WE (Eds). Williams & Wilkins, NY, USA 933–945 (1999).
    8 Germin‌ B, Wiggelinkuisen J, Bonnici F. Nephrocalcinosis in children. Br. J. Radiol.55,413–418 (1982). [Medline]
    9 Kroovard‌ LR. Pediatric urolithiasis. Urol. Clin. North Am.924,173–184 (1978).
    10 Al-Mosawi‌ AJ. A possible role of essential oil terpenes in the management of childhood urolithiasis.Therapy3(2),301–321 (2005).
    11 Gemia‌ B, Tormene A. Treatment of urinary calculosis with terpenes Rassega Internazionali di Clinica E Therpia 35,16 (1955).
    12 Hammer‌ O, Rothe K. On the conservative therapy of nephrolithiasis. Med. Welt.31,1576–1581 (1961).
    13 Choi‌ H, Snyder HN III, Duckett JW. Urolithiasis in childhood: current management.J. Pediatr. Surg.22,158–164 (1987). [CrossRef] [Medline]


    Last edited by guomanman on Thu 25 Jun 2009, 10:14 pm; edited 1 time in total

    YangChunHua

    Posts : 20
    Join date : 2009-06-23

    Treatment of kidney stone by YuanShuHUa & YangChunHua

    Post  YangChunHua on Wed 24 Jun 2009, 5:12 pm

    Tamsulosin treatment increases clinical success rate of single extracorporeal shock wave lithotripsy of renal stones

    Received 19 July 2004; accepted 7 January 2005. Available online 1 July 2005.
    Objectives
    To design a randomized, no-treatment, controlled, prospective study to determine whether the administration of tamsulosin, as adjunctive medical therapy, increases the efficacy of one extracorporeal shock wave lithotripsy (ESWL) session to treat renal stones and decreases the use of analgesic drugs after the procedure.
    Methods
    A total of 130 patients underwent a single ESWL session to treat solitary radiopaque renal stones 4 to 20 mm in diameter. After treatment, all patients were randomly assigned to receive our standard medical therapy alone (controls) or in association with 0.4 mg tamsulosin daily for a maximum of 12 weeks. All 130 patients were followed up for 3 months or until an alternative treatment was given.
    Results
    Of the 130 patients, 78.5% of those receiving tamsulosin and 60% of controls had achieved clinical success at 3 months (P = 0.037). When we stratified patients according to stone size, for those with a stone size larger than 10 mm, the success rate was significantly greater in the tamsulosin group (P = 0.028). Renoureteral colic occurred in 76.9% of patients treated with standard therapy but in only 26.1% of those receiving tamsulosin (P <0.001). The mean cumulative diclofenac dose was 375 mg per patient in the tamsulosin group and 675 mg per patient in the control group (P <0.001).
    Conclusions
    The results of our study have demonstrated that tamsulosin therapy, as an adjunctive medical therapy after ESWL, is more effective than lithotripsy alone for the treatment of patients with large renal stones and is equally safe. In addition, our results also indicated that adjunctive treatment with tamsulosin could decrease the use of analgesic drugs after ESWL.
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    gillegarda/joanalynbalino

    Posts : 31
    Join date : 2009-06-19
    Age : 31

    Re: treatment for kidney stone by guomanman and chenya

    Post  gillegarda/joanalynbalino on Thu 25 Jun 2009, 9:38 pm

    RESPONSE: Kidney Stones
    By: D2: Gil Legarda and Joanalyn Balino

    Oxalobacter formigenes May Reduce the Risk of Calcium Oxalate Kidney Stones
    David W. Kaufman, Judith P. Kelly, Gary C. Curhan, Theresa E. Anderson, Stephen P. Dretler, Glenn M. Preminger and David R. Cave

    This research is a case control study identifying the effect of oxalobacter formigenes in reducing the risk for calcium oxalte kidney stones. The purpose of this study is to decrease the prevalence of having calcium oxalate kidney stones. There were 379 eligible cases identified at hospitals in Boston, MA and Durham, 65% or 247 were completed the study procedures. Among 339 control participants initially matched to case patients, 76% or 259 completed the study including the 12 control subjects matched to potential case patients who were subsequently excluded. As an inclusion criteria the composition of the stone should be confirmed by laboratory analysis . Patients with this potential case will be excluded such as inflammatory bowel, spinal cord injury, gastrointestinal condition that predisposes to malabsorption, cystic fibrosis, internalized double J urethral stent, chronic indwelling foley catheter, history of organ transplantation, current chemotherapy and pregnancy within the preceding 2 months. The patients thal also were excluded who had received treatment with tetracyclines, macrolides, chlorampheicol, metronidazole, rifampin in the 2 months period before the stone. This studey was held in three hospitals in Boston, Massachusetts these are Boston Medical Center, St. Elizabeth’s Medical Center, Massachusetts General Hospital an Duke University Medical Center in Durham, NC. A nurse used an interview to gather informations from the participants by the use of telephone call also for demographic factors, relevant medical history, use of antibiotics in the past 5 yr and use of diuretics, allopurinol, potassium citrate and potassium phosphate. In the analysis of data the case patients anf the control subjects were classified into O. formegenes positive or negative and the OR group was estimated, overall and among subgroups such as according to gender. Confounding was controlled by unconditional and conditional logistic regression. Case patients and control subjects were divided into approximate tertiles of oxalate consumption. Among the control subjects, the prevalence of O. Formigenes was 31 percent in the lowest tertile, among the case patients. Both the 139 case patients and 138 control subjects completed the 24 hours urine collection, the OR for developing kidney stones increased urinary oxalte excretion.

    O. Formigenes overall prevalence was 38 percent among the control subjects, 33 percent among the control subjects nominated by included case patients, 39 percent among control subjects nominated by ineligible patients, and 40 percent among volunteers. And 17 percent among the case patients, giving a crude odds ration of 0.3; also there is a 0.3 in multivariate estimation or 95% confidence interval 0.2 to 0.5. The analysis was restricted to 209 case patients who did not contribute to any nominated control subjects to the final series and the 219 control subjects who were not nominated by included case patients, the crude OR was 0.3. There was a consistent inverse association present within strata of age, gender, race or ethnicity and region.

    It was observed in this study the strong inverse association between colonization with O. Formigenes and recurrent Calcium Oxalate renal stones, with a 70 percent reduction in overall risk. The relationships between age, gender, race or ethnicity and region. O. Formigenes prevalence was related to the use of antibiotics to which the bacterium has been previously reported to be sensitive and to lesser extent, other antibiotics. The association of bacterium to kidney stones did not seem to be materially affected by antibiotic use. It was not also affected by oxalate consumption or urinary oxalate excretion.

    Reference:
    Kaufman D. W. et. al. (2007) Oxalobacter formigenes May Reduce the Risk of Calcium Oxalate Kidney Stones. Journal of the American Society of Nephrology Vol. 19: 1197-120. Retrieved June 25, 2009 from http://jasn.asnjournals.org/cgi/reprint/19/6/1197?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&minscore=5000&resourcetype=HWCIT

    nancelle
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    Treatment for kidney stones

    Post  nancelle on Fri 26 Jun 2009, 12:36 am

    Dyad 1 : Nancelle Dumlao/ Rodel Perez

    Treatment and Medications for Glomerulonephritis

    Efficacy and safety of ‘rescue therapy’ with mycophenolate mofetil in resistant primary glomerulonephritis—A multicenter study
    by: Alfons Segarra, M Luisa Amoedo, Jose M Martinez Garcia, Salvador Pons, Manuel Praga, Elvira Izquierdo Garcia, Juan Carlos Alonso, Joan M. Gascó, L. Pou and Luís Piera.

    End-stage renal disease is currently on the rise and primary glomerular diseases is considered the leading cause especially in young patients. There are several measures being utilized to prevent deterioration of a patient with primary glomerular diseases such as blood pressure control, salt restrictions and ACE inhibitors, glucocorticoids and classic immunosuppressive drugs. However, adverse effects of the drugs and inability to sustain positive outcomes warrants the need to discover new treatments for the disease. There are two transplant immunosuppressants now being used for primary glomerulonephritis: (1) calcineurin inhibitors (such as ciclosporin A) and (2) mycophenolate mofetil (MMF). For the former, many clinical studies have proven that it resulted to sustained remission for many patients with idiopathic focal segmental glomerulosclerosis (FSGS) or membranous nephropathy, (MN). There is a drawback though, which is chronic nephrotoxicity for the long-term use of ciclosporin A. However, for mycophenolate mofetil (MMF) there is still a need to further study how best to utilize the drug. Hence, the undertaking of this multicenter large cohort study which intends to analyse the efficacy and safety of MMF as a monotherapy for primary glomerulonephritis for those patients that are nonresponding to conventional treatments. This is only a 12-month study to determine short-term efficacy data, minimum treatment period, potential predictors of outcome and response rates in each type of disease. The 98 subjects from 8 hospitals had renal biopsy-proven primary glomerulonephritis and are not responding to other drugs were given MMF for 1 year. Outcomes of the study were measured using urinary protein excretion, complete (defined as PR < 0.3 g/day in two consecutive measurements within 3 months) or partial remission of proteinuria (defined for IgAN as PR 0.3 and
    1 g/day), changes in the slope of creatinine clearance.


    The result of the large cohort study showed that fifty-four percent (54%) of the patients had either complete or partial remission of proteinuria in any type of glomerulonephritis. The treatment with MMF only induced complete remissions of proteinuria in a minority of patients. On the other hand, it improved urinary protein excretion in more than 50% of the patients with resistance to other immunosuppressant drugs and who had persistent proteinuria, even if they have ACEI or AIIRA and a low-salt diet. Furthermore, there was higher reduction in urinary protein excretion in patients with basal nephrotic proteinuria and preserved renal function. Also, the mean blood pressure decreased significantly resulting to reduction in antihypertensive drugs.


    The study was beneficial in ascertaining that another important immunosuppressive drug which is the mycophenolate mofetil (MMF) could be helpful in prolonging the lives of patients with primary glomerulonephritis. The MMF monotherapy was used to gain moderate decrease in proteinuria in more than half of the patients who do not have other treatment options. The positive outcome of the therapy was largely due to a patient having preserved renal function and having sustained MMF treatment.

    This new treatment option, particularly to those unresponsive to the current available drugs, have given new hope for a better and longer life for the patients. Considering the high cost of the immunosuppressive drugs, the study is also beneficial in lowering their medical bills by reducing the use of antihypertensive drugs since MMF has contributed in controlling the mean blood pressure of the patients.

    Reference:

    Segarra,A.; Amoedo, L; Garcia, J.; Pons, S.; Praga,M.; Garcia, E.; Alonso,J.; Gascó, J.; Pou,L.; and Piera, L. Efficacy and safety of ‘rescue therapy’ with mycophenolate mofetil in resistant primary glomerulonephritis—A multicenter study. Oxford University Journal. 2007.

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    alkhaloidz

    Posts : 27
    Join date : 2009-06-19
    Age : 31
    Location : Sampaloc, Manila

    D4 RESPONSE

    Post  alkhaloidz on Fri 26 Jun 2009, 9:37 am

    DYAD 4
    BALAJADIA, BOND
    ZANO, ALEXIS

    Nephrology: 1. Investigation and treatment of recurrent kidney stones

    Case 1
    A 60-year-old man is discharged from hospital after his second bout of renal colic in 2 years. Both times, he passed a stone without any need for surgical intervention. There is no other relevant history. The stones were analyzed biochemically and found to be composed of pure calcium oxalate. Imaging studies do not suggest the presence of residual calculi in the renal tract. The patient is, understandably, reluctant to pass any more kidney stones. The results of relevant laboratory investigations are as follows: serum biochemistry normal, urine volume 1.75 L over 24 hours, urinary calcium excretion 2.9 mmol/day, urinary phosphate excretion 24 mmol/day, urinary uric acid excretion 5.5 mmol/day, urinary oxalate excretion 270 μmol/day and urinary citrate excretion 0.6 mmol/day. The patient asks you what the probable cause is of his recurrent nephrolithiasis. What medication could be prescribed to help him and what side effects could he anticipate? What other measures could the patient take to reduce his risk of stone recurrence?

    Case 2
    A 55-year-old woman with recurrent uric acid stones has begun treatment with potassium citrate, 60 mEq/day, in divided doses and allopurinol, 300 mg/day. She finds the potassium citrate unpalatable but, on your advice, agrees to continue the medication. She comes to your office 10 days after starting the medications describing general malaise, weakness, mild dysphagia and nausea. She has a generalized rash and some oral ulcers. What are the side effects of the prescribed medication? What is your diagnosis? What measures would you recommend?
    Kidney stones are rarely, if ever, fatal. The main impact of nephrolithiasis is felt by young, otherwise healthy adults in the form of acute renal colic, causing symptoms of pain, nausea, vomiting and hematuria. The estimated cost of this condition in the United States for 1993 was US$1.83 billion.1 The lifetime risk of passing a kidney stone is about 8%–10% among North American males, and the peak age of incidence is 30 years. The rate of kidney stone formation in women is about half that in men, with 2 peaks, the first among women aged 35 years and the second among those aged 55 years.2 Among patients who have passed one kidney stone, the lifetime recurrence rate is 60%–80%.2 There is significant geographic and seasonal variation in rates of stone formation. The reasons for this variation are not entirely clear, but they may relate to climate and the mineral content of drinking water. The frequency of kidney stones (notably calcium oxalate stones) has increased with improved standards of living.

    Medical management
    Medical interventions for kidney stones can be classified as general or specific. General measures, which are advisable for all patients, include increasing fluid intake to produce a urine volume of 2–3 L/day. Data on the benefits of dietary interventions are less conclusive,6,12 and well-conducted, prospective studies are lacking. Good advice is to reduce the intake of animal protein and sodium, because reduction in the renal excretion of sodium will also reduce renal calcium excretion and thus render the urine less lithogenic. As described earlier, patients should moderate their calcium intake to 1 g/day.
    These general measures should be instituted in all patients with recurrent stone formation to take advantage of the well-recognized phenomenon of the “stone clinic effect,” which, it has been suggested, can reduce the 5-year stone recurrence rate by 60%.13 Specific interventions depend on stone type and identifiable factors in the urine that may increase lithogenicity, as outlined here.
    Calcium oxalate stones
    A recently published meta-analysis of randomized trials on preventing the recurrence of calcium oxalate stones suggested that the greatest benefit from pharmacologic intervention is associated with thiazide diuretics.14 Five trials involving thiazide diuretics and a single trial with the closely related drug indapamide suggested a risk reduction for developing new stones of 21.3% (95% confidence interval –29.2% to –13.4%) in the patients receiving medication. The combination of hydrochlorothiazide, 25–50 mg, with amiloride, 5 mg, to prevent potassium wasting was appropriate. Benefits were seen only after 3 years of treatment, so therapy should not be abandoned if stones recur early. Less benefit was conferred by citrate-containing alkalinizing compounds and allopurinol. However, oral potassium citrate, 30–80 mEq daily, is indicated for patients in whom hypocitraturia has been detected.
    A randomized, placebo-controlled study showed a benefit of allopurinol, 100 mg 3 times daily, in people with hyperuricosuria and formation of calcium oxalate stones.15 In addition to a requirement for both hyperuricosuria and normocalciuria, patients who were selected for the study had formed 2 or more calculi in the 5 years before the study and at least one calculus in the previous 2 years. The rate of new stone events (defined as a composite of stone passage and the appearance of a new stone, or enlargement of an existing stone on abdominal radiography) was much higher among the 31 patients receiving placebo than among the 29 receiving allopurinol (0.26 v. 0.12 per patient year, p < 0.02).
    There is no strong evidence to support the use of measures to reduce urinary oxalate, such as oral calcium supplementation and administration of cholestyramine.
    Uric acid stones
    Uric acid is soluble in alkaline urine. Thus, management of uric acid stones generally involves alkalinization of the urine. The target range for urine pH should be 6.0–6.5 for therapy, because formation of another type of stone, calcium phosphate, may be induced by urinary pH above 7. Urine can be alkalinized with either oral potassium citrate or sodium bicarbonate. The former has the advantage of avoiding a sodium load, which may lead to hypercalciuria, and has been shown to reduce significantly the recurrence of uric acid stones when given at doses of 30–80 mEq/day,16 but it should be used cautiously in combination with potassium-sparing diuretics because of concerns about hyperkalemia.
    Struvite stones
    Struvite stones form in infected urine and are frequently large enough to fill the entire pelvicalyceal system; in this situation, they are known as staghorn calculi. In rare cases, staghorn calculi are composed purely of cystine or calcium oxalate monohydrate. Because of their size and the presence of infection, a combined surgical and medical approach, including increased fluid intake and the use of antibiotics, is required. The American Urological Association has published clinical practice guidelines for the management of staghorn calculi.17 It recommends extracorporeal shock wave lithotripsy (ESWL) combined with percutaneous stone removal. Removal of all stone fragments and antibiotic therapy to sterilize the urine are required to prevent recurrence.
    Cystine stones
    Despite the rarity of cystine stones (1%–2% in adults, 6%–8% in children), they deserve special mention. Cystinuria is an inborn error of metabolism characterized by defective tubular and intestinal transport of cystine, ornithine, lysine and arginine. Although large amounts of all of these amino acids appear in the urine, only the cystine precipitates at physiologic pH. A high fluid intake throughout each 24-hour period decreases the rate of recurrence. Sodium restriction (to 80–100 mmol/day) significantly reduces cystine excretion.18 Other therapies for cystine stones include drugs such as penicillamine, tiopronin and captopril.19 These medications increase the solubility of cystine by cleaving the disulfide bond of the amino acid.
    Surgical management
    There have been major advances in the surgical management of renal and ureteric calculi over the past 15 years. Renal calculi that are increasing in size or causing symptoms or obstruction should be dealt with by one of the techniques that result in complete clearance of the stone and any fragments.
    First described by Chaussy in 1982,20 ESWL is now the primary surgical modality for most renal calculi, although the clearance rate for all stone fragments is not as high as originally reported. Plain radiography indicates stone-free status in approximately 34% of patients, but nephrotomography indicates this degree of success in only 17%.21 The success of ESWL varies with the composition, location and size of the stone, the type of generator used and the “targetability” of the stone. Close follow-up to ensure passage and removal of all stone fragments is required. The rate of recurrence after ESWL varies according to stone type but is as high as 20% in patients with infected stones. If stone fragments are retained, regrowth rates are about 33% at 3.6 years.21
    For most ESWL procedures conducted with modern equipment, anesthesia is not required, and patients are treated in the outpatient setting with light sedation. During the treatment, the patient receives about 2000 shocks from an ellipsoid generator; this lasts about 30 minutes depending on the size of the stone and the number of shocks that have to be delivered. This is associated with some discomfort, hematuria and the passage of multiple small stone fragments.
    A number of other minimally invasive ureteroscopic and percutaneous surgical procedures are available. The combination of these with ESWL for large and staghorn calculi has given rise to the term “sandwich therapy.”22 This combined therapy entails percutaneous fragmentation and removal of as much stone as possible, followed by ESWL to those areas that could not be reached initially. Fewer percutaneous passes are required, and the risk of bleeding and infection is lessened. Second-look percutaneous nephrostomy passing through previously created tracts can be performed to remove stone fragments that are not passed after ESWL. Follow-up surveillance and antibiotic therapy, where appropriate, form an integral part of this therapy.
    Newer techniques involving retrograde approaches to ureteral and renal calculi use miniature flexible and semi-rigid ureteroscopes, which permit access to the entire ureter and collecting system. There are few stones that cannot be managed by minimally invasive techniques. Open stone removal is necessary only for patients with anatomic anomalies and those for whom the newer modalities have failed.

    Morton, A R et. al. Nephrology: 1. Investigation and treatment of recurrent kidney stones. PMC. January 2002

    NurseMon
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    Respose for kidney stone treatment

    Post  NurseMon on Thu 09 Jul 2009, 4:09 am

    Dyad 3:
    Byron Webb A. Romero
    Von Deneb H. Vitto
    Raymond C. Ursal

    Medical Evaluation and Treatment of Urolithiasis
    Julie A. Nicoletta, MDT, Marc B. Lande, MD

    The research talks about the nephrolithiasis which is common to children especially the white, with African American and Asian children rarely affected. Seventy-five percent of children who have nephrolithiasis have an identifiable predisposition to stone formation. Metabolic risk factors account for more than fifty percent of cases, structural urinary tract abnormalities account for thirty-two percent, and infection accounts for four percent. It is not uncommon to find more than one predisposing factor in the evaluation of a child who has nephrolithiasis. Adults who have nephrolithiasis typically present with debilitating flank pain and hematuria. This classic clinical presentation is less common in the pediatric population.

    Increased fluid intake is the first line of therapy for all stone types. Although this approach is effective in treating patients with any cause of nephrolithiasis, long-term compliance with an increased fluid regimen is often poor. Increasing urine volume to more than 2 liters a day in adolescents who have nephrolithiasis would be ideal. Patients who are asymptomatic and patients not associated with impending or ongoing obstruction may be managed conservatively. Most stones that measure less than 5 mm in diameter likely pass spontaneously, even in young children.

    The initial treatment of hypercalciuria in a child who has nephrolithiasis should be increased fluid intake, reduction of dietary sodium, and the reduction of excessive dietary calcium to that of the recommended daily allowance recommendations. Care should be taken not to restrict calcium intake to less than these guidelines. Dietary sodium restriction may help to reduce urinary calcium losses, especially in patients with excessive dietary sodium intake. Excessive dietary protein intake also should be avoided because research has proposed that it increases endogenous acid production and leads to metabolic acidosis, which increases calcium reabsorption of bone and urinary calcium excretion. If these measures are not effective alone, a thiazide diuretic may be added.

    Thiazide diuretics are hypocalciuric and natriuretic. Thiazides not only directly stimulate distal tubular calcium reabsorption but also increase calcium reabsorption in the proximal tubule secondary to mild volume contraction. The effects of thiazide diuretics are fully exerted when combined with salt restriction and are blocked by excessive dietary sodium. Hypokalemia that may be precipitated by the use of a thiazide diuretic should be corrected because it can lead to intracellular acidosis and a decrease in urinary citrate excretion. Serum lipid levels should be monitored periodically in patients on thiazide diuretics, because increases in total serum cholesterol and low-density lipoprotein cholesterol are adverse effects of these drugs. Amiloride also stimulates distal tubular calcium reabsorption and can be added to a thiazide diuretic for additive effects if hypercalciuria persists. Neutral phosphate can be used as an adjuvant therapy for nephrolithiasis secondary to hypercalciuria. In patients who have calcium oxalate stones, calcium oxalate supersaturation is most affected by the urinary oxalate concentration.

    Dietary restriction of calcium increases the risk of stone formation by increasing the supersaturation of this salt, because more oxalate is absorbed by the gastrointestinal tract. In the hopes of decreasing this absorption of oxalate, dietary and supplemental calcium have been tried with conflicting results. In two large population studies, dietary calcium significantly decreased the risk of stone formation in male and female patients, but supplemental calcium was found to increase significantly the risk of stone formation in women. Other studies examined calcium supplementation either for stone disease or osteoporosis and did not find any increase in the risk of calcium oxalate stone formation.Eight hundred to 1200 mg of dietary calcium is recommended per day. If this amount is exceeded, urinary calcium levels should be monitored because they can increase significantly. If calcium supplements are used, they should be given with meals to prevent the absorption of oxalate and calcium. Further studies must be performed before further recommendations can be made in regard to calcium supplementation in the treatment of stone formation.

    References:

    Nicoletta, J.A. et. al. (2006) Medical Evaluation and Treatment of Urolithiasis. MD Consult Journal; 53(3): 479-91, vii. Retrieved July 09, 2009 from Retrieved June 25, 2009 from http://www.mdconsult.com/das/article/body/148419737-4/jorg=journal&source=MI&sp=16225280&sid=860395405/N/534739/s0031395506000290.pdf?issn=0031-3955

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