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o f M e d i c a l M a n a g e m e n t This publication is printed and distributed for education purposes by MISSION PHARMACAL COMPANY, San Antonio, TX 78230 1355 Curriculum vitae for authors available on request.
For additional copies call: 1-800-292-7364
or e-mail: customerservice@missionpharmacal.com
o f M e d i c a l M a n a g e m e n t A simple, step-by-step approach to diagnosis andp revention of nephro l i t h i a s i s .
This text has been prepared by the authors purely foreducational purposes, in response to requests fro mmany physicians who are confounded bycomplexities of medical approach to stone disease.
There is no restriction on duplication or disseminationof the material. Enclosed recommendations representa consensus view of the authors. They do notpreclude other options or approaches.
Selection of simplified or extensive evaluation at initial visit.
Apply a simplified evaluation in patients with single stoneepisode without risk. Consider an extensive evaluation inpatients with recurrent episode or first episode at risk. SCHEME FOR DIAGNOSTIC EVALUATION
H i s t o ry constituting increased risk for stone development. Ifp resent in patients with first episode, an extensiveevaluation is advised. If absent, a simplified evaluation maybe applied. RISK ASSESSMENT
First Episode
Family History of StonesBone/G-I DiseaseGoutChronic UTINephrocalcinosis SIMPLIFIED EVALUATION
H i s t o ry andl a b o r a t o ry tests tobe obtained during Stone-provoking medicationsFluid lossUrinary tract infection Laboratory Tests:
Stone analysis (e.g., StoneComp® Test)Serum Ca, P, electrolytes and uric acid 24-hour urine stone risk profile analysis (e.g. StoneRisk® Diagnostic Profile, UroRisk®Diagnostic Profile) Urinalysis & urinary sediment (crystals)Urine culture (if clinically indicated)KUB DIETARY ABERRATIONS
StoneComp®, StoneRisk®, and UroRisk® are registered trademarks of Mission PharmacalCompany.
STONE-PROVOKING MEDICATIONS
STONE ANALYSIS
Diagnostic importance of stone analysis.
STONE TYPE
ETIOLOGY
Radiopaque Stone
hyperuricosuria, hypocitraturia, hypomagnesiuria, low urine v o l u m e Radiolucent Stones
chronic diarrheal syndrome,dehydration, low urinary pH URINALYSIS
During simplifiede v a l u a t i o n , • Quantitative cystine (if suspect cystinuria) TREATMENT OF FIRST EPISODE
C o n s e rv a t i v em e a s u res to be Conservative Measures
Do not restrict calcium if bone diseaseis present/suspected EXTENSIVE EVALUATION
Recurrent Episode
First Episode at Risk
FULL AMBULATORY PROTOCOL
: Random diet
factors on customary diet and fluid intake : Restricted diet
w a rranted by persistent h y p e rc a l c i u r i a ) Visit 1 and 2 - two weeks apart. If possible,bone density with hypercalcemia or markedh y p e rc a l c i u r i a SIMPLIFIED
AMBULATORY EVALUATION
1. 24-hour urine stone risk analysis (e.g., S t o n e R i s k® Diagnostic Profile, Uro R i s k® 2. Dietary modification pending results of 1 3. Abbreviated stone risk analysis (e.g. S t o n e Tr a c k® Monitoring Te s t) plus serum Ca, P, electro l y t e s ,uric acid and PTH fol owing dietary modification 4. Bone density in hypercalcemia or marked StoneRisk®, UroRisk®, and StoneTrack® are registered trademarks of MissionPharmacal Company.
DIETARY MODIFICATION
urine stone riskanalysis, identify Modification
d i e t a ry measure sas described DIETARY MODIFICATION
m e a s u res. After 1-4 months of such a dietarym o d i f i c a t i o n , At least 10-10 oz glasses/day (enough to risk profile. Fro mresults of full and a b b reviated stonerisk analysis, make Avoidance of dairy products, spinachDiagnostic purpose only DIETARY MODIFICATION
m e t a b o l i ca b n o rmalities arep resent fro m p re c e d i n gd i a g n o s t i c to all patients withre c u rrent episode • Avoidance of purine gluttony if possible h y p e rcalciuria (only in the presence of P rovide additionalspecific measure sfor diff e re n tm e t a b o l i ca b n o rmalities (tobe described). TREATMENT
h y p e rcalciuria withlow bone density Hypercalcemia:
Hypercalciuria with Low Bone Density and
Normal Serum Ca:
Urocit®-K and Neutra-Phos-K® are registered trademarks of Mission PharmacalCompany and Alza Pharmaceuticals respectively ABSORPTIVE HYPERCALCIURIA TYPE I
FASTING HYPERCALCIURIA w Normal PTH
a b s o r p t i v eh y p e rc a l c i u r i a U r i n a ry Ca > 250 mg/day on StoneRisk® Diagnostic Profile, Uro R i s k® Diagnostic P rofile or StoneTr a c k® Monitoring Te s t C h l o rthalidone 25 mg/day or Indapamide 2.5 mg/day + K Cit (e.g., Uro c i t®-K) SCP (e.g., Calcibind®) 5 g bid with oxalate restriction in TZ resistance/intolerance without bone disease ABSORPTIVE HYPERCALCIURIA TYPE II
> 250 mg/day on StoneRisk® Diagnostic P rofile or Uro R i s k® Diagnostic Profile < 250 mg/day on StoneTr a c k® Monitoring Test (fol ow-up abbreviated test pro f i l e ) Normal Serum Ca and PTHNo evidence of bone disease Moderate dietary Ca restriction, orC h l o rthalidone 25 mg/day or Indapamide 2.5 mg/day + K Cit (e.g., Uro c i t®-K) 10 meq bid StoneRisk®, UroRisk®, and StoneTrack®, Calcibind® and Urocit®-K are registered trademarks of Mission Pharmacal Company.
RENAL HYPERCALCIURIA
Indapamide 2.5 mg/day + K3Cit (e.g., Uro c i t®-K) 20 meq bid Urocit®-K is a registered trademark of Mission Pharmacal Company.
HYPERURICOSURIC CA
NEPHROLITHIASIS
h y p e ruricosuric Can e p h ro l i t h i a s i s . Urinary uric acid > 700 mg/daypH > 5.50CaOx stones (recurrent)History of animal protein excess (purine Al opurinol (e.g., Zyloprim®) 300 mg/day, if serum uric acid > 8 mg/dlurinary uric acid > 800 mg/day 15 meq bid, if hypocitraturicurinary uric acid 600-800 mg/day Zyloprim® and Urocit®-K are registered trademarks of Prometheus Laboratories andMission Pharmacal Company respectively.
HYPOCITRATURIC CA NEPHROLITHIASIS
protein excess,deficient intakeof citrus fruits orsodium abuse. GOUTY DIATHESIS
Urinary pH < 5.50Uric acid/Ca stonesPersonal/family history of goutHigh serum uric acid and triglyceridesNo animal protein excess or CDS Allopurinol (e.g., Zyloprim®) 300 mg/day for Serum uric acid > 8 mg/dlUrinary uric acid > 800 mg/day Zyloprim® and Urocit®-K are registered trademarks of Prometheus Laboratoriesand Mission Pharmacal Company respectively.
Comparative effects of potassium citrate and sodium citrate. COMPARISON OF POTASSIUM CITRATE ACTION WITH
THAT OF SODIUM CITRATE
Potassium
INFECTION STONES
Positive culture with urea-splitting organism A c e t o h y d roxamic Acid (e.g., Lithostat®) a urease Treatment of associated metabolic abnorm a l i t i e s CYSTINE STONES
K Cit (e.g., Urocit®-K) 10-20 meq bid to If urinary cystine concentration is > 300 mg/l, Tiopronin (e.g., Thiola®) or d-Penicillamine Adjust dose to keep cystine < 200 mg/l Lithostat® andThiola ® are registered trademarks of Mission Pharmacal Company.
Cuprimine® is a registered trademark of Merck and Company.
ABBREVIATIONS
1. AH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .absorptive hyperc a l c i u r i a 2. CDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .c h ronic diarrheal syndro m e 3. G-I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .g a s t ro i n t e s t i n a l 4. UTI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .u r i n a ry tract infection 5. Ox. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .o x a l a t e 6 . RTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .renal tubular acidosis 7 . S C P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .sodium cel ulose phosphate 8 . S t o n e C o m p® Te s t . . . . . . . . . . . . . . . . . . . . . . identifies chemical components 9 . S t o n e R i s k® Diagnostic Profile . . assessment of urinary U ro R i s k® Diagnostic Profile metabolic, environmental and 10. StoneTr a c k® Monitoring Test . .simplified profile with Ca, oxalate, uric acid, citrate, sodium, total volume and pH 11. TV. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .total volume 12. TZ. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .t h i a z i d e o f M e d i c a l M a n a g e m e n t This publication is printed and distributed for education purposes by MISSION PHARMACAL COMPANY, San Antonio, TX 78230 1355 Curriculum vitae for authors available on request.
For additional copies call: 1-800-292-7364
or e-mail: customerservice@missionpharmacal.com

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