Thuyết trình Anh Văn chuyên ngành Kidney stone

KIDNEY STONE
I.
1.

OVERVIEW
What is kidney stone?
Kidney stone, also known as urolithiasis, is a condition when a solid piece of material
occurs in the urinary tract.
The kidneys filter waste products from the blood and add them to the urine that the
kidneys produce. When waste materials in the urine do not dissolve completely, crystals
and kidney stones may form.
Most kidney stones will pass spontanetously through the ureter to the bladder on their
own with time but some of them may become sticked in the ureter (then we call them
ureterolithiasis). A sticked stone can block the flow of urine, causing pressure to build in
the affected ureter and kidney. Increased pressure results in stretching and spasm, which

cause the severe pain.
2.
Who can get kidney stone?
One in every 20 people develop kidney stones at some point in their life.
Anyone may develop a kidney stone, but people with certain diseases and conditions
or those who are taking certain medications are more susceptible to their development.
Urinary tract stones are more common in men than in women. Most urinary stones
develop in people 20 to 49 years of age, and those who are prone to multiple attacks of
kidney stones usually develop their first stones during the second or third decade of life.
People who have already had more than one kidney stone are prone to developing further
stones. About half of people will have another stone within ten years.
A small number of pregnant women develop kidney stones, and there is some
evidence that pregnancy-related changes may increase the risk of stone formation.
Factors that may contribute to stone formation during pregnancy include a slowing of the
passage of urine due to increased progesterone levels and diminished fluid intake due to a

decreasing bladder capacity from the enlarging uterus. Healthy pregnant women also
have a mild increase in their urinary calcium excretion. However, it remains unclear

1


whether the changes of pregnancy are directly responsible for kidney stone formation or
if these women have another underlying factor that lead them to kidney stone formation.
• New words:
- urinary tract: đường tiết niệu
- ureter: niệu quản
- bladder: bàng quang
II.

- urine: nước tiểu
- uterus: tử cung
- excretion: sự bài tiết

EPIDEMIOLOGY
Kidney stones affect all geographical, cultural, and racial groups. The lifetime risk is
about 10 to 15% in the developed world, but can be as high as 20 to 25% in the Middle
East.
The number of deaths due to kidney stones is estimated at 19,000 per year being
consistent between 1990 and 2010.
In North America and Europe, the annual number of new cases per year of kidney
stones is roughly 0.5%. In the United States, the frequency in the population of
urolithiasis has increased from 3.2% to 5.2% from the mid-1970s to the mid-1990s. In the
United States, about 9% of the population has had a kidney stone.
In residents of industrialized countries, kidney stones are more common than stones in
the bladder. The opposite is true for residents of developing areas of the world, where

bladder stones are the most common. This difference is believed to be related to dietary
factors.
The total cost for treating urolithiasis was 2 billion USD in 2003. About 65–80% of
those with kidney stones are men; most stones in women are due to either metabolic
defects (such as cystinuria) or infection. Men most commonly experience their first
episode between 30 and 40 years of age, whereas for women, the age at first presentation
is somewhat later, 35 and 55 years. Recurrence rates are estimated at 50% over a 10-year
and 75% over 20-year period, with some people experiencing ten or more episodes over
the course of a lifetime.
A 2010 review concluded that rates of disease are increasing.

2


III.

SIGNS AND SYMPTOMS
Small, smooth kidney stones may remain in the kidney or pass without causing pain

(called "silent" stones). A "small" stone (usually 4 mm in diameter or less) has a 90
percent chance of passing. Stones that are 8 mm in diameter or larger usually require
medical intervention.
The feature of a stone that obstructs the ureter or renal pelvis is violent, intermittent
pain that radiates from the flank to the groin or to the inner thigh. This pain, known as
renal colic, is often described as one of the strongest pain sensations known.
Renal colic caused by kidney stones is commonly accompanied by:
- Blood in the urine (hematuria)
- Increased frequency of urination (urinary urgency)
- Nausea and vomiting
- Pain during urination (stinging, burning)

- Tenderness in the abdomen and kidney region
- Urinary tract infection (fever, chills, loss of appetite)
It typically comes in waves lasting 20 to 60 minutes caused by peristaltic contractions
of the ureter as it attempts to expel the stone. The link between the urinary tract, the
genital system, and the gastrointestinal tract is the basis of the radiation of pain to the
gonads, as well as the nausea and vomiting that are also common in urolithiasis.
Pain in the lower left quadrant can sometimes be confused with diverticulitis because
the sigmoid colon overlaps the ureter and the exact location of the pain may be difficult
to isolate due to the close proximity of these two structures
Postrenal azotemia and hydronephrosis can be observed following the obstruction of
urine flow through one or both ureters.
Kidney stone complications include kidney damage and scarring, decreased kidney
function, obstruction of the ureter.
• New words:
- diameter đường kính
- medical intervention: can thiệp y
học
- intermittent: gián đoạn

- groin: vùng bẹn
- thigh: đùi
- renal colic: đau thận

3


- nausea and vomitting: buồn nôn

- postrenal azotemia: tăng ure huyết

và ói mửa
- peristaltic contraction: sự co bóp

sau thận
- hydronephrosis: ứ nước
- diverticulitis: viêm ruột thừa
- sigmoid colon: kết tràng xích-ma

nhu động
- gonad: tuyến sinh dục
IV.

CAUSES AND RISK FACTORS
1. Dehydration
Dehydration refers to total body water deficency, with an accompaning disruption
of metabolic processes. Dehydration from reduced fluid intake or strenuous exercise
without adequate fluid replacement increases the risk of kidney stones. People living
in areas with high temperature and humidity have a higher incidence of stone
formation.
2. Dietary
Improper dietary intake of certain substances increases the risk of kidney stone
formation
a. Calcium
Calcium is one component of the most common type of human kidney stones,
calcium oxalate. Some studies suggest people who take calcium as a dietary
supplement have a higher risk of developing kidney stones.
Unlike supplemental calcium, high intakes of dietary calcium do not appear to
cause kidney stones and may actually protect against their development. This is
perhaps related to the role of calcium in binding ingested oxalate in the
gastrointestinal tract. As the amount of calcium intake decreases, the amount of

oxalate available for absorption into the bloodstream increases. For most
individuals, other risk factors for kidney stones, such as high intakes of dietary
oxalates and low fluid intake, play a greater role than calcium intake.
b. Other electrolytes

4


Calcium is not the only electrolyte that influences the formation of kidney
stones. For example, by increasing urinary calcium excretion, high dietary sodium
(Na) may increase the risk of stone formation.
Drinking fluoridated tap water may increase the risk of kidney stone formation
High dietary intake of potassium appears to reduce the risk of stone formation
because potassium (K) promotes the urinary excretion of citrate, an inhibitor of
calcium crystal formation.
Kidney stones are more likely to develop, and to grow larger, if a person has
low dietary magnesium (Mg). Magnesium inhibits stone formation.
c. Animal protein
Consumption of animal protein creates an acid load that increases urinary
excretion of calcium and uric acid and reduced citrate. Urinary excretion of excess
sulfurous amino acids (e.g., cysteine and methionine), uric acid, and other acidic
metabolites from animal protein acidifies the urine, which promotes the formation
of kidney stones.
Low urinary citrate excretion is also commonly found in those with a high
dietary intake of animal protein, whereas vegetarians tend to have higher levels of
citrate excretion. Low urinary citrate, too, promotes stone formation.
d. Vitamins
The evidence linking vitamin C supplements with an increased rate of kidney
stones is inconclusive. The excess dietary intake of vitamin C might increase the
risk of calcium oxalate stone formation, in practice this is rarely encountered. The

link between vitamin D intake and kidney stones is also tenuous. Excessive
vitamin D supplementation may increase the risk of stone formation by increasing
the intestinal absorption of calcium; correction of a deficiency does not.
3. Medical conditions
A number of different medical conditions can lead to an increased risk for
developing kidney stones:
- Urinary tract infection may cause struvite stone formation

5


- Gout results in chronically increased amount of uric acid in the blood and urine
and can lead to the formation of uric acid kidney stones
- Inherited conditions such as hyperparathyroidism, hypercalciuria (high unrine
calcium levels), hyperoxaluria (high unrine oxalate levels), medullary sponge
kidney (cystic dilatation of the collecting tubules in kidney), renal tubular acidosis
(kidney unable to excrete acid)...
- Chronic diseases such as diabetes and high blood pressure (hypertension) are also
associated with an increased risk of developing kidney stones.
- Obesity is a leading risk factor as well.
• New words:
-

V.

Strenous: kịch liệt
excrete: bài tiết
electrolyte: chất điện li
acidify: axit hoá

- cystic: (thuộc) nang
- dilatation: sự giãn nỡ
- colleting tubule: ống góp (của
thận)

PATHOPHYSIOLOGICAL
1. Four stages of stone formation:
Stage 1:Nucleation
When the urine becomes supersaturated (when the urine solvent contains more
solutes than it can hold in solution) with one or more crystal-forming substances, ions
will spontaneously join together to form a solid crystal, this is called nucleation.
There are two kinds of nucleation: ho and. In homogeneous nucleation, crystals
form around the nucleus with the same composition, crystals of a different
composition can also form around the nucleus. In heterogeneous nucleation, organic
material such as cell debris may be deposited between the crystal as a matrix.
Heterogeneous nucleation proceeds more rapidly than homeogeneous nucletion
because it requires less energy.
Stage 2: Growth
The tiny crystal formations travel down the nephron and they are usually deposited
at the renal papilla.

6


Stage 3: Aggregation
Crystals that have already form then begin to stick together forming large stones.
Stage 4: Retention
New stones are retained in the kidney where they can continue to grow for an
unspecified length of time until they are displaced and travel through the kidney in to
the ureter.

If a stone continues to grow until it reaches a critical size (4-5mm in diameter), it
may be too large to pass easily through the ureter. The edges of the stone may become
stuck inside the ureter at three constriction of the ureter: at the junction of the renal
pelvis and the ureter, where the ureter crosses over the iliac artery, at the juntion as
the ureter enters the bladder wall.
2. Factors involved stone formation
Depending on the chemical composition of the crystal, the stone-forming process
may proceed more rapidly when the urine pH is unusually high or low. For example,
at a pH of 7.0, the solubility of uric acid in urine is 158 mg/100 ml. Reducing the pH
to 5.0 decreases the solubility of uric acid to less than 8 mg/100 ml.
The formation of uric acid stones requires a combination of hyperuricosuria (high
urine uric acid levels) and low urine pH; hyperuricosuria alone is not associated with
uric acid stone formation if the urine pH is alkaline. Supersaturation of the urine is a
necessary, but not a sufficient, condition for the development of any urinary stone
formation. Supersaturation is likely the underlying cause of uric acid and cystine
stones, but calcium-based stones (especially calcium oxalate stones) may have a more
complex cause.
Urine normally contains chemicals - citrate, magnesium, pyrophosphate - that help
prevent the formation of crystals and stones. Low levels of these inhibitors can
contribute to the formation of kidney stones. Of these, citrate is the most important.
• New words:
- supersaturation: sự siêu bão hoà
- solvent: dung môi
- solute: chất tan

- solution: dung dịch
- renal papilla: nhú thận
- alkaline: kiềm tính

7

VI.

CLASSIFICATION
Kidney stones are typically classified by their chemical composition
1. Calcium containing stones
By far, the most common type of kidney stones worldwide contains calcium,
represent about 80% of all cases; these typically contain calcium oxalate either alone
or in combination with calcium phosphate in the form of apatite or brushite. Factors
that promote the precipitation of oxalate crystals in the urine, such as primary
hyperoxaluria, are associated with the development of calcium oxalate stones. The
formation of calcium phosphate stones is associated with conditions such as
hyperparathyroidism and renal tubular acidosis.
Calcium oxalate crystals in urine appear as 'envelopes' microscopically. They may
also form 'dumbbells.'
2. Struvite stones
About 10–15% of urinary calculi are composed of struvite (ammonium magnesium
phosphate, NH4MgPO4·6H2O). Struvite stones (also known as "infection stones",
urease or triple-phosphate stones), form most often in the presence of infection by
urea-splitting bacteria. Using the enzyme urease, these organisms metabolize urea into
ammonia and carbon dioxide. This alkalinizes the urine, resulting in favorable
conditions for the formation of struvite stones.
These infection stones are commonly observed in people who have factors that
lead them to urinary tract infections, such as those with spinal cord injury. They are
also commonly seen in people with underlying metabolic disorders, such as idiopathic
hypercalciuria, hyperparathyroidism, and gout. Infection stones can grow rapidly,
forming large calyceal staghorn (antler-shaped) stone requiring invasive surgery such
as percutaneous nephrolithotomy (procedure to remove stones from the kidney by a
small puncture wound through the skin) for final treatment.

Struvite stones have a 'coffin lid' morphology by microscopy.
3. Uric acid stones

8


About 5–10% of all stones are formed from uric acid. People with certain
metabolic abnormalities, including obesity, may produce uric acid stones.They may
also form in association with disorders of acid/base metabolism where the urine is
excessively acidic (low pH), resulting in precipitation of uric acid crystals.
Uric acid stones appear as pleomorphic crystals, usually diamond-shaped. They
may also look like squares or rods which are polarizable (ability to form dipoles).
Patients with hyperuricosuria can be treated with allopurinol which will reduce
urate formation. Urine alkalinization may also be helpful in this setting.
4. Others
People with certain rare n errors of metabolism have a trend to accumulate crystalforming substances in their urine. For example, those with cystinuria, cystinosis, and
Fanconi syndrome may form stones composed of cystine. Cystine stone formation can
be treated with urine alkalinization and dietary protein restriction. People afflicted
with xanthinuria often produce stones composed of xanthine.
• New words:
- precipitation: sự kết tủa
- renal tubular acidosis: toan ống
thận
- evelope: hình bao (toán học)

-

dumbbells: quả tạ
spinal cord: tuỷ sống
idiopathic: vô căn

invasive: xâm lấn
dilope: lưỡng cực

VII. DIAGNOSIS
a) Imaging studies
In people with a history of stones, who are less than 50 years of age and are
presenting with the symptoms of stones without any concerning signs do not
require helical CT scan imaging.
Otherwise, a helical CT scan is the diagnostic modality of choice in the
radiographic evaluation of suspected kidney stone. All stones are detectable on CT
scans except very rare stones composed of certain drug residues in the urine.
Calcium-containing stones are relatively radiodense (or radiopaque - inhibit the

9


passage of electromagnetic radiation), and they can often be detected by a
traditional radiograph of the abdomen that includes the kidneys, ureters, and
bladder (KUB film). Some 60% of all renal stones are radiodense. In general,
calcium phosphate stones have the greatest density, followed by calcium oxalate
and magnesium ammonium phosphate stones. Cystine stones are only radiodense,
while uric acid stones are usually entirely radiolucent (allow radation to pass more
freely).
When a CT scan is unavailable, an intravenous pyelogram may be performed to
help confirm the diagnosis of urolithiasis. This involves intravenous injection of a
contrast agent followed by a KUB film. Stones present in the kidneys, ureters or
bladder may be better defined by the use of this contrast agent. Stones can also be
detected by a retrograde pyelogram, where a similar contrast agent is injected
directly into the distal ostium of the ureter (where the ureter terminates as it enters
the bladder).

Ultrasound imaging of the kidneys can sometimes be useful, as it gives details
about the presence of hydronephrosis, suggesting the stone is blocking the outflow
of urine. Radiolucent stones, which do not appear on KUB, may show up on
ultrasound imaging studies. Other advantages of renal ultrasonography include its
low cost and absence of radiation exposure. Ultrasound imaging is useful for
detecting stones in situations where X-rays or CT scans are discouraged, such as in
children or pregnant women. Despite these advantages, renal ultrasonography in
2009 was not considered a substitute for noncontrast helical CT scan in the initial
diagnostic evaluation of urolithiasis. The main reason for this is that compared
with CT, renal ultrasonography more often fails to detect small stones (especially
ureteral stones), as well as other serious disorders that could be causing the
symptoms.
b) Laboratory examination
Laboratory investigations typically carried out include:

10


- Microscopic examination of the urine, which may show red blood cells, bacteria,
leukocytes, urinary casts and crystals;
- Urine culture to identify any infecting organisms present in the urinary tract and
determine the susceptibility of these organisms to specific antibiotics;
- Complete blood count, looking for neutrophilia (increased neutrophil granulocyte
count) suggestive of bacterial infection, as seen in the setting of struvite stones;
- Renal function tests to look for abnormally high blood calcium blood levels
(hypercalcemia);
- 24 hour urine collection to measure total daily urinary volume, magnesium,
sodium, uric acid, calcium, citrate, oxalate and phosphate;
- Collection of stones (by urinating through a StoneScreen kidney stone collection
cup or a simple tea strainer) is useful. Chemical analysis of collected stones can

establish their composition, which in turn can help to guide future prevention and
management.
• New words:
- modality: phương thức
- evaluation: sự đánh giá
- residue: chất cặn
- density: tỉ trọng
- hydronephrosis: ứ nước
- explosure: phơi sáng
VIII. MANAGEMENT
1. Pain management
Management of pain often requires intravenous injection of NSAIDs or opioids.
Oral medication are often effective for less severe discomfort. The use of
antispasmodics does not have further benefit
2. Expulsion theraphy
The use of medications to speed the spontaneous passage of stones in the ureter is
referred to as medical expulsive therapy. Several agents, including alphaadrenergic blockers (such as tamsulosin) and calcium channel blockers (such as
nifedipine), have been found to be effective. Alpha-blockers appear to lead to both
higher and faster stone clearance rates. Alpha-blockers, however, only appear to be
11


effective for stones over 4 mm but less than 10 mm in size. A combination of
tamsulosin and a corticosteroid may be better than tamsulosin alone. These
treatments also appear to be a useful extra to lithotripsy.
3. Lithotripsy
Extracorporeal shock wave lithotripsy (ESWL) is a noninvasive technique for the
removal of kidney stones. Most ESWL is carried out when the stone is present near
the renal pelvis. ESWL involves the use of a machine to deliver externally applied,
focused, high-intensity pulses of ultrasonic energy to cause fragmentation of a

stone over a period of around 30–60 minutes. Then, the tiny pieces of stone can
pass out of the body in the urine.
ESWL is currently used in the treatment of uncomplicated stones located in the
kidney and upper ureter. Some 80 to 85% of simple renal stone can be effectively
treated with ESWL. For a stone greater than 10 mm , ESWL may not help break
the stone in one treatment; instead, two or three treatments may be needed.
A number of factors can influence its efficacy, including chemical composition of
the stone, presence of abnormal renal anatomy and the specific location of the
stone within the kidney, presence of hydronephrosis, body mass index, and
distance of the stone from the surface of the skin. Common adverse effects of
ESWL include acute trauma, such as bruising at the site of shock administration,
and damage to blood vessels of the kidney. In fact, most of people who are treated
with a typical dose of shock waves using currently accepted treatment settings are
likely to experience some degree of acute kidney injury. ESWL-induced acute
kidney injury is dose dependent and can be severe, including internal bleeding and
subcapsular hematomas
4. Ureteroscphic surgery
A ureteroscopy is an examination or procedure using a ureteroscope. A
ureteroscope is an instrument for examining the inside of the urinary tract.Some
ureteroscopes are flexible like a thin, long straw. Others are more rigid and firm.
Through the ureteroscope, the doctor can see a stone in the ureter and then remove
12


it with a small basket at the end of a wire inserted through an extra channel in the
ureteroscope. Another way to treat a stone through a ureteroscope is to extend a
flexible fiber through the scope up to the stone and then, with a laser beam shone
through the fiber, break the stone into smaller pieces that can then pass out of the
body in the urine.
Ureteroscopic techniques are generally more effective than ESWL for treating

stones located in the lower ureter, with success rates of 93–100%. Although ESWL
has been traditionally preferred by many practitioners for treating stones located in
the upper ureter, more recent experience suggests ureteroscopic techniques offer
distinct advantages in the treatment of upper ureteral stones. Specifically, the
overall success rate is higher, fewer repeat interventions and postoperative visits
are needed, and treatment costs are lower after ureteroscopic treatment when
compared with ESWL.
• New words:
- inpulsion: sự trục xuất
- lithotripsy: tán sỏi
- extracorporeal: ở bên ngoài cơ
thể
- high-intensity : cường độ cao
- uncomplicated: không biến
chứng
IX.

- adverse: bất lợi
- acute trauma: chấn thương cấp
tính
- bruishing: bầm tím
- subcapsular hematomas: máu tụ
dưới bao
- postoperative: sau phẫu thuật

PREVENTION
1. Diatary measures
Specific therapy should be proper to the type of stones involved. Diet can have a
great influence on the development of kidney stones. Preventive strategies include
some combination of dietary modifications and medications with the goal of

reducing the excretory load of calculogenic compounds on the kidneys. Current
dietary recommendations to minimize the formation of kidney stones include:
13


- Increasing total fluid intake to more than two liters per day of urine output.
If you live in a hot, dry climate or you exercise frequently, you may need to
drink even more water to produce enough urine. If your urine is light and
clear, you're likely drinking enough water.
- Increasing citric acid intake; lemon/lime juice is the richest natural source.
- Moderate calcium intake: continue eating calcium-rich foods, but use
caution with calcium supplements
- Limiting sodium intake (salt)
- Avoidance of large doses of supplemental vitamin C
- Limiting animal protein intake and choose nonanimal protein source such as
legumes
- Limiting consumption of cola soft drinks, which contain phosphoric acid, to
less than one liter of soft drink per week.
2. Medication
Medications can control the amount of minerals and acid in your urine and may be
helpful in people who form certain kinds of stones. The type of medication your
doctor prescribes will depend on the kind of kidney stones you have. Here are
some examples:
- Calcium stones: To help prevent calcium stones from forming, your doctor
may prescribe a thiazide diuretic or a phosphate-containing preparation.
- Uric acid stones: Your doctor may prescribe allopurinol (Zyloprim,
Aloprim) to reduce uric acid levels in your blood and urine and a medicine
to keep your urine alkaline. In some cases, allopurinol and an alkalizing
agent may dissolve the uric acid stones.
- Struvite stones: To prevent struvite stones, your doctor may recommend

strategies to keep your urine free of bacteria that cause infection. Long-term
use of antibiotics in small doses may help achieve this goal. For instance,
your doctor may recommend an antibiotic before and for a while after
surgery to treat your kidney stones.
- Cystine stones: Cystine stones can be difficult to treat. Your doctor may
recommend that you drink more fluids so that you produce a lot more urine.
14


If that alone doesn't help, your doctor may also prescribe a medication that
decreases the amount of cystine in your urine
.

15