Upload File

update on the medical management of urolithiasisurinary ph •new: complex pathophysiologic...

  • Home
  • Documents
  • Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the
84
Update on the Medical Management of Urolithiasis Or Why do I form kidney stones and what can I do about it? Scott J. Fabozzi, MD, FACS Director, Kidney Stone Treatment and Prevention Program Concord Hospital Center for Urologic Care

Upload: others

Post on 20-Jan-2020

2 views

Category:

Documents


0 download

Report

TRANSCRIPT

Page 1: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Update on the Medical Management of Urolithiasis

Or Why do I form kidney stones and what

can I do about it?

Scott J. Fabozzi, MD, FACS Director, Kidney Stone Treatment and Prevention Program

Concord Hospital Center for Urologic Care

Page 2: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Objectives

• Introduce new concepts regarding stone formation

• Provide an overview of the medical evaluation of the stone former

• Highlight important medical and surgical risk factors for stone formation

• Discuss the medical management of the stone former

Page 3: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

ESWL

Page 4: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Laser lithotripsy

Page 5: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

PCNL

Page 6: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Technologic Advances are Wonderful! BUT:

• Surgical treatments do not alter the course of the disease

• 10% prevalence in the US • Recurrence after first stone:

– Year 1 : 10-15% – Year 5 : 50-60% – Year 10: 70-80%

• $2.1 billion / year in 2000 (Pearle et al 2005) • Fails to account for the lost wages, reduced work

productivity

Page 7: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Prevalence of Kidney Stones by Age (Males)

0

2

4

6

8

10

12

14

20-29 30-39 40-49 50-59 60-69 70-74 All

1976-1980

1988-1994

Perc

ent

Age (years)

Stamatelou, Kidney Int, 2003

Page 8: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Prevalence of History of Kidney Stones By Age (Females)

0

1

2

3

4

5

6

7

8

20-29 30-39 40-49 50-59 60-69 70-74 All

1976-1980

1988-1994

Perc

ent

Age (Years) Stamatelou, Kidney Int, 2003

Page 9: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

National Health and Nutrition Examination Survey

0

2

4

6

8

10

12

1994 2012

Men

Women

Scales Eur Urol 2012

Page 10: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Why do stones form ? Free Crystal Particle Growth

• Urine contains stone forming salts such as calcium and oxalate

• If these stay in solution, crystals do not form

• Crystals, which can become stones, form under certain circumstances

Page 11: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Factors That Promote Crystal Formation

• Concentration of stone forming salts

• pH

• Concentration of inhibitors

Page 12: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Pathophysiology: Supersaturation

Page 13: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Randall’s Plaque

Page 14: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Randall’s Plaque

Stone former Normal

Page 15: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Randall’s Plaque

Page 16: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Attached Stone

Page 17: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Unattached Stone

Page 18: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Renal Medulla

Page 19: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Calcium Oxalate Stone Former

Page 20: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Calcium Oxalate Stone Former

Page 21: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Intestinal Bypass Patient

Page 22: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Intestinal Bypass Patient

Page 23: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Brushite Stone Former

Page 24: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Renal Medulla

Page 25: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Vascular Etiology Theory

Page 26: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Evidence for Vascular Theory

• Epidemiologic – Association of atherosclerosis and hypertension with

stones

• Clinical – Absence of stones with abnormal urinary studies and

recurrent stones in spite of normal urinary studies

• Anatomical – Association of calcified vasculature with collecting

tubules

• Physiological – Blood flow: laminar to turbulent and calcified vessels

Page 27: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Why do I form stones?

• Classic: Concentrations stone forming salts and inhibitors along with other factors such as urinary pH

• New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the tip of the papilla is the initial stone forming event

• New: Vascular pathology is the initial stone forming event

Page 28: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

What can I do to prevent another attack?

• Improved diagnostic methods now uncover the underlying cause of stone disease in the vast majority of individuals

• Advances in selective therapy can reduce stone forming risk

Page 29: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Diagnostic Approach

• History and Physical

• Urine sediment

• Serum Chemistries

• Appropriate imaging

• 24 hour urine stone risk profile

Page 30: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

History

• Prior stones and treatments

• Medical History: HTN, DM, Gout, others

• Prior GU surgery

• Prior GI surgery

• Bowel disease, fluid loss

• Stone-provoking medications

• Dietary factors

Page 31: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Medications

• Calcium and Vitamin D supplements

• Antacid and laxative use

• Lasix

• Vitamin C

• Topiramate

Page 32: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Minimal Diagnostic Tests

• Stone Analysis

• BMP

• Appropriate imaging

• Urinalysis

• 24 hour urine for Diagnostic Panel

Page 33: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Stone Composition

• Calcium containing: 75-80%

• Uric Acid: 10%

• Others: 10%

– Struvite

– Cystine

– Sodium urate

– Ammonium acid urate

Page 34: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

24 Hour Urine

• Standardized, automated

• Volume recorded and aliquot sent to central lab

• Metabolic Factors (Ca, Ox, UA, citrate, pH)

• Environmental Factors (TV, Na, Sulfate, Phos, Mg)

• Physiochemical: Supersaturations

Page 35: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the
Page 36: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Diagnostic Approach

Page 37: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Calcium Stone Formation

• Hypercalciuria

• Hypocitraturia

• Hyperoxaluria

• Hyperuricosuria

Page 38: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Hypercalciuria

• Absorptive

• Renal

• Resorptive: Primary Hyperparathyroidism

Page 39: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Absorptive Hypercalciuria

Increased GI calcium absorption

Increased plasma Ca++

Increased urinary Ca++ Decreased PTH

Page 40: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Renal Hypercalciuria “renal leak”

Increased urinary calcium Decreased plasma Ca++

Increased PTH

Increased GI absorption

Inc. Vit. D

Increased bone resorption

Page 41: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Resorptive Hypercalciuria “Primary Hyperparathyroidism”

Increased PTH

Increased bone resorption

Increased GI Ca++ absorption

Increased plasma Ca++

Increased urinary Ca++

Page 42: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Calcium Metabolism and Parathyroid Function

Page 43: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Bone Mineral Density and Hypercalciuria

Page 44: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Kidney Stones and Bone Health

Melton, Kidney Int, 1993

Page 45: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Hypocitraturia

• Citrate is a well recognized inhibitor of stone formation

• Defined as <300 mg/day (arbitrary)

• 20-60% of calcium stone formers

Page 46: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Hypocitraturia

• Citrate is a well recognized inhibitor of stone formation

• Defined as <300 mg/day (arbitrary)

• 20-60% of calcium stone formers

Page 47: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Hypocitraturia Pathogenesis

• Type I (Distal) RTA

• Chronic diarrheal states

• Excessive animal protein intake

• Thiazide induced hypokalemia

• Idiopathic

• Medication induced

Page 48: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Renal Tubular Acidosis: Clues to Diagnosis

• Young female with early age of onset

• Nephrocalcinosis

• Urine pH > 6.5

• Profound hypocitraturia

• Hyperchloremic, hypokalemic acidosis

• Stone composition: Calcium phosphate

Page 49: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Topiramate and Hypocitraturia

Page 50: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Hyperoxaluria

• Idiopathic

– Most common

• Enteric

– Intestinal disease/resection

– Bariatric surgery

• Primary

– rare

Page 51: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Oxalate Production

Dietary Oxalate 100 mg

GI Absorption 10 mg

Stool 90 mg

Glyoxalate Ascorbic Acid

Endogenous Production 24 mg

Urinary oxalate 34 mg

Page 52: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Enteric Hyperoxaluria

• Should be suspected in any patient with hyperoxaluria and a small bowel abnormality

• 5% of patients in specialized metabolic stone clinics

• Low urine volume

• Low calcium, magnesium, citrate excretion

Page 53: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Bariatric Surgery

Page 54: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Bariatric Surgery and Stone Treatment

Matlaga, J. Urol 2009

Page 55: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Hyperuricosuria

• Arbitrarily defined as uric acid excretion exceeding 600 mg/day

• Independent risk factor for calcium oxalate stone formation

• Excess dietary purine intake is the most common cause

• Others include gout, myeloproliferative disorders, multiple myeloma, hemolytic disorders

Page 56: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Hyperuricosuric CaOx Lithiasis: Pathogenesis

pH

Page 57: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Obesity and Stones

• Increasing incidence of stones has paralleled the increasing incidence of obesity

• Higher stone risk with increasing BMI

• Obesity closely associated with development of metabolic syndrome

• Higher risk of uric acid nephrolithiasis

Page 58: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Obesity Trends

0

0.5

1

1.5

2

2.5

<21 21-22.9 23-24.9 25-27.4 27.5-29.9 >30

HPFS

NHS1

NHS2

BMI

Rel

ativ

e R

isk

Taylor , JAMA 2008

Page 59: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

NHANES: Prevalence of Kidney Stones

0

2

4

6

8

10

12

14

Normal Overweight Obese

Men

Women

BMI Category

Percent Prevalence

Page 60: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Childhood Obesity

Page 61: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

24 hour urine and Obesity

• Lower pH

• Lower citrate

• Higher oxalate

• Higher sodium and sulfate

• Higher uric acid

Page 62: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Diabetes and Stones

• DM (Type II) has been shown in population based studies to raise the risk of kidney stones

• Insulin resistance is the primary mechanism resulting in low urinary pH increasing uric acid stone risk

• Insulin resistance lowers urinary citrate thus increasing calcium stone risk

Page 63: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Prevalence of Uric Acid Lithiasis

0

5

10

15

20

25

30

35

40

Reported in Literature Non-diabetic Diabetic

Pak et al, Urol 2003

Page 64: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Pathogenesis of Uric Acid Lithiasis

Page 65: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Uric Acid Lithiasis: Pathogenesis

pH

Page 66: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Uric Acid Lithiasis

Page 67: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Treatment: Dietary Modification

• Borghi et al, Nutrition Rev. July 2006, 301-312

• High Fluid Intake: Ten 10 oz. glasses H20/day or 2-2.5L urine/day

• Sodium Restriction: Keep salt intake to 2500 mg/day

• Oxalate restriction: oxalate rich foods and Vitamin C

• Adequate calcium rich foods

• Limit animal protein intake: 6 oz. servings

• Increase citrus fruit and juice intake

Page 68: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Medical Therapy: Rationale

• Many patients will have stone recurrence in spite of dietary modification

• Most stone formers have metabolic abnormalities that are not caused by, but are exacerbated by dietary indiscretions

• Many patients are poorly compliant with dietary modification

Page 69: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the
Page 70: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Thiazide Diuretics

• Patients with severe hypercalciuria (>275 mg/day)

• Patients with mild hypercalciuria and reduced bone mineral density

• Hypocalciuric action due to enhanced calcium reabsorption in the proximal renal tubule

Page 71: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Thiazides

• HCTZ 25-50 mg/BID

• Indapamide 1.25 – 2.5 mg/day

• Chlorthalidone 25 mg/day

K-Cit 40-60 meq/day

• Moduretic (amiloride + HCTZ) ½ tab BID

Page 72: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Thiazides Potential Hazards

• Hypokalemia: closely monitor and use potassium supplements

• Hypocitraturia: monitor and use KCit supplements

• Hyperuricosuria: purine restriction, possibly use allopurinol

Page 73: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Hypocitraturia: Potassium Citrate

• Corrects hypocitraturia in patients with calcium oxalate stones

• Provides potassium supplementation for patients on thiazides

• Corrects hypocitraturia in patients with RTA

• Maintains pH between 6.0-6.5 in patients with uric acid stones

Page 74: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Potassium Citrate

• Liquids/crystals

– Polycitra-K

– Citra-K

• Slow release pills

– Urocit K

Page 75: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Potassium Citrate

Liquid Tablets

Minor GI complaints + ++

Gastric erosions 0 0/+

Convenience + +++

Citraturic action ++ +++

Half-life short prolonged

Dose schedule tid/qid bid/tid

Page 76: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Allopurinol

• Used most appropriately in the recurrent calcium oxalate stone former with moderate to severe hyperuricosuria

• Failed dietary modification

• Dosed 200-300 mg/day

• Monitor liver enzymes

• Stephens-Johnson Syndrome: Report of skin rash or urticaria should prompt immediate cessation

Page 77: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Do Medications Work? Thiazides

Pearle J Endourol 1999

Page 78: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Barcelo, J Urol, 1993

Page 79: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Potassium Citrate Effectiveness Long-term

Robinson J Urol, 2009

Page 80: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Medical and Dietary Treatment and Bone Health

Pak, J Urol, 2003

Page 81: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

BMD and Potassium Citrate

Pak, J Urol, 2002

Page 82: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Take Home Points

• Research into Randall’s plaque formation is providing new insights into calcium stone formation

• A careful medical history and simple diagnostic evaluation will characterize most patient’s stone forming risk

Page 83: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Take Home Points

• Obesity and metabolic syndrome are important risk factors for stone formation

• Type 2 DM is an important risk factor for stone formation

• Bariatric surgery is an important and increasing cause of stone formation

• Dietary modification can help lower stone forming risk

Page 84: Update on the Medical Management of Urolithiasisurinary pH •New: Complex pathophysiologic processes not fully understood in the renal medulla involving deposition of apatite at the

Take Home Points

• For many stone formers, genetic and medical risk factors will limit the effectiveness of diet changes alone

• For these patients, medical therapy is available and effective in reducing stone forming risk and in preventing complications of stones such as bone loss

• Kidney stone formation is often a reflection of a systemic medical/metabolic syndrome


Apatite Microstructure and Composition in … › pdf › JMMCE20110500002_70965281.pdfVol.10, No.5 Apatite Microstructure and Composition 409 Naturally occurring apatite is represented

Heavy mineral analysis - uni-goettingen.de · ATiATi Apatite = Apatite – Tourmaline index = 100 * apatite / (apatite + tourmaline) HvE - Sedimentpetrologie Morton & Hallsworth 1994

Medulla Oblongata

Brainstem Medulla

Review of Opioid Pharmacology and Emerging Treatment Options for Opioid … · 2016-10-12 · Depress cough reflex in the medulla Pharmacotherapy A Pathophysiologic Approach, 8th

Tumor Medulla Spinalis

Coronary Atherosclerosis: Pathophysiologic Basis …...Special Article Coronary Atherosclerosis: Pathophysiologic Basis for Diagnosis and Management Konstantinos Dean Boudoulasa,⁎,

MEDULLA OBLONGATA MEDULLA OBLONGATA INTERNAL FEATURES

Program - Apatite Science

Pathophysiologic Mechanisms DIARE REFKAS

Postpartum Optic Neuritis: Etiologic and Pathophysiologic

Ranula: Current Concept of Pathophysiologic Basis and

Medulla by DR.ARSHAD

medulla spinalis.docx

Referat Medulla Spinalis

Lapkas Medulla Spinalis

Hyphema. Part I. Pathophysiologic Considerations

Medulla answer

Hanford Apatite Treatability Test Report Errata: Apatite Mass

MEDULLA Original

Acute Spinal Cord Injury, Part I: Pathophysiologic …grants.hhp.coe.uh.edu/clayne/6397/SCI_online/Dumont_patho...Acute Spinal Cord Injury, Part I: Pathophysiologic Mechanisms

Medulla Spinalis,Medulla Oblongata,Pons,Mesencephalon

Medulla spinalis

Medulla oblengata

Askep Trauma Medulla

Experimental limbic epilepsy: models, pathophysiologic

Adams, Pharmacology for Nurse: A Pathophysiologic Approach ... · Adams, Pharmacology for Nurse: A Pathophysiologic Approach, 4/E 2

Apatite Diamonds - Quebec.ca

BEYİN VE MEDULLA SPİNALİS - acikarsiv.ankara.edu.tracikarsiv.ankara.edu.tr/browse/32502/Beyin ve medulla spinalis zarları... · BEYİN VE MEDULLA SPİNALİS ZARLARI, BOS VE BEYNİN

Trauma Medulla Spinalis

Pathophysiologic Results of Neurologic Oncologic Disorders Manifestations depend upon the tissues infiltrated and compressed by the neoplasm Pathophysiologic

ADRENAL MEDULLA

Adrenal Medulla Pheochromocytoma

Tumor Medulla Spinalis cimmangTumor Medulla Spinalis cimmang

Uterine Myoma, Epidemiology, Pathophysiologic ...jmscr.igmpublication.org/v3-i7/38 jmscr.pdf · Uterine Myoma, Epidemiology, Pathophysiologic, Reproductive, ... (32.6% and 14.5% vs