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Uric Acid Nephrolithiasis

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141. Recurrent exercise-induced acute renal failure in a young Pakistani man with severe renal hypouricemia and SLC2A9 compound heterozygosity. (PubMed)

Recurrent exercise-induced acute renal failure in a young Pakistani man with severe renal hypouricemia and SLC2A9 compound heterozygosity. Familial renal hypouricemia (RHUC) is a hereditary disease characterized by hypouricemia, high renal fractional excretion of uric acid (FE-UA) and can be complicated by acute kidney failure and nephrolithiasis. Loss-of-function mutations in the SLC22A12 gene cause renal hypouricemia type 1 (RHUC1), whereas renal hypouricemia type 2 (RHUC2) is caused

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2014 BMC Medical Genetics

142. Pathophysiological and physicochemical basis of ammonium urate stone formation in dolphins. (PubMed)

represent a continuum of stone risk. On analysis combining cases and controls in a single cohort we noted significant postprandial increases in urinary uric acid, sulfate and net acid excretion accompanied by increased urinary ammonium excretion and a commensurate increase in urine pH. The supersaturation index of ammonium urate increased more than twofold postprandially.These findings suggest that dolphins are susceptible to ammonium urate nephrolithiasis at least in part because a high dietary load (...) Pathophysiological and physicochemical basis of ammonium urate stone formation in dolphins. Nephrolithiasis is increasingly reported in bottle-nosed dolphins. All cases to date have been ammonium urate nephrolithiasis.A case-control study was performed in dolphins with and without evidence of nephrolithiasis to identify biomarkers and risk factors associated with stone formation in a managed population. Dolphins were sampled in fasting and postprandial states to study the effect of dietary

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2014 Journal of Urology

143. Extracorporeal Shockwave Lithotripsy (Overview)

for detecting and tracking calcified and otherwise radio-opaque stones, both in the kidney and the ureter. Conversely, it is usually poor for localizing radiolucent stones (eg, uric acid stones). To compensate for this shortcoming, intravenous contrast can be introduced or (more commonly) cannulation of the ureter with a catheter and retrograde instillation of contrast (ie retrograde pyelography) can be performed. Ultrasonographic localization allows for visualization of both radiopaque and radiolucent (...) , Gutierrez-Aceves J, et al. Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results. J Urol . 2001 Dec. 166(6):2072-80. . Anagnostou T, Tolley D. Management of ureteric stones. Eur Urol . 2004 Jun. 45(6):714-21. . Auge BK, Preminger GM. Update on shock wave lithotripsy technology. Curr Opin Urol . 2002 Jul. 12(4):287-90. . Chacko J, Moore M, Sankey N, Chandhoke PS. Does a slower treatment rate

2014 eMedicine.com

144. Ureteroscopy (Diagnosis)

treatment of ureteropelvic junction obstruction. J Urol . 1998 Nov. 160(5):1643-6; discussion 1646-7. . Teichman JM, Champion PC, Wollin TA, Denstedt JD. Holmium:YAG lithotripsy of uric acid calculi. J Urol . 1998 Dec. 160(6 Pt 1):2130-2. . Wollin TA, Teichman JM, Rogenes VJ, Razvi HA, Denstedt JD, Grasso M. Holmium:YAG lithotripsy in children. J Urol . 1999 Nov. 162(5):1717-20. . Bus MT, de Bruin DM, Faber DJ, Kamphuis GM, Zondervan PJ, Laguna Pes MP, et al. Optical diagnostics for upper urinary tract (...) patterns in urologic management of upper-tract transitional-cell carcinoma. J Endourol . 2005 Apr. 19(3):366-71. . Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE, et al. Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. J Urol . 1994 Jun. 151(6):1648-51. . Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, Lingeman JE, et al. Ureteral Stones Clinical

2014 eMedicine.com

145. Radiographic Evaluation of the Pediatric Urinary Tract (Follow-up)

Baseline renal US is usually performed, though upper urinary tract abnormalities are rare in patients with classic bladder exstrophy. Renal abnormalities are much more common in patients with cloacal exstrophy. VUR is present in nearly all patients with exstrophic anomalies. After closure of the bladder, VCUG is useful to assess bladder capacity and to evaluate the competency of the bladder neck. Nephromegaly Renal vein thrombosis, uric acid nephropathy, , infection, and nephroblastomatosis are all (...) the end of their hospital stay. Approximately 50% of patients younger than 1 year who present with a febrile UTI have VUR, compared with 33% of patients older than 1 year. [ ] Of patients younger than 1 year with VUR, 50% will have evidence of renal lesions on dimercaptosuccinic acid (DMSA) scan; patients older than 1 year old with VUR have a 33% chance of having renal scarring. [ ] This has led some centers to use DMSA scanning as the initial test after a child has a febrile UTI. It is proposed

2014 eMedicine Pediatrics

146. Glycogen-Storage Disease Type I (Diagnosis)

the nucleic acid degradation pathway and resulting in increased uric acid, the end product. Hyperuricemia can reach levels that require use of xanthine oxidase inhibitors to prevent nephrolithiasis. Nephrolithiasis secondary to increased uric acid is a constant threat to patients with poorly controlled disease. Severe hypoglycemia stimulates epinephrine secretion, which activates lipoprotein lipase and the release of free fatty acids. These fatty acids are transported to the liver, where they are used (...) the substrate for glycolysis and produces lactate. Lactate exits the hepatocyte, causing clinically significant lactic acidemia in proportion to the degree of stimulus for glycogen breakdown. The accumulation of lactic acid in blood can cause true acidosis with a large anion gap, a characteristic of glycogen-storage disease type I. The immense increase in the intracellular phosphorylated intermediate compounds of glycolysis concurrently inhibits rephosphorylation of adenine nucleotides, activating

2014 eMedicine Pediatrics

147. Disorders of Bone Mineralization (Diagnosis)

not be needed. Approximately 800-1000 IU/day, plus good calcium intake, may be sufficient. Previous Next: Renal Causes Fanconi syndrome is a disorder of proximal renal tubular transport. Phosphate, amino acid, glucose, bicarbonate, and uric acid wasting characterize this disorder. Dysfunctions in tubular phosphate reabsorption via the sodium-phosphate cotransporter, endocytotic reabsorption of the vitamin D–vitamin D–binding protein complex mediated by megalin and cubilin, and acid-base regulation (...) ( DMP1 ), respectively. Degradation of matrix extracellular phosphoglycoprotein (MEPE) and DMP-1 and release of acidic serine-rich and aspartate-rich MEPE-associated motif (ASARM) peptides are chiefly responsible for the hypophosphatemic rickets mineralization defect and changes in osteoblast-osteoclast differentiation. [ ] In patients with oncogenic osteomalacia, intact and C-terminal fibroblast growth factor-23 (FGF-23) levels are elevated, and the tumors responsible for this disease show increased

2014 eMedicine Pediatrics

148. Gout (Follow-up)

, with its uricosuric effect, may reduce the serum concentration of uric acid. In one study, 500 mg/day for 2 months reduced uric acid by a mean of 0.5 mg/dL in patients without gout. [ ] However, gout patients appear to be less responsive to such a low dose of ascorbate. Vitamin C treatment should be avoided in patients with nephrolithiasis, urate nephropathy, or cystinuria. Kobylecki et al reported that each 10 µmol/L higher plasma vitamin C level was associated with a 2.3 µmol/L lower plasma urate (...) . Clinical spectrum and uric acid metabolism. Arch Intern Med . 1991 Apr. 151(4):726-32. . Meyers OL, Monteagudo FS. Gout in females: an analysis of 92 patients. Clin Exp Rheumatol . 1985 Apr-Jun. 3(2):105-9. . Macfarlane DG, Dieppe PA. Diuretic-induced gout in elderly women. Br J Rheumatol . 1985 May. 24(2):155-7. . Kramer HM, Curhan G. The association between gout and nephrolithiasis: the National Health and Nutrition Examination Survey III, 1988-1994. Am J Kidney Dis . 2002 Jul. 40(1):37-42

2014 eMedicine Surgery

149. Gout (Diagnosis)

(11):692-4. . Puig JG, Michan AD, Jimenez ML, et al. Female gout. Clinical spectrum and uric acid metabolism. Arch Intern Med . 1991 Apr. 151(4):726-32. . Meyers OL, Monteagudo FS. Gout in females: an analysis of 92 patients. Clin Exp Rheumatol . 1985 Apr-Jun. 3(2):105-9. . Macfarlane DG, Dieppe PA. Diuretic-induced gout in elderly women. Br J Rheumatol . 1985 May. 24(2):155-7. . Kramer HM, Curhan G. The association between gout and nephrolithiasis: the National Health and Nutrition Examination (...) , blurred vision, anterior uveitis (rare), scleritis Complications of gout include the following: Severe degenerative arthritis Secondary infections Urate or uric acid nephropathy Increased susceptibility to infection Urate nephropathy Renal stones Nerve or spinal cord impingement Fractures in joints with tophaceous gout See for more detail. Diagnosis Studies that may be helpful include the following: Joint aspiration and synovial fluid analysis Serum uric acid measurement (though hyperuricemia

2014 eMedicine Surgery

150. Diabetic Nephropathy (Diagnosis)

for uric acid stones. J Am Soc Nephrol . 2006 Jul. 17 (7):2026-33. . . Zelnick LR, Weiss NS, Kestenbaum BR, et al. Diabetes and CKD in the United States Population, 2009-2014. Clin J Am Soc Nephrol . 2017 Dec 7. 12 (12):1984-90. . Cheung CY, Ma MKM, Chak WL, Tang SCW. Cancer risk in patients with diabetic nephropathy: a retrospective cohort study in Hong Kong. Medicine (Baltimore) . 2017 Sep. 96 (38):e8077. . . Fan JZ, Wang R. Non-diabetic renal diseases in patients with type 2 diabetes: a single (...) to accumulation of extracellular matrix. The image below is a simple schema for the pathogenesis of diabetic nephropathy. Simple schema for the pathogenesis of diabetic nephropathy. Light microscopy findings show an increase in the solid spaces of the tuft, most frequently observed as coarse branching of solid (positive periodic-acid Schiff reaction) material (diffuse diabetic glomerulopathy). Large acellular accumulations also may be observed within these areas. These are circular on section and are known

2014 eMedicine.com

151. Gout (Diagnosis)

(11):692-4. . Puig JG, Michan AD, Jimenez ML, et al. Female gout. Clinical spectrum and uric acid metabolism. Arch Intern Med . 1991 Apr. 151(4):726-32. . Meyers OL, Monteagudo FS. Gout in females: an analysis of 92 patients. Clin Exp Rheumatol . 1985 Apr-Jun. 3(2):105-9. . Macfarlane DG, Dieppe PA. Diuretic-induced gout in elderly women. Br J Rheumatol . 1985 May. 24(2):155-7. . Kramer HM, Curhan G. The association between gout and nephrolithiasis: the National Health and Nutrition Examination (...) , blurred vision, anterior uveitis (rare), scleritis Complications of gout include the following: Severe degenerative arthritis Secondary infections Urate or uric acid nephropathy Increased susceptibility to infection Urate nephropathy Renal stones Nerve or spinal cord impingement Fractures in joints with tophaceous gout See for more detail. Diagnosis Studies that may be helpful include the following: Joint aspiration and synovial fluid analysis Serum uric acid measurement (though hyperuricemia

2014 eMedicine.com

152. Gout (Diagnosis)

(11):692-4. . Puig JG, Michan AD, Jimenez ML, et al. Female gout. Clinical spectrum and uric acid metabolism. Arch Intern Med . 1991 Apr. 151(4):726-32. . Meyers OL, Monteagudo FS. Gout in females: an analysis of 92 patients. Clin Exp Rheumatol . 1985 Apr-Jun. 3(2):105-9. . Macfarlane DG, Dieppe PA. Diuretic-induced gout in elderly women. Br J Rheumatol . 1985 May. 24(2):155-7. . Kramer HM, Curhan G. The association between gout and nephrolithiasis: the National Health and Nutrition Examination (...) , blurred vision, anterior uveitis (rare), scleritis Complications of gout include the following: Severe degenerative arthritis Secondary infections Urate or uric acid nephropathy Increased susceptibility to infection Urate nephropathy Renal stones Nerve or spinal cord impingement Fractures in joints with tophaceous gout See for more detail. Diagnosis Studies that may be helpful include the following: Joint aspiration and synovial fluid analysis Serum uric acid measurement (though hyperuricemia

2014 eMedicine.com

153. Metabolic Acidosis (Diagnosis)

has to pump protons (intracellular pH 7.5 to luminal pH 5) becomes too steep. A maximally acidified urine, even with a volume of 3 L, would thus contain a mere 30 µEq of free H + . Instead, more than 99.9% of the H + load is excreted buffered by the weak bases NH 3 or phosphate. Titratable acidity The amount of secreted H + that is buffered by filtered weak acids is called titratable acidity. Phosphate as HPO 4 2- is the main buffer in this system, but other urine buffers include uric acid (...) , 2018 Author: Christie P Thomas, MBBS, FRCP, FASN, FAHA; Chief Editor: Vecihi Batuman, MD, FASN Share Email Print Feedback Close Sections Sections Metabolic Acidosis Overview Practice Essentials Metabolic acidosis is a clinical disturbance characterized by an increase in plasma acidity. Metabolic acidosis should be considered a sign of an underlying disease process. Identification of this underlying condition is essential to initiate appropriate therapy. (See Etiology, , , and .) Understanding

2014 eMedicine.com

154. Medullary Sponge Kidney (Diagnosis)

or cuboidal epithelium and rarely by transitional epithelium, which is caused by the effects of calculi. Closed cysts are lined with atrophic epithelium. The rest of the kidney usually is normal, unless or renal obstruction complicates the course of the disease. Etiology Most cases of medullary sponge kidney are sporadic. Theories suggest that dilatation of a collecting duct may occur, caused by occlusion by uric acid during fetal life or resulting from tubular obstruction due to calcium oxalate calculi (...) , and the prevalence may be as much as 1 case per 1000 population in urology clinics. In addition, medullary sponge kidney has been identified in 12-20% of patients who form calcium stones. [ ] Approximately 0.5% of patients undergoing intravenous urography are estimated to have medullary sponge kidney, while another 1% have papillary blush. No autopsy series have examined the prevalence of medullary sponge kidney specifically. In patients with nephrolithiasis, up to 20% may have mild degrees of medullary sponge

2014 eMedicine.com

155. Lesch-Nyhan Syndrome (Diagnosis)

was cloned and sequenced by Friedmann and colleagues in 1985. Lesch-Nyhan disease is a genetic disorder associated with 3 major clinical elements: overproduction of uric acid, neurologic disability, and behavioral problems. [ ] The overproduction of uric acid is associated with . If left untreated, it can produce nephrolithiasis with renal failure, gouty arthritis, and solid subcutaneous deposits known as tophi. The neurologic disability is dominated by dystonia but may include choreoathetosis, ballismus (...) have overproduction of uric acid and its consequences alone. These patients are identified by demonstrating HPRT deficiency or a mutation in the HPRT gene. Collectively, they are referred to as Lesch-Nyhan variants. Treatment of the condition is limited. Allopurinol is useful to control the overproduction of uric acid and reduces the risk of nephrolithiasis and gouty arthritis. Few treatments have proven consistently helpful for the neurologic or behavioral difficulties. Motor disability is managed

2014 eMedicine.com

156. Extracorporeal Shockwave Lithotripsy (Diagnosis)

for detecting and tracking calcified and otherwise radio-opaque stones, both in the kidney and the ureter. Conversely, it is usually poor for localizing radiolucent stones (eg, uric acid stones). To compensate for this shortcoming, intravenous contrast can be introduced or (more commonly) cannulation of the ureter with a catheter and retrograde instillation of contrast (ie retrograde pyelography) can be performed. Ultrasonographic localization allows for visualization of both radiopaque and radiolucent (...) , Gutierrez-Aceves J, et al. Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results. J Urol . 2001 Dec. 166(6):2072-80. . Anagnostou T, Tolley D. Management of ureteric stones. Eur Urol . 2004 Jun. 45(6):714-21. . Auge BK, Preminger GM. Update on shock wave lithotripsy technology. Curr Opin Urol . 2002 Jul. 12(4):287-90. . Chacko J, Moore M, Sankey N, Chandhoke PS. Does a slower treatment rate

2014 eMedicine.com

157. Hyperoxaluria (Treatment)

to have no substantially beneficial role and acts as a metabolic end-product, much like uric acid. If not for oxalate’s high affinity for calcium and the low solubility of calcium oxalate, oxalate and oxalate metabolism would be of little interest. Urinary oxalate is the single strongest chemical promoter of kidney stone formation. Ounce for ounce, it is roughly 15-20 times more potent than excess urinary calcium. Daily oxalate intake in humans is usually 80-120 mg/d; it can range from 44-350 mg/d (...) excretion levels or concentration between geriatric and younger cohorts of individuals with calcium oxalate stones have been found. [ , ] Primary hyperoxaluria type I presents primarily as a pediatric disease, with symptoms first appearing before age 4 in nearly half of the patients. [ ] Kidney stones are 3 times more common in men than in women, but the reason for this difference is not always clear. Different reference ranges of several urinary metabolites (eg, uric acid, calcium, oxalate) illustrate

2014 eMedicine.com

158. Pregnancy and Urolithiasis (Treatment)

with the normal extracellular volume expansion of pregnancy. The safest method of medically managing calcium stone disease during pregnancy is to increase fluid intake and to avoid excessive calcium intake (including calcium-fortified prenatal vitamins). Typically, calcium intake should not exceed 1000-1200 mg/d during pregnancy. This treatment may prevent or reduce the risk of urolithiasis during pregnancy. Sodium intake and protein consumption should also be curtailed. Uric acid disease In uric acid stone (...) disease, xanthine oxidase inhibitors (eg, allopurinol) prevent uric acid stone formation by inhibiting the final step in human purine metabolism, thereby decreasing both serum and urinary uric acid levels. However, use of xanthine oxidase inhibitors is contraindicated during pregnancy because the effects of the drug on the fetus are unknown. Alternative treatment modalities for uric acid stones during pregnancy include increasing fluid intake, limiting dietary purine intake, and increasing urinary

2014 eMedicine.com

159. Hyperuricosuria and Gouty Diathesis (Treatment)

are urinary alkalinization (ie, pH 6.5-7.0), hydration (ie, urinary output 1500-2000 mL/d), and allopurinol (ie, patients with hyperuricosuric calcium nephrolithiasis) to decrease serum and urinary uric acid levels. The authors have observed impressive dissolution of large uric acid stones (staghorn) with oral alkalinization (see the images below). These measures are effective for dissolving existing uric acid stones and for stone prophylaxis. CT scan demonstrating right partial staghorn uric acid (...) . Metabolic syndrome and uric acid nephrolithiasis. Semin Nephrol . 2008 Mar. 28(2):174-80. . Mehta TH, Goldfarb DS. Uric acid stones and hyperuricosuria. Adv Chronic Kidney Dis . 2012 Nov. 19(6):413-8. . Wan KS, Liu CK, Ko MC, Lee WK, Huang CS. Nephrolithiasis among male patients with newly diagnosed gout. Hong Kong Med J . 2016 Dec. 22 (6):534-7. . . Abu-Ghanem Y, Kleinmann N, Winkler HZ, Zilberman DE. Nephrolithiasis in Israel: Epidemiological Characteristics of Return Patients in a Tertiary Care

2014 eMedicine.com

160. Hyperuricemia (Treatment)

-hour urine uric acid excretion of less than 800 mg in 24 hours, no history of nephrolithiasis, and good renal function (creatinine clearance >80 mL/min). The starting dose for probenecid is 250 mg twice a day, which can be increased gradually to a maximum daily dose of 3 g/d. Some degree of gastrointestinal irritation is experienced by approximately 2% of patients. Allopurinol is the most widely used antihyperuricemic agent. The major metabolite of allopurinol is oxypurinol, and both allopurinol (...) and oxypurinol are competitive inhibitors of the enzyme xanthine oxidase. The ideal candidates for allopurinol treatment are as follows: Uric acid overproducers (24-h urinary uric acid excretion >800 mg on general diet or >600 mg on a purine-restricted diet) Patients with renal insufficiency, nephrolithiasis, or tophaceous gout Patients at risk for developing uric acid nephropathy Although allopurinol can be used in almost any hyperuricemic state, the above-mentioned conditions are more specific indications

2014 eMedicine.com

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