[An efficacy study of the treatment of patients with chronic pyelonephritis and urolithiasis using sulfate-bicarbonate calcium-magnesium mineral water]

Clinical effects of spa treatment on renal function in middle-aged and elderly male and female patients with chronic pyelonephritis and urolithiasis was studied. Combined sanatorium treatment included a course intake of low-mineral sulphate-hydrocarbonate calcium-magnesium mineral water Kazanskaia. Diuresis, especially daytime, was activated in all the patients. Maximum diuresis was observed in cool seasons in the elderly patients. To the end of the treatment proteinuria, oxaluria and uraturia diminished. A course of drinking mineral water Kazanskaia proved effective and is recommended for patients with chronic pyelonephritis and urolithiasis.

Role of inter-alpha-inhibitor and its related proteins in experimentally induced calcium oxalate urolithiasis. Localization of proteins and expression of bikunin gene in the rat kidney

Our earlier studies indicated that members of the inter-alpha-inhibitor (IalphaI) family of glycoproteins may play an important role in urolithiasis. Indeed bikunin, the light chain of IalphaI is a potent inhibitor of calcium oxalate crystallization. In order to understand this role, the distribution of IalphaI and its related proteins, as well as the expression of bikunin, were studied in normal and nephrolithic rats. In normal rats, IalphaI immunoreactivity was located mainly in proximal tubules. However, in nephrolithic rats, in addition to proximal tubules, the staining was intensively extended to tubules in the corticomedullary junction. Furthermore, by using polymerase chain reaction technique, we demonstrated that gene encoding for bikunin was activated in kidneys of nephrolithic rats. We have previously demonstrated increased staining for osteopontin in association with calcium oxalate crystal deposition in rat kidneys. Others have shown an increase in osteopontin production by renal epithelial cells on exposure to calcium oxalate crystals. Based on these observations we conclude that kidney cells possess an auto-defense system against calcium oxalate crystallization and stone formation in which members of the IalphaI family may be closely involved.

[The effects of human urine on the adhesion of calcium oxalate crystal to renal tubular cells]

PURPOSE

We examined the effects of human urine on the adhesion of calcium oxalate monohydrate (COM) crystals to Madin-Darby canine kidney (MDCK) cells in vitro.

METHODS

Quantitative assay of COM crystal adhesion to MDCK cells: MDCK cells were exposed to COM crystal suspension for 5 minutes. Various urine samples were added in the COM crystal suspension. The adherent COM crystals on the MDCK cells were dissolved by 5 N hydrochloric acid. Calcium concentration of the solution was measured by atomic absorption analysis to quantify the volume of adherent COM crystals. This assay was applied for the experiments as follows. (1) Effect of human urine on COM crystal adhesion. (2) To investigate whether human urine inhibited COM crystal adhesion by acting on the crystal surface or on the cell surface. (3) Isolation of the substance from human urine that inhibits COM crystal adhesion. (4) Comparison of the inhibitory activities of the urine between from stone formers and healthy controls.

RESULTS AND CONCLUSION

(1) Human urine had a strong inhibitory effect on COM crystal adhesion to MDCK cells. (2) The capacity of human urine to inhibit adhesion of COM crystals to MDCK cells was shown to be mediated by their ability to act on the crystal surface. (3) We isolated a macromolecular fraction (MW 60,000) that had strong capacity to inhibit cellular adhesion of COM crystals through ion exchange and gel filtration chromatography. (4) Nine urine samples from stone formers demonstrated extreme low inhibitory activities, which supposed us that the inhibitory capacity of the urine against crystal adhesion might be one of the risk factors in kidney stone formation.

[Medical aspects of urinary tract lithiasis]

The authors review some etiological, clinical and diagnostic aspects of nephrolithiasis, describing briefly the approach that should be taken to study this disease. Some of the practical aspects of its treatment are also discussed.

[The effect of ureteral stents on the peristalsis of the upper urinary tracts]

Ureteral motility changes were followed up in 10 patients with hydronephrosis and urolithiasis which were recorded by multichannel impedance ureterography prior to internal drainage and during stent manipulations. The establishment of the ureteral stents reduces peristaltic amplitude and frequency as well as ureteral tonicity. After the stent removal 20% of the examinees showed peristaltic hyperfunction of the ureter. Urodynamic positive effects of the stents consist in better regulation of the motility, elimination of its local disturbance foci, improved coordination of movements of different parts of the upper urinary tracts. For positive results it is important to practice an individual approach to choice of drainage time and stent size. Urodynamic impedance studies can be used in control of endoscopic treatment adequacy.

Pathogenesis of idiopathic calcium nephrolithiasis: update 1997

Idiopathic calcium nephrolithiasis (ICN) is a frequent disease in Western countries. The physicochemical theory of lithogenesis, which explains stone formation by the precipitation, growth, and crystalline aggregation of lithogenic salts in the urine, has contributed greatly to the understanding of the pathogenesis of calcium urolithiasis. However, several aspects are still unexplained; the co-existence of familial occurrence, primary tubular dysfunctions with ICN, and anomalies in the systemic handling of oxalate and calcium led to the development of a cellular hypothesis of ICN. A number of cellular defects in the handling of ions has been reported that involves both anion and cation transport. These anomalies are probably the expression of a still unknown cellular defect in idiopathic calcium stone formers. We suggested that an anomaly in the cell membrane composition might be responsible for the complex array of cell ion flux abnormalities observed in ICN. Recently, a disorder in the n-6 polyunsaturated fatty acid series has been described; it is characterized by a lower linoleic acid content and a higher arachidonic acid concentration in both plasma and erythrocyte membrane phospholipids of renal calcium stone patients. This anomaly could cause an increased activity of ion carriers; furthermore, it may lead to increased prostaglandin synthesis and to secondary phenomena at the kidney, skeletal, and intestinal level. As a consequence, critical conditions for lithogenesis in the kidney may ensue. The data suggest a common pathogenesis for hypercalciuria and hyperoxaluria. The systemic defect in the phospholipid arachidonic acid level may be both of dietary or genetic origin; experimental data suggest that the increase in delta-6 desaturase activity, the limiting enzyme in the metabolic pathway of polyunsaturated fatty acids, might be relevant to the pathogenesis of lipid abnormalities observed in nephrolithiasis and to the pathogenesis of ICN and its related problems (at the kidney, intestinal, and bone level).

Prevalence and risk factors of urinary stones in Koreans

To estimate the prevalence of urinary stone disease in Koreans, and to determine the inter-relationships between urinary stone disease and various epidemiological factors, 1,521 controls and 1,177 cases with urinary stones were evaluated. Of special interest in this study were: 1) proportion of past urinary stone history among controls; 1.9% 2) the point prevalence rate of urinary stones among controls; 0.2% 3) the recurrence rate of urinary stones (the proportion of past history of urinary stone) among cases; 56.8% 4) high incidences (76.3%) in the thirties to the fifties among cases 5) the risk factors for urolithogenesis; obesity [higher than 25 of BMI (body mass index, weight/height2)], more than 10 year-experience as a production worker, past stone history, familial stone history, low physical activity (< 2,000 Kcal/day), and low intake of fruit. However, the well-known risk factors for urinary stones; over intake of meat or fish and milk or dairy products, perspiration, amount and kind of drinking water, and stress unexpectedly were not significantly different between the controls and the cases.

[Effect of proctocolectomy on fluid balance--comparison of conventional ileostomy, ileorectal anastomosis and ileoanal pouch operation]

Total colectomy for ulcerative colitis (UC) and familiar adenomatous polyposis coli (FAP) is mainly performed as an ileoanal Pouch procedure (IAP). Alternatives are ileorectal anastomosis (IRA) and conventional proctocolectomy with Brooke ileostomy (CPS). The different surgical techniques may influence the excretion of water and electrolytes in stool and urine and may lead to a higher risk for urolithiasis. We investigated patients (12 IAP, 12 IRA and 8 CPS) several years after surgery and compared them to twelve normal controls. Total fecal and urinary output was collected at two consecutive days. Volume and electrolytes were determined in stool and urine. The risk for urinary stone formation was calculated by nomograms. Fecal volume and sodium (Na+) excretion was increased in all therapy groups compared to controls. IAP and IRA had significant less stool volume and Na+ excretion compared to CPS. Augmented fecal Na+ excretion was compensated by reduction of renal output after colectomy compared to controls. There were no significant differences in the daily urine volume between any groups. There was no urolithiasis in any groups. The nomograms showed a risk for all groups and controls to develop urinary stones.

[Urinary lithiasis: epidemiology and physiopathology]

Urolithiasis has an incidence of about 12% in men and about 5% in women before the age of 70 years. Several epidemiological factors are involved in the predisposition to the urinary stone disease, notably: age, sex, race, climate, geography, profession, social class, nutritional factors and inherent genetic particularities. A number of physicochemical mechanisms govern lithogenesis, passing from saturation and supersaturation of urine to nucleation, crystallization and crystal growth to clinically significant sizes when the inhibition mechanisms are overwhelmed or absent. Generally urinary stone are of diverse aetiologies, that can essentially be grouped in calcium, uric acid, cystine and magnesium ammonium phosphate stones with subgroups in relation to the varied pathophysiological mechanisms involved in each case.

[A metabolic approach to patients with calculi]

Metabolic evaluation remains cornerstones in the treatment and prevention of recurrence in patients with urolithiasis. The various chrystallographic, biological and radiological investigation should be done only in patients presenting recurrence and/or given risks factor of recurrences. The choice of the investigation is guided by the knowledge of the pathophysiological phenomena and should thus be adapted to each patient. Results should be analyzed by a multidisciplinary team. This aspect will be developed in the next paragraph.

[Clinical phase III study of cimetropium bromide (DA3177) on the pain with upper urinary calculus: a double-blind study in comparison with scopolamine butylbromide. DA3177 Study Group]

A double-blind study was conducted to evaluate the efficacy, safety and usefulness of cimetropium bromide (DA3177) in the patients with pain caused by upper urinary calculus at a daily dose of 75 mg t.i.d. (Group D, 97 patients) in comparison with scopolamine butylbromide at a daily dose of 60 mg t.i.d. (Group B, 101 patients). According to patient's impression, the rate of "moderately improved" or better was significantly higher in Group D (68.7%) than in Group B (53.5%; Wilcoxon 2 sample test: p = 0.0044). For pain, the rate of "moderately improved" or better was 69.1% in Group D and 60.4% in Group B. In global improvement, the rate of "moderately improved" or better was significantly higher in Group D (70.1%) than in Group B (61.4%; Wilcoxon 2 sample test: p = 0.0469). The rate of "no problem in safety" showed no significant difference between Group D (91.5%) and Group B (93.3%). Adverse reactions occurred in 8.5% in Group D and 6.7% in Group B. The major adverse reactions were "dry mouth", "abdominal distension", "constipation" and "nausea". The rate of "useful" or better was 68.7% in Group D, and 60.4% in Group B. In conclusion, DA3177 was confirmed to be a useful drug for patient with pain caused by upper urinary calculus.

[The DIC syndrome as a complication of the surgical treatment of urolithiasis in urology patients]

The authors discuss the causes of the DIC syndrome in urological patients operated on for urolithiasis. They enumerate the factors predisposing to the DIC syndrome and causing it. The predisposing factors are chronic renal insufficiency and metabolic disorders caused by azotemia, infectious inflammatory complications of urolithiasis, and intoxication. The causes of the disease are massive blood loss involving disorders of the hemodynamics and blood rheology, bacterial shock, and other stress conditions. A protocol for treating this complication and validation of pathogenetic therapy is offered.

Effects of artificial calculosis on rat ureter motility: peripheral contribution to the pain of ureteric colic

The contribution of changes in ureter motility produced by a stone to the pain of ureteric calculosis is unclear. In this study we measured ureter motility as changes in intraureter pressure in anesthetized rats 1, 4, and 8 d ys after implantation of an artificial calculus (n = 33) and compared it with motility in normal (n = 8) and ligated (n = 4) ureters. Partial obstruction of the ureter by the stone produced a 478% increase in the amplitude of contractions, a 70% decrease in the rate of contractions, and a 66% decrease in the baseline pressure. The pressures reached during contractions were equivalent to those evoking nociceptive reactions in animals and humans. These changes persisted in rats that had spontaneously eliminated the stone. Complete obstruction of the ureter by the stone or by ligation abolished contractions. We conclude that the increased motility caused by a stone likely contributes to the development and maintenance of visceral pain and referred hyperalgesia in ureteric colic and to the persistence of referred hyperalgesia after elimination of the stone.

Postprandial hyperinsulinaemia, insulin resistance and inappropriately high phosphaturia are features of younger males with idiopathic calcium urolithiasis: attenuation by ascorbic acid supplementation of a test meal

In idiopathic recurrent calcium urolithiasis (RCU) the state of insulin and carbohydrate metabolism, and relationships to minerals such as phosphate, are insufficiently understood. Therefore, in two groups of males with RCU (n = 30) and healthy controls (n = 8) the response to an oral carbohydrate- and calcium-rich test meal was studied with respect to glucose, insulin, and C-peptide in peripheral venous blood (taken before and up to 180 min post-load), and phosphate and glucose in fasting and post-load urine. In one RCU group (n = 16) the meal was supplemented with ascorbic acid (ASC; 5 mg/kg body weight). The mean age (RCU 29, RCU + ASC 30, controls 27 years) and mean body mass index [RCU 24.4, RCU + ASC 25.0, controls 24.0 kg/m2] were similar. Insulin resistance (synonymous sensitivity of peripheral organs to insulin) was calculated from insulin serum concentration, as was also integrated insulin, C-peptide, and glucose. Untreated stone patients (RCU) developed hyperinsulinaemia between 60 and 120 min post-load, increased integrated insulin, and insulin resistance (P < or = 0.05 vs controls), whereas the rise of C-peptide and glycaemia (absolute and integrated values) was only of borderline significance. Fasting phosphaturia was low in both RCU subgroups vs controls; however, phosphaturia in untreated RCU rose in response to the meal, contrasting sharply with a decrease in controls. ASC supplementation of the meal (in the RCU + ASC subgroup) normalized insulin, failed to normalize post-load phosphaturia, but reduced post-load glucosuria and urinary pH significantly (mean pH values 5.55 vs 5.93 in untreated RCU, controls 5.50). Postprandial urinary oxalate, calcium, protein, and supersaturation products were not changed. The postprandial changes in phosphaturia and insulin sensitivity were inversely correlated (n = 38, r = -0.44, P = 0.007). It was concluded that in younger RCU males: (1) postprandial hyperinsulinaemia, the failure to reduce phosphaturia and - within limits - glucosuria, appropriately, as well as poor urine acidification are important features of the metabolism; (2) these phenomena are probably caused by insulin resistance of organs, the kidney included; and (3) the addition of a supraphysiological dose of ASC to a meal, the subsequent abolition of hyperinsulinaemia, and the restoration of normal urine acidification suggest that this antioxidant is capable of counteracting some pre-existing basic abnormality of cell metabolism in RCU.

[Acoustic stimulation of the upper urinary tract in the combined treatment of urolithiasis]

Sound stimulation of the upper urinary tracts in urolithiasis is validated pathogenetically in experiment and in 544 patients. The highest efficacy has been reached under the sound frequency 2.0-3.4 kHz and diuretic action of herbal decoction in ureteroliths. Under the use of sound waves in the range 2.0-3.4 kHz modulated by low-frequency vibrations good results were obtained in calyculopelvic concrements. In view of faster elimination of concrement fragments as a result of sound stimulation after impulse lithotripsy, the device for sound stimulation would be a useful supplement for lithotripsy units. Sound stimulation is indicated in any uroliths in the absence of obstruction in distal to the stone position. There are no sex-, age- and other disease-related contraindications for the above technique of sound stimulation in urolithiasis.

[The diagnostic significance of enzymuria in assessing kidney function in patients with urolithiasis]

Urinary levels of L-, Y-glutamyl transferase, alkaline phosphatase, L-leucine arylaminidase, lactate dehydrogenase, N-acetyl-beta-D-glucose aminidase, pseudocholine esterase, neutral L-glucosidase were examined in 76 urolithiasis patients. The activity of the above enzymes was found enhanced. This may be due to dysfunction of the tubular system. The content of L-leucine arylaminidase, N-acetyl-beta-D-glucose aminidase, L-glucosidase provide the most complete diagnostic information compared to the other enzyme tests.

Intratubular crystallization events

Can urolithiasis start as an intratubular event? Under severe hyperoxaluric conditions in animal models at least crystal formation can. Recently models have been presented that assess the chances of crystal formation under more normal conditions. These models describe changes in fluid composition as this passes through the nephron, these conditions being simulated in in vitro experiments. It appears that under naturally occurring intratubular conditions calcium-salt crystallization takes place within the time tubular fluid normally spends in the nephron. Precipitation starts with a calcium-phosphate phase under conditions found in the thin lambs. This crystalline phase then (partly) dissolves when collecting duct conditions are used, thereby inducing formation of calcium oxalates. Under these conditions the latter increase in size by way of crystal growth and agglomeration. Large particle formation and cell adhesion can eventually result in particle retention and subsequent stone formation. Viewing urolithiasis as originally an intratubular event has consequences for in vitro experiments and treatments, which are discussed in this paper.

Long-lasting functional abdominal pain and duodenal ulcer are associated with stress, vulnerability and symptoms of psychological stress. A controlled study including healthy and patient controls

OBJECTIVE

To assess psychological differences between patients with functional abdominal pain (FUNC) and three separate control groups comprising patients with duodenal ulcer (DU), patients with gallstone or urinary tract stone (STONE), and healthy non-patient controls (HEALTH).

METHODS

All participants completed a self-administered questionnaire including questions about the relationship between symptoms and certain life events and psychometric tests for psychological distress (SCL-90) and vulnerability.

PARTICIPANTS

The FUNC group consisted of 27 hospital outpatients with long-lasting abdominal pain without demonstrable abnormalities (ten men and 17 women; mean age 38 years). The DU group consisted of 13 untreated outpatients with endoscopically proven duodenal ulcer (nine men and four women; mean age 42 years) while the STONE group comprised 13 untreated patients with gallstone (n = 7) or urinary calculi (n = 6) (six men and seven women; mean age 43 years). The HEALTH group consisted of five men and nine women (mean age 36 years).

RESULTS

Significantly more FUNC and DU patients compared with STONE patients experienced an association with at least one of 14 life events (74%, 77%, and 31%, respectively; p = 0.02). The FUNC and DU groups showed significantly higher scores on the depression subscale of the SCL-90 than the HEALTH group (p < 0.05), and on the anxiety subscale compared with the STONE and HEALTH groups (p < 0.05). The FUNC group scored significantly higher on the somatization subscale compared with all the other groups (p < 0.05). As an overall measure of psychological distress the Global Severity Index (GSI) was calculated. GSI was significantly higher in the FUNC group compared with the HEALTH group (p < 0.01) and tended to be higher in the DU group (p = 0.06). The FUNC and DU groups had significantly higher scores for vulnerability than the STONE and HEALTH groups (p < 0.05).

CONCLUSION

FUNC as well as DU outpatients seem to be more psychologically distressed and vulnerable than healthy controls or outpatients suffering from pain caused by stones in the gallbladder or urinary tract. As opposed to the STONE group, a high proportion of the FUNC and DU patients experienced that the onset or aggravation of abdominal pain was associated with certain life events. The similarities between the FUNC and DU group demonstrate that it is important to separate DU patients from other "organic" patients in such investigations.

Pathogenesis and treatment of calcium stones

Calcium stones arise from imbalances between urinary excretions of insoluble salts and water. Idiopathic hypercalciuria and hyperparathyroidism are the calcium disorders usually associated with elevated levels of calcium in the urine. Renal tubular acidosis is associated with a disordered acid-base status that results in low urine citrate. Hypocitraturia itself is a cause of calcium stones because it leaves urine calcium free to complex with either oxalate or phosphate. Elevated urine oxalate is commonly associated with dietary excesses, bowel disease, and, rarely, primary hyperoxaluria. Hyperuricosuria, usually of dietary origin, when reversed can cause a fall in new calcium stones.

Management of urocystoliths by voiding urohydropropulsion

Voiding urohydropropulsion is a nonsurgical method of removing uroliths from the urinary bladder. Any urocystolith of sufficient size to pass through the distended urethral lumen can be safely and effectively removed by this new technique. Compared to cystotomy, voiding urohydropropulsion offers several advantages: urolith removal can be performed in minutes, anesthetic period is shorter, postprocedural dysuria and hematuria are less severe, and it provides greater success for complete removal of small urocystoliths. This technique is not suitable for removal of large urocystoliths or uroliths that become lodged in the urethral lumen.

Stones in enterocystoplasties

OBJECTIVES

To assess the aetiology of stones which occur in enterocystoplasties and continent diversions, generally attributed to the presence of foreign material, e.g. staples, or to recurrent urinary infection, in patients with augmented or substituted bladders.

PATIENTS AND METHODS

The study comprised 467 patients who had undergone reconstruction of the lower urinary tract and had been followed up for at least 3 years using videourodynamics and ultrasonography.

RESULTS

Stones were found in 42 patients (9%); 50% were found incidentally and the remaining patients presented with symptomatic infections (27%) or deterioration in urinary continence (23%). Stones occurred in 6% of patients with augmentation, in 7% of those with substitution cystoplasty and in 22% of patients with continent diversions. Most patients with stones (88%) used clean intermittent self-catheterization (CISC). Stones were 5-10 times commoner in patients using CISC than in patients voiding spontaneously.

CONCLUSION

Urinary stasis was a more important cause of stone formation than was bacteriuria in patients with cystoplasty. The presence of mucus and bacteriuria are presumed to be contributory. To reduce the risk of stone formation, orthotopic cystoplasty and spontaneous voiding are to be preferred to continent diversion and CISC. Periodic bladder washouts may be an alternative solution.

Feline urolithiasis. Etiology and pathophysiology

A variety of different types of uroliths occur in cats, of which calcium oxalate and magnesium ammonium phosphate are the most common. Treatment and prevention are most likely to be successful if associated risk factors are identified and eliminated or controlled.