Transient renal impairment in the absence of pre-existing chronic kidney disease in patients with unilateral ureteric stone impaction

2022 Recommendations of the AFU Lithiasis Committee: Specific cases - chronic kidney disease, bilateral stones, and solitary kidney

Chronic kidney disease, diabetes and hypertension are risk factors of kidney function impairment. The relative risk of kidney failure is 1.52 in patients with urinary stone disease. The various techniques used to remove upper urinary tract stones generally do not alter kidney function in patients with normal kidney function and may sometimes improve kidney function or slow its deterioration in patients with kidney disease. Compared to the asynchronous treatment of bilateral renal and ureteral stones, concomitant treatment is associated with higher risk of anuria and the need of additional interventions, in the absence of postoperative stenting. For the treatment of solitary kidney stones, the absence of postoperative stenting increases the risk of postoperative anuria. Moreover, the multiplication of percutaneous nephrolithotomy access tracts increases the risk of bleeding and that of kidney function impairment. METHODOLOGY: These recommendations were developed according to two methods: the Clinical Practice Recommendations (CPR) method and the ADAPTE method, depending on whether the question was considered in the European Association of Urology (EAU) recommendations (https://uroweb.org/guidelines/urolithiasis) [EAU Guidelines on urolithiasis. 2022] and their adaptability to the French context.

Clinical Score Application for Abdominopelvic Computed Tomography Used in the Diagnosis of Renal Colic Patients

Background To develop risk scoring for the use of computed tomography (CT) imaging using the visual analog scale (VAS), physical examination, and laboratory findings of renal colic patients admitted to the emergency department (ED).

Materials and Methods This is prospective observational study. Among the patients who presented to the ED with abdominal or flank pain, patients who were scheduled for CT imaging for urolithiasis were included in the study. The mean VAS pain scores, physical examination findings, laboratory parameters, and macroscopic and microscopic values in urinalysis were compared between the two groups with and without stones on CT.

Results Of the 196 urolithiasis patients included in the study, 165 had ureteral stones, 76 had renal stones, and 45 had renal and ureteral stones. While the difference between the urine erythrocyte averages of the two groups was borderline significant (p = 0.04), there was a high difference between the urinary hemoglobin amounts (p < 0.001). In patients with urinary system stone disease, hydronephrosis, and ureteral dilatation, hemoglobin ++ and above were more significant (p < 0.001). For ureteral stones, pain intensity increased as the size increased (r = 0.34 p < 0.001). White blood cells > 10,000 103/mL, and C-reactive protein (CRP) ≤ 5 mg/L were more significant in patients with acute renal colic.

Conclusions Although we cannot develop a clinical scoring system for renal colic patients, the meaningful results we found for urinary stone disease can be used in a newly developed scoring system. It can be used in new scoring systems in the ED using a high VAS score, presence and amount of urine hemoglobin, CRP) ≤ 5 mg/L, and creatinine value.

What is the incidence of renal impairment in patients presenting with renal colic?

Objective:

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the recommended agents for treatment of renal colic pain. Some clinicians express concern about their prescription when renal function in unknown. This study aimed to determine the prevalence of renal impairment in patients presenting to emergency departments (ED) with a clinical diagnosis of renal colic.

Patients and methods:

This retrospective observational study included patients with an ED diagnosis of renal colic. Exclusions were patients younger than 18, previous inclusion and missing medical records. The primary outcome of interest was the proportion of patients with abnormal estimated glomerular filtration rate (eGFR), stratified by eGFR group.

Results:

A total of 1805 patients were studied: median age 46 years and 72% male. In the population overall, the proportion with eGFR less than 45 was 2.6% (95% confidence interval (CI) 2–3.4%). In the subgroup without known renal impairment, the proportion with eGFR less than 45 was 1.7% (95% CI 1.2–2.4%). On multivariate analysis, the only variable predictive of eGFR less than 45 in patients without known renal impairment was age 60 years or older (odds ratio 1.09, 95% CI 1.06–1.12).

Conclusion:

The proportion of patients with clinical renal colic who have an eGFR less than 45 at ED presentation is very low (<2%). This evidence supports administration of NSAIDs for pain relief in patients without known renal impairment before eGFR is known.

Level of evidence:

Not applicable for this multicentre audit.

Imaging strategies for patients with suspicion of uncomplicated colic pain: diagnostic accuracy and management assessment

OBJECTIVE

Compare different imaging scenarios in the diagnosis of uncomplicated renal colic due to urolithiasis (URCU).

MATERIALS AND METHODS

A total of 206 prospectively included patients had been admitted with suspected URCU and had undergone abdominal plain film (APF), US and unenhanced CT after clinical STONE score evaluation. CT was the reference standard. We assessed sensitivity (Se), specificity (Spe) and Youden index for colic pain diagnosis, percentage of patients managed by urologic treatment with stone identified, percentage of alternative diagnoses (AD) and exposure to radiation, according to single imaging approaches, strategies driven by patient characteristics and conditional imaging strategies after APF and US.

RESULTS

One hundred (48.5%) patients had a final diagnosis of URCU and 19 underwent urologic treatment. The conditional strategy, i.e. CT in patients who had no stone identified at US, had a perfect sensitivity and specificity. This enabled diagnosis of all stones requiring urology management while decreasing the number of CT exams by 22%. The strategy whereby CT was used when there was neither direct or indirect APF + US finding of colic pain nor alternative diagnoses in patients with a STONE score ≥ 10 had a sensitivity of 0.95 and a specificity of 0.99, identified 84% of stones managed by urologic treatment and decreased the number of CT examinations by 76%.

CONCLUSION

In patients with clinical findings consistent with URCU, the use of ultrasound as first-line imaging modality, with CT restricted to patients with negative US and a STONE score ≥ 10, led to a sensitivity and specificity of above 95%, identified 84% of stones requiring urological management and reduced the number of CT scans needed by fourfold.

KEY POINTS

• For diagnosis, the use of APF + US as first-line imaging, with CT restricted to patients with both a normal APF + US and a STONE score ≥ 10, provides both a sensitivity and specificity superior or equal to 95% and reduces the number of CT scans necessary by fourfold. • For management, the use of APF + US as first-line imaging, with CT restricted to patients with both a normal APF + US and a STONE score ≥ 10, maintains a 84% stone identification rate in urology-treated patients.

The stress model of abutment tooth and periodontal tissues with unilateral mandibular dissociation and loss by precision extracoronal attachment

In order to explore the application of the precision extracoronal attachment based on three-dimensional finite element stress model in the repair of unilateral mandibular dissociation and loss, the stress distribution of the butment and periodontal tissues when the precision extracoronal attachment was used in unilateral mandibular dissociation and loss was analyzed, so as to provide reference for the application of materials in clinical repair. In this study, the biomechanics of oral cavity and its attachment were analyzed to provide theoretical basis for model construction. Because the degree of periodontal tissue absorption and the number of abutment teeth affected the restoration effect of the coronal precision attachment, the models were established from these two perspectives. The results showed that when the periodontal tissue absorption of both abutment teeth exceeded 1/3, the method of double abutment restoration was not recommended. When three abutments were used, there was a significant decrease compared with the absorption of the periodontal tissue of the double abutment. In clinic, the stress distribution of the distal abutment teeth and its periodontal tissues can be improved by increasing the number of abutment tooth. However, since increasing the number of abutments required an increase in the amount of healthy tooth tissue, it couldn’t be blindly selected in the clinic. After comprehensive consideration, it is appropriate to choose two abutment teeth for restoration.

The Role of Antegrade Irrigation via Percutaneous Nephrostomy on Surgical Outcomes in Semirigid Ureteroscopy among Patients with Upper Ureteral Stones

Objective

We aimed to investigate the role of antegrade irrigation via percutaneous nephrostomy on surgical outcomes in retrograde ureteroscopy in patients with upper ureter stones.

Materials and Methods

In this retrospective study, we analyzed 134 patients who underwent retrograde semirigid ureteroscopy for upper ureter stones between August 2012 and December 2017. Patients were divided into two groups: retrograde irrigation group (conventional URS) and antegrade irrigation group (using percutaneous nephrostomy). Operation time, postoperative hospital stay, complications, and stone-free rate were measured for each patient after ureteroscopy.

Results

The mean age in the retrograde irrigation and antegrade irrigation groups was 53.3 and 60.7 years, respectively (p=0.007). The operation time was 60.8 min vs. 43.0 min (p=0.002), and stone-free rate was 82.0 % vs. 95.5 % (p=0.033). Stone size, laterality, the proportion of male patients, and urinary tract infection prevalence were comparable between the groups. In the subgroup analysis of stone size >10 mm, the antegrade irrigation group had a shorter operation time and a higher stone-free rate. For stone size of 5-10 mm, operation time in the antegrade irrigation group was shorter and the stone-free rate between the two groups was comparable.

Conclusion

Antegrade irrigation via percutaneous nephrostomy during ureteroscopy has a higher stone-free rate with a shorter operation time without an increased urinary tract infection risk. Therefore, if percutaneous nephrostomy is necessary before ureteroscopy, antegrade irrigation of external fluid via percutaneous nephrostomy is strongly recommended.