100% uric acid stone formers: what makes them different?

Effects of size and shape of the side holes of a double J stent on the ureter fluid flow after stenosis

The effect of side holes morphology changes in double J stent (DJS) on encrustation was analyzed using computational fluid dynamics (CFD). We analyzed DJS side holes with inner diameter of 1 mm and outer diameters of 1 (type A), 1.2 (type B) and 1.4 (type C) mm, respectively. Concentric stenosis with three intraureteral degree (0%, 12%, and 88%) was analyzed. The flow rate, shear stress and wall shear stress (WSS) distribution were investigated. Urine flow through SH1 before the ureteropelvic junction (UPJ) differed based on the ureteral stenosis degree. The sum of flow rates through the SHs increased with diameter. In the stented ureter with 12% stenosis, the flow rate through SH1 approximately doubled than that without ureteral stenosis, and the flow rate through SH1 was maximal for the type 'C' stent in both 12% and 88% ureteral stenosis. The mean shear stress in the SHs increased with the degree of stenosis. The WSS around the SHs was higher for type 'C' than types A and B. From the flow rates and shear stresses in and around the SHs, the larger SH diameter of the DJS from the UPJ to mid-ureter is expected to induce encrustation reduction, especially in patients with urinary lithiasis.

The Effect of Size of Materials Formed or Implanted In Vivo on the Macrophage Response and the Resultant Influence on Clinical Outcome

Both the chemistry and size of a material formed in vivo, or an implanted biomaterial, can alter the in vivo host response. Within the size range covered within this review, over 1 μm, chemistry is only important if the solid material is unstable and leeching small molecules. The macrophage activity and the resultant inflammatory response, however, are related to the size of the solid material. The premise of this review is that differences in size of the solid material, in different cases, can be the reason why there is some individual-to-individual variation in response. Specifically, the inflammatory response is enhanced when the size is between 1-50 μm. This will be looked at for three configurations: spherical particulate (silicone oil or gel from breast implants), elongated particulate (monosodium urate [MSU] crystals in gout or in kidney stones), and fibers (e.g., polyester used in fabric implants). These specific examples were selected because many still believe that the clinical outcome for each is controlled by the surface chemistry, when in fact it is the size. In each case, specific studies will be highlighted to either show a mechanism for creating different sizes and therefore a differential biological response (first three) or how changing the size and shape (diameter and spacing of fibers, in this example) can affect the response and can help explain the different responses to fabric implants found in vivo within the 1-50 μm size range. It was found that polyester fibers under 70 μm had a significant increase in macrophage response. Further, it was found that compounds found in synovial fluid could limit MSU crystal size. In addition, it was shown that plasma with low triglyceride levels emulsifies silicone oils to a greater extent than plasma with higher triglyceride levels. Therefore, in three cases it appears that differences in the inflammatory response between individuals and between different implants could be explained just by the size of the material formed or implanted.

Using micro computed tomographic imaging for analyzing kidney stones

Stone analysis is a critical part of the clinical characterization of urolithiasis. This article reviews the strengths and limitations of micro CT in the analysis of stones. Using micro CT alone in a series of 757 stone specimens, micro CT identified the 458 majority calcium oxalate specimens with a sensitivity of 99.6% and specificity of 95.3%. Micro CT alone was also successful in identifying majority apatite, brushite, uric acid, and struvite stones. For some minor minerals-such as apatite in calcium oxalate or calcium salts in uric acid stones-micro CT enables the detection of minute quantities well below 1%. The addition of a standard for calibrating X-ray attenuation values improves the ability of micro CT to identify common stone minerals. The three-dimensional nature of micro CT also allows for the visualization of surface features in stones, which is valuable for the study of stone formation.

Outcomes of dissolution therapy and monitoring for stone disease: should we do better?

PURPOSE OF REVIEW

Surgical management is the cornerstone of urolithiasis treatment, but high recurrence rates and associated complications necessitate the existence of medical treatment options, aiming at dissolution of kidney stones and prevention of recurrence. The purpose of this review is to present the most recent knowledge existing in scientific literature, regarding dissolution therapy and ways of monitoring nephrolithiasis patients.

RECENT FINDINGS

A number of laboratory studies have been performed testing experimental treatments (tolvaptan, chlorthalidone, atorvastatin, a-lipoic acid, glucosaminoglycans, plant extracts), to reduce kidney stone formation and cellular damage and showed encouraging results. Uric acid stones is the main target of dissolution therapy, but until last years, existing level of evidence was low. A number of prospective and randomized studies, proved the efficacy and safety of oral chemolysis for radiolucent stones and associated prognostic features of success. Tolvaptan and a-Lipoic acid were also tested in patients with cystinuria and resulted in reduction of recurrence. Finally, some new diagnostic markers are suggested as tests for the monitoring of urolithiasis patients, with satisfying accuracy and discriminative ability.

SUMMARY

Medical dissolution therapy for nephrolithiasis is an effective option, especially for patients with radiolucent/uric acid stones. In the future, we need clinical trials to confirm the encouraging results of pilot studies testing several agents for patients with cystinuria.

Comprehensive Nomogram for Prediction of the Uric Acid Composition of Ureteral Stones as a Part of Tailored Stone Therapy

BACKGROUND

Oral chemolitholysis is a noninvasive therapy for uric acid (UA) stones. Proper patient selection is crucial for success of the therapy.

OBJECTIVE

To develop a nomogram for prediction of UA stones using parameters gathered during emergency work-up for flank pain.

DESIGN, SETTING, AND PARTICIPANTS

A single-center cohort (459 patients) with singular ureteral stones and available stone analysis was retrospectively reviewed for radiological, urinary, and serological findings indicating UA stones.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

A Mann-Whitney U test or Kruskal-Wallis test was applied for univariate analysis. Categorical variables were compared using a χ² test. Binary logistic regression of significant parameters was performed to design the nomogram.

RESULTS AND LIMITATIONS

Univariate analysis revealed statistically significant differences in parameters between predominantly UA and non-UA groups, including median age (60 yr, interquartile range [IQR] 51.5-70.5 vs 51 yr, IQR 39-62; p < 0.001), body mass index (30.0 kg/m², IQR 27.25-35.0 vs 26.6 kg/m², IQR 24.0-30.467; p < 0.001), stone density (435.0 HU, IQR 329.0-528.0 vs 750.0 HU, IQR 548.0-995.0; p < 0.001), serum UA (437.5 μmol/l, IQR 374.25-478.0 vs 321.0 μmol/l, IQR 273.0-377.0; p < 0.001), and urine pH (5.5, IQR 5.0-5.5 vs 6.0, IQR 5.5-6.5; p < 0.001). Radiolucency was more frequent in the predominantly UA group (88.60% vs 32.70%; p < 0.001). Multivariate binary logistic regression confirmed age, body mass index, stone density, serum UA, urine pH, and radiolucency as independent predictors of UA stones and these parameters were used to design the nomogram.

CONCLUSIONS

We present a nomogram for the prediction of uric acid stones.

PATIENT SUMMARY

We developed a nomogram as a simple tool with potential to be useful in patient counseling regarding chemolitholysis as a tailored stone treatment for uric acid urinary stones.

A New Artificial Urine Protocol to Better Imitate Human Urine

Artificial urine has many advantages over human urine for research and educational purposes. By closely mimicking healthy individuals’ urine, it may also be important in discovering novel biomarkers. However, up until now, there has not been any specific protocol to prove the similarity in terms of the chemical composition at the molecular level. In this study, a new artificial urine protocol is established to mimics the urine of healthy individuals. The multi-purpose artificial urine (MP-AU) presented here is compared with two other protocols most cited in literature. Furthermore, these three protocols are also compared with samples from 28 healthy young individuals. To do so, attenuated total reflection-Fourier transform infrared spectroscopy (ATR-FTIR) is used, according to which MP-AU shows a significantly close similarity with human urine. In formulating MP-AU, the infrared spectra of nine compounds is provided, making possible the band assignment of some absorption bands to certain compounds. Given its properties, the MP-AU protocol introduced here is both economical and practical, making it useful when designing comparative-controlled experiments.

Decreased Associated Risk of Gout in Diabetes Patients with Uric Acid Urolithiasis

Uric acid urolithiasis constitutes approximately 7–10% of all urinary stones. Previous studies have revealed that patients with gout do not equally have uric acid stones. Instead, the risk of gout in patients with uric acid stones remains controversial. This study aimed to investigate whether there is different associated risk of gout for diabetes mellitus (DM) and non-diabetes patients with uric acid urolithiasis. Therefore, we examined all baseline chemistries to determine any risk factors or protective factors related to developing gout in patients with uric acid stones. Ninety-nine patients from a single medical center, who had a uric acid component in their stone specimen were enrolled and their medical records were reviewed retrospectively between January 2010 and December 2016. All patients were divided into gout and non-gout groups. Gout was confirmed in 24 patients in this study (24.2%). The proportion of DM was significantly higher in the non-gout group (34.7%) than in the gout group (4.3%, p < 0.05). Renal function was decreased and serum triglyceride was higher in patients with gout. Uric acid urolithiasis patients with DM had a lower risk for gout (adjusted odds ratio: 0.08; 95% confidence interval (CI) = 0.01–0.61, p = 0.015). In 89 patients with predominant uric acid stones (>50% uric acid composition), the risk for gout was still lower in patients with diabetes than non-diabetes (adjusted odds ratio: 0.08; 95% confidence interval (CI) = 0.01–0.61, p = 0.015). These findings suggest that decreased risk of gout is found in uric acid urolithiasis patients with diabetes. Our results imply that patients with uric acid stones should have complete diabetes evaluation before the administration of uric acid controlling medication.

Long-term Recurrence Rates in Uric Acid Stone Formers With or Without Medical Management

OBJECTIVE

To determine if medical therapy affects long-term clinical outcomes in uric acid stone formers (UASF).

METHODS

We identified 53 UASF who had complete stone clearance following stone procedure by computed tomography (CT) and had ≥1 postoperative 24-hour urine collection and a clinical follow-up ≥6 months with a surveillance CT scan. Patients were divided into "adherent to medical therapy" (compliance with potassium citrate ± allopurinol verified by computerized pharmacy data) or nonadherent groups. Primary outcomes were CT stone recurrence rate and need for surgical stone intervention.

RESULTS

We found 28 of 53 (53%) adherent and 25 of 53 (47%) nonadherent individuals (14 declined medication, 11 intolerant). With median follow-up of 24 months, no significant differences were noted between groups in regards to stone recurrence (32%; P = .99) or in 24-hour urine pH compared to baseline or follow-up (range 5.46-5.62; P = 0.06). Adherent patients, however, had smaller CT stone recurrence sizes (6.3 ± 3.8 vs 11.8 ± 6.2 mm, P = .02), were 28% less likely to require stone surgery compared to those without therapy (P <.01), and trended toward longer time intervals without recurrence (23.1 ± 18.8 vs 10.5 ± 7.5 months, P = .10) compared to nonadherents. Study confounders included a variety of medication dosages and adherences, limited nonadherent follow-up, and small study number.

CONCLUSION

UASF adherent to medical therapy had smaller recurrence sizes and fewer surgical interventions vs nonadherent, highlighting the protective role of potassium citrate in UA stone disease. The comparable urine pH and stone recurrence rates between groups, however, underscore areas for improvement in future UA stone prevention strategies.

Medical dissolution therapy for the treatment of uric acid nephrolithiasis

INTRODUCTION

Uric acid (UA) nephrolithiasis represents 10% of kidney stones in the US with low urine pH and high saturation of UA as the main risk factors for stone development. Dissolution therapy for UA kidney stones via urinary alkalization has been described as a treatment option. We present our experience in treating UA nephrolithiasis with medical dissolution therapy.

METHODS

A retrospective review was performed of UA stone patients referred for surgery but treated with dissolution therapy between July 2007 and July 2016. Patients were identified using ICD-9 codes. Patients were treated with potassium citrate alone or in combination with allopurinol. Serial imaging and urine pH were obtained at follow-up. Demographics, aggregate stone size, time to stone clearance, urine pH (office dip), and complications were recorded.

RESULTS OBTAINED

Twenty-four patients (14 men and 10 women) were identified that started medical dissolution therapy for UA nephrolithiasis after initial referral for surgical management. Three patients (13%) did not tolerate the initiation of dissolution therapy and discontinued this treatment. Of the 21 patients that were maintained on dissolution therapy, 14 patients (67%) showed complete resolution of nephrolithiasis and 7 patients (33%) showed partial reduction. Patients with partial response had a mean reduction in stone burden of 68%. There were 3 recorded complications (UTI, GI upset with therapy, and throat irritation) and 4 recorded stone recurrences among these 21 patients.

CONCLUSION

Based on our study population, medical dissolution therapy is a well-tolerated, non-invasive option for UA nephrolithiasis.

Medical therapy for nephrolithiasis: State of the art

The prevalence of nephrolithiasis is increasing worldwide. Understanding and implementing medical therapies for kidney stone prevention are critical to prevent recurrences and decrease the economic burden of this condition. Dietary and pharmacologic therapies require understanding on the part of the patient and the prescribing practitioner in order to promote compliance. Insights into occupational exposures and antibiotic use may help uncover individual risk factors. Follow-up is essential to assess response to treatment and to modify treatment plans to maximize therapeutic benefit.

Influence of nutritional status, laboratory parameters and dietary patterns upon urinary acid excretion in calcium stone formers

INTRODUCTION

Obesity and Metabolic Syndrome (MS) are associated with low urinary pH and represent risk factors for nephrolithiasis, especially composed by uric acid. Acidogenic diets may also contribute to a reduction of urinary pH. Propensity for calcium oxalate precipitation has been shown to be higher with increasing features of the MS.

OBJECTIVE

A retrospective evaluation of anthropometric and body composition parameters, MS criteria and the dietary patterns of overweight and obese calcium stone formers and their impact upon urinary pH and other lithogenic parameters was performed.

METHODS

Data regarding anthropometry, body composition, serum and urinary parameters and 3-days dietary records were obtained from medical records of 102(34M/68F) calcium stone formers.

RESULTS

A negative correlation was found between urinary pH, waist circumference and serum uric acid levels (males). The endogenous production of organic acids (OA) was positively correlated with triglycerides levels and number of features of MS (males), and with glucose, uric acid and triglycerides serum levels, and number of features of MS (females). No significant correlations were detected between Net Acid Excretion (NAE) or Potential Renal Acid Load of the diet with any of the assessed parameters. A multivariate analysis showed a negative association between OA and urinary pH.

CONCLUSION

The endogenous production of OA and not an acidogenic diet were found to be independently predictive factors for lower urinary pH levels in calcium stone formers. Hypercalciuric and/or hyperuricosuric patients presented higher OA levels and lower levels of urinary pH.

Investigation of Adipose Tissue Fatty Acid Composition in Men with Uronephrolithiasis and Metabolic Syndrome

Background

Fatty acids (FA) and their metabolites are closely related to some mechanisms involved in the development of uronephrolithiasis. The aim of this study was to evaluate the relationship between FA composition and type of kidney stones.

Material/Methods

Abdominal adipose tissue fatty acid methyl esters of 71 men with nephrolithiasis were identified by GC/MS, and the type of kidney stones was identified using FTIR infrared spectroscopy. Patients were divided into groups according to diagnosis of metabolic syndrome (MS) and type of kidney stone. The composition of FA was compared within different groups of patients with different types of kidney stones and between the patients and healthy individuals (control group) (n=100).

Results

Individuals with nephrolithiasis had a significantly higher level of monounsaturated fatty acids (MUFA) and a lower level of polyunsaturated fatty acids (PUFA) versus healthy individuals. Patients with MS had a higher level of 18: 1ω9 and a lower level of 16: 1ω7 than patients without MS. Individuals with nephrolithiasis, but without MS, had a higher level of saturated fatty acids (SFA) compared to controls. The level of PUFA was higher in the control group (p<0.0001) compared to individuals with uronephrolithiasis, with or without MS. PUFA, ω – 6 PUFA, and 18: 2ω6 were higher in patients with calcium-based kidney stones without MS versus patients with uric acid kidney stones with MS.

Conclusions

The levels of MUFA were significantly higher and the levels of PUFA were significantly lower in patients with uronephrolithiasis compared to controls.

Biochemical and dietary factors of uric acid stone formation

The aim of this study was to compare the clinical characteristics of "pure" uric acid renal stone formers (UA-RSFs) with that of mixed uric acid/calcium oxalate stone formers (UC-RSFs) and to identify which urinary and dietary risk factors predispose to their formation. A total of 136 UA-RSFs and 115 UC-RSFs were extracted from our database of renal stone formers. A control group of 60 subjects without history of renal stones was considered for comparison. Data from serum chemistries, 24-h urine collections and 24-h dietary recalls were considered. UA-RSFs had a significantly (p = 0.001) higher body mass index (26.3 ± 3.6 kg/m²) than UC-RSFs, whereas body mass index of UA-RSFs was higher but not significantly than in controls (24.6 ± 4.7) (p = 0.108). The mean urinary pH was significantly lower in UA-RSFs (5.57 ± 0.58) and UC-RSFs (5.71 ± 0.56) compared with controls (5.83 ± 0.29) (p = 0.007). No difference of daily urinary uric acid excretion was observed in the three groups (p = 0.902). Daily urinary calcium excretion was significantly (p = 0.018) higher in UC-RSFs (224 ± 149 mg/day) than UA-RSFs (179 ± 115) whereas no significant difference was observed with controls (181 ± 89). UA-RSFs tend to have a lower uric acid fractional excretion (0.083 ± 0.045% vs 0.107+/-0.165; p = 0.120) and had significantly higher serum uric acid (5.33 ± 1.66 vs 4.78 ± 1.44 mg/dl; p = 0.007) than UC-RSFs. The mean energy, carbohydrate and vitamin C intakes were higher in UA-SFs (1987 ± 683 kcal, 272 ± 91 g, 112 ± 72 mg) and UC-SFs (1836 ± 74 kcal, 265 ± 117, 140 ± 118) with respect to controls (1474 ± 601, 188 ± 84, 76 ± 53) (p = 0.000). UA-RSFs should be differentiated from UC-RSFs as they present lower urinary pH, lower uric acid fractional excretion and higher serum uric acid. On the contrary, patients with UC-RSFs show urinary risk factors more similar to those for calcium oxalate stones. The dietary approach in patients forming uric acid stones should be reconsidered with more attention to the quantity and quality of carbohydrate intake.

Evolving Guidance on Ureteric Calculi Management in the Acute Setting

Ureteric colic is a common presentation to acute emergency services. The gold standard test for the diagnosis of acute ureteric colic is a non-contrast computer tomography of the kidneys ureters and bladder (CT KUB). Non-steroidal anti-inflammatory drugs (NSAIDs) should be used as first-line analgesia, with studies showing that there is no role for steroid or phosphodiesterase-5 inhibitors. There is emerging evidence that a high body mass index (BMI) is a risk factor. The drugs used to facilitate stone passage are known as medical expulsive therapy (MET). The most evaluated being alpha-blockers. The Spontaneous Urinary Stone Passage Enabled by Drugs (SUSPEND) trial was designed to evaluate the use of MET (tamsulosin and nifedipine). This trial showed that there was no difference with MET and placebo for the spontaneous passage of ureteric stones. There is an emerging role for the use of primary ureteroscopy in the management of non-infective ureteric stones.