Epidemiology and medical management of stone disease

Baicalin attenuated oxidative stress and inflammation in ethylene glycol-induced urolithiasis in adult male SD rats

AIMS

Baicalin is a flavonoid derived from the root of the medicinal plant Scutellaria baicalensis Georgi (S. baicalensis) and is known for its various pharmacological properties. This study aimed to investigate the impact of baicalin (BAI) on the occurrence of kidney calcium oxalate crystal formation induced by ethylene glycol in male SD rats.

MAIN METHODS

A rat model of renal stones was created and various concentrations of baicalin were used for intervention. Samples of urine, blood, and kidney tissue were taken from the rats, and they were euthanized for biochemical and histopathological examinations.

KEY FINDINGS

Our results show that baicalin treatment improved the weight loss induced by ethylene glycol (EG) and ammonium chloride (AC) in rats. Baicalin also reduced the formation of calcium oxalate crystals and protected kidney function in rats with urolithiasis. Furthermore, it lowered the level of malondialdehyde (MDA) and elevated the activity of antioxidant enzymes compared to the stone control group. Additionally, baicalin notably alleviated renal inflammation in rats with urolithiasis.

SIGNIFICANCE

The present study attributed clinical evidence first time that claiming the significant antiurolithic effect of baicalin and could be a cost-effective candidate for the prevention and treatment of urolithiasis.

Antiurolithiatic effects of Cassia fistula Lin. fruit extracts on ethylene glycol-induced nephrolithiasis in rats

Urinary stones are a growing disease that results from pathological biomineralization. Cassia fistula Lin. is traditionally used to treat urinary stones. However, no scientific evidence is available to prove its antilithiatic effect. This study evaluates the antilithiatic potential of aqueous and ethanolic extract of Cassia fistula Lin. fruit (Cff) against calcium oxalate kidney stones. Forty-two male Wistar rats were divided into seven groups (n = 6/group): Group I (control), Group II (rats treated with ethylene glycol and ammonium chloride developed nephrolithiasis after 28 days), Group III (lithiatic rats receiving distilled water for 30 days), Group IV and V (lithiatic rats receiving aqueous extract of Cff at doses of 1 and 100 mg/kg body weight for 30 days, respectively) and Group VI and VII (lithiatic rats receiving ethanolic extract of Cff at doses of 1 and 100 mg/kg body weight for 30 days, respectively). Some parameters of urine and serum, and also renal oxidative stress and histopathology were used to determine the antilithiatic effect of aqueous and ethanolic extract of Cff. Therefore, the types of extracts of Cff improved abnormal levels of urine, serum, and renal oxidative stress and histopathology parameters. This antilithiatic effect of aqueous and ethanolic extracts of Cff, can be attributed to the anti-crystallization and antioxidant properties of the extracts and the ability to improve urine and serum biochemistry. RESEARCH HIGHLIGHTS: Ethylene glycol and ammonium chloride-induced urolithiasis, aggregation of calcium oxalate deposits, increase of some urinary and serum parameters, relative kidney weight, kidney size and MDA activity, decrease of some urinary parameters, relative body weight and SOD activity. Aqueous and ethanolic extracts of Cassia fistula Lin. lead to the treatment of urolithic rats by decreasing levels of urinary oxalate, phosphate, urea, serum urea, uric acid, creatinine, calcium, phosphate, MDA, kidney weight and kidney size, increasing levels of urinary calcium, creatinine, magnesium, citrate, body weight and SOD activity in the kidney, eliminating CaOx deposition (esp. ethanolic extract).

Prevalence and related factors of nephrolithiasis among medical staff in Qingdao, China: a retrospective cross-sectional study

BACKGROUND

Certain occupations may predispose individuals to urolithiasis, a multi-factorial disease. The study aimed to evaluate the prevalence and related factors of nephrolithiasis in medical staff in Qingdao, China.

METHODS

Physical examination results of 5115 in-service medical staff aged 22-60 years old were retrospectively analyzed. Multivariable logistic regression analysis and stratified analyses by age and gender were applied to explore the related factors of nephrolithiasis in these medical staff.

RESULTS

The overall nephrolithiasis prevalence in medical staff in Qingdao, China was 4.65%. Doctors were more prone to nephrolithiasis than nurses (5.63% vs. 3.96%, P = 0.013) and the peak prevalence (6.69%) was observed in medical staff working in the emergency department (ED). Male gender (OR = 1.615, 95% CI = 1.123-2.323, P = 0.010), overweight or obesity (OR = 1.674, 95% CI = 1.266-2.214, P < 0.001), work seniority ≥ 10 years (OR = 2.489, 95%CI = 1.675-3.699, P < 0.001) and working in the ED (OR = 1.815, 95% CI = 1.202-2.742, P = 0.005) were independent predictors for nephrolithiasis in medical staff based on the results of multivariate logistic regression analysis. The associations between overweight or obesity and nephrolithiasis risk as well as between work seniority ≥ 10 years and nephrolithiasis risk in medical staff were independent of age or gender in stratified analysis.

CONCLUSIONS

Nephrolithiasis prevalence in medical staff in Qingdao, China seemed not to be higher than that in the general population. Medical staff with work seniority ≥ 10 years and working in the ED should pay abundant attention to take measures to modify their nephrolithiasis risk.

Medical management of urolithiasis: Great efforts and limited progress

Objective

To provide a comprehensive review on the existing literature on medical management of urolithiasis.

Methods

A thorough literature review was performed using Medline, PubMed/PMC, Embase, and the Cochrane Database of Systematic Reviews up to December 2022 to identify publications on the medical management of urolithiasis. Studies that assessed dietary and pharmacologic management of urolithiasis were reviewed; studies on medical expulsive therapy were not included in this review.

Results

Medical management of urolithiasis ranges from the prophylactic management of kidney stone disease to dissolution therapies. While most treatment concepts have been long established, large randomized controlled trials are scarce. Dietary modification and increased fluid intake remain cornerstones in the conservative management of urolithiasis. A major limitation for medical management of urolithiasis is poor patient compliance.

Conclusion

Medical management of urolithiasis is more important in patients with recurrent urolithiasis and patients with metabolic abnormalities putting them at higher risk of developing stones. Although medical management can be effective in limiting stone recurrence, medical interventions often fail due to poor compliance.

Harnessing Artificial Intelligence for Enhanced Renal Analysis: Automated Detection of Hydronephrosis and Precise Kidney Segmentation

Background and objective

Hydronephrosis is essential in the diagnosis of renal colic. We automated the detection of hydronephrosis from ultrasound images to standardize the therapy and reduce the misdiagnosis of renal colic.

Methods

Anonymously collected ultrasound images of human kidneys, both normal and hydronephrotic, were preprocessed for neural networks. Six "state of the art" models were trained and cross-validated for the detection of hydronephrosis, and two convolutional networks were used for kidney segmentation. In the testing phase, performance metrics included true positives, true negatives, false positives, false negatives, accuracy, and F1 score, while the evaluation of the segmentation task involved accuracy, precision, dice, jaccard, recall, and ASSD.

Key findings and limitations

A total of 523 sonographic kidney images (423 nonhydronephrotic and 100 hydronephrotic) were collected from three different ultrasound devices. After training on this dataset, all models were used to evaluate 200 new ultrasound kidney images (142 nonhydronephrotic and 58 hydronephrotic kidneys). The highest validation accuracy (98.5%) was achieved by the AlexNet model (GoogLeNet 97%, AlexNet_v2 96%, ResNet50 96%, ResNet101 97.5%, and ResNet152 95%). The deeplabv3_resnet50 and deeplabv3_resnet101 reached a dice coefficient of 94.74% and 94.48%, respectively, on the task of automated kidney segmentation. The study is limited by analyzing only hydronephrosis, but this specific focus enabled high detection accuracy.

Conclusions and clinical implications

We show that our automated ultrasound deep learning model can be trained and used to interpret and segmentate ultrasound images from different sources with high accuracy. This method will serve as an automated tool in the diagnostic algorithm of acute renal failure in the future.

Patient summary

Hydronephrosis is crucial in the diagnosis of renal colic. Recent advances in artificial intelligence allow automated detection of hydronephrosis in ultrasound images with high accuracy. These methods will help standardize the diagnosis and treatment renal colic.

Phytochemicals and Their Usefulness in the Maintenance of Health

Inflammation is the immune system's first biological response to infection, injury, or irritation. Evidence suggests that the anti-inflammatory effect is mediated by the regulation of various inflammatory cytokines, such as nitric oxide, interleukins, tumor necrosis factor alpha-α, interferon gamma-γ, as well as the non-cytokine mediator, prostaglandin E2. Currently, the mechanism of action and clinical usefulness of phytochemicals is known; their action on the activity of cytokines, free radicals, and oxidative stress. The latter are of great relevance in the development of diseases, such that the evidence collected demonstrates the beneficial effects of phytochemicals in maintaining health. Epidemiological evidence indicates that regular consumption of fruits and vegetables is related to a low risk of developing cancer and other chronic diseases.

Risk factors for the comorbidity of osteoporosis/osteopenia and kidney stones: a cross-sectional study

Low femoral neck bone mineral density (BMD) was associated with the increased risk of kidney stones. Low dietary magnesium intake and increased serum alkaline phosphatase were associated with the increased risk of low femoral neck BMD in kidney stone formers.

PURPOSE

To evaluate whether low femoral neck bone mineral density (BMD) was associated with a higher risk of kidney stones, and identify risk factors for the comorbidity of osteoporosis/osteopenia and kidney stones.

METHODS

We analyzed individuals aged ≥ 20 years from National Health and Nutrition Examination Survey 2007-2020 data. Osteoporosis/osteopenia is defined as any T-score < -1.0 of femoral neck, total femoral, and mean lumbar spine (L1-L4) BMD. Dietary intakes (sodium, potassium, magnesium, calcium, phosphorus, calcium/phosphorus, vitamin D (25OHD2+25OHD3)) and serum parameters (sodium, potassium, calcium, phosphorus, bicarbonate, vitamin D, alkaline phosphatase (ALP)) were screened for identifying risk factors for the comorbidity.

RESULTS

The prevalence of comorbidity of osteoporosis/osteopenia and kidney stones was 4.82%. Femoral neck BMD T-score was negatively associated with the prevalence of kidney stones (n=11,864). Dietary magnesium intake, serum phosphorus, and bicarbonate were negatively associated with the comorbidity prevalence, and serum ALP was positively associated with the comorbidity prevalence (n=6978). Additionally, there remain significant associations of dietary magnesium intake, serum ALP, and bicarbonate with not only femoral neck BMD T-score (n=11331), but also the prevalence of kidney stones (n=23,111) in general population. Furthermore, dietary magnesium intake was positively correlated to femoral neck BMD T-score in stone formers (SFs), while serum ALP was negatively correlated to femoral neck BMD T-score in SFs (n=1163).

CONCLUSION

Low femoral neck BMD was closely associated with an increased risk of kidney stones. Low magnesium intake and increased serum ALP were associated with the increased risk of the comorbidity, as well as indicative of low femoral neck BMD T-score in SFs, which offered a clue to further clarify the mechanism leading to paradoxical calcification of bone resorption and kidney stones, and had the potential to perform personalized diagnostic workup for low BMD in SFs.

The effect of nutritional factors on urolithiasis: A case-control study

Urolithiasis, a prevalent chronic kidney disease affecting all age groups, can be influenced by nutritional factors. The incidence of urolithiasis in Asian countries ranges from 1% to 19.1%, attributed to geographical and lifestyle differences. In Iran, several risk factors, including ethnicity, dietary habits, gender, and age, are associated with urolithiasis. This study aimed to assess the impact of nutritional factors on kidney and urinary tract stone formation. This case-control study enrolled 127 newly diagnosed urolithiasis patients, and 127 matched healthy participants between February to May 2017. Exclusion criteria included diabetes and acute or chronic renal failure. Data were collected using the Food Frequency Questionnaire (FFQ) and analyzed using chi-square and logistic regression tests. Water (95% CI: 0.09-0.89, OR=0.28), natural juices (95% CI: 0.10-0.65, OR=0.53), mineral water (95% CI: 0.05-0.64, OR=0.18), legumes (95% CI: 0.00-0.38, OR=0.032), butter, cream, or peppermint (95% CI: 0.09-0.95, OR=0.30), and ice cream (95% CI: 0.07-0.54, OR=0.203) had a significant protective effect against kidney and urinary tract stone formation. Conversely, tea consumption (95% CI: 1.15-7.99, OR=4.70), beverages (95% CI: 4.45-23.32, OR=23.32), coffee (95% CI: 1.63-11.78, OR=4.39), bread (95% CI: 1.1-10.59, OR=3.37), meat (95% CI: 1.01-8.01, OR=2.85), liver (95% CI: 3.37-488.90, OR=40.58), fish (95% CI: 2.89-216.39, OR=25.03), and various canned foods (95% CI: 1.34-10.25, OR=3.70) were significantly associated with kidney and urinary tract stone risk. These findings showed that the risk of urinary stones formation had a significant relationship with dietary habits. Therefore, the correct dietary pattern and sufficient fluid consumption may play an important role in preventing urinary stones.

An insight investigation to the antiurolithic activity of Trachyspermum ammi using the in vitro and in vivo experiments

The crude extract of Trachyspermum ammi seeds (Ta.Cr) was studied for its antiurolithic activity using the in vivo and in vitro experiments. In the in vivo experiments, Ta.Cr treatment showed a diuretic activity at the dose of 30 and 100 mg/kg and exhibited curative effect in male hyperoxaluric Wistar rats, which received 0.75% ethylene glycol (EG) in drinking water given for 3 weeks, with 1% ammonium chloride (AC) for initial three days. In the in vitro experiments, Ta.Cr delayed the slopes of nucleation and inhibited the calcium oxalate (CaOx) crystal aggregation in a concentration-dependent manner like that of potassium citrate. Ta.Cr also inhibited DPPH free radicals like standard antioxidant drug butylated hydroxytoluene (BHT), and significantly reduced cell toxicity and LDH release in Madin-Darby canine kidney (MDCK) cells, exposed to oxalate (0.5 mM) and COM (66 µg/cm²) crystals. In isolated rabbit urinary bladder strips, Ta.Cr relaxed high K⁺ (80 mM) and CCh (1 µM)-induced contractions, showing antispasmodic activity. The findings of this study suggest that the antiurolithic activity of crude extract of Trachyspermum ammi seeds may be mediated by a number of mechanisms, including a diuretic, an inhibitor of CaOx crystal aggregation, an antioxidant, renal epithelial cell protection, and an antispasmodic, thus, showing the therapeutic potential in urolithiasis, for which there is no viable non-invasive option in modern medicine.

The effects of Cynodon dactylon (Poaceae family) and Dolichos biflorus (Fabaceae family) extracts on decreasing size and excretion of kidney and urinary tract stones: a randomized, double-blind controlled trial

OBJECTIVES

Given high and growing prevalence rate of urolithiasis in most societies as well as the problems caused by this issue, it is necessary to apply more cost-effective and safer therapeutic methods, which are accessible for all the individuals worldwide. Therefore, this study aimed to investigate efficacy of herbal medicines named Cynodon dactylon and Dolichos biflorus on solving and excretion of renal and urinary tract stones in patients with urolithiasis.

METHODS

This study included 96 patients with urolithiasis who were randomly allocated into three groups. The first group received the extract of D. biflorus seeds (1,600 mg), the second group received extract of C. dactylon rhizome (1,600 mg) and the third group received placebo for 21 days. In this study, we used an hydroalcoholic extract of D. biflorus and C. dactylon prepared by Soxhlet method. For each patient, the size of the stones, the amount of calcium in the urine, the number of stones excreted and their chemical substance type were measured.

RESULTS

In this study, changes were observed at the significance level in the interventions groups of 1 and 2, and the placebo group in the left kidney, so that changes in size of the stone in left kidney as intergroup were significantly different in these three groups (p=0.02). The mean of changes in stone size in left kidney in the group C. dactylon was 3.78 ± 7.1 and in the group D. biflorus, it was 0.27 ± 0.6.

CONCLUSIONS

A significant difference in the results of this study show that C. dactylon rhizome and D. biflorus seed extracts are able to decrease the size of the stone and can be effective on kidney stones excretion.

Extracorporeal shockwave therapy in an immobilized knee model in rats prevents progression of joint contracture

Joint immobilization, which ensures rest and accelerates tissue recovery in musculoskeletal disorders, often causes joint contracture, for which there is still no effective prevention. To address this, we investigated the effects of extracorporeal shockwave therapy (ESWT) in preventing joint contracture, in a unilaterally immobilized knee rat model. Under general anesthesia, ESWT (0.25 mJ/mm² , 3000 shot, 4 Hz, 3 days/week) was administered from 1 day after immobilization up to 2, 4, and 6 weeks. The immobilized control group received general anesthesia without ESWT. We evaluated joint angle, tissue elasticity, and gene and protein expression related to fibrosis, inflammation, and angiogenesis in the joint capsule. Relative to the control, the ESWT group had greater joint angle at 4 and 6 weeks, and lower posterior-capsule elasticity at 6 weeks. In the ESWT group, at 6 weeks, gene expression of collagen type I (col1α1), connective tissue growth factor (CTGF), and α-smooth muscle actin (α-SMA) was significantly downregulated, whereas interleukin-6 (IL-6) and hypoxia-inducible factor-1α (HIF-1α) gene expression was upregulated, relative to that in the control. Compared with that in the control, at 4 and 6 weeks, the ratio of CTGF⁺ cells was significantly lower in the ESWT group; at 4 weeks, the ESWT group had significantly fewer CD68⁺ cells in the adhesion area, and at 6 weeks, significantly more blood vessels. Statement of Clinical Significance: In a rat model, ESWT counteracted fibrosis, suppressed macrophage infiltration, and promoted neovascularization, reducing elasticity, and increasing joint range-ofmotion. ESWT offers a potential new strategy to prevent progression in joint contracture.

Effect of tamsulosin versus tamsulosin plus tadalafil on renal calculus clearance after shock wave lithotripsy: An open-labelled, randomised, prospective study

Objectives

To compare the efficacy of tamsulosin versus tamsulosin plus tadalafil in achieving clearance of fragments after shock wave lithotripsy (SWL) to treat renal calculi.

Methods

Between January 2016 to December 2017, 140 patients with solitary, non-branched, non-lower calyceal renal calculus and measuring less than 20 mm and treated with SWL were randomized to tamsulosin (group A) or tamsulosin plus tadalafil (group B). Therapy was given for a period of 4 weeks. Stone clearance rate, analgesic requirement, occurrence of steinstrasse, need for auxiliary procedures (endoscopic treatment), and adverse effects of drugs were recorded.

Results

The overall clearance rate was 72.5% (50/69) in the group A and 90.1% (64/71) in the group B (p=0.007). For stones up to 12 mm, the difference in the clearance rate was significant (p=0.039) while it was not so for stones larger than 12 mm (p=0.151). There was no statistically significant difference between the two groups with regards to analgesic requirement (p=0.94), occurrence of steinstrasse (p=0.101), need for auxiliary procedures (p=0.76), and adverse effects of the drugs (p=0.148).

Conclusion

Our study shows that adjunctive medical expulsive therapy with tamsulosin and tadalafil achieves better clearance rate than tadalafil alone in patients receiving SWL for renal stones.

Nephroprotective effect of Bryophyllum pinnatum-mediated silver nanoparticles in ethylene glycol-induced urolithiasis in rat

A large population is suffering from multifactorial urolithiasis worldwide with a reoccurrence rate of almost 70%-80% in males and 47%-60% in females. In the present study, the nephroprotective effect of silver nanoparticles (AgNPs) synthesised by Bryophyllum pinnatum was evaluated in ethylene glycol-induced urolithiasis in rat. B. pinnatum-mediated AgNPs which were found to be spherical and polydispersed particles with an average size of 32.65 nm determined by transmission electron microscopy analysis, and showing an absorption peak at 432 nm by the UV-Vis spectrophotometric analysis, revealing the role of hydroxyl group in the synthesis by Fourier Transformed Infrared Spectroscopy analysis, with a zeta potential value of -15.7 mV. The crystalline nature and fcc structure was demonstrated based on X-ray diffraction analysis. Animal study was performed on 36 male Wistar rats divided into six equal groups, which demonstrated significant increase in serum total protein, albumin and globulin and significant decrease in AST, ALT, creatinine, BUN, calcium and phosphorus in group V and VI when compared with group II and IV. No crystalluria was observed in rats given B. pinnatum AgNPs. Histopathological observations in group V and VI showed mild degenerative changes and restoration or maintenance of kidney parenchyma when compared with group II and IV rats. Thus, the authors conclude with the beneficial preventive and therapeutic nephroprotective effect of B. pinnatum-mediated AgNPs against ethylene glycol-induced urolithiasis in rats.

The efficacy and safety of alpha-adrenergic blockers for medical expulsion therapy in patients with ureteral calculi: A meta-analysis of placebo-controlled trials

PURPOSE

Alpha-adrenergic blockers are commonly used as a medical expulsive therapy (MET) for patients with ureteral calculi. The aim of this meta-analysis was to evaluate the efficacy and safety of alpha-adrenergic blockers compared with a placebo when used as a MET.

MATERIALS AND METHODS

We carried out a systematic search of the PubMed, EMBASE, and Web of Science databases, and the Cochrane Library, for relevant articles from inception to November 2020. Our aim was to identify placebo-controlled trails in which patients were randomized to receive either alpha-adrenergic blockers (tamsulosin, alfuzosin, doxazosin, terazosin, naftopidil, or silodosin) or a placebo for the treatment of ureteral calculi.

RESULTS

According to strict inclusion criteria, database searches identified 8 placebo-controlled studies that included 2284 patients. Generally, α-blockers had no significant effect on the clearance of stones in the urinary tract (risk ratio [RR] = 1.05; 95% confidence interval [CI] = 1.00-1.11). However, subgroup analysis showed that α-blockers were effective in treating distal urinary tract stones (RR = 1.08; 95% CI = 1.02-1.15). With regards to adverse events, our analysis showed that the combination of MET with α-blockers was likely to cause dizziness (RR = 1.37; 95% CI = 1.06-1.79) and retrograde ejaculation (RR = 3.10; 95% CI = 1.81-5.29).

CONCLUSION

Although α-blockers cannot improve the overall ureteral stone clearance rate, these drugs are still effective for the treatment of stones in the distal urinary tract. However, the application of α-blockers is likely to cause dizziness and/or retrograde ejaculation.

Time dependant functional and morphological recovery of the kidney after relief of obstruction in patients with impacted ureteral stones

OBJECTIVES

To assess the course of functional and morphological recovery of the kidney following the relief of obstruction with ureteral JJ stent in cases with unilateral impacted stones.

MATERIALS AND METHODS

A total of 42 adult patients who were admitted to our clinic with unilateral obstructing impacted ureteral stones requiring JJ stent placement were included in the study. The course of functional recovery was assessed by evaluating the serum creatinine levels, renal resistive index (RRI) values and urinary levels of kidney injury molecule-1, neutrophil gelatinaseassociated lipocalin as well as microalbumin before at 1 day, 1 week and 4 weeks after JJ stent placement. Course of morphologic recovery was evaluated by evaluating the degree of hydronephrosis, kidney size, perirenal straining and ureteral diameter.

RESULTS

Our results showed that all relevant parameters began to decrease after 24 hours and continue to normalize during 1 week evaluation; majority of these variables indicating the functional and morphological recovery were in normal range after 4 weeks. Decompression of the obstructed kidneys with JJ stent placement in patients with impacted ureteral stones was found to be effective enough with recovery of normal renal functional and morphological status after a minimum time period of 4 weeks. Morphological recovery of affected kidneys following JJ stenting was obtained with a significant difference between baseline and 1-month evaluation findings (p = 0.001, p < 001, p < 001, respectively). KIM-1 excretion began to decline to normal levels after 4 weeks (3.52 ± 0.99 ng/ml versus 2.84 ± 0.66 ng/ml, p < 0.001). The same findings were observed for the urinary excretion levels of NGAL, which normalized at the 1-month evaluation (604.55 ± 140.28 ng/ml versus 596.87 ± 80.17 ng/ml p = 0.895). Urinary microalbumin excretion levels however remained high even until 1-month follow-up with a statistically significant difference when compared with the normal excretion values (p < 0.001). There was a statistically significant difference in RRI values between baseline and 1-month follow-up findings in obstructed kidney (p < 0.001).

CONCLUSIONS

Elective management of the obstructing impacted ureteral stone(s) will be safer with limited risk of infective complications after functional and morphological normalization in such kidneys following 4 weeks of JJ stent placement.

Structural and chemical heterogeneities of primary hyperoxaluria kidney stones from pediatric patients

OBJECTIVE

Calcium oxalate stones are the most common type among stone-forming patients and in some cases result from predisposed genetic conditions. In this work, we examined the differences in structure and chemical composition between oxalate stones from patients from three groups: 1) pediatric patients that were genetically predisposed (primary hyperoxaluria) to form stones (PPH); 2) control pediatric patients that did not have such genetic predisposition (PN-PH); 3) adult patients that formed oxalate stones without the genetic predisposition (A-CaOx). A variety of instrumental analyses were conducted to identify physicochemical properties of stones characteristic of predisposed pediatric (PPH), pediatric hyperoxaluria (PN-PH), and adult (A-CaOx) patient populations.

METHODS

Genetic variants of 16 stone-forming patients were determined using whole-exome gene sequencing. Components of stones from PPH (n = 6), PN-PH (n = 5), and A-CaOx (n = 5) groups were identified using Fourier transform infrared (FTIR) spectroscopy. Stone morphology and density were evaluated using high resolution X-ray computed tomography (micro-XCT). Stone microstructure and elemental composition were mapped with scanning electron microscopy (SEM) and energy dispersive X-ray (EDX) spectroscopy, respectively.

RESULTS

Calcium oxalate bipyramidal crystals were found on stones from all groups. Stones from PPH patients with PH types I and II were composed of calcium oxalate monohydrate (COM) with relatively uniform mineral density (1224 ± 277 mg/cc) and distinct smooth surfaces. By contrast, micro-spherical calcium phosphate particles were found only on PN-PH stones, which also showed a broader range of mineral densities (1266 ± 342 mg/cc). Stones from the PN-PH group also contained phosphorus (P), which was absent in NP-PH stones. A-CaOx stones were of significantly lower mineral density (645 ± 237 mg/cc) than pediatric stones and were more heterogeneous in their elemental composition.

CONCLUSION

Unique structural and compositional characteristics were identified in stones from pediatric patients with primary hyperoxaluria. These include the absence of phosphorus, a narrower mineral density distribution, and a uniform elemental composition compared to stones from pediatric patients without the genetic predisposition. Thus, characterization of stones at the macro- and micro-scales in combination with genetic testing of patients can provide insights and accurate diagnosis to develop a treatment plan for effective patient care.

6-Shogaol attenuated ethylene glycol and aluminium chloride induced urolithiasis and renal injuries in rodents

The 6-shogaol, is a flavanone type flavonoid that is abundant in citrus fruit and has a wide range of pharmacological effects. The present study attempted to evaluate the antiurolithic effect of 6-shogaol on ethylene glycol (EG) and ammonium chloride (AC)-induced experimental urolithiasis in rats. The efficacy of 6-shogaol 50 mg/kg and 100 mg/kg was studied in EG 0.75% (V/V) and AC 1% (W/V) experimentally induced urolithiasis in rats for 21 days. The weight difference, urine volume, the levels of calcium, phosphate, magnesium, oxalate and uric acid in urine was observed. The blood urea nitrogen, creatinine, uric acid in serum and levels of malondialdehyde (MDA) and glutathione (GSH) were also measured. Histopathological analyses in kidneys were also performed. The rats weights were higher in the 6-shogaol groups than the urolithiasis group. EG caused a significant increase in serum creatinine (p < 0.05), BUN (P < 0.001), and uric acid (p < 0.01) while treatment with Cystone (750 mg/kg), and 6-shogaol (50 and 100 mg/kg) showed the significant reduction in increased serum levels of creatinine (p < 0.001), uric acid (p < 0.01) and BUN (p < 0.001). Administration of EG and AC showed statistically significant (p < 0.001) elevated levels of MDA and reduction in GSH levels. Treatment of Cystone (750 mg/kg), and 6-shogaol (50 and 100 mg/kg) significantly (p < 0.001) reduced MDA levels and an increase GSH levels as compared to EG and AC-treated group. The histological findings further attested antiurolithiatic properties of 6-shogaol. The present study attributed clinical shreds of evidence first time that claiming the significant antiurolithic effect of 6-shogaol and could be a cost-effective candidate for the prevention and treatment of urolithiasis.

Nephroprotective Effect of Pleurotus ostreatus and Agaricus bisporus Extracts and Carvedilol on Ethylene Glycol-Induced Urolithiasis: Roles of NF-κB, p53, Bcl-2, Bax and Bak

This study was designed to assess the nephroprotective effects of Pleurotus ostreatus and Agaricus bisporus aqueous extracts and carvedilol on hyperoxaluria-induced urolithiasis and to scrutinize the possible roles of NF-κB, p53, Bcl-2, Bax and Bak. Phytochemical screening and GC-MS analysis of mushrooms’ aqueous extracts were also performed and revealed the presence of multiple antioxidant and anti-inflammatory components. Hyperoxaluria was induced in Wistar rats through the addition of 0.75% (v/v) ethylene glycol in drinking water for nine weeks. The ethylene glycol-administered rats were orally treated with Pleurotus ostreatus and Agaricus bisporus aqueous extracts (100 mg/kg) and carvedilol (30 mg/kg) daily during the last seven weeks. The study showed that Pleurotus ostreatus, Agaricus bisporus and carvedilol all successfully inhibited ethylene glycol-induced histological perturbations and the elevation of serum creatinine, serum urea, serum and urinary uric acid, serum, urinary and kidney oxalate, urine specific gravity, kidney calcium, kidney NF-κB, NF-κB p65, NF-κB p50, p53, Bax and Bak expressions as well as serum TNF-α and IL-1β levels. Moreover, the treatment decreased the reduction in urinary creatinine, urinary urea, ratios of urinary creatinine to serum creatinine and urinary urea to serum urea, Fex Urea and Bcl-2 expression in kidney. In conclusion, although Pleurotus ostreatus and Agaricus bisporus extracts and carvedilol all significantly inhibited the progression of nephrolithiasis and showed nephroprotective effects against ethylene glycol-induced kidney dysfunction, Pleurotus ostreatus and Agaricus bisporus seemed to be more effective than carvedilol. Moreover, the nephroprotective effects may be mediated via affecting NF-κB activation, extrinsic apoptosis and intrinsic apoptosis pathways.

Effect of low-energy shock wave therapy on intravesical epirubicin delivery in a rat model of bladder cancer

OBJECTIVES

To study the efficacy of low-energy shock wave therapy (LESW) on enhancing intravesical epirubicin (EPI) delivery in a rat model of bladder cancer (BCa).

MATERIALS AND METHODS

A total of 100 female Fischer rats were randomly allocated into five groups: control; BCa; LESW; EPI; and EPI plus LESW. After BCa induction by N-butyl-N-(4-hydroxybutyl)nitrosamine, EPI (0.6 mg/0.3 mL of EPI diluted in 0.3 mL saline) or saline (0.6 mL) was administered and retained in the bladders for 1 h with or without LESW treatment (300 pulses at 0.12 mJ/mm² ). This was repeated weekly for 6 weeks. Survival was then calculated, rats were weighed and their bladders were harvested for bladder/body ratio estimation, histopathological examination, p₅₃ immunostaining, miR-210, hypoxia-inducible factor (HIF)-1α, tumour necrosis factor (TNF)-α and interleukin (IL)-6 relative gene expression and fluorescence spectrophotometric drug quantification. Heart and blood samples were also collected for assessment of the safety profile and toxicity.

RESULTS

The EPI plus LESW group had significantly lower mortality rates, loss of body weight and bladder/body ratio. Histopathological results in terms of grossly visible bladder lesions, mucosal thickness, dysplasia formation and tumour invasion were significantly better in the combined treatment group. The EPI plus LESW group also had statistically significant lower expression levels of p₅₃ , miR-210, HIF-1α, TNF-α and IL-6. LESW increased urothelial concentration of EPI by 5.7-fold (P < 0.001). No laboratory variable exceeded the reference ranges in any of the groups. There was an improvement of the indicators of EPI-induced cardiomyopathy in terms of congestion, hyalinization and microvesicular steatosis of cardiomyocytes (P = 0.068, 0.003 and 0.046, respectively) in the EPI plus LESW group.

CONCLUSIONS

The combined use of intravesical EPI and LESW results in less BCa invasion and less dysplasia formation, as LESW increases urothelial permeability of EPI and enhances its delivery into tumour tissues, without subsequent toxicity.

Association Between Serum Magnesium and the Prevalence of Kidney Stones: a Cross-sectional Study

Kidney stones, a painful and costly disease, have become a public health problem worldwide. The aim of this study was to evaluate the association between serum magnesium levels and the prevalence of kidney stones in a large population context. This study was conducted in Xiangya Hospital, Central South University in Changsha, Hunan, China, between October 2013 and December 2015. A total of 6228 subjects aged ≥ 18 years old were included. Kidney stones were diagnosed by (1) direct visualisation of stone(s) on the abdominal ultrasound examination, and (2) presence of stone(s) with a diameter ≥ 4 mm. The chemiluminescence method was used to measure the serum magnesium concentration. The association between serum magnesium and the prevalence of kidney stones was evaluated using logistic and spline regression in a cross-sectional study. The prevalence of kidney stones was 6.1% (7.5% in men and 4.2% in women). Compared with the lowest quartile, the crude odds ratio for kidney stones was 0.62 (95% CI 0.46-0.85) for the highest quartile of serum magnesium, and there was an inverse dose-response relationship (P for trend = 0.038). Similar results were observed for men and women separately. The findings were not materially altered by adjustment for potential confounders. In conclusion, subjects with relatively lower levels of serum magnesium, even though within the normal range, were subject to a higher prevalence of kidney stones in a dose-response relationship manner, indicating that magnesium may play a certain role in the prevention or treatment of kidney stones.

Endoscopic observations as a tool to define underlying pathology in kidney stone formers

PURPOSE

Advancements in endoscopy offer the possibility of inspection of intrarenal anatomy and pathology. The aim of the study was to evaluate renal papillary appearance in kidney stone formers and to correlate papillary findings with stone type and patient metabolic data.

MATERIALS AND METHODS

A consecutive cohort of 46 kidney stone formers undergoing retrograde intrarenal surgery was enrolled. During surgery, renal papillae were characterized in the domains of ductal Plugging (DP), surface Pitting, Loss of papillary contour, and Amount of Randall's plaque (RP, PPLA scoring). Stone material was analyzed using micro-CT and infrared spectroscopy, and blood and urine were collected for metabolic evaluation.

RESULTS

In all patients, renal papillae had changes in at least one of the domains of the PPLA score. Examining the total population, it was evident that patients with predominantly plugging (DP > 0) all had very low RP scores. There were no significant trends between mean PPLA scores and urinary analytes for the total group.

CONCLUSION

Efforts to prevent renal stone formation have so far been insufficient in majority of patients. Digital endoscopy reveals that kidney stone formers have different and distinct papillary morphologies that seem to be linked to specific stone-forming pathways. Since renal papillary abnormalities may be easily identified during endoscopy, this may in the future prove to be an important method for tailoring prevention strategies in kidney stone patients.

Urolithiasis in immigrant groups: a nationwide cohort study in Sweden

Objective: To study the association between country of birth and incident urolithiasis in immigrant groups in Sweden, using individuals born in Sweden (or with Swedish-born parents in the second-generation study) as referents. Methods: This nationwide follow-up study included first- and second-generation immigrants residing in Sweden between 1 January 1998 and 31 December 2012. Urolithiasis was defined as having at least one registered diagnosis of urolithiasis in the National Patient Register. Cox regression analysis was used to estimate the risk (hazard ratios (HR) with 95% confidence intervals (CI)) of incident urolithiasis. The models were stratified by sex and adjusted for age, sociodemographic status and co-morbidity. Results: Compared to referents, slightly higher incidence rates and HRs of urolithiasis (HR; 95% CI) were observed among first-generation men (1.06; 1.04-1.09) and women (1.12; 1.08-1.16) but not among second-generation immigrants (persons born in Sweden with foreign-born parents). Among first-generation immigrants, higher HRs were noted among men and women from Central and Eastern Europe, Russia, Latin America, Africa and Asia. Lower HRs were seen among men and women from the Nordic countries, most Western European countries and North America. Among second-generation immigrants, higher HRs were noted among men and women from Denmark, Germany and Hungary, in men from Austria, and in women from the Netherlands and Poland. Lower HRs were seen in second generation immigrants from Latin America, Africa and Asia (men and women). Conclusions: We observed substantial differences in incidence of urolithiasis between certain immigrant groups and the Swedish-born population, of importance in the clinical situation.

A review of dexketoprofen trometamol in acute pain

OBJECTIVE

Dexketoprofen trometamol is a modified non-selective COX inhibitor with a rapid onset of action that is available as both oral and parenteral formulations. The aim of this narrative review was to assess the efficacy and tolerability/safety of dexketoprofen trometamol in acute pain states using the best available published scientific evidence (randomized controlled clinical trials and systematic reviews/meta-analyses).

METHODS

Literature retrieval was performed via Medline, Embase and the Cochrane Library (from inception up to March 2017) using combinations of the terms "randomized controlled trials", "dexketoprofen", "celecoxib", "etoricoxib", "parecoxib" and "acute pain".

RESULTS

Single-dose dexketoprofen trometamol provides effective analgesia in the treatment of acute pain, such as postoperative pain (dental and non-dental surgery), renal colic, acute musculoskeletal disorders and dysmenorrhea, and reduces opioid consumption in the postoperative setting. It has a rapid onset of action (within 30 minutes) and is well tolerated during short-term treatment. Direct comparisons with COX-2 inhibitors are lacking; however, the efficacy and tolerability of single-dose dexketoprofen trometamol appears to be consistent with that seen with celecoxib, etoricoxib and parecoxib in the acute pain setting.

CONCLUSION

In conclusion, dexketoprofen trometamol appears to provide similar analgesic efficacy to COX-2 inhibitors when used to treat acute pain, has a rapid onset of action, is well tolerated, and has an opioid-sparing effect when used as part of a multimodal regimen in the acute pain setting.

Phosphaturia in kidney stone formers: Still an enigma

Calcium kidney stones are common worldwide. Most are idiopathic and composed of calcium oxalate. Calcium phosphate is present in around 80% and may initiate stone formation. Stone production is multifactorial with a polygenic genetic contribution. Phosphaturia is found frequently among stone formers but until recently received scant attention. This review examines possible mechanisms for the phosphaturia and its relevance to stone formation from a wide angle. There is a striking lack of clinical data. Phosphaturia is associated, but not correlated, with hypercalciuria, increased 1,25 dihydroxy-vitamin D [1,25 (OH)₂D], and sometimes evidence of disturbances in proximal renal tubular function. Phosphate reabsorption in the proximal renal tubules requires tightly regulated interaction of many proteins. Paracellular flow through intercellular tight junctions is the major route of phosphate absorption from the intestine and can be reduced therapeutically in hyperphosphatemic patients. In monogenic defects stones develop when phosphaturia is associated with hypercalciuria, generally explained by increased 1,25 (OH)₂D production in response to hypophosphatemia. Calcification does not occur in disorders with increased FGF23 when phosphaturia occurs in isolation and 1,25 (OH)₂D is suppressed. Candidate gene studies have identified mutations in the phosphate transporters, but in few individuals. One genome-wide study identified a polymorphism of the phosphate transporter gene SLC34A4 associated with stones. Others did not find mutations obviously linked to phosphate reabsorption. Future genetic studies should have a wide trawl and should focus initially on groups of patients with clearly defined phenotypes. The global data should be pooled.

Inhibitory effects of taraxasterol and aqueous extract of Taraxacum officinale on calcium oxalate crystallization: in vitro study

Objective: We investigated and compared the effects of taraxasterol, aqueous extract of T. officinale (AET) aerial part, and potassium citrate (PC) on calcium oxalate (CaOx) crystallization in vitro.

Materials and methods: CaOx crystallization was induced by adding sodium oxalate to synthetic urine. Taraxasterol (2.5, 5, 7.5 and 12.5 μg/mL), extract (1, 2, 4 and 8 mg/mL), and PC (100, 150, 200 and 350 mg/mL) were subjected to anti-crystallization activities. The absorbance and %inhibition of nucleation of CaOx crystals were evaluated by spectrophotometer at 2, 4, 6, 8, 10, 20, 30, 40, 50 and 60 min and the number and morphology of crystals were studied by light microscopy after 60 min.

Results: Presence of taraxasterol, extract and PC decreased absorbance in experimental samples compared to control, significantly. The nucleation of crystals is inhibited by taraxasterol, extract, and PC (26–64, 55–63 and 60–70%, respectively). The number of CaOx crystals were decreased in presence of taraxasterol (p < .01), extract (p < .001), and PC (p < .001) in a dose-dependent manner. Presence of taraxasterol, extract, and PC decreased the number of CaC₂O₄ monohydrate, while increased CaC₂O₄ dihydrate crystals, significantly. Also, the diameter of CaC₂O₄ dihydrate crystals was decreased in presence of taraxasterol, extract and PC, significantly.

Conclusions: This research indicated that taraxasterol and extract have anti-crystallization activities and effectiveness of the extract is more potent than taraxasterol. It could be because of another constituent in the extract with the synergistic effect.

Familial risks in and between stone diseases: sialolithiasis, urolithiasis and cholelithiasis in the population of Sweden

BACKGROUND

According to the literature the three stone diseases, sialolithiasis (SL), urolithiasis (UL) and cholelithiasis (CL) share comorbidities. We assess familial and spouse risks between these stone disease and compare them to familial risks for concordant (same) stone disease.

METHODS

Study population including familiar relationships was obtained from the Swedish Multigeneration Register and stone disease patients were identified from nation-wide medical records. Standardized incidence ratios (SIRs) were calculated for 0-83 year old offspring when their first-degree relatives were diagnosed with stone disease and the rates were compared to individuals without a family history of stone disease. Numbers of offspring with SL were 7906, for UL they were 170,757 and for CL they were 204,369.

RESULTS

SIRs for concordant familial risks were 2.06 for SL, 1.94 for UL and 1.82 for CL. SIRs for SL and UL were slightly higher for women than for men. Familial risks between stone diseases were modest. The highest risk of 1.17 was for UL when family members were diagnosed with CL, or vice versa. The SIR for UL was 1.15 when family members were diagnosed with SL. Familial risks among spouses were increased only for UL-CL pairs (1.10).

CONCLUSIONS

Familial risks for concordant SL were 2.06 and marginally lower for the other diseases. Familial risks between stone diseases were low but higher than risks between spouses. The data show that familial clustering is unique to each individual stone disease which would imply distinct disease mechanisms. The results cast doubt on the reported comorbidities between these diseases.

The usefulness of agent emission imaging - high mechanical index ultrasound mode in the diagnosis of urolithiasis: a prospective preliminary study

PURPOSE

We aimed to determine the feasibility and effectiveness of agent emission imaging - high mechanical index (AEI-High MI) mode ultrasonography (US) compared with gray-scale and color Doppler US, alone or in combination, for the diagnosis of urolithiasis with reference to unenhanced computed tomography (CT).

METHODS

This prospective study included 72 consecutive patients (40 males, 32 females; mean age, 45.9±14.7 years) referred by the department of urology for acute or elective symptoms of urolithiasis and confirmed to have urinary calculi on unenhanced abdominal CT, between January 2015 and June 2015. Gray-scale, color Doppler, and AEI-High MI US were performed by two radiologists to determine the effectiveness of these methods in the diagnosis of urinary stones and to compare them with the reference modality.

RESULTS

A total of 189 calculi were detected on CT examination. Gray-scale US had a sensitivity of 66.1% and positive predictive value (PPV) of 88.7% for detecting calculi, while twinkling artifact of color Doppler had a sensitivity of 70.4% and PPV of 94.3%. The scintillation artifact of AEI-High MI mode had a sensitivity of 75.1% and PPV of 95.9%. When all ultrasound-based modalities were combined, the sensitivity and PPV rose to 83.1% and 88.2%, respectively. When calculi were grouped according to their size ( < 5 mm, 5-10 mm, > 10 mm), AEI-High MI mode had a higher sensitivity (60%) compared with gray-scale (32.5%) and color Doppler (41.3%) for calculi < 5 mm.

CONCLUSION

AEI-High MI mode had a higher sensitivity compared with gray-scale and color Doppler for the detection of calculi smaller than 5 mm, but it did not make a significant contribution to detection of larger calculi. The combined use of gray-scale US with AEI-High MI mode could increase the detection rate of calculi smaller than 5 mm and provide a method for verification of suspected calculi on gray-scale US.

Alpha-blockers as medical expulsive therapy for ureteral stones

BACKGROUND

Ureteral colic is a common reason for patients to seek medical care. Alpha-blockers are commonly used to improve stone passage through so-called medical expulsive therapy (MET), but their effectiveness remains controversial. This is an update of a 2014 Cochrane review; since that time, several large randomised controlled trials (RCTs) have been reported, making this update relevant.

OBJECTIVES

To assess effects of alpha-blockers compared with standard therapy for ureteral stones 1 cm or smaller confirmed by imaging in adult patients presenting with symptoms of ureteral stone disease.

SEARCH METHODS

On 18 November 2017, we searched CENTRAL, MEDLINE Ovid, and Embase. We also searched ClinicalTrials.gov and the WHO Portal/ICTRP to identify all published/unpublished and ongoing trials. We checked all references of included and review articles and conference proceedings for articles relevant to this review. We sent letters to investigators to request information about unpublished or incomplete studies.

SELECTION CRITERIA

We included RCTs of ureteral stone passage in adult patients that compared alpha-blockers versus standard therapy.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for inclusion and extracted data using standard methodological procedures. We performed meta-analysis using a random-effects model. Primary outcomes were stone clearance and major adverse events; secondary outcomes were stone expulsion time, number of pain episodes, use of diclofenac, hospitalisation, and surgical intervention. We assessed the quality of evidence on a per-outcome basis using the GRADE approach.

MAIN RESULTS

We included 67 studies with 10,509 participants overall. Of these, 15 studies with 5787 participants used a placebo.Stone clearance: Based on the overall analysis, treatment with an alpha-blocker may result in a large increase in stone clearance (risk ratio (RR) 1.45, 95% confidence interval (CI) 1.36 to 1.55; low-quality evidence). A subset of higher-quality, placebo-controlled trials suggest that the likely effect is probably smaller (RR 1.16, 95% CI 1.07 to 1.25; moderate-quality evidence), corresponding to 116 more (95% CI 51 more to 182 more) stone clearances per 1000 participants.Major adverse events: Based on the overall analysis, treatment with an alpha-blocker may have little effect on major adverse events (RR 1.25, 95% CI 0.80 to 1.96; low-quality evidence). A subset of higher-quality, placebo-controlled trials suggest that alpha-blockers likely increase the risk of major adverse events slightly (RR 2.09, 95% CI 1.13 to 3.86), corresponding to 29 more (95% CI 3 more to 75 more) major adverse events per 1000 participants.Patients treated with alpha-blockers may experience shorter stone expulsion times (mean difference (MD) -3.40 days, 95% CI -4.17 to -2.63; low-quality evidence), may use less diclofenac (MD -82.41, 95% CI -122.51 to -42.31; low-quality evidence), and likely require fewer hospitalisations (RR 0.51, 95% CI 0.34 to 0.77; moderate-quality evidence), corresponding to 69 fewer hospitalisations (95% CI 93 fewer to 32 fewer) per 1000 participants. Meanwhile, the need for surgical intervention appears similar (RR 0.74, 95% CI 0.53 to 1.02; low-quality evidence), corresponding to 28 fewer surgical interventions (95% CI 51 fewer to 2 more) per 1000 participants.A predefined subgroup analysis (test for subgroup differences; P = 0.002) suggests that effects of alpha-blockers may vary with stone size, with RR of 1.06 (95% CI 0.98 to 1.15; P = 0.16; I² = 62%) for stones 5 mm or smaller versus 1.45 (95% CI 1.22 to 1.72; P < 0.0001; I² = 59%) for stones larger than 5 mm. We found no evidence suggesting possible subgroup effects based on stone location or alpha-blocker type.

AUTHORS' CONCLUSIONS

For patients with ureteral stones, alpha-blockers likely increase stone clearance but probably also slightly increase the risk of major adverse events. Subgroup analyses suggest that alpha-blockers may be less effective for smaller (5 mm or smaller) than for larger stones (greater than 5 mm).

Anti-Transforming Growth Factor β IgG Elicits a Dual Effect on Calcium Oxalate Crystallization and Progressive Nephrocalcinosis-Related Chronic Kidney Disease

Crystallopathies are a heterogeneous group of diseases caused by intrinsic or environmental microparticles or crystals, promoting tissue inflammation and scarring. Certain proteins interfere with crystal formation and growth, e.g., with intrarenal calcium oxalate (CaOx) crystal formation, a common cause of kidney stone disease or nephrocalcinosis-related chronic kidney disease (CKD). We hypothesized that immunoglobulins can modulate CaOx microcrystal formation and crystal growth and that therefore, biological IgG-based drugs designed to specifically target disease modifying proteins would elicit a dual effect on the outcome of CaOx-related crystallopathies. Indeed, both the anti-transforming growth factor (TGF)β IgG and control IgG1 antibody impaired CaOx crystallization in vitro, and decreased intrarenal CaOx crystal deposition and subsequent CKD in mice on an oxalate-rich diet compared to oxalate-fed control mice. However, the TGFβ-specific IgG antibody showed nephroprotective effects beyond those of control IgG1 and substantially reduced interstitial fibrosis as indicated by magnetic resonance imaging, silver and α-smooth muscle actin staining, RT-qPCR, and flow cytometry for pro-fibrotic macrophages. Suppressing interstitial fibrosis slowed the decline of glomerular filtration rate (GFR) compared to treatment with control IgG1 [slope of m = −8.9 vs. m = −14.5 μl/min/100 g body weight (BW)/day, Δ = 38.3%], an increased GFR at the end of the study (120.4 vs. 42.6 μl/min/100 g BW, Δ = 64.6%), and prolonged end stage renal disease (ESRD)-free renal survival by 10 days (Δ = 38.5%). Delayed onset of anti-TGFβ IgG from day 7 was no longer effective. Our results suggest that biological drugs can elicit dual therapeutic effects on intrinsic crystallopathies, such as anti-TGFβ IgG antibody treatment inhibits CaOx crystallization as well as interstitial fibrosis in nephrocalcinosis-related CKD.

Dietary Plants for the Prevention and Management of Kidney Stones: Preclinical and Clinical Evidence and Molecular Mechanisms

Kidney stones are one of the oldest known and common diseases in the urinary tract system. Various human studies have suggested that diets with a higher intake of vegetables and fruits play a role in the prevention of kidney stones. In this review, we have provided an overview of these dietary plants, their main chemical constituents, and their possible mechanisms of action. Camellia sinensis (green tea), Rubus idaeus (raspberry), Rubia cordifolia (common madder), Petroselinum crispum (parsley), Punica granatum (pomegranate), Pistacia lentiscus (mastic), Solanum xanthocarpum (yellow-fruit nightshade), Urtica dioica (stinging nettle), Dolichos biflorus (horse gram), Ammi visnaga (khella), Nigella sativa (black-cumin), Hibiscus sabdariffa (roselle), and Origanum vulgare (oregano) have received considerable interest based on scientific evidence. Beside these dietary plants, phytochemicals—such as catechin, epicatechin, epigallocatechin-3-gallate, diosmin, rutin, quercetin, hyperoside, and curcumin—as antioxidant dietary phyto-phenols were found to be effective for the prevention of urolithiasis (the process of stone formation in the urinary tract). The main underlying mechanisms of these dietary plants and their isolated phytonutrients in the management of urolithiasis include diuretic, antispasmodic, and antioxidant activity, as well as an inhibitory effect on crystallization, nucleation, and aggregation of crystals. The results as presented in this review demonstrate the promising role of dietary plants and phytophenols in the prevention and management of kidney stones. Further investigations are required to confirm the safety and efficacy of these compounds.

Numerical Response Surfaces of Volume of Ablation and Retropulsion Amplitude by Settings of Ho:YAG Laser Lithotripter

Objectives

Although laser lithotripsy is now the preferred treatment option for urolithiasis due to shorter operation time and a better stone-free rate, the optimal laser settings for URS (ureteroscopic lithotripsy) for less operation time remain unclear. The aim of this study was to look for quantitative responses of calculus ablation and retropulsion by performing operator-independent experiments to determine the best fit versus the pulse energy, pulse width, and the number of pulses.

Methods

A lab-built Ho:YAG laser was used as the laser pulse source, with a pulse energy from 0.2 J up to 3.0 J and a pulse width of 150 μs up to 1000 μs. The retropulsion was monitored using a high-speed camera, and the laser-induced craters were evaluated with a 3-D digital microscope. The best fit to the experimental data is done by a design of experiment software.

Results

The numerical formulas for the response surfaces of ablation speed and retropulsion amplitude are generated.

Conclusions

The longer the pulse, the less the ablation or retropulsion, while the longer pulse makes the ablation decrease faster than the retropulsion. The best quadratic fit of the response surface for the volume of ablation varied nonlinearly with pulse duration and pulse number.

Familial Risks Between Urolithiasis and Cancer

Urolithiasis (UL, urinary tract stone disease) has been reported to increase subsequent cancers in the urinary tract. Recently, we showed data that surveillance bias may be an important confounder in the reported associations. In the present approach we want to address the question of possible cancer risk posed by UL mechanistically. Both UL and cancer have strong genetic components and we hypothesize that familial association between UL and cancer may be plausible. We thus assess familial risks between UL and cancer, hoping to find an explanation why UL may pose a risk of cancer. UL patients were identified from hospital inpatient and outpatient records and they were organized in families based on the Multigeneration Register into which also national cancer data were linked. Standardized incidence ratios were calculated for cancer in the offspring generation when parents were diagnosed with UL, and conversely for UL when parents were diagnosed with cancer. Familial risks between UL and cancer were generally small and inconsistent providing no convincing support of genetic sharing between UL and cancer. However, bladder UL was associated weakly with prostate cancer, and ureter and bladder UL were associated with salivary gland cancer. Potential mechanisms for these findings are proposed.

Familial risks in urolithiasis in the population of Sweden

OBJECTIVE

To assess detailed familial risks for medically diagnosed urolithiasis (UL, urinary tract stone disease) based on nationwide hospital and population records.

PATIENTS/SUBJECTS AND METHODS

Subjects were identified from the Swedish Multigeneration Register in which there were 211 718 patients with UL. Standardised incidence ratios (SIRs) were calculated by comparison to individuals without a family history of UL.

RESULTS

The highest familial SIRs were invariably found for the same (concordant) type of UL: 2.18 for kidney, 2.20 for ureter, and 1.93 for bladder. SIRs increased from 1.84, when one parent was affected, to 3.54 when both parents were affected, which was a multiplicative interaction. The SIR was 1.79 when one sibling was affected but it increased to 24.91 when two siblings were affected. Such excessive risks (5.2% of familial cases) are probably explained by high-penetrant genes. A low SIR of 1.29 between spouses suggested a minor contribution by shared environmental factors on the familial risk.

CONCLUSIONS

The results point to underlying genetic causes for the observed familial clustering and establish the genetic landscape of UL. Family histories should be taken in UL diagnostics and prevention could follow guidelines recommended for recurrent UL.

Treatment of Distal Ureteral Calculi Using Extracorporeal Physical Vibrational Lithecbole Combined with Tamsulosin: A New Option to Speed Up Obstruction Relief

INTRODUCTION

The obstruction of the urinary tract by calculi at the narrowest anatomical areas leads to impaired drainage and severe pain. The aim of this study was to evaluate a new technology, extracorporeal physical vibrational lithecbole (EPVL) combined with tamsulosin, as a treatment for distal ureteral calculi (DUC).

MATERIALS AND METHODS

Between July 2013 and July 2014, 672 patients diagnosed with DUC were randomly divided into three groups; a group receiving EPVL plus 0.4 mg oral tamsulosin daily (PO qd) (experimental group, n = 236), a group receiving 0.4 mg tamsulosin PO qd (n = 222), and a group receiving EPVL only (n = 214) (control groups).

RESULTS

There were no significant differences in general characteristics between the three groups. Stone diameters ranged from 0.32 to 1 cm. In the EPVL plus tamsulosin group, 60.1% of patients showed detectable fragment expulsion at 48 hours, and 91.1% were stone free at 7 days. Compared with the two control groups, these rates were significantly higher (EPVL group was 0% and 50.5% and medical expulsive therapy group was 0% and 50.0%, p < 0.05). The stone-free rates were similar in the three groups 2 weeks later (94.5%, 93.6%, and 93.5%; p > 0.05). Patients in the EPVL plus tamsulosin group achieved similar stone-free rates compared with the other two groups, but the speed of the stone expulsion was quicker for both sexes and all age groups (about a week; p < 0.05).

CONCLUSION

This indicates that EPVL plus tamsulosin could be used as an effective, but faster treatment option for patients with DUC, alleviating the symptoms of DUC in a shorter period of time.

How can and should we optimize extracorporeal shockwave lithotripsy?

It is well recognized that the popularity of extracorporeal shock wave lithotripsy (SWL), despite its non-invasive character, has decreased during recent years. This is partly explained by the technological achievements in endoscopy and urologists’ enthusiasm for such procedures. Another explanation is that many urologists have been insufficiently successful with SWL. The latter effect might to some extent be a result of the performance of the lithotripter used, but in too many cases, it is evident that the principles of how shock wave lithotripsy should be carried out are poorly applied. The purpose of this article is to emphasize some important aspects on how SWL best should be used. Based on decades of experience, it stands to reason that success with SWL does not come automatically and attention has to be paid to all details of this technique.

Improving Drainage After Percutaneous Nephrolithotomy Based on Health-Related Quality of Life: A Prospective Randomized Study

PURPOSE

The impact of drainage type after percutaneous nephrolithotomy (PCNL) on the health-related quality of life (HRQoL) has been rarely studied. We conducted a prospective randomized study to evaluate the differences in HRQoL among patients who received different drainage types.

METHODS

A total of 90 patients who underwent PCNL were randomized into three groups to receive a nephrostomy tube (Group 1), a Double-J (JJ) stent (Group 2), and an open-ended ureteral catheter (Group 3) after PCNL, respectively. We compared the perioperative characteristics, surgical outcomes, and HRQoL using Wisconsin Stone Quality of Life (WiSQoL) questionnaire among three groups.

RESULTS

There were no significant differences in patients' characteristics such as age, gender ratio, body mass index, stone burden, and so on. Majority of the surgical outcomes (operative time, estimated blood loss, hemoglobin drop, postoperative complications, and stone-free rate) were also comparable, except for the duration of hospitalization, visual analog scale, and analgesic required. The preoperative WiSQoL scores were similar among the three groups, but significant differences occurred postoperation (Groups 1, 2, and 3, 122.0 vs 105.6 vs 124.4, p < 0.001). Besides, patients in Group 2 had lower willingness (Groups 1, 2, and 3, 86.7% vs 70.0% vs 96.7%, p = 0.02) to undergo the same procedure as future treatment, if needed.

CONCLUSIONS

Our study suggested that the drainage types after PCNL using a nephrostomy tube or a JJ stent or an open-ended ureteral catheter were equally safe and efficacious, but patients who received a nephrostomy tube or an open-ended ureteral catheter had better HRQoL.

Surveillance Bias in Cancer Risk After Unrelated Medical Conditions: Example Urolithiasis

We analysed cancer risks in patients with urinary tract stones but some features of the generated results alarmed us about possible surveillance bias, which we describe in this report. We used nationwide Swedish hospital records to identify patients with urinary tract stones (N = 211,718) and cancer registration data for cancer patients for years 1987 to 2012. Standardized incidence ratios (SIRs) for cancer were calculated after the last medical contact for urinary tract stones. All cancers were increased after kidney (SIR 1.54, 95%CI: 1.50–1.58), ureter (1.44, 1.42–1.47), mixed (1.51, 1.44–1.58) and bladder stones (1.63, 1.57–1.70). The risk of kidney cancer was increased most of all cancers after kidney, ureter and mixed stones while bladder cancer was increased most after bladder stones. All SIRs decreased steeply in the course of follow-up time. Tumour sizes were smaller in kidney cancer and in situ colon cancers were more common in patients diagnosed after urinary tract stones compared to all patients. The results suggest that surveillance bias influenced the result which somewhat surprisingly appeared to extend past 10 years of follow-up and include cancers at distant anatomical sites. Surveillance bias may be difficult to avoid in the present type of observational studies in clinical settings.

Shockwave lithotripsy: techniques for improving outcomes

OBJECTIVES

Shock wave lithotripsy (SWL) remains the only effective truly non-invasive treatment for nephrolithiasis. While single-treatment success rates may not equal those of ureteroscopy and percutaneous nephrolithotomy, it has an important role to play in the management of stones. In this paper, we outline the latest evidence-based recommendations for maximizing SWL outcomes, while minimizing complications.

MATERIALS AND METHODS

A comprehensive review of the current literature was performed regarding maximizing SWL outcomes.

RESULTS

Several different considerations need to be made regarding patient selection with respect to body habitus, body mass index, anatomical location and underlying urologic abnormalities. Stone composition and stone density (Hounsfield Units) are important prognostic variables. Patient positioning is critical to allow for adequate stone localization with either fluoroscopy or ultrasound. Coupling should be optimized with a low viscosity gel applied to the therapy head first and patient movement should be limited. SWL energy should be increased slowly and shockwave rates of 60 or 90 Hz should be used. Medical expulsive therapy with alpha-blockers after SWL treatment has shown benefit, particularly with stones greater than 10 mm.

CONCLUSION

While single-treatment success rates may not equal those of ureteroscopy or percutaneous nephrolithotomy, with proper patient selection, optimization of SWL technique, and use of adjunctive treatment after SWL, success rates can be maximized while further reducing the already low rate of serious complications. SWL remains an excellent treatment option for calculi even in 2017.