Stones of the Kidney

Stones of the Kidney, Ureter and Bladder

Stones in the urinary tract are common. Often these do not produce symptoms and are detected accidentally. Some of the conditions causing stones are genetic in nature. Recurrence of these stones is common, although difficult to diagnose correctly but if not treated in time may lead to permanent damage to the kidney.

Recurrent stone disease should always be investigated thoroughly to find out the underlying cause.

Investigations Involve

Analysis of the stone if it has been passed spontaneously or removed surgically.

Urine routine examination to look for crystals of oxalates, uric acid, cystine or other salts.

Blood tests are done for levels of calcium, uric acid, oxalate, acid content, phosphorus, magnesium, parathormone levels etc. Kidney function also needs to be evaluated at the time.

X Rays are carried out to know whether the stones are radioopaque (seen on X Rays) or radiolucent (seen only on USG).

Urine tests are done to know specific gravity, acidity, calcium excretion, urate excretion, citrate excretion etc.

For urine tests, 24 hour collection of urine is collected in acidic and alkaline media and then analysed.

In most cases of recurrent stone formations, a cause can be found or excluded and a proper therapy is instituted.

Accurate Blood Pressure Measurement

How to measure Blood Pressure accurately by Automated Electronic Devices

Modern automated BP recording devices are now widely available through Online shopping sites. The following points need to be kept in mind while using these devices for BP recording.

Position of person:

Sitting upright, back supported, feet flat on ground, arm supported on a table horizontally at approximately the middle of the chest.

Time:

For persons on BP medications, the best time for recording is when the next dose of medicine is due.

Don’t measure BP within ½ an hour of smoking, coffee, tea or meals.

Don’t measure BP if the bladder is full, you are anxious, or having a headache or disturbing pain anywhere in the body. The results are likely to be higher.

Cuff size:

Bladder length should be ideally >80% of the circumference of the arm.

Cuff width should be >1/2 of the length of the arm (elbow to shoulder).

Small sized cuff tends to overestimate BP. Large size does not matter too much.

Other pointers:

The person should be sitting quietly for 5 mins before measurement.

Measure 3 or 4 times in case of high readings at an interval of 3-5 mins till last 2 readings are similar. The lowest readings are usually the most accurate!

Nephrotic Syndrome

Kidneys receive approximately 1 liter of blood every minute. Of this, about 100 ml gets filtered in the kidney. This contains, small molecules and few large molecules. This is due to the intricate cellular structure that prevents proteins from getting filtered into the urinary space. A derangement of this filter results in passage of heavy amounts of proteins in urine. This condition is called heavy proteinuria or Nephrotic syndrome or Nephrosis.

Definition:

In the urine, the protein excretion is > 3.5 gm/day or in children, it is >50mg/kg of body weight. In most cases, the serum albumin is <3gm/dl (normal>4), and passage of lipids in the urine. The lipids in the blood increase and swelling of face and feet also occur.

Causes of Nephrotic Syndrome:

In children, most cases are due to Minimal Change Disease, FSGS, MPGN etc. In adults, most cases are due to primary illness while upto 30% may be due to secondary illness.

Clinical Features:

Apart from edema, there is a tendency towards clotting of the blood in blood vessels. If this involves a critical area, like heart, brain or kidneys complications may occur. Infections also are common. In addition, kidney function may be reduced due to either the disease or its treatment. Sometime the blood pressure may be elevated.

In some cases, continuation of excess proteins in the urine may lead to glomerular damage and Chronic kidney disease leading to renal failure.

Diagnosis:

After confirmation of excess protein in the urine, a kidney biopsy is required in most cases. In children between 2 to 8 years, a biopsy may be deferred if there is a good response to steroids as Minimal Change disease is presumed.

Treatment:

The treatment consists of steroids in primary cases and in case of poor response other immunosuppressants and ACE-Inhibitors. Disease often has remissions and relapses which need to be monitored and treated appropriately.

Urinary Tract Infection: Men

UTI in Men

Compared to women, Urinary tract infections in men are uncommon. This is due to the longer length of urethra and dryness of the urethral opening (called meatus). Prostatic secretions have antibacterial properties and hence these may prevent urinary tract infections. Non-circumcision is also a risk factor for UTI. The commonest organism is E coli.

UTI is common if there is an anatomic abnormality, obstruction, instrumentation of the urinary tract or prior surgery. In men after 50 years of age, prostatic enlargement can make a person prone to UTI.

As in the case of women, the infections of the urinary tract may involve urethra, bladder or kidney or a combination of all of them. In addition, the prostate gland can also be infected.

Symptoms :

Symptoms are similar to those in women. However, infections of the prostate can give rise to fever and pain in the perineum (the area between anus and scrotum).

Diagnosis of UTI is by its symptoms, physical examination and laboratory tests. The prostate is tender on digital examination of the rectum.

Urine shows increased pus cells, nitrate test is positive and midstream urine culture shows >105 bacteria /ml of urine. In case of recurrence, if no cause is apparent, tests are done to ascertain anatomical details of the urinary tract.

Treatment is started empirically. In case of no or poor response in 2-3 days, the drugs are modified based on culture results.

Urinary Tract Infections : Women

UTI in short, is a common illness in woman, especially during the reproductive period. The incidence in western countries is .5/woman /year.

It is commoner in women compared to men due to their shorter urethra (Tube from the lower end of the bladder to opening for urine). Bacteria from large intestines contaminate the skin around the anus, migrate to the vaginal opening and may ascend through the urethra to the bladder and sometimes via ureter to the kidneys.

Infections of the bladder are called cystitis, infections of urethra  urethritis and that of kidneys pyelonephritis.

Symptoms of UTI

In cases of urethritis, pain while passing urine (dysuria), more frequency, pus discharge from urine opening may occur.

In cases of cystitis, dysuria, frequency, urgency (inability to hold urine), lower abdominal pain or discomfort and sometimes blood in urine may occur.

In pyelonephritis the symptoms usually are : fever (temp above 38° C ), flank pain or discomfort, tenderness on touching at the angle of lower ribs with muscles( costovertebral angle) in addition to dysuria frequency etc. Nauusea and vomitings are also common. This can be a serious illness with fall of BP, shock and malfunction of other organs in the body.

Risk Factors In Women

Risk factors for UTI in a woman are previous UTI’s, abnormal anatomy, stones or other obstructions, sexual intercourse and use of spermicidal jellies. Women in some countries may not complain due to social taboos.

Diagnosis is based on history and finding of pus cells and bacteria in midstream urine. It can be confirmed by urine culture. Collection of proper midstream sample after proper cleaning and drying of genital areas is important to avoid false results.

Treament consists of short course of antibiotics in uncomplicated cases. Complicated cases may require hospitalisation and injectable antibiotics. Antibiotic selection depends on the usual causative agents in the area. Treatment of repeated UTI is different. In urethritis the organisms are often different and require other chemotherapeutic agents.