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Stone disease evaluation in Pathology laboratory: Current prospective.

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Sanjeev Mehta
Sanjeev Mehta

This document discusses metabolic evaluation and stone analysis for kidney stones. It explains that stone analysis identifies the stone composition and underlying causes, which helps determine the appropriate treatment plan. A variety of tests are used, including blood and urine tests, 24-hour urine collection to measure supersaturation levels, and analyzing the stone composition. Integrating the results of these analyses can identify metabolic abnormalities and other factors in 90-95% of cases, guiding personalized medical management and prevention of future stone recurrences.

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Metabolic and Renal Stone Analysis : Current prospective DDrr.. SSaannjjeeeevv MMeehhttaa MMDD Uro Lab. 1
Stone disease evaluation in Laboratory Series of tests to identify underlying causes. 1.Identify treatable metabolic abnormality 2.Identify underlying medical disease that predisposes to stone formation. 3.Outline a treatment plan ; focal Uro Lab. 2
Why Do Kidney Stones Form? Reasons: Gnetic/dietary/Environmental Urine is supersaturated 2009: Supersaturation can be fix Therefore, our job is to figure out what is causing the urinary Supersaturation and How best to fix it! Uro Lab. 3
Stone Formation : Supersaturation k Uro Lab. 4
Actually up to 65 different chemical compounds are found in urinary calculi. Uro Lab. 5
Metabolic evaluation Blood and Urinary Tests ; routine Stone Analysis 24 hrs Urinary Metabolic Profile with SUPERSATURTION. New advances in Stone analysis, Blood and Urinary Chemical analysis can find out 90-95% cause.* * Preminger G.M., Guidelines for medical management of urolithiasis, bussin. meet us kid and urol dis,2005 Uro Lab. 6
Evaluation : First time stone with low risk Blood screen; Low K and HCO3, High Chloride - RTA High Uric acid - gouty diathesis High Calcium - Pri. Hyperparathyroidism Low Phosphorus Renal phosphate leak. Stone analysis ; all cases Uro Lab. 7
Evaluation: First time stone Urine Urinalysis : Routine pH > 7.5 - infection lithiasis pH < 5.5 - Uric acid lithiasis Sediments for crystalluria Urine culture : Urea-splitting organisms infection lithiasis. Screening / quantitative Cystine Uro Lab. 8
24 hrs Urine metabolic profile ; Extensive Uro Lab. 9
24 hrs extensive Metabolic evaluation: indications Stone recurrence Motivated patients wants to investigate. Select one-time formers: - Solitary Kidney - Renal insufficiency. - Residual stone burden. All children Uro Lab. 10
Extensive Metabolic Evaluation 24 hrs Urine collections. Stone risk factors : Volume Calcium , Calcium to creatinine index. Oxalate . ?Primary hyperoxaluria Citrate Uric acid. Uro Lab. 11
Extensive Metabolic Evaluation Dietary risk factors: Sodium, Potassium Magnesium Urinary analytes : phosporus, sulfate, Urea Marker for accuracy : Creatinine. Repeat 24 hrs Urine collection 4-6 weeks post intervantion. Uro Lab. 12
24 hrs Urine metabolic profile graph Uro Lab. 13
Follow-up in same patient Uro Lab. 14
Stone analysis Uro Lab. 15
Renal Calculus Analysis Essential step in the examination and initial treatment of Urolithiasis. Composition yields fundamental information of pathogenesis of disease like ; - Metabolic abnormality. - Presence of infection. - Possible artifacts. - Drug metabolism. Uro Lab. 16
Integrated analysis: Techniques Optical Crystallogrphy Chemical Microscopy. Polarizing Microscopy. Infrared spectroscopy. X-ray diffraction. Electron Microscopy Fluorescence and chromatography. Final , semi quantitative, modified estimate from above results. * herringlab.com Uro Lab. 17
Significance of Stone analysis Exact composition gives important clue as to how Stone formed. Information may not available from any other type of work-up. Identify factors leading to clinical events. Identify Risk factors. Uro Lab. 18
Significance of Stone analysis Three categories : 1.Composition and hardness of Renal Stones. 2.Composition and its predictive value. 3.Composition and related metabolic abnormalities. Uro Lab. 19
Hardness Factor of Stone Calcium Oxalate Dihydrate 1.0 Calcium Oxalate Monohydrate 1.3 Hydroxy-peptite 1.1 Brushite 2.2 Uric Acid/ Urate 1.0 Cystine 2.4 Carbonate Apatite 1.3 Struvite 1.0 Mixed Stone 1.0 * Ringden I, Scand J Urol Nephrol.2007;41(4):316-23 Uro Lab. 20
Clinical Significance: Hardness pattern in Stone. Useful in describing consistency in individual. Formulation of treatment strategies. - Number of re-treatments. - Number of Shock waves. Energy index (KV x number of shock waves). PMID:17763224( PubMed-indexed for MEDLINE) Uro Lab. 21
Calcium stone. Pure Calcium oxalate: More Acid urine, Low urine volume, high oxalate excretion. Mixed Stone formers ; High Calcium, pH and Stone formation rate. High Calcium excretion. * Schroeppel j Smith et all ; J Am Soc Nephrol 1997;8:568A Uro Lab. 22
Calcium.. Calcium Oxalate Monohydrate : Hypomagnesuria, acid urine, low volume More hard then dihydrate. Calcium Oxalate Dihydrate : - hypercalciuria. High Urine pH and hypocitraturia. Uro Lab. 23
Calcium Stone with Carbonate apatite : may indicate Renal Tubular Acidosis (RTA). - Increases with amount of apatite. ( 5 39%). Brushite Stones : Consider Renal tubular Acidosis (RTA). Uro Lab. 24
Struvite Stones Mixed Stone, infection. Mostly Proteus Ammonium Urate Elders : associated with infection. Children : May also form as result of hyperuricosuria, but NO urinary tract infection. Rare in pure form (0.03%) Uro Lab. 25
Uric Acid Hyperuricemia, hyperuricosuria. Low Urine Ph. < 6.2 Causes: - Gout. - Myeloproliferative processes associated with pathological increased purine metabolism. - Chemotherapy and Radiotherapy. Uro Lab. 26
Rare Cystine : Cysteinuria. Acidic Autosomal recessive disorder. Xenthene: Xanthinuria. Absence of Xanthinooxidase. Genetic autosomal hereditary recessive enzyme disorder. Uro Lab. 27
Conclusion. Combined with Optical Crystallography, appropriate Blood & 24 Urine metabolic work-up with super-saturation, it can find out the cause of stone formation in nearly all cases Supersaturation Index is GOLD Standard to know exactly patho-physiological basis of Stone formation to guide proper treatment. Uro Lab. 28
Thank You ! Uro Lab. 29

More Related Content

Stone disease evaluation in Pathology laboratory: Current prospective.

  • 1. Metabolic and Renal Stone Analysis : Current prospective DDrr.. SSaannjjeeeevv MMeehhttaa MMDD Uro Lab. 1
  • 2. Stone disease evaluation in Laboratory Series of tests to identify underlying causes. 1.Identify treatable metabolic abnormality 2.Identify underlying medical disease that predisposes to stone formation. 3.Outline a treatment plan ; focal Uro Lab. 2
  • 3. Why Do Kidney Stones Form? Reasons: Gnetic/dietary/Environmental Urine is supersaturated 2009: Supersaturation can be fix Therefore, our job is to figure out what is causing the urinary Supersaturation and How best to fix it! Uro Lab. 3
  • 4. Stone Formation : Supersaturation k Uro Lab. 4
  • 5. Actually up to 65 different chemical compounds are found in urinary calculi. Uro Lab. 5
  • 6. Metabolic evaluation Blood and Urinary Tests ; routine Stone Analysis 24 hrs Urinary Metabolic Profile with SUPERSATURTION. New advances in Stone analysis, Blood and Urinary Chemical analysis can find out 90-95% cause.* * Preminger G.M., Guidelines for medical management of urolithiasis, bussin. meet us kid and urol dis,2005 Uro Lab. 6
  • 7. Evaluation : First time stone with low risk Blood screen; Low K and HCO3, High Chloride - RTA High Uric acid - gouty diathesis High Calcium - Pri. Hyperparathyroidism Low Phosphorus Renal phosphate leak. Stone analysis ; all cases Uro Lab. 7
  • 8. Evaluation: First time stone Urine Urinalysis : Routine pH > 7.5 - infection lithiasis pH < 5.5 - Uric acid lithiasis Sediments for crystalluria Urine culture : Urea-splitting organisms infection lithiasis. Screening / quantitative Cystine Uro Lab. 8
  • 9. 24 hrs Urine metabolic profile ; Extensive Uro Lab. 9
  • 10. 24 hrs extensive Metabolic evaluation: indications Stone recurrence Motivated patients wants to investigate. Select one-time formers: - Solitary Kidney - Renal insufficiency. - Residual stone burden. All children Uro Lab. 10
  • 11. Extensive Metabolic Evaluation 24 hrs Urine collections. Stone risk factors : Volume Calcium , Calcium to creatinine index. Oxalate . ?Primary hyperoxaluria Citrate Uric acid. Uro Lab. 11
  • 12. Extensive Metabolic Evaluation Dietary risk factors: Sodium, Potassium Magnesium Urinary analytes : phosporus, sulfate, Urea Marker for accuracy : Creatinine. Repeat 24 hrs Urine collection 4-6 weeks post intervantion. Uro Lab. 12
  • 13. 24 hrs Urine metabolic profile graph Uro Lab. 13
  • 14. Follow-up in same patient Uro Lab. 14
  • 16. Renal Calculus Analysis Essential step in the examination and initial treatment of Urolithiasis. Composition yields fundamental information of pathogenesis of disease like ; - Metabolic abnormality. - Presence of infection. - Possible artifacts. - Drug metabolism. Uro Lab. 16
  • 17. Integrated analysis: Techniques Optical Crystallogrphy Chemical Microscopy. Polarizing Microscopy. Infrared spectroscopy. X-ray diffraction. Electron Microscopy Fluorescence and chromatography. Final , semi quantitative, modified estimate from above results. * herringlab.com Uro Lab. 17
  • 18. Significance of Stone analysis Exact composition gives important clue as to how Stone formed. Information may not available from any other type of work-up. Identify factors leading to clinical events. Identify Risk factors. Uro Lab. 18
  • 19. Significance of Stone analysis Three categories : 1.Composition and hardness of Renal Stones. 2.Composition and its predictive value. 3.Composition and related metabolic abnormalities. Uro Lab. 19
  • 20. Hardness Factor of Stone Calcium Oxalate Dihydrate 1.0 Calcium Oxalate Monohydrate 1.3 Hydroxy-peptite 1.1 Brushite 2.2 Uric Acid/ Urate 1.0 Cystine 2.4 Carbonate Apatite 1.3 Struvite 1.0 Mixed Stone 1.0 * Ringden I, Scand J Urol Nephrol.2007;41(4):316-23 Uro Lab. 20
  • 21. Clinical Significance: Hardness pattern in Stone. Useful in describing consistency in individual. Formulation of treatment strategies. - Number of re-treatments. - Number of Shock waves. Energy index (KV x number of shock waves). PMID:17763224( PubMed-indexed for MEDLINE) Uro Lab. 21
  • 22. Calcium stone. Pure Calcium oxalate: More Acid urine, Low urine volume, high oxalate excretion. Mixed Stone formers ; High Calcium, pH and Stone formation rate. High Calcium excretion. * Schroeppel j Smith et all ; J Am Soc Nephrol 1997;8:568A Uro Lab. 22
  • 23. Calcium.. Calcium Oxalate Monohydrate : Hypomagnesuria, acid urine, low volume More hard then dihydrate. Calcium Oxalate Dihydrate : - hypercalciuria. High Urine pH and hypocitraturia. Uro Lab. 23
  • 24. Calcium Stone with Carbonate apatite : may indicate Renal Tubular Acidosis (RTA). - Increases with amount of apatite. ( 5 39%). Brushite Stones : Consider Renal tubular Acidosis (RTA). Uro Lab. 24
  • 25. Struvite Stones Mixed Stone, infection. Mostly Proteus Ammonium Urate Elders : associated with infection. Children : May also form as result of hyperuricosuria, but NO urinary tract infection. Rare in pure form (0.03%) Uro Lab. 25
  • 26. Uric Acid Hyperuricemia, hyperuricosuria. Low Urine Ph. < 6.2 Causes: - Gout. - Myeloproliferative processes associated with pathological increased purine metabolism. - Chemotherapy and Radiotherapy. Uro Lab. 26
  • 27. Rare Cystine : Cysteinuria. Acidic Autosomal recessive disorder. Xenthene: Xanthinuria. Absence of Xanthinooxidase. Genetic autosomal hereditary recessive enzyme disorder. Uro Lab. 27
  • 28. Conclusion. Combined with Optical Crystallography, appropriate Blood & 24 Urine metabolic work-up with super-saturation, it can find out the cause of stone formation in nearly all cases Supersaturation Index is GOLD Standard to know exactly patho-physiological basis of Stone formation to guide proper treatment. Uro Lab. 28
  • 29. Thank You ! Uro Lab. 29