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Nephrology


Answer 4
  1. Extracorporeal shock wave lithotripsy to break apart larger stones in the renal pelvis. The patient has a classic presentation for nephrolithiasis. Small stones will pass on their own, but stones larger than 8 mm often require urologic intervention. ESWL is useful for large stones in the renal pelvis or ureter. An abdominal flat plate radiograph demonstrates radiopaque stones, such as calcium oxalate and struvite. It is essential to identify the composition of the stones because therapy will be guided by this information. Patients with recurrent nephrolithiasis should undergo 24-hour urine collection for sodium, calcium, phosphate, oxalate, citrate, and uric acid. Serum electrolytes, calcium, phosphate, uric acid, parathyroid hormone, and serum creatinine also should be measured. Evidence of obstruction on renal imaging warrants urgent urologic consultation for nephrostomy tube placement and stone retrieval. Flank CT would not add any further information because the patient has large stones identified on the abdominal radiograph. Oral hydration alone may help prevent stones but would not permit large stones to be passed without a procedure to reduce their size. Ureteroscopy with retrieval of the bladder stone is not necessary and would only be required if ESWL failed to eliminate the stones in the renal pelvis.

    SUGGESTED READINGS
    1.
     Korbet SM. Percutaneous renal biopsy. Semin Nephrol 2002;22:254-67.

    2. Sutton JM. Evaluation of hematuria in adults. JAMA 1990;263:2475-80.

    3. Topham PS, Harper SJ, Furness PN, et al. Glomerular disease as a cause of isolated microscopic haematuria. Q J Med 1994;87:329-35.

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