344.4 📋 章末速蚘 Summary

344.4.1 🔑 䞀句話瞜結

Nephrolithiasis 党球盛行率䞊升 (~ 12% 男, ~ 6% 女 lifetime), 台灣高癌五倧 stone types(1) calcium oxalate ~ 70-80% (most) + calcium phosphate 5-10%(2) uric acid 5-10% — 酞性 urine + gout + hyperuricosuria(3) struvite 5-10% — magnesium ammonium phosphate + urease-producing bacteria (Proteus, Klebsiella, Pseudomonas, S. aureus) + 鹌性 urine + staghorn calculi(4) cystine 1% — autosomal recessive cystinuria (SLC3A1/SLC7A9)(5) drug-induced (acyclovir, indinavir, sulfonamide, triamterene, topiramate)acute presentation = renal colic (severe flank pain → groin radiation, hematuria, nausea)diagnosis = non-contrast CT gold standard (> 95% sensitive); US for pregnancy/pediatric/follow-upstone passage by size: < 5 mm 80% / 5-10 mm 50% / > 10 mm < 25%acute management: NSAIDs (ketorolac) first-line + opioids backup + hydration + anti-emetics + MET (tamsulosin α-blocker for 5-10 mm ureteral — SUSPEND 2015 mixed evidence)urgent intervention indications: obstruction + infection (urosepsis emergency!) + AKI + solitary functional kidney + severe pain; procedures: ureteroscopy + laser lithotripsy (most < 2 cm) + ESWL (small upper urinary) + PCNL (> 2 cm, staghorn) + ureteral stent (bridging)prevention strategies by stone typecalcium oxalate (thiazide for hypercalciuria + K citrate for hypocitraturia + calcium with meals for hyperoxaluria), uric acid (alkalinize urine pH 6.5-7.0 + allopurinol), struvite (antibiotics + surgical removal), cystine (hydration > 4 L/d + alkalinize pH > 7.5 + tiopronin/penicillamine); emerging: lumasiran (Oxlumo, FDA 2020) + nedosiran for primary hyperoxaluria (siRNA AGXT)。

344.4.2 💊 治療粟芁

  • acute painketorolac IV/IM/PO first-line + opioid backup + hydration + anti-emetics
  • MET (medical expulsive therapy)tamsulosin 0.4 mg daily for 5-10 mm distal ureteral stones (SUSPEND 2015 negative overall, some benefit subgroups)
  • urgent interventionurosepsis + AKI + solitary kidney + severe persistent pain + pregnancy complications
  • calcium oxalate preventionthiazide (hypercalciuria) + potassium citrate (hypocitraturia + alkalinize) + calcium with meals (hyperoxaluria) + maintain adequate dietary calcium (don’t restrict!)
  • uric acid preventionalkalinize urine (potassium citrate to pH 6.5-7.0) + allopurinol + low purine + hydration
  • struvite preventionlong-term antibiotics targeting urease bacteria + surgical removal (PCNL for staghorn) + treat underlying chronic infection
  • cystine preventionheavy hydration > 4 L/d + alkalinize (potassium citrate pH > 7.5) + tiopronin (preferred) or penicillamine + low Na + low protein
  • primary hyperoxaluria type 1lumasiran (Oxlumo, FDA 2020) siRNA against AGXT
  • diet generalhydration > 2.5 L urine + low Na + moderate protein + adequate dietary Ca (binds oxalate in gut, paradoxically reduces stones) + low oxalate + citrus juices

344.4.3 🎯 盧醫垫的考前提醒

  1. stone composition 五倧calcium oxalate (most ~ 70-80%) + calcium phosphate (alkaline urine, RTA-1) + uric acid (acid urine) + struvite (urease bacteria, staghorn) + cystine (autosomal recessive)
  2. non-contrast CT gold standard > 95% sensitive for all stone types; HU helps composition: < 600 (uric acid), 600-1000 (cystine), 1000-1500 (struvite, Ca phosphate), > 1500 (calcium oxalate densest)
  3. stone passage by size: < 5 mm 80%, 5-10 mm 50%, > 10 mm < 25% — guides decision for spontaneous vs intervention
  4. SUSPEND trial (2015): tamsulosin vs placebo for ureteral stones — no overall benefit; some benefit in distal 5-10 mm; still commonly tried
  5. urosepsis with obstruction = emergencyobstruction + infection (positive UA + signs of sepsis) → emergent decompression (stent or nephrostomy) + antibiotics (don’t delay)
  6. calcium oxalate prevention paradoxmaintain adequate dietary calcium (DO NOT restrict) — calcium binds oxalate in gut, reduces oxalate absorption + stone formation
  7. struvite stones = “infection stones”urease-producing bacteria (Proteus mirabilis, Klebsiella, Pseudomonas, S. aureus) → alkaline urine + Mg + NH4 + PO4 crystals; staghorn calculi (filling renal pelvis); need PCNL + long-term antibiotics
  8. uric acid stonesacid urine (pH < 5.5) + gout + high purine + TLS + DKD; alkalinize urine with potassium citrate to pH 6.5-7.0 + allopurinol — stones can dissolve!
  9. cystinuriaautosomal recessive (SLC3A1, SLC7A9) + faint sweet odor of cysteine + recurrent + young onsettreatment heavy hydration > 4 L/d + alkalinize > 7.5 + tiopronin (better tolerated than penicillamine)
  10. lumasiran (Oxlumo, FDA 2020) for primary hyperoxaluria type 1siRNA against AGXT (alanine glyoxylate aminotransferase) → reduces urinary oxalate; preventing ESKD; nedosiran emerging