The general practitioner and nephrolithiasis

Nephrolithiasis is a multifactorial disease the genesis of which is influenced by genetic, metabolic and environmental factors which determine a series of alterations in the urinary excretion of a number of substances, the cause of the disease
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  Emanuele Croppi a Federica Cioppi b Corrado Vitale c a University of Florence, ASL 10 Florence, Italy b Department of Internal Medicine, University of Florence, Florence, Italy c Nephrology and Dialysis Unit, ASO Ordine Mauriziano, Turin,ItalyAddress for correspondence: Emanuele Croppi, M.D.Via del Giuggiolo 10, Florence, ItalyPh.+39 055 470606E-mail: emcroppi@mark.it SummaryNephrolithiasis is a multifactorial disease the genesis of whichis influenced by genetic, metabolic and environmental factorswhich determine a series of alterations in the urinary excretionof a number of substances, the cause of the disease itself. Thegeneral practitioner is often the first professional to be consult-ed as regards clinical and therapeutic treatment at the momentof the onset of nephrolithiasis, renal colic, inasmuch as con-tacted directly by the patient. His role however should not belimited to this initial phase but becomes of strategic importancethroughout the subsequent diagnostic procedure; this is espe-cially true with regard to relapses, in correctly placing the pa-tient and, if necessary, referring him/her to the most appropri-ate specialist area. Running through the entire process whichthe lithiasic patient encounters from the onset of the diseaseuntil therapeutic treatment begins, it is clear how an appropri-ate initial approach can, in many cases, simplify and optimisesuch process. On the basis therefore of a complete medicalrecord, and a few simple, biochemical and instrumental tests,the general practitioner is in a position to decide whether totreat the patient directly or to refer him/her to the most appro-priate specialist field for investigation at a higher level.Over the last decades nephrolithiasis has progressivelychanged from being a disease of mainly surgical pertinence tobeing one of multidisciplinary medical interest in which thefigure of the General Practitioner has a primary role, both dur-ing the initial diagnostic phase, by means of the correctphysio-pathological identification of the problem, and in thesubsequent phases as regards the choice and co-ordinationof the various specialists involved. KEY WORDS: General Practitioner and nephrolithiasis. Nephrolithiasis is a disease with a strong epidemiological im-pact known of since ancient times; even though comprehen-sive data is not available, it is estimated that it has an inci-dence, constantly on the increase in industrialised countries,between 5% and 10% of the general population (1-10). Formany years the disease was of strictly surgical pertinence andthe surgical approach has made significant progress over thelast three decades; in fact the modern extra-corporeal and en-doscopic methods of removing calculi have, in most cases, re-placed the traditional surgical procedure (11-13). Still todayhowever, the surgical approach to the disease has the draw-backs of not being entirely risk-free, not always being applica-ble and not affecting the probability of relapses (14-16). Overthe same years the perfecting of laboratory techniques and theincreased knowledge of pathophysiology have opened the wayfor a medical approach to the kidney stone disease which com-plements and integrates the surgical approach; in fact a seriesof anomalies of a metabolic or other nature srcin, in turn re-sulting from an interaction of genetic and environmental fac-tors, have been progressively identified which facilitate the on-set of the disease and the correction of which modifies theprognosis (17-35). In other words the kidney behaves like ahomeostatic organ which responds efficiently to a metabolic in-sult by correcting it, to the detriment of the upheaval of the uri-nary environment which is thus exposed to a lithogenic riskthrough the imbalance of over-saturation and inhibition. Theidentification and treatment of such anomalies is the purpose ofthe diagnostic-therapeutic process of medical pertinence, or-ganised at various levels of diverse complexity in relation to thetype of calculosis present and to the degree of activity of thedisease (36).The transit of the calculus along the urinary tract is often thefirst clinical sign of renal stone disease. Initial intervention isusually by the general practitioner or emergency services doc-tor (37); subsequent management of the disease is then takenover by the urologist with non-invasive or semi-invasive proce-dures which permit resolution of the contingent problem in over90% of cases. After the surgical phase an appropriate metabol-ic assessment of the patient means that the pathogenesis ofthe nephrolithiasis can be investigated and the dietary-pharma-cological measures identified to resolve the clinical manifesta-tions. The multidisciplinary nature of the approach to the patient af-fected by renal stone disease with the consequent risk of frag-mentary intervention and the absence of a systematic ap-proach thus emerges (38). The general practitioner is often involved in dealing with a dis-ease which has come to his/her knowledge in varying circum-stances: because called in directly during a renal colic or as aresult of echography and/or X-rays performed on account ofthe presence or suspicion of other diseases or simply as theconclusion of an anamnesis (38).The purpose of this study is to focus on the instruments avail-able to the general practitioner through which he/she can per-form a clearly-defined role in the diagnostic-therapeuticprocess of nephrolithiasis.The general practitioner is often the first professional figure in-volved at the moment of the onset of the disease: renal colic.This is an acute clinical phase caused by the engagement ofthe calculus in the excretory tract, characterised by the onset ofaviolent visceral pain with cramps at the side of the body, withmore or less extensive anterior irradiation as far as the hy-pogastric-inguinal region as a result of the varying section of Clinical Cases in Mineral and Bone Metabolism 2008; 5(2): 145-148  145 The general practitioner and nephrolithiasis Mini-review  the ureter affected. It is often associated with neuro-vegetativesymptoms such as nausea, vomit, sweating and micro/macro-hematuria. Faced with the presence of renal colic the approachof the general practitioner must be focused, first of all, on ex-cluding emergencies of a surgical nature (appendicitis, extra-uterine pregnancy, ruptured aneurysm, perforated ulcer, etc.),by means of patient’s case-history, a physical examination(tenderness at the costal-vertebral angle on tapping or in thelower quadrant of the abdomen), the presence or not of mi-cro/macro-hematuria. Subsequently treatment must be begunwhich aims at achieving three basic objectives: treatment of thepain, removal of the calculus, safeguarding of renal function. The administration of an antispastic drug is a therapeuticchoice which is only partially adequate for treating the pain; infact this category of drugs acts exclusively on the spasm com-ponent of the pain, which is not the only algogenic cause, andwhich at the same time may prevent the progression of the cal-culus by altering uretheral motility and therefore its sponta-neous expulsion. For the treatment of pain in the first place, theadministration of NSAIDs appears more appropriate and sec-ondly of opiates.The role of NSAIDs in particular is of considerable impor-tance during the first phase of the natural progress of renalcolic, in that these drugs block the events induced by theprostaglandins,such as the vasodilation of the afferent arteri-ole, thus reducing diuresis and consequently the intracavitarypressure; in addition by reducing the oedema and inflammationtoo, they lead to an attenuation of the painful symptoms andfavour the progression of the calculus; the duration of their useis subordinate to the side-effects which they may produce onthe gastroenteric tract and renal perfusion. The use of opiatesis recommended when the effect of NSAIDs on the pain provesinsufficient.While treatment of the painful symptoms is almost always ef-fective the expulsive aspect is much more complicated. Thefactors influencing expulsion of the calculus are basically thesize and the location but the type of calculus and the compli-ance of the excretory tract also play their part. Knowing the lo-cation may be important for choosing appropriate treatment, asin the case in which the calculus is near the urethra-bladder junction: by associating an alpha-lithic drug with the NSAIDsthe urethral muscles are relaxed, facilitating emission. Drinkingliquids does not seem to affect the progress of the colic, eventhough an increase in diuresis may facilitate the progression ofthe calculus in cases where the obstruction is not total and thepain can be controlled pharmacologically (39-50).By means of the anamnesis and clinical semiotics it is oftenpossible to predict the location of the calculus and identifythose situations in which the patient must be promptly sent tohospital, as in the case of a bilateral obstruction, an infectedobstruction or pain which resists treatment. The anamnesis also enables the general practitioner to gatherinformation about family history of the disease and to assessthe importance of genetic and/or environmental factors whichmay have determined it. By means of the anamnesis it is alsopossible to determine the degree of activity of the diseasewhich in some cases presents itself as episodic and in othersas seriously recurrent. Such information gives the generalpractitioner an idea of the degree of urgency with which tosend the patient for a specialist examination.Once past the acute phase, for an optimal clinical picture it isadvisable to perform an echography of the urinary tract and adirect X-ray of the abdomen. In almost all cases the perfor-mance of these two test enables the general practitioner toconfirm the diagnosis and obtain information about the natureof the calculi present on the basis of their radio-opacity or ra-dio-transparency; it also permits the identification of calculialong the excretory tract, a case requiring prompt urological in-tervention since even the recovery of an asymptomatic condi-tion after the colic does not exclude the occurrence of underly-ing uropathies, which may be severe (51). The decision as to study all patients affected by nephrolithiasisfrom a metabolical point of view or whether to reserve such as-sessment only to patients with recurrent calculosis is still amatter of debate. There are in fact studies which show how pa-tients suffering their first episode of the disease have the sameincidence and severity of metabolic alterations as patients withrecurrent nephrolithiasis; the first renal calculus could more-over be the first clinical sign of a systemic disease, asympto-matic until such moment, such as renal tubular acidosis (52-55)or hyper-parathyroidism (56, 57). At the Consensus Confer-ence of the National Institutes of Health on the Prevention andTreatment of Renal Calculi (58) it was in fact decided that allpatients, including those suffering their first episode ofnephrolithiasis, should undergo first level metabolic assess-ment. On the other hand, a complete metabolic study per-formed on the total population of lithiasic patients, even at theirfirst episode, is not always feasible for reasons of cost and pa-tient compliance. It is here that the importance of a metabolicassessment at various levels, of the patient affected bynephrolithiasis comes into play, based on the number of calculipresent and the number of relapses. Within the sphere of thiscontext, it is the task of the general practitioner to make a pri-mary assessment of the patient by means of blood tests andurine tests, simple to perform and low in cost (Table I), aimedat confirming the diagnosis, excluding the main causes of sec-ondary renal calculosis and deciding whether or not to send thepatient for further specialist advice. In fact one of the essential tasks of the general practitioner isthat of making an initial distinction between primary idiopathiccalculosis, of strictly nephrological competence, and secondarycalculosis. Table I - The patient affected by renal calculosis in the GeneralPractitioner’s setting: first-level biochemical framework.Renal function: creatininaemia, azotemia, complete urine tests,urine cultureMetabolic profile: glycemia, uricemia, lipid profilePlasmatic electrolytes: sodium, potassium, chloride, calcium, phosphorusAnalysis of the calculus expelled (semi-quantitative method) The assessment of any reduction of renal function in the sub- ject affected by nephrolithiasis is important because the calcu-losis may be the cause; but on the other hand the deficit ofconcentration accompanying the reduction of the filtrate mayresult in an improvement of a previously active nephrolithiasis. The assay of the humoral parameters relative to the glycolipidmetabolism means that diseases such as metabolic syndromeand overweight, factors potentially favouring the presence ofnephrolithiasis, may be investigated (59-69).The assay of the plasmatic uric acid is justified by the fact thatan increase in its haematic share may predispose to calculosisby increasing its urinary excretion (34-36).The determination of calcium and phosphorus permits the ex-clusion, in almost all cases, of the presence of primitive hyper-para-thyroidism: a pathological condition of which nephrolithia-sis may be the only clinical sign present at its onset (70). Theassay of the plasmatic electrolytes permits investigation of clin-ical conditions such as hyperaldosteronism or other states ofhypopotassiemia: electrolytic disorders responsible for an al- 146 Clinical Cases in Mineral and Bone Metabolism 2008; 5(2): 145-148  E.Croppi et al.  tered equilibrium between the urinary excretion of calcium andcitrate. The correct performance of a standard urine test andurine culture also permits the exclusion of infections of the uri-nary tract as the possible cause of secondary calculosis (71-73) and provides important information on the nature of the cal-culosis by observing the type of crystalluria present in the sedi-ment. Lastly, the chemical analysis of the calculi expelled (tobeperformed using high-precision, reliable methods, such asinfrared spectrophotometry) enables determination of the com-position, an important starting point facilitating the metabolicstudy of the subsequent level and of specialistic pertinence. Aso-called, first-level screening performed by the generalpractitioner must therefore consist of a general look at the pa-tient, starting from the calculosis event and from what might becorrelated to it. The task of the general practitioner should not be limited to thisfirst phase but remains extremely important during the subse-quent diagnostic-therapeutic course of the lithiasic disease, toverify compliance with dietetic-pharmacological prescriptionsand to monitor any relapses, since, as we know, nephrolithiasismay worsen over time with total absence of symptoms, some-times with serious and irreversible effects on kidney function. Auseful contribution to the study of nephrolithiasis could comefrom the involvement of general practitioners in research of anepidemiological nature. 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