DISKUSI MODUL NEFROLOGI KLINIK

EVALUASI DAN PENGOBATAN MEDIK SUBSPESIALISTIK

OBSTRUKSI DAN BATU SALURAN KEMIH

Abdul Rahman
2206095180

Fasilitator
Prof. dr. Aida Lydia, SpPD,KGH, Ph.D

Divisi Ginjal Hipertensi

Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia
RSUPN Cipto Mangunkusumo
2023
 INTRODUCTION

• Urinary stone disease is a highly prevalent disease worldwide, 7–13%

in North America, 5–9% in Europe, and 1–5% in Asia
• In last 2 decades, the male to female ratio is about 2:1
• Risk for recurrence is high: patients have a risk of 15% to develop a
second stone within a year and a risk of almost 50% within 10 years.

Pfau et al. Am J Kidney Dis.  2016

 ETIOLOGI
Tipe/Jenis Batu Frekuensi (%)

Calcium Oxalate 54 – 60

Calcium Phospate 6 – 15

Uric Acid 10 – 16

Magnesium Ammonium Phospate 1–3

Cystine 6–9

Pfau et al. Am J Kidney Dis.  2016

 FAKTOR RISIKO

Skolarikos et al. EUA.  2023

 FAKTOR RISIKO

Skolarikos et al. EUA.  2023

 FAKTOR RISIKO

Skolarikos et al. EUA.  2023

 PATOGENESIS
• Undersaturated zone: crystals will not formed,
existing stones will dissolve.

• Metastable supersaturation: nucleation and

crystallization conditions are formed 
Inhibitors  stone is not formed.

• Unstable supersaturation: nucleation occurs.

presence of inhibitors is not effective against
inhibition of stone formation.

Pfau et al. Am J Kidney Dis.  2016

 PATOGENESIS
Promoters
• pH
• Oxalate
• Calcium
• Natrium

Inhibitors
• Citrate
• Magnesium
• Phospate

Pfau et al. Am J Kidney Dis.  2016

 PATOGENESIS
(BLOCKED LYMPHATIC THEORY)

King et al. Clin Chem.  1971

 PATOGENESIS
(VASCULAR THEORY)

Stollern et al. J Urol.  2004

 PATOGENESIS
(FREE PARTICLE THEORY)

Knoll et al. Eur Urol Suppl.  2010

 PATOGENESIS
(FIXED PARTICLE THEORY)

Evan et al. Anat Rec.  2007

 PATOGENESIS
(RANDALL’S PLAQUE THEORY)

Evan et al. Anat Rec.  2007

 KLASIFIKASI
Stone Size Stone Location

• Under 5 cm • Upper/middle/lowr calyx

• 5-10 cm • Proximal/distal ureter
• 10-20 cm • Urinary bladder
• Above 20 cm

Xray

Radiopaque Poor radiopacity Radiolucent

• Calcium oxalate • Magnesium ammonium phosphate • Uric acid

• Calcium phospate • Cystine • Ammonium urate
• Xanthine
• Drugs
Skolarikos et al. EUA.  2023
 KLASIFIKASI

Pfau et al. Am J Kidney Dis.  2016

 KLASIFIKASI

Pfau et al. Am J Kidney Dis.  2016

 KLASIFIKASI

Pfau et al. Am J Kidney Dis.  2016

 DIAGNOSIS
Symptom Physical examination
• Colic pain • CVA pain
• Dysuria • Fever
• Urgency symptom
• Hematuria
• Systemic symptom
• asymptomatic

Urine Blood
• Red cells • Creatinine
• White cells • Uric acid
• Nitrites
• Urine pH • Calcium (ion)
• Urine microscopy • Natrium
• Urine culture*
• Potassium
• Blood cell
• CRP

Pfau et al. Am J Kidney Dis.  2016

 DIAGNOSIS
USG
• Primary diagnostic tools
Can identify stones located in
• radiopaque stones
the calyces, pelvis,
pyeloureteric & vesico-ureteral
junctions
• Sen 45%; Sp 94%
KUB NCCT CCT
• Helpful in differentiating • The standard for diagnosing • Perform a contrast study if
between radiolucent & acute flank pain  to confirm stone removal is planned &
the anatomy of the renal
stone
• Sen 44%; Sp 77% collecting system needs to be
Should not be performed if • Sen 93%; Sp 97% assessed.
•
NCCT

Stone analysis
• Stone analysis should be performed in all
first-time stone formers.

Repeat analysis:
• Recurrence under pharmacological prevention
• Early recurrence after interventional therapy with
complete stone clearance
• Late recurrence after a prolonged stone-free period

Skolarikos et al. EUA.  2023

 TATALAKSANA
(RENAL COLIC)

• NSAIDs and paracetamol are effective in patients with acute stone colic and have
better analgesic efficacy than opioids.
• Metamizole can be first line for relieve renal colic

• Ibuprofen compared to ketorolac is a more rapid acting drug in controlling pain

caused by renal colic with a similar side effect profile.
• If analgesia cannot be achieved medically, drainage, using stenting, percutaneous
nephrostomy, or stone removal, is indicated
Skolarikos et al. EUA.  2023
 TATALAKSANA
(OBSTRUCTION)

• Urgently decompress the collecting system in case of obstructing stones with sepsis
or decline renal function.
• Start antibiotics if infection or sepsis occurs.
• Delay definitive treatment of the stone until sepsis is resolved.

Skolarikos et al. EUA.  2023

 TATALAKSANA
(DRUGS)

Medical expulsive therapy (MET): Chemolytic dissolution:

• a-blockers as MET as one of the • Oral chemolysis  uric acid stones by
treatment options for (distal) ureteral alkaline citrate/natrium bicarbonate
stones > 5 mm.
• Calcium channel blockers
• Phosphodiesterase type 5
Not significant
• Corticosteroids
• Bromelain

Voncent et al. EUA. 2019

Skolarikos et al. EUA.  2023
 TATALAKSANA
(STONE REMOVAL)
• Perform urine microscopy or urine culture (if infection) before treatment
• Treat urinary tract infection prior to stone removal
• Peri-operative antibiotic prophylaxis to all patients undergoing endourological treatment.

Renal Stone Ureter Stone

• Stone Growth • Stones with a low likelihood of spontaneous
• Stones in high-risk patients for stone passage;
formation; • Persistent pain despite adequate pain
• Obstruction caused by stones; medication;
• Infection; • Persistent obstruction;
• Symptomatic stones • Renal insufficiency
• Stones > 15 mm;
• Patient preference;
• Comorbidity;
• Social situation of the patient

Skolarikos et al. EUA.  2023

 TATALAKSANA
(URETERAL STONE)

Skolarikos et al. EUA.  2023

 TATALAKSANA
(KIDNEY STONE)

Skolarikos et al. EUA.  2023

 Fluid intake • Fluid amount: 2500-3000 ml/day
• Water ist the preferred fluid
• Target diuresis: 2000-2500 ml/day
• BJ urin: < 1.010

Diet • Balanced diet

TATALAKSANA • Normal calcium consumption (1000-1200 mg/day)
• Limited Natrium load (< 2000 mg/day)
(GENERAL PREVENTIVE) • Limited animal protein: 0.8-1.0 g/kg/day

Lifestyle modification • Normal BMI

• Adequate physical activity
• Reduce the intake of alcohol; sodas, & calorie-
containing fluids

Skolarikos et al. EUA.  2023

 TATALAKSANA
(CALCIUM OXALAT)

Skolarikos et al. EUA.  2023

 TATALAKSANA
(CALCIUM PHOSPATE)

Skolarikos et al. EUA.  2023

 TATALAKSANA
(ASAM URAT)

Skolarikos et al. EUA.  2023

 TATALAKSANA
(URIC ACID & AMMONIUM
URATE)

Skolarikos et al. EUA.  2023

 TATALAKSANA
(CYSTINE)

Skolarikos et al. EUA.  2023

 TATALAKSANA
(CYSTINE)

Skolarikos et al. EUA.  2023

 FOLLOW UP

Skolarikos et al. EUA.  2023

 PROGNOSIS

ESRD Mortality

Dhondup et al. Am J kidney.  2018

 PROGNOSIS

Dhondup et al. Am J kidney.  2018

 THANKS!
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IRGN Hepatitis C Virus

Rovin BH, Adler SG, Barratt J, et al. Executive summary of the KDIGO 2021 Guideline for the Management of Glomerular Diseases. Kidney Int.
2021;100(4):753-779. doi:10.1016/j.kint.2021.05.015