Bubrežni kamenac – posljedica metaboličkog poremećaja!
Dijagnoza se postavlja na osnovu historije bolesti, pregleda bolesnika, radiološkog pregleda i laboratorijskih pretraga. Izuzetno su važne također mikrobiološke i biohemijske analize urina, te određivanje hemijskog sastava kamenca, što se rutinski radi u Zavodu “Nalaz”
Stvaranje kamenaca u bubrezima i urinarnim putevima multifaktorijalna je bolest u čijoj se osnovi uvijek nalazi određeni metabolički poremećaj. Većinom pogađa ljude u dobi od 20 do 40 godina, češća je kod muškaraca, nego kod žena.
Bubrežni kamenci
Bubrežni kamenci sastoje se od normalnih produkata metabolizma svake osobe. Ovim produktima je često je zasićen filtrat bubrega (glomerularni filtrat) i sasvim male promjene u sastavu mokraće mogu pokrenuti proces taloženja sastojaka u obliku kristala i/ili kamenaca u tkivu bubrega ili u mokraćnim putevima. Brojni su uslovi koji pogoduju nastanku kamenca. Među najznačajnijim je visoka koncentracija jednog ili više sastojaka koji stvaraju kamenac u glomerularnom filtratu. Do povećane koncentracije tih sastojaka dolazi – ili zbog smanjenog unosa tečnosti, ili zbog nenormalno velike brzine njihovog izlučivanja. Preveliko izlučivanje produkata metabolizma od kojih se sastoji kamenac, posljedica je metaboličkih bolesti, npr. prekomjernog rada paratireoiden žljezde (hiperparatireoidizam), ili poremećaja funkcije bubrega. Stvaranju bubrežnih kamenaca pogoduju također: promjena u kiselosti (pH) urina, bakterijska infekcija mokraćnih puteva, nedostatak supstanci koje sprečavaju stvaranje kamenaca, zastoj u oticanju mokraće, anomalije mokraćnog sistema, ishrana, klimatski faktori, naslijeđe i slično.
Prema hemijskom sastavu, bubrežni kamenci dijele se na anorganske i organske. Anorganski kamenci vide se na nativnim rendgenskim snimcima, dok su organski kamenci nevidljivi. Najčešća vrsta kamenaca ipak su anorganski, a njih 75-85% sadrži kalcij u kombinaciji s oksalatom ili fosfatom.
Poznato je i da određene bolesti, stanja, ishrana i životne navike utiču na stvaranje određenih vrsta kamenaca. Tako se kalcijumski kamenci stvaraju između ostalog kod bolesnika s hiperparatireoidizmom ili hipervitaminozom D. Nastanku ovih kamenaca pogoduju bolesti crijeva i povećan nivo oksalata, a on se može javiti zbog njegovog prevelikog unosa u organizam u obliku hrane koja sadrži špinat ili peršun. S druge strane, nastanku organskih kamenaca pogoduje povećana koncentracija mokraćne kiseline u serumu i urinu. Javlja se kod osoba koje imaju giht, mijeloproliferativnu bolest ili primaju citostatike. Važno je istaći i da svaka infekcija mokraćnih puteva olakšava nastanak kamenca.
Klinička slika
Klinički znakovi i simptomi bolesti, koja također može biti i asimptomatska, zavise od veličine kamenca i mjesta gdje se nalazi. Manifestnu bolest karakterišu izuzetno jaki bolovi locirani na onom mjestu na kojem se kamenac nalazi. Prisutnost kamenaca u bubregu također izaziva bol u području slabina. Kamenci u mokraćovodima izazivaju bubrežne kolike s tendencijom širenja od slabina do prepona, ili se bol može osjetiti tek u vrhu penisa. Kamenac u bešici može stvoriti neugodan osjećaj i potrebu da se izmokri i nešto što se ne može izmokriti. Prisustvo kamenca u bilo kom dijelu mokračnih puteva može spriječiti isticanje urina. Kretanje kamenaca niz mokraćne puteve gotovo uvijek je povezano s oštećenjem sluznice, krvarenjem i infekcijom, dok su renalne kolike često praćene mučninom i povraćanjem.
Dijagnostika
Dijagnoza se postavlja na osnovu historije bolesti, pregleda bolesnika, radiološkog pregleda i laboratorijskih pretraga. Laboratorijske pretrage krvi i urina veoma su bitne za dijagnosticiranje prisustva kamenca i otkrivanje mogućih uzroka njegovog nastanka. Također, izuzetno su važne mikrobiološke i biohemijske analize urina, te određivanje hemijskog sastava kamenca, što se rutinski radi u Zavodu “Nalaz”. Rezultati ovih ispitivanja pomažu kod određivanja odgovarajućeg liječenja. Nakon što je kamenac izbačen ili je uklonjen, potrebno je od bolesnik zatražiti da sakuplja mokraću 24 sata. Uzorak se koristi za mjerenje volumena mokraće i nivoa kiselosti, kalcija, natrija, mokraćne kiseline, oksalata, citrata i kreatinina. Dobijeni rezultati su dobar pokazatelj postoji li opasnost od ponovnog stvaranja kamenca i putokaz za poduzimanje prevetivnih mijera.
Liječenje
Većina pacijenata kamence izbacuje spontano. U slučajevima kada to nije moguće, mora se pristupiti razbijanju kamena ili hirurškom zahvatu. Za vrijeme napada bubrežnih kolika, pacijentu se daju analgetici i spazmolitici, preporučuje se da piju dosta tekućine, najmanje dva do tri litra kako bi se olakšalo izbacivanje kamena. Sve infekcije urinarnog trakta i bubrega moraju se energično liječiti.
Prevencija
Da bi se spriječilo stvaranje kamenaca, potrebno je utvrditi uzrok njihovog nastanka. Laboratorijska ispitivanja, uključujući ispitivanja krvi i mokraće, omogućit će urologu da poduzme odgovarajuće preventivne mjere.
Kod hiperparatiroidnih bolesnika uklanjaju se sve paratiroidne žlijezde. Ovim činom rješavaju se bolesnikovi problemi s bubrežnim kamencima. U zavisnosti od hemijskog sastava kamenca, bolesnicima se daju lijekovi pomoću kojih se postiže željena kiselost mokraće, a mogu se davati i diuretici.
Dijetetske preporuke
S obzirom da je u osnovi stvaranja kamenca neki metabolički poremećaj, uvođenje odgovarajuće dijete ima terapijski, ali i preventivni učinak. Najjednostavnija i najvažnija stavka u dijeti je unošenje velike količine vode, a očekivani rezultat bi trebao biti proizvodnja najmanje dva litra mokraće u 24 sata.
Osobe koje su sklone stvaranju kamenaca kalcijevog oksalata trebale bi da smanje unos određenih namirnica. Na listi su sljedeće: jabuke, pivo, cvekla, jezgričasto voće (npr. brusnica, jagoda), crni biber, čokolada, kakao, kafa, kola, raštika, špinat, blitva, brokula, šparoge, repa, peršun, smokve, grožđe, mlijeko, sir, jogurt, sladoled, kikiriki maslac, ananas, narandže, čaj i vitamin C. Bez prethodnog dogovora s doktorom, bolesnici ne trebaju prestati jesti ili izbjegavati ovu vrstu hrane! U većini slučajeva, može se jesti, ali u ograničenim količinama.
Hrana s manje oksalata i mesa preporučuje se bolesnicima koji imaju visok nivo oksalata u mokraći. Nekada je korisno izbjegavati hranu s dodatkom vitamina D, te određene vrste antacida na bazi kalcija.
Uz sve navedeno, postoje i cistinski kamenci koji nastaju kao posljedica nasljednog poremećaja i teško se mogu kontrolisati dijetom. Bolesnici bi trebali svaki dan piti više od četiri litra vode, od čega jedna trećina mora biti popijena tokom noći.
Na kraju, vrijedi naglasiti da bi osobe sklone stvaranju kamenaca trebale povremeno uraditi urinokulturu, odnosno kontrolu kiselosti urina, njegovog hemijskog sastava i sterilnosti, kako bi se na vrijeme uočile promjene i poduzele preventivne mjere.
Kidney stones – consequence of metabolic disorder!
Diagnosis is base according to the history of the disease, patient examination, radiographic examination, and laboratory tests. Extremely important are biochemical and microbiological urine analysis and determination of chemical composition of stone, which is routinely done in the Institute “NALAZ”.
Formation of stones in kidneys and urinary pathways is a multifactorial disease and it is always followed by some metabolic disorder. Usually, affected persons are between 20 and 40 years old. Kidney stones are more likely to occur in males than females.
Kidney stones
Kidney stones are composed of normal metabolic products found in every person. These compound usually saturate kidney filtrate (glomerular filtrate) and only minor changes in the composition of urine can initiate the precipitation of ingredients in form of crystals and/or stones in the kidney or in the urinary tracts. Many conditions are suitable for kidney stones formation. Among the most important is the higher concentration of one or more ingredients that are responsible for the kidney stones formation. Increased concentration of these ingredients can be caused by abnormal secretion or because of reduced fluid uptake. Abnormal secretion of metabolic products that comprise kidney stones is a consequence of a metabolic disorder. Such as overwork of parathyroid glands known as hyperparathyroidism or impaired kidney function. Causes of kidney stone formation are: changes in urine acidity (pH), bacterial infection of urinal tracts, lack of substances that inhibit stone formation, delay in urine runoff, urinary tract anomalies, nutrition, climatic factors, inheritance and etc.
According to the chemical composition, kidney stones can be divided in to organic and inorganic. Organic stones are visible on the native x-ray examinations, whereas inorganic stones are invisible. However the most common type of kidney stone is inorganic and 75-85% contains calcium in the combination with oxalate or phosphate.
It is known that certain diseases, conditions, nutrition and lifestyles also contribute to the kidney stones formation. Thus calcium stones are usually created among patients with hyperparathyroidism or hypervitaminosis D. Bowl diseases and elevated levels of oxalate are suitable conditions for calcium stone formation, excessive intake of food that contains calcium such as spinach or parsley can also stimulate its formation. On the other hand elevated concentration of urine acid in serum and blood stimulate organic stone formation. It occurs in people who have gout, myeloproliferative disorders or receiving cytostatics. It is important to know that any urinary tract infection facilitates kidney stones formation.
Clinical picture
Clinical signs and symptoms of the disease, which can also be asymptomatic, depend on the size of the stone and its location. Manifestation of the disease is characterized by an extremely strong pain located at the point where the stone is located. Presence of stones in kidneys also causes pain in the lumbar region. Stones in the urinary tract cause renal colic that have a tendency to spread from the loin to groin, or the pain can be felt in the penis. Bladder stone can cause uncomfortable feeling during the urination. Presence of stones in any part of the urinary tract can prevent the flow of urine. Movement of urinary tract stone is almost always associated with mucosal damage, bleeding and infection, while renal colic is often accompanied by nausea and vomiting.
Diagnosis
Diagnosis is based according to the history of disease, patient examination, radiographic examination, and laboratory tests. Laboratory blood and urine test are important for stone presence detection and for the detection of possible causes of its origin. Microbiological and biochemical analysis of urine as well as determination of the chemical composition of the stone, which are routinely done in the Institute “NALAZ”, are extremely important. Results of these tests help to determine appropriate treatment. After the stone is thrown out or removed, patient should be asked to collect its urine for 24 hours. Sample is used to measure urine volume and levels of acidity, calcium, sodium, uric acid, oxalate, citrate, and creatinine. Obtained results can indicate is there any risk of stone reformation.
Treatment
Kidney stones are usually thrown out spontaneously. In cases where this is impossible, stone breaking or chirurgical procedures are preformed. During the renal colic attack, the patient is given analgesics and spasmolytic, it is recommended to drink more fluids, at least two to three liters in order to facilitate stone ejection. All of the urinary tracts and kidneys infections should be vigorously treated.
Prevention
In order to prevent kidney stone formation, it is necessary to determine the cause of their generation. Laboratory tests, including blood and urine tests, will allow urologist to take appropriate preventive measures.
In patients suffering from hyperparathyroidism, all parathyroid glands have to be removed. Removal of parathyroid glands will stop stone formation. Depending on the chemical composition of stone, patients are given drugs that help to achieve a desired acidity of urine, sometimes diuretics are also prescribed.
Dietary recommendations
Taking in consideration that stone formation is caused by some metabolic disorder, introduction of specific diet will have therapeutic and preventive effects. Most important thing is to drink large amounts of water; expected results should be production of at last two liters of urine in 24 hours.
People who are prone to stone calcium oxalate stone formation should reduce their intake of certain foods. The list includes the following: apples, beer, beets, nuts (such as cranberries, strawberries), black pepper, chocolate, cocoa, coffee, cola, collard greens, spinach, chard, broccoli, asparagus, beets, parsley, figs, grapes, milk, cheese, yogurt, ice cream, peanut butter, pineapple, oranges, tea and vitamin C. Without prior consultations with the doctor, patients should not stop eating or avoiding this type of food! In most cases, you can eat it, but in limited quantities.
Food with less oxalate and meat is recommended for patients who have high levels of oxalate in the urine. Sometimes it is useful to avoid food with added vitamin D and certain types of calcium-based antacids.
Additionally, there are also cystine stones that occur as a result of hereditary disorders, and it is hard to control them by diet. Patients should drink every day four or more than four liters of water, out of which one third must be drunk during the night.
In the end, it is worth to emphasize that people who are prone to stones formation should occasionally do urine culture, or control the acidity of urine, its chemical composition and sterility, in order to detect alterations in time and take preventive measures.
