Hyperuricosuria and Gouty Diathesis Follow-up

  • Author: Bijan Shekarriz, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS   more...
 
Updated: Nov 23, 2011
 

Further Outpatient Care

  • All patients should undergo regular follow-up imaging studies with KUB imaging, renal ultrasonography, or unenhanced CT scanning, as indicated.
  • Measuring urinary pH is important to monitor the efficacy of urinary alkalinization and to adjust medications accordingly. A repeat 24-hour urinary collection after initiation of medical therapy is beneficial. Furthermore, with any significant change in medication or diet, a repeat 24-hour urinary collection is indicated.
  • Patients may titrate their own urinary alkalinization program with the aid of Nitrazine pH paper or other available pH monitoring systems. One should strive to maintain a urinary pH of 6.5-7.0. Medications may need to be adjusted during certain periods of the day.
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Complications

  • Untreated urinary stones may result in urinary obstruction (with or without pain) and subsequent urinary tract infection. If severe, this may result in life-threatening urosepsis. This condition requires immediate resolution of obstruction.
  • In the chronic phase, recurrent obstruction and infections rarely lead to loss of renal function.
  • Severe hyperuricemia may result in acute urate nephropathy in patients with myeloproliferative or lymphoproliferative disorders. The mechanism of urate nephropathy involves precipitation of urate within the renal tubules, with subsequent intratubular obstruction and severe azotemia.
  • Allopurinol has been associated with the development of hemorrhagic skin lesions, exfoliation, and a rare fatal systemic vasculitis. Pruritus often precedes the development of rash and should prompt patients to discontinue the medication. Alterations in hepatic function and jaundice have been reported with allopurinol use; these complications require monitoring of serum liver function test results soon after the institution of therapy. Allopurinol may result in an acute gouty attack in patients with hyperuricemia.
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Prognosis

  • With appropriate medical and surgical management, the prognosis is excellent in the majority of cases.
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Patient Education

  • With appropriate diet and medical therapy, uric acid–related urolithiasis is a preventable disease. Patients should be instructed to maintain a daily fluid intake sufficient to generate a urinary output of at least 1.5-2 L, to avoid an excessively purine-rich diet (eg, red meat, solid-organ meats), and to limit the sodium content of their diet.
  • Patients with uric acid stones should be instructed to measure their urinary pH at home with the aid of Nitrazine pH paper and to adjust their dosage of the alkalinizing agent accordingly. Generally, achieving and maintaining a urinary pH in the range of 6.5-7.0 requires a motivated and compliant patient. UriDynamics, Inc offers an improved urinary dipstick (Stone Guard 2) specifically designed for patient use to monitor urine pH. The authors usually recommend checking urine pH 3 times per day and then adjusting oral alkalinization and retesting until the daily urinary pH is in the desired range. Testing can then be reduced to once per day or even less depending on the individual’s daily variation.
  • An excellent patient education book called The Kidney Stones Handbook was written specifically for patients with stones and their families by a urology expert on kidney stone disease. The authors of this article highly recommend it. The book is available from Internet online booksellers (eg, Amazon.com) or can be ordered directly from the publisher (Grant Gibbs) by calling (530) 889-1727 or emailing gsavitz@earthlink.net.
  • For excellent patient education resources, visit eMedicine's Arthritis Center. Also, see eMedicine's patient education article Gout.
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Contributor Information and Disclosures
Author

Bijan Shekarriz, MD  Director, Laparoscopy and Minimally Invasive Surgery, Associate Professor of Urology, Department of Urology, State University of New York Upstate Medical University

Bijan Shekarriz, MD is a member of the following medical societies: American Urological Association and Endourological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Marshall L Stoller, MD  Professor and Vice Chairman, Medical Director of Urinary Stone Center, Department of Urology, University of California, San Francisco, School of Medicine

Marshall L Stoller, MD is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Brian H Eisner, MD  Instructor in Surgery, Department of Urology, Massachusetts General Hospital-Harvard Medical School; Fellow in Endourology, Department of Urology, University of California

Brian H Eisner, MD is a member of the following medical societies: American Urological Association and Endourological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Allen Donald Seftel  MD, Professor of Urology, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School; Head, Division of Urology, Director, Urology Residency Training Program, Cooper University Hospital

Allen Donald Seftel is a member of the following medical societies: American Urological Association

Disclosure: lilly Consulting fee Consulting; sanofi-aventis Consulting fee Consulting; auxilium Consulting fee Consulting; solvay Consulting fee Consulting; plethora Grant/research funds clinical trial; endo Consulting fee Consulting; nature publishing journal editor

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

J Stuart Wolf Jr, MD, FACS  The David A Bloom Professor of Urology, Director, Division of Endourology and Stone Disease, Department of Urology, University of Michigan Medical School

J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology

Disclosure: Nothing to disclose.

Chief Editor

Bradley Fields Schwartz, DO, FACS  Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, and Society of University Urologists

Disclosure: Nothing to disclose.

References

  1. Sakhaee K, Maalouf NM. Metabolic syndrome and uric acid nephrolithiasis. Semin Nephrol. Mar 2008;28(2):174-80. [Medline].

  2. Del Valle EE, Negri AL, Spivacow FR, Rosende G, Forrester M, Pinduli I. Metabolic diagnosis in stone formers in relation to body mass index. Urol Res. Jun 10 2011;[Medline].

  3. Asplin JR. Uric acid stones. Semin Nephrol. Sep 1996;16(5):412-24. [Medline].

  4. Bernardo NO, Smith AD. Chemolysis of urinary calculi. Urol Clin North Am. May 2000;27(2):355-65. [Medline].

  5. Cameron MA, Sakhaee K. Uric acid nephrolithiasis. Urol Clin North Am. Aug 2007;34(3):335-46. [Medline].

  6. Coe FL, Kavalach AG. Hypercalciuria and hyperuricosuria in patients with calcium nephrolithiasis. N Engl J Med. Dec 19 1974;291(25):1344-50. [Medline].

  7. Low RK, Stoller ML. Uric acid-related nephrolithiasis. Urol Clin North Am. Feb 1997;24(1):135-48. [Medline].

  8. Moe OW, Abate N, Sakhaee K. Pathophysiology of uric acid nephrolithiasis. Endocrinol Metab Clin North Am. Dec 2002;31(4):895-914. [Medline].

  9. Pak CY. Medical management of urinary stone disease. Nephron Clin Pract. 2004;98(2):c49-53. [Medline].

  10. Pak CY, Moe OW, Sakhaee K, Peterson RD, Poindexter JR. Physicochemical metabolic characteristics for calcium oxalate stone formation in patients with gouty diathesis. J Urol. May 2005;173(5):1606-9. [Medline].

  11. Pak CY, Poindexter JR, Peterson RD, Koska J, Sakhaee K. Biochemical distinction between hyperuricosuric calcium urolithiasis and gouty diathesis. Urology. Nov 2002;60(5):789-94. [Medline].

  12. Pak CY, Sakhaee K, Moe O, Preminger GM, Poindexter JR, Peterson RD, et al. Biochemical profile of stone-forming patients with diabetes mellitus. Urology. Mar 2003;61(3):523-7. [Medline].

  13. Shekarriz B, Stoller ML. Uric acid nephrolithiasis: current concepts and controversies. J Urol. Oct 2002;168(4 Pt 1):1307-14. [Medline].

  14. Steele TH. Hyperuricemic nephropathies. Nephron. 1999;81 Suppl 1:45-9. [Medline].

  15. Stoller ML. Gout and stones or stones and gout?. J Urol. Nov 1995;154(5):1670. [Medline].

 
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CT scan demonstrating right partial staghorn uric acid calculus. Uric acid stones appear dense on CT scan and radiolucent on kidneys, ureters, and bladder (KUB) imaging (not shown).
Follow-up CT scan of patient in the image above (ie, with partial staghorn uric acid calculus) 1 year later. This patient was treated with oral urinary alkalinization with sodium bicarbonate. Note only a small residual fragment is present (right image).
 
 
 
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