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Hyperuricosuria and Gouty Diathesis Follow-up

  • Author: Bijan Shekarriz, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
 
Updated: Apr 20, 2015
 

Further Outpatient Care

See the list below:

  • 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

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  • 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

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  • 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 patient education information, see 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, 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, Endourological Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, Society of Laparoendoscopic Surgeons, Society of University Urologists, Association of Military Osteopathic Physicians and Surgeons, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Additional Contributors

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

Disclosure: Received consulting fee from lilly for consulting; Received consulting fee from abbott for consulting; Received consulting fee from auxilium for consulting; Received consulting fee from actient for consulting; Received honoraria from journal of urology for board membership; Received consulting fee from endo for consulting.

References
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  2. Ferraro PM, Robertson WG, Johri N, Nair A, Gambaro G, Shavit L, et al. A London experience 1995-2012: demographic, dietary and biochemical characteristics of a large adult cohort of patients with renal stone disease. QJM. 2014 Dec 17. [Medline].

  3. 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. 2011 Jun 10. [Medline].

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  5. Leng S, Shiung M, Ai S, Qu M, Vrtiska TJ, Grant KL, et al. Feasibility of discriminating uric acid from non-uric acid renal stones using consecutive spatially registered low- and high-energy scans obtained on a conventional CT scanner. AJR Am J Roentgenol. 2015 Jan. 204(1):92-7. [Medline]. [Full Text].

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

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

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

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

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

  13. 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. 2005 May. 173(5):1606-9. [Medline].

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

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

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

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

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

  19. Xu H, Zisman AL, Coe FL, Worcester EM. Kidney stones: an update on current pharmacological management and future directions. Expert Opin Pharmacother. 2013 Mar. 14(4):435-47. [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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