泌尿系结石成分450例分析

目的分析泌尿系结石患者的发病年龄及性别特点,探讨结石部位与患者年龄及性别的关系,根据结石不同成分采用不同预防措施。方法应用化学分析法对450例尿路结石做成分分析,结合临床资料,对尿路结石患者发病年龄、性别、结石部位及结石成分做对比分析。姑杲男性患者321例,高发年龄21～60岁;女性129例,高发年龄41～60岁;男性发病率是女性的2．49倍。发病部位肾脏结石319例（70．8％）,输尿管结石115例（25．6％）,膀胱结石16例（3．6％）;单一成分结石275例（61％）,其中单纯草酸钙结石260例（57．7％）,两种及以上混合成分结石175例（39．0％）。结论尿路结石的发病率及发病年龄存在着明显的性别差异;尿路结石发病部位主要为上尿路结石;单一成分结石以草酸钙为主,约40％的尿路结石为两种及以上混合成分结石。     

Quantitative observations on the crystalline composition of urinary stones

Quantitative analytical findings on upper urinary tract stones from 500 patients are reported and compared to data in the literature. Methods of presentation of quantitative data are discussed. A wide range of findings between recurrent stones in the same patient and between stones from patients with the same cause of stone formation was found. No immediate clinical value of quantitation can be seen, but larger materials and correlation with metabolic investigations in stone formers may reveal correlations of clinical interest. Quantitative observations may identify groups of patients and types of stones not recognised on the basis of qualitative analysis. Examples of this are given for calcium oxalate-calcium phosphate stones and for stones containing brushite. The organic matrix which usually contributes 2-3% of stone mass was not considered, but distinctly visible and separate organic material in 7 stones was quantitated by visual estimate. 32 stones were incomplete, and their quantitation may not be wholly representative. Their exclusion, however, would have led to major bias because most were large and nearly half were triple phosphate stones, both properties being relatively rare. In cases of multiple stones, usually only one was quantitated. Seventy patients provided more than one stone for analysis (Otnes, 1983b), but except when specifically stated only the first stone is considered.     

Crystalline composition of urinary stones in recurrent stone formers

175 stones from 70 recurrent stone formers with each at least two stones available for analysis were studied crystallographically. The chance that a subsequent stone belonged to the same of five major stone groups was 65% but rose to 91% if three of these groups were considered as one (calcium stones). Other findings, however, indicate that distinction between the three groups of calcium stones is of interest. Thus, pure calcium oxalate stones (Ox) did not occur in the same patients as pure calcium phosphate stones (P). In comparable stones containing both the above types of components (OxP), the calcium phosphate content was significantly lower (average apatite content per stone 9%) in stones from patients who also had Ox stones than (37%) in those who had associated P stones. Also, the stone nucleus was frequently Ox in the OxP stones from the former and usually P in the OxP stones of the latter patients. Brushite occurred in 10% of the stones, which is more frequent than in unselected stone materials and largely due to a tendency for it to recur in a few patients. Patients who provide more than one stone for analysis appear to differ considerably in stone composition from stone patients in general, and inclusion of several stones from some patients will lead to bias in materials purporting to reflect stone composition in a population. When available, several stones from each patient should preferably be analysed. Exceptions may be made for cystine and, possibly, pure uric acid stone patients.     

CT检查对三聚氰胺所致婴幼儿尿路结石成分演变的预测价值和意义

目的 探讨CT检查对三聚氰胺所致婴幼儿尿路结石成分演变的预测价值和意义.方法 收集三聚氰胺所致婴幼儿尿路结石25枚.根据治疗方法,18枚肾结石分为单纯碱化治疗组(n=9枚)和综合处理组(n=9枚).采用原子吸收光谱精确测定结石中钙含量.使用螺旋CT检查体外测量婴幼儿尿路结石(实验组)和随机选择的61枚成人尿路结石(对照组)的最大CT值. 结果 婴幼儿尿路结石钙含量0.11％ ～26.30％.婴幼儿尿路结石CT值与结石钙含量呈显著正相关(r =0.855,P＜0.01).单纯碱化治疗组和综合处理组肾结石CT值分别为(162±60) HU与(783±476) HU,钙含量分别为(1.30±1.51)％与(19.83±7.48)％,组间差异有统计学意义(P＜0.01).与CT值≤400 HU的婴幼儿尿路结石比较,＞400 HU的结石钙含量显著升高[(21.71±5.27)％,(1.65±1.82)％,P＜0.01],且对单纯碱化治疗效果不好(x2=11.455,P＜0.01). 结论 三聚氰胺所致婴幼儿尿路结石成分演变的预测中,CT是一种很有价值的辅助诊断工具.临床CT值＞400HU的婴幼儿尿路结石可能由于含有更多钙而对单纯碱化治疗效果不好.     

尿石成分与血尿理化性质的关系

目的探讨本地区不同成分的结石与血尿理化性质之间的关系。方法对645例泌尿系结石成分进行分析,其中284例获取完整的24h尿液分析及血电解质的结果,与对照组进行比较。结果645例结石中以混合性结石占多数,其中以草酸钙为主。4种结石类型结石患者的24h尿量均显著低于对照组（P〈O．01）;尿酸为主结石组尿pH值明显低于其他类型结石组及对照组（P〈O．01）;草酸盐为主结石组的尿钙排泄及高尿钙病例数明显高于其他类型结石组及对照组（P〈O．01）。各组间及对照组之间血钾、钠、钙、磷、镁及氯无差异。结论结石成分与尿液理化性质之间有着密切关系。24h尿量、尿pH及高尿钙会对相应成分的结石产生影响,对于各种成分结石治疗与预防具有积极的临床意义。     

The severity of infection stones compared to other stones in the upper urinary tract

A retrospective study of the case records of 391 adult patients with spontaneously passed or surgically removed concrements from the upper urinary tract during the period 1982-1983 was performed. According to chemical analysis, 66% of the stones were calcium stones, 30% were infection stones, 4% were uric acid/urate stones and 1% were cystine stones. Of the infection stones 12 (10%) were staghorn calculi. The infection stones placed a greater strain on the patients than the calcium stones. Thus, infection stones were significantly more often recurrent stones and required surgery significantly more often than the calcium stones. Only 6% of the patients with infection stones had proved abnormalities predisposing to upper urinary tract infection. Urinary tract infection with a urease-producing microorganism was detected in only 52% of the patients with infection stones. As infection with a urease-producing microorganism is a prerequisite for the formation of infection stones in the urinary tract a careful microbiological investigation to find and treat the infection responsible for the stone formation is mandatory.     

Infection-induced urinary stones

Infection stones make up approximately 15% of urinary stone diseases and are thus an important group. These stones are composed of struvite and/or carbonate apatite. The basic precondition for the formation of infection stones is a urease-positive urinary tract infection. Urease is necessary to split urea into ammonia and CO(2). As a result, ammonia ions can form and at the same time alkaline urine develops, both being preconditions for the formation of struvite and carbonate apatite crystals. When these crystals are deposited infection stones form. Pathogenetically, various risk factors play a role: urinary obstruction, neurogenic bladder, dRTA, and MSK. If these infections are not treated and the stones are not removed, the kidney will be damaged. Modern methods are available for stone removal, e.g., ESWL and/or instrumental urinary stone removal. Here, especially less invasive methods are preferable. Any treatment must be adjusted to the patient individually. Patients should be examined frequently for recurrent urinary tract infections and stone recurrences, and new infections must be resolutely treated. Good therapy and prophylaxis are possible with present-day treatment modalities.     

Matrix glycosaminoglycan in urinary stones

At first, urinary stones were classified according to their inorganic components (apatite, struvite, calcium oxalate monohydrate, calcium oxalate dihydrate and uric acid). Then, matrix glycosaminoglycan was extracted from the stones in each group and was analyzed by 2-dimensional electrophoresis. There were differences in the glycosaminoglycan content of matrices among different groups of urinary stones. The principal matrix glycosaminoglycan content consisted of hyaluronic acid in apatite and struvite stones, heparan sulfate in calcium oxalate monohydrate and uric acid stones, and hyaluronic acid and heparan sulfate in calcium oxalate dihydrate stones. We conclude that hyaluronic acid and/or heparan sulfate has an important role in urinary stone formation.     

Heavy elements in urinary stones

The presence and role of heavy metals in urinary stones is debated. We investigated the distribution of trace heavy metals in 78 calculi of well-defined composition by means of microfluorescence X analysis using synchrotron radiation. Seven elements were identified, the most abundant being Zn and Sr which together accounted for 91% of the heavy metal content of stones. The other heavy metals were Fe, Cu, Rb, Pb and Se. Zn and Sr were virtually confined to calcium-containing stones, whereas only trace amounts were found in uric acid or cystine stones. Among calcium stones, Zn and Sr were more abundant in calcium phosphate than in calcium oxalate stones and, in the latter, in weddellite than in whewellite stones. Fe, Cu and Rb were much less abundant and also found mainly in calcium stones. Pb was significantly less abundant than in previous studies, thus suggesting a rarefaction of Pb in the environment, and appreciable amounts of Se were found only in cystine stones. In conclusion, the preponderance of Zn and Sr, both bivalent ions, in calcium-containing stones suggests a substitution process of calcium by metal ions with similar charge and radius rather than a contribution of the metals to stone formation. Further studies are needed to examine the relationships between urine concentration in calcium or other solutes and the amount of Zn and Sr in calcium stones.     

284例泌尿系结石成分分析与代谢评价

目的 研究结石成分与代谢异常的关系。方法 分析284例泌尿系结石患者的结石成分及其中191例完整血生化及24h尿分析结果。结果 草酸钙结石195例（68．7％），感染性结石41例（14．4％），尿酸结石38例（13．4％），磷酸盐结石6例（2．1％），胱氨酸结石4例（1．4％）。191例有完整血生化及24h尿分析结果患者中代谢异常176例（92．1％），其中高钙尿症27例（14．1％），高尿酸尿症54例（28．3％），高草酸尿症41例（21．5％），高尿磷55例（28．8％），低枸橼酸尿症128例（67．0％），低尿镁症80例（41．9％），24h尿量〈2000ml者65例（34．0％），高胱氨酸尿症4例（2．1％）。94例随访10～58个月，平均22个月。无泌尿系结石复发52例，复发42例，无复发组代谢无异常12例，复发组2例（P〈0．01），无复发组和复发组4种异常者分别为2例和7例（P〈0．01）。结论　结石复发与多种代谢异常关系密切；确定结石成分及患者的代谢评价对泌尿系结石的成因、治疗和预防有重要的临床意义。     

Ammonium urate urinary stones

Summary Until the last century, ammonium urate stones were quite common in preindustrial Europe. In contemporary practice these stones are found in developing countries, and are associated with uric acid and ammonium-enriched urine. Such conditions may occur with a) urealytic infection, resulting in mixed ammonium urate/magnesium ammonium phosphate precipitates and b) urinary phosphate deficiency of alimentary origin, resulting in precipitates free of magnesium ammonium phosphate, in sterile urine. The latter situation is closely related to a diet poor in phosphate and to a low fluid intake common in endemic lithiasis areas. Ammonium urate and uric acid have different solubility patterns dependent on pH, and consequently treatment will be different in each case.     

The role of the matrix substance in formation of urinary stones.

This study deals with the role of the stone matrix substance in formation of urinary stones. A series of coagulation experiments were conducted by determining the sedimentation rate of calcium carbonate suspension with respect to the following substances: sodium alginate, stone matrix substance, bovine albumin and chondroitin sulfate C, these were each added to a separate fine particle suspension of calcium carbonate. Changes in zeta-potential of the suspension particles after addition of the above materials were determined microscopically using Usui's method. The results obtained in this study indicate that sodium alginate, the matrix substance, bovine albumin and chondroitin sulfate C act on the suspension particles, and as a result, coagulation is produced by a decrease of the zeta-potential of the particles. Application of kinetic energy to the coagulate caused by sodium alginate resulted in the formation of a solid. From these results it is considered that the matrix substance is not incorporated by accident in urinary stones, but it participates in the formation of them.     

Economic impact of urinary stones

Kidney stones have been rising in prevalence in the United States and worldwide, and represent a significant cost burden. Cost effectiveness research in this area may enable improvements in treatment efficiency that can benefit patients, providers and the healthcare system. There has been limited research in the cost effectiveness of surgical interventions for stone disease, despite the diverse treatment approaches that are available. Medical expulsive therapy (MET) has been shown to improve rates of stone passage for ureteral stones, and there is evidence that this practice should be liberalized from the standpoint of both clinical and cost effectiveness. While conservative treatment following a primary stone event appears to be cost effective, the economic impact of medical therapy for recurrent stone formers requires clarification despite its clinical efficacy. Future study regarding the cost effectiveness of prevention and interventions for stone disease are likely to improve both the quality and efficiency of care.