Renal complications and quality of life in postsurgical hypoparathyroidism: a case-control study.

PURPOSE: Conventional therapy (calcium and activated vitamin D) does not restore calcium homeostasis in patients with chronic hypoparathyroidism (HypoPT) and is associated with renal complications and reduced quality of life (QoL). The aim of this study was to evaluate in a case-control, cross-sectional study, the rate of renal complications and QoL in two sex- and age-matched cohort of patients with differentiated thyroid cancer with (n = 89) and without (n = 89) chronic post-operative HypoPT (PoHypoPT) and their relationship with the biochemical control of the disease. METHODS: Serum and urinary parameters, renal ultrasound and QoL were assessed by SF-36 and WHO-5 questionnaires. RESULTS: Forty-three (48.3%) PoHypoPT patients reported symptoms of hypocalcemia. Twenty-six (29.2%) patients were at target for all 6 parameters, 46 (51.6%) for 5. The most frequently unmet targets were gender-specific 24-h urinary calcium (44.9%) and serum calcium (37.1%). Serum phosphate, magnesium and 25(OH)D were in the normal range in > 90% of patients. Renal calcifications were found in 26 (29.2%) patients, with no correlation with 24-h urinary calcium. eGFR did not differ between patients and controls. Conversely, patients had a significant higher rate of renal calcifications and a lower SF-36, but not WHO-5, scores. SF-36 scores did not differ between PoHypoPT patients who were, or not, hypocalcemic. CONCLUSIONS: Our study shows that the rate of renal calcifications was higher in patients with PoHypoPT than in those without. This finding, together with the reduced QoL and the presence of hypocalcemic symptoms in about half patients, underscores that the treatment of chronic HypoPT with conventional therapy is suboptimal.

Two case reports of novel syndrome of bizarre performance of gastrointestinal endoscopy due to toxic encephalopathy of endoscopists among 181767 endoscopies in a 13-year-university hospital review: Endoscopists, first do no harm!

BACKGROUND: Although deficient procedures performed by impaired physicians have been reported for many specialists, such as surgeons and anesthesiologists, systematic literature review failed to reveal any reported cases of deficient endoscopies performed by gastroenterologists due to toxic encephalopathy. Yet gastroenterologists, like any individual, can rarely suffer acute-changes-in-mental-status from medical disorders, and these disorders may first manifest while performing gastrointestinal endoscopy because endoscopy comprises so much of their workday. CASE SUMMARIES: Among 181767 endoscopies performed by gastroenterologists at William-Beaumont-Hospital at Royal-Oak, two endoscopies were performed by normally highly qualified endoscopists who manifested bizarre endoscopic interpretation and technique during these endoscopies due to toxic encephalopathy. Case-1-endoscopist repeatedly insisted that gastric polyps were colonic polyps, and absurdly "pressed" endoscopic steering dials to "take" endoscopic photographs; Case-2-endoscopist repeatedly insisted that had intubated duodenum when intubating antrum, and wildly turned steering dials and bumped endoscopic tip forcefully against antral wall. Endoscopy nurses recognized endoscopists as impaired and informed endoscopy-unit-nurse-manager. She called Chief-of-Gastroenterology who advised endoscopists to terminate their esophagogastroduodenoscopies (fulfilling ethical imperative of "physician, first-do-no-harm"), and go to emergency room for medical evaluation. Both endoscopists complied. In-hospital-work-up revealed toxic encephalopathy in both from: case-1-urosepsis and left-ureteral-impacted-nephrolithiasis; and case-2-dehydration and accidental ingestion of suspected illicit drug given by unidentified stranger. Endoscopists rapidly recovered with medical therapy. CONCLUSION: This rare syndrome (0.0011% of endoscopies) may manifest abruptly as bizarre endoscopic interpretation and technique due to impairment of endoscopists by toxic encephalopathy. Recommended management (followed in both cases): 1-recognize incident as medical emergency demanding immediate action to prevent iatrogenic patient injury; 2- inform Chief-of-Gastroenterology; and 3-immediately intervene to abort endoscopy to protect patient. Syndromic features require further study.

Association Between Daily Water Intake and 24-hour Urine Volume Among Adolescents With Kidney Stones.

OBJECTIVE: To determine the association between daily water intake and 24-hour urine volume among adolescents with nephrolithiasis in order to estimate a "fluid prescription," the additional water intake needed to increase urine volume to a target goal. METHODS: We conducted a secondary analysis of an ecological momentary assessment study that prospectively measured daily water intake of 25 adolescents with nephrolithiasis over 7 days. We identified 24-hour urine volumes obtained for clinical care within 12 months of water intake assessment. A linear regression model was fit to estimate the magnitude of the association between daily water intake and 24-hour urine volume, adjusting for age, sex, race, and daily temperature. RESULTS: Twenty-two participants completed fifty-seven 24-hour urine collections within 12 months of the study period. Median daily water intake was 1.4 L (IQR 0.67-1.94). Median 24-hour urine volume was 2.01 L (IQR 1.20-2.73). A 1 L increase in daily water intake was associated with a 710 mL increase in 24-hour urine output (95%CI 0.55-0.87). Using the model output, the equation was generated to estimate the additional fluid intake needed fluid prescription (FP) to produce the desired increase in urine output (dUOP): FP = dUOP/0.71. CONCLUSION: The FP equation (FP = dUOP)/0.71), which reflects the relationship between water intake and urine volume, could be used to help adolescents with nephrolithiasis achieve urine output goals to decrease stone recurrence.

Variation in National Opioid Prescribing Patterns Following Surgery for Kidney Stones.

Background: Opioid misuse is a significant public health problem. As initial exposures to opioids are frequently encountered through the management of postoperative pain, we examined patterns of opioid prescribing following surgical treatment for nephrolithiasis. Methods: We identified patients with nephrolithiasis in the national Women Veterans Cohort Study (WVCS) who were treated surgically by diagnosis and procedure codes. Using standard conversion factors, we calculated the morphine milligram equivalent (MME) dose prescribed. We used descriptive statistics to characterize opioid prescription across management strategy and multivariable regression to examine clinical and demographic characteristics associated with dispensed dose. Results: We identified 22,609 patients diagnosed with kidney stones during 1999-2014, 1,976 of whom were treated surgically and 1,582 (80.1%) of whom received an opioid prescription. The median age was 39 years, and 1,366 (90%) were male; 1,314 (86.3%) were treated with ureteroscopy, 172 (11.3%) with extracorporeal shockwave lithotripsy, and 36 (2.4%) with percutaneous nephrolithotomy. The median number of days supplied per opioid prescription (interquartile range) was 10 (5-14), and patients were dispensed a median of 180 (140-300) MME. A total of 6.4% of patients received ≥50 MME/d. On multivariable analysis, comorbid diagnosis of post-traumatic stress disorder (PTSD) was associated with higher total dispensed dose, whereas surgery type was not. Conclusions: We observed substantial variation in opioid prescribing following surgical treatment of nephrolithiasis. Although type of surgical intervention did not impact opioid dosing, patients with a diagnosis of PTSD were more likely to receive higher doses. This work can inform efforts to improve the safety and efficacy of postoperative opioid prescribing.

Patient-Reported Outcomes in Nephrolithiasis: Can We Do Better?

PURPOSE: Nephrolithiasis contributes significantly to the worldwide healthcare burden. Patient-reported outcome measures (PROMs) are widely recognized as important outcome measures for patient-centered care. We sought to summarize what is currently known about PROMs in urinary stone disease and to characterize use of PROMs in randomized controlled trials (RCTs) for nephrolithiasis. MATERIALS AND METHODS: Health-related quality of life (HRQOL) in patients with nephrolithiasis is reviewed. A search of both MEDLINE and EMBASE databases for RCTs in nephrolithiasis was performed to assess utilization of PROMs in these trials. All searches were for articles published between 1990 and 2014. Two independent reviewers reviewed all abstracts to determine inclusion for full-text review, with disagreements reviewed by a separate arbitrator. RESULTS: Validated methods for collecting PROMs include symptom diaries, pain scales, and validated HRQOL instruments. HRQOL is impacted in patients with nephrolithiasis and may be related to gender, proximity of a recent colic episode, or treatment modality. One validated instrument has been created in the nephrolithiasis population, while a treatment-specific questionnaire on ureteral stents has also been developed. PROMs are variably reported in RCTs for nephrolithiasis. Few trials utilize validated HRQOL instruments and none utilizes a disease-specific instrument. CONCLUSIONS: HRQOL is diminished in patients with urolithiasis, especially in times near to an acute stone event. Only one validated HRQOL instrument exists specific to nephrolithiasis. No validated instrument exists to assess the outcomes from different management options for renal and ureteral stones. Development of condition-specific PROMs instruments should aim to account for the heterogeneous and episodic nature of the disease and its treatment. Effective reporting of PROMs is lacking in the RCTs for nephrolithiasis. Future RCTs for urolithiasis standardize reporting of PROMs.

[Psychological aspects of treating staghorn nephrolithiasis using percutaneous and retrograde nephrolithotripsy].

AIM: To investigate the level of anxiety and the severity of asthenic state in patients with staghorn nephrolithiasis treated by of minimally invasive therapies - percutaneous nephrolithotripsy (PNLT) and retrograde nephrolithotripsy (RNLT). PATIENTS AND METHODS: This study analyzed the psychological state of 150 patients with staghorn nephrolithiasis aged 25 to 75 years before and after PNLT and RNLT. Testing was performed at baseline, at 5-7 day of hospital stay (average time of preparing for surgery) and after treatment with the use of various questionnaires: Anxiety Scale, Asthenic conditions scale and Pain questionnaire. RESULTS: The follow-up findings shower positive changes, including reduction in the level of anxiety and severity of asthenia in patients of different age groups. The decrease in anxiety level and severity of fatigue was associated with decreased rates of neuropathic component of pain. CONCLUSION: The psychological state of patients with staghorn nephrolithiasis depends on the characteristics of minimally invasive methods of treatment and requires attending physicians and medical personnel to take into consideration the mental and emotional state of patients.

Heritability of dietary traits that contribute to nephrolithiasis in a cohort of adult sibships.

BACKGROUND: Kidney stones and their risk factors aggregate in families, yet few studies have estimated the heritability of known risk factors. OBJECTIVE: Estimate the heritability of dietary risk factors for kidney stones. METHODS: Dietary intakes were assessed using the Viocare Food Frequency Questionnaire in sibships enrolled in the Rochester, MN cohort of the Genetic Epidemiology Network of Arteriopathy. Measures of urinary supersaturation were determined using 24 h urine samples. Heritabilities and genetic correlations were estimated using variance components methods. RESULTS: Samples were available from 620 individuals (262 men, 358 women, mean (SD) age 65 (9) years). Dietary intakes of protein, sucrose, and calcium had strong evidence for heritability (p < 0.01) after adjustment for age, sex, height and weight. Among the significantly heritable dietary intakes (p < 0.05), genetic factors explained 22-50 % of the inter-individual variation. Significant genetic correlations were observed among dietary protein, dietary sucrose, and dietary calcium intakes (p < 0.001). CONCLUSIONS: Evidence from this relatively large cohort suggests a strong heritable component to dietary intakes of protein, sucrose and calcium that contributes to nephrolithiasis risk. Further efforts to understand the interplay of genetic and environmental risk factors in kidney stone pathogenesis are warranted.

Chronic stress and calcium oxalate stone disease: influence on blood cortisol and urine composition.

OBJECTIVE: To evaluate the influence of chronic stress (CS) on urine composition of calcium oxalate (CaOx) stone patients and controls. METHODS: This case-control study enrolled 128 patients during a period of 20 months. The cases were CaOx stone formers with a recent stone episode. Controls were matched by sex and age. Dimensions of CS were evaluated in cases and controls by validated self-report questionnaires measuring stressful life events, perceived stress, anxiety, depression, burnout, and satisfaction with life. Blood and urine samples were collected to determine cortisol levels and urinary composition. RESULTS: More relations between CS dimensions and blood and urine parameters were observed in cases than in controls. In cases, the blood cortisol level was related positively with the number of stressful life events (P = .03), intensity of these events (P = .04), and anxiety (P = .04). In addition, urinary magnesium (P = .03) and pyrophosphate (P = .05) levels were positively related with satisfaction with life and burnout, respectively. In contrast, urinary magnesium levels were negatively related with perceived stress (P = .01), anxiety (P = .016), and depression (P = .03). In controls, the number of stressful life events and the intensity of stressful life events was related positively with magnesium (P = .06, P = .02) levels and negatively with blood cortisol levels (P = .03, P = .004). CONCLUSION: Based on the variation between cases and controls in relations between CS dimensions and biochemical parameters, we hypothesize that CS may trigger a differential biological response in CaOx stone formers and controls, which in turn may promote or protect against CaOx stone formation.

Anxiety and depression symptoms in recurrent painful renal lithiasis colic.

Several studies have reported that symptoms of anxiety and depression are significantly associated with diseases characterized by painful crises. However, there is little information about the psychological aspects of recurrent painful episodes of renal stone disease. Our objective was to evaluate the association of symptoms of anxiety, depression and recurrent painful renal colic in a case-control study involving 64 subjects (32 cases/32 controls) matched for age and sex. Cases were outpatients with a confirmed diagnosis of nephrolithiasis as per their case history, physical examination, image examination and other laboratory exams. Patients had a history of at least two episodes within a 3-year period, and were currently in an intercrisis interval. The control group consisted of subjects seen at the Ophthalmology Outpatient Clinic of this University Hospital with only eye refraction symptoms, and no other associated disease. Symptoms of anxiety were evaluated by the State-Trait Anxiety Inventory and symptoms of depression by the Beck Depression Inventory. Statistically significant differences were observed between patients with nephrolithiasis and controls for anxiety state (P = 0.001), anxiety trait (P = 0.005) and symptoms of depression (odds ratio = 3.74; 95%CI = 1.31-10.62). The Beck Depression Inventory showed 34.5% of respondents with moderate and 6% with severe levels of depression. There was a significant linear correlation between symptoms of anxiety (P = 0.002) and depression (P < 0.001) and the number of recurrent colic episodes (anxiety-state: P = 0.016 and anxiety-trait: P < 0.001). These data suggest an association between recurrent renal colic and symptoms of both anxiety and depression.

Anxiety and depression symptoms in recurrent painful renal lithiasis colic

Several studies have reported that symptoms of anxiety and depression are significantly associated with diseases characterized by painful crises. However, there is little information about the psychological aspects of recurrent painful episodes of renal stone disease. Our objective was to evaluate the association of symptoms of anxiety, depression and recurrent painful renal colic in a case-control study involving 64 subjects (32 cases/32 controls) matched for age and sex. Cases were outpatients with a confirmed diagnosis of nephrolithiasis as per their case history, physical examination, image examination and other laboratory exams. Patients had a history of at least two episodes within a 3-year period, and were currently in an intercrisis interval. The control group consisted of subjects seen at the Ophthalmology Outpatient Clinic of this University Hospital with only eye refraction symptoms, and no other associated disease. Symptoms of anxiety were evaluated by the State-Trait Anxiety Inventory and symptoms of depression by the Beck Depression Inventory. Statistically significant differences were observed between patients with nephrolithiasis and controls for anxiety state (P = 0.001), anxiety trait (P = 0.005) and symptoms of depression (odds ratio = 3.74; 95 percentCI = 1.31-10.62). The Beck Depression Inventory showed 34.5 percent of respondents with moderate and 6 percent with severe levels of depression. There was a significant linear correlation between symptoms of anxiety (P = 0.002) and depression (P < 0.001) and the number of recurrent colic episodes (anxiety-state: P = 0.016 and anxiety-trait: P < 0.001). These data suggest an association between recurrent renal colic and symptoms of both anxiety and depression.