<prompt> All are indicated in a patient with cystinuria with multiple renal stones except:CysteamineIncrease fluid intakeAlkalinization of urinePenicillamine  <response>: Ans. a. Cysteamine Ref: Harrison 19e p1868, 1871, 18e p3221; Smith 17e p249-254; Campbell 10th1296-1302: Bailey 25e p1295-1300Patient with cystinuria with multiple renal stones should be treated with increase urine volume high fluid intake, alkalinization of urine Penicillamine and tiopronin.Cystinuria ARInheritance: Autosomal recessiveQMolecular defect: Shared dibasic cystine transporter SLC3A1, SLC7A9QTissue manifesting transport defect: Proximal renal tubule, jejunal mucosaQIndividual substrate: COLA Cystine, Ornithine, Lysine, ArginineQClinical features: Cystine nephrolithiasisQTreatment:Increase urine volumeQ high fluid intakeAlkalinization of urineQPenicillamineQ and tiopronin undergoes sulfhydryl-disulphide exchange with cystine to form mixed disulphides, since these disulphides are much soluble than cystine, pharmacologic therapy can prevent and promote dissolution of calculi.In the given image, which shows enveloped or bipyramidal crystals are seen in calcium oxalate dihydrate stones.Calcium oxalateCalcium oxalate monohydrateBrushiteEnveloped or bipyramidalQDumbbell or hourglassQNeedle shapedQ StruviteUric acidCystineCoffin lidQMultifaceted, irregular plates or rosettesHexagonal or benzene ringQTypes of Renal CalculiCalcium oxalate:MC type of kidney stone 85QRisk factors are hypercalciuria, hypercalcemia, hyperoxaluriaHave hard, small jagged surfaceUric acid stones:5-10 of all kidney stones, MC radiolucent urinary calculiQ, formed in acidic urinePatients with uric acid stones may have gout, myeloproliferative disorders or Lesch-Nehan syndrome hyperuricemiaUric Acid Stones ManagementCornerstone of treatment: Low purine diet hydration alkalization of urineQAllopurinolQ Inhibits conversion of hypoxanthine xanthine to uric addAcetazolamideQ may be added if urine pH is 6.5Struvite stones Infection stones:Composed of calcium, ammonium, magnesium phosphate Triple phosphate stonesQTend to grow in alkaline urineQ, especially with Proteus infection and fill whole of the PCS. forming staghorn calculiyQFormed in high urinary concentration of ammoniaMore common in womenQ increased susceptibility for UTIMost of the stag horn calculi are silentQ cause progressive destruction of renal parenchymaQ.Increased tendency to form struvite calculi is seen in: Foreign body in the urinary tract Foleys catheter Neurogenic bladderQ Bladder dysfunctionBladder outlet obstructionStruvite stones ManagementComplete stone removal Treatment of a metabolic abnormality Correction of any anatomic abnormalities contributing to stasisPCNLESWL best treatment optionQAntibiotics to prevent stone recurrences or growth after operative procedureAcetohydroxamic acid irreversible inhibitor of ureaseQ decreases likelihood of precipitationLow calcium, low phosphorus diet.Upto 50 of patient have stone recurrences or UTI over 10 years follow upCystine:Extremely hard stone, formed in acidic urineRelatively resistant to fragmentation by ESWLOccur in cystinuria with typical ground glass appearance with a round smooth outlineQTypical benzene or hexagonal cystine crystalsQ in urine.Cystine Stones ManagementStone removalTo lower cystine concentration in urine Low methionine diet alkalizationQCystine complexing agents: D- PenicillamineQ Alpha-mercaptopropionylglycine MPGQXanthine:Seen in xanthinuria, radioluscentQStones are smooth, brick red colored, round show lamination on cross sectionQ.Management: High fluid intake most effective therapy AllopurinolQIndinavir:A protease inhibitor used in AIDS patients, resulting in radioluscent calculiQ in 6 patients.Silicate: Associated with long term use of antacids containing silicaQTriamterene: Antihypertensive medication, leading to radioluscentQ stones 