RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCESBENGALURU, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECTFOR DESSERTATION

1 Name of the candidate and address

Lighty.P.A

I year M.Sc(N)

Koshys College of Nursing,

Sy.No.31/1, Hennur-Bagalur Road,

Kadusonnappanahalli,

Kannur Post,

Bengaluru- 562149

2 Name of the institution

Koshys College of Nursing

3 Course of study and subjectI year M.Sc. Nursing

Medical and Surgical Nursing

4 Date of admission

16- 06-2009

5 Title of the topic

“ A study to determine the knowledge on

prevention of urinary calculi among clients in

selected urology Hospital of Bangalore with a

view to prepare a Self Instructional Module”.

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6. BRIEF RESUME OF THE INTENDED WORK. INTRODUCTION

“My help comes from the LordThe maker of Heaven and Earth.”

- Psalms 121:2-

The word "calculus" in Latin means "a pebble." Pebbles were once used for counting, from which came the

mathematical field of calculus. A urinary calculus is a pebble in the urinary system.

If you have ever experienced passing a kidney stone, it’s not likely that you will ever forget it – it can be that

agonizingly painful! Kidney stones, also known as renal calculi or renal stones, have afflicted us humans since

ancient times, and can be traced back to the era of the Egyptian pyramids, and yet, they are still as common today.

However, it has been observed that kidney stone incidences have been on the rise in recent decades. Although it is

not clear what exactly the reasons are for this, most experts agree that lack of fluids and dietary choices are

important contributory factors for the increase.

The kidneys are bean-shaped organs, which are located on either side of the spine in the rear side of the

abdomen. Their chief function is removing waste from the blood, inessential electrolytes, and surplus fluid in the

form of urine. The urine is carried from the kidneys to the bladder via the ureters. The urine is stored in the bladder

until it is eliminated from the body.

Usually, kidney stones form when the urine becomes concentrated to a great extent. This results in minerals,

along with other substances, to form into crystals, which occur in the inner surface of the kidneys. In time, these

crystals have the tendency to combine, forming a hard, small mass, or a kidney stone. The crystals that become

kidney stones have a propensity of forming when the urine has high concentrations of particular substances such as

uric acid, oxalate, calcium, and sometimes, cystine. Kidney stones can also form if the body has low levels of

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magnesium and citrate, which help in preventing crystal formation. Crystals can also form if the urine is too

alkaline, or too acidic, or if it becomes too concentrated.

Urolithiasis is the medical term used to describe stones occurring in the urinary tract. Other frequently

used terms are urinary tract stone disease and nephrolithiasis

Certain foods may promote stone formation in people who are susceptible, scientists do not believe that

eating any specific food causes stones to form in people who are not susceptible. A person with a family history of

kidney stones may be more likely to develop stones. Urinary tract infections, kidney disorders such as cystic kidney

diseases, and certain metabolic disorders such as hyperparathyroidism are also linked to stone formation.

In addition, more than 70 percent of people with a rare hereditary disease called renal tubular acidosis

develop kidney stones. Causes of kidney stones are hyperuricosuria, which is a disorder of uric acid metabolism;

gout; excess intake of vitamin D; urinary tract infections; and blockage of the urinary tract. Certain diuretics,

commonly called water pills, and calcium-based antacids may increase the risk of forming kidney stones by

increasing the amount of calcium in the urine. Kidney stones often do not cause any symptoms. Usually, the first

symptom of a kidney stone is extreme pain, which begins suddenly when a stone moves in the urinary tract and

blocks the flow of urine. Typically, a person feels a sharp, cramping pain in the back and side in the area of the

kidney or in the lower abdomen. Sometimes nausea and vomiting occur. Later, pain may spread to the groin.

If the stones are small, they will often pass out of the body unnoticed. Often, kidney stones are found on

an x ray or ultrasound taken of someone who complains of blood in the urine or sudden pain. These diagnostic

images give the doctor valuable information about the stone’s size and location. Blood and urine tests help detect

any abnormal substance that might promote stone formation

Doctor may decide to scan the urinary system using a special test called a computerized tomography (CT)

scan or an intravenous pyelogram (IVP). The results of all these tests help determine the proper treatment.

Surgery is not usually necessary. Most kidney stones can pass through the urinary system with plenty of water—2 to

3 quarts a day—to help move the stone along. Often, the patient can stay home during this process, drinking fluids 3

and taking pain medication as needed. The doctor usually asks the patient to save the passed stone(s) for testing. It

can be caught in a cup or tea strainer used only for this purpose

Extracorporeal lithotripsy (262 cases) is mainly indicated in pelvic and calyceal stones measuring less than

2.5 cm, stones located in the lumbar ureter and previously flushed, and some stones of the pelvic ureter.

Percutaneous nephrolithotomy now has very few indications but remains useful in large pelvic stones,

(Tolley & Segura, 2001). Analysis of results showed that extracorporeal lithotripsy achieved fragmentation in

80% of cases and complete elimination 3 months after the procedure in 70% of cases. Repeat procedures were

needed in 23% of patients. Complementary procedures were required to relieve obstruction in 4% of patients.

Open surgery (24 cases) is still useful for complex staghorn stones, soft stones in febrile patients, calyceal

stones with destruction of the neighboring renal parenchyma, incarcerated lumbar stones, and stones associated with

an obstructive malformation of the urinary tract. Ureteroscopy (69 cases) proved highly reliable in stones located in

the pelvic ureter. An improvement, therefore, but no miracle. Recent technological advances allow stones to be

treated with less-invasive methods, including extracorporeal shock wave lithotripsy, ureteroscopic and percutaneous

procedures. While many stones usually pass without intervention, approximately 10% to 20% will require

intervention for removal .

Surgical management of stones becomes necessary in the setting of symptomatic calculi, urinary tract

obstruction, staghorn calculi (symptomatic or asymptomatic), stones in high-risk patients for infection (for example,

transplant or immunocompromised patients) . During the past 20 years, advances in imaging modalities, and

endoscopic devices and shock wave lithotripsy led to significant improvements in the management of stones.

Prevention of progressive or recurrent stone formation is best managed by diet, adequate fluid intake, and in

some cases, dietary supplements or medications. Comprehensive management of urinary lithiasis necessitates

collaboration between the urologist, urology health care professionals, and medical colleagues that possess

knowledge of medical prevention of urinary calculi.

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6.1 NEED FOR THE STUDY.

An epidemiologic study reveals that the occurrence of urolithiasis in the nineteenth century population in

Europe is quite similar to that of the twentieth century in Asia. The analogy is demonstrated for age distribution,

stone localization, male/female ratio, and stone composition. The distribution of urolithiasis in a low socioeconomic

level population is defined by: more than 40% bladder stones, less than 20% female patients, less than 40% calcium-

oxalate stones, and more than 30% uric acid/urate stones. Typical for a population with a high level these

characteristics of urolithiasis are: highest frequency among adults, less than 10% bladder stones, more than 25%

female patients, more than 60% calcium oxalate stones, and less than 20% uric acid/urate stones.

In partially developed countries the incidental rates values fall in between (70.42%) male and 76 (29.56%)

female with male to female ratio of 2.3:1.The age ranged from 1 year to 80 with the mean of 25.8 years. The peak

incidence of upper urinary tract stones was in 20-30 years while lower urinary tract stones in both sexes were under

10 years.

Anatomical distribution of stone showed 116 (45.16%) renal, 21 (8.17%) ureteric, 108 (42%) bladder and 12

(4.66%) urethral calculi The commonest clinical presentation was that of pain in 67.31% of patients associated with

haematuria in 26.7% of cases. Clinical urinary tract infection (UTI) was in 15% and 8.9% of patients had

spontaneous stone passage (lithuria).

The symptoms of bladder outlet obstruction (BOO) including retention of urine were in 7% of cases.

Calculus anuria was in 1.9% of cases and 8.1% patients had asymptomatic stones. Bilithiasis (chole-nephrolithiasis)

was in 5% of cases Open stone surgery included 84 (32.68%) simple pylolithotomies, 15 (5.83%) extended

pylolithotomies, 6 (2.33%) pylolithotomies and pyloplasty, 5 (1.94%) nephrolithotomy, 6 (2.33%) nephrectomies,

21 (8.17%) uretrolithotomy, Cystolithotomy was 113 (43.96%) cystolithotomy, 2 (0.77%) urethrolithotomy and

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meatotomy in 5 (1.94%) of patients. Urolithiasis is increasing problem with high with high frequency of bladder

stones and male predominance in our part of Sindh province.

Certain foods may promote stone formation in people who are susceptible, scientists do not believe that eating

any specific food causes stones to form in people who are not susceptible. A person with a family history of kidney

stones may be more likely to develop stones. Urinary tract infections, kidney disorders such as cystic kidney

diseases, and certain metabolic disorders such as hyperparathyroidism are also linked to stone formation. In

addition, more than 70 percent of people with a rare hereditary disease called renal tubular acidosis develop kidney

stones.

Uric acid calculi develop with increased urine acidity (urine pH < 5.5), or rarely with severe hyperuricosuria

(urinary uric acid > 1500 mg/day [> 9 mmol/day]), which crystallizes undissociated uric acid. Uric acid crystals may

comprise the entire calculus or, more commonly, provide a nidus on which Ca or mixed Ca and uric acid calculi can

form. Cystine calculi occur only in the presence of cystiuria ,the presence of a UTI caused by urea-splitting bacteria

(eg, Proteus sp, Klebsiella sp). The calculi must be treated as infected Mg ammonium phosphate calculi (struvite,

infection calculi) indicate foreign bodies and removed in their entirety. Unlike other types of calculi, Mg ammonium

phosphate calculi occur 3 times more frequently in women.

Most people also complain of an intermittent dull ache in the area of the kidneys, or in the loin region, which

gets aggravated when there is movement and subsides when at rest. If the stone lodges in the ureter, it can lead to

severe pain. This pain can rise steadily, peaking in a few minutes, and radiating to the testis or labium, and the

flanks. Some of the other kidney stone symptoms are: Excessive sweating along with pallor occurring with

pain ,Nausea as well as vomiting ,Chills along with fever ,Cloudy or blood tinged urine ,Urine that smells foul , A

constant need to urinate

The Kidney Stone Treatment under experienced physicians and is known for its best deal for treatment, better

environment, friendly staff, and personal physicians to entertain each and every query asked by the patient.

Physicians take responsibility to cure their patients with utmost care and comfort6

India proves itself to be one of the best places for the Kidney Stone Treatment in the world. Varies Health

Group in India is becoming known for its international standard for health care delivery, success rates and service

levels. India has the technology and the skilled Physicians & Surgeons along with outstanding infrastructure and

professional management, nurses and paramedical staff to take on international competition. India is one of the

finest in Kidney Stone Treatment, adding recreational packages offered by Medical Tourism in India. The

urolithiasis is a growing disease because of the changes in dietary habits and in he general life style. Urolithiasis is

characterized by the recurrent clinical manifestation and possible effect of structural damage of the kidneys and of

the urinary tract ast well as the potential increase in systemic blood pressure these reasons, prevention of new

urolithiasis in patients, and in particular in those with high risk, appears to be clinically important

On account of above stated matters the researcher understood that appropriate care is very important for

healthy living through the prevention thus be always effective in the promotion of happy living.Thus it was a

motivation for the researcher to conduct this study.

6.2 REVIEW OF THE LITERATURE.

Review of literature is defined as a broad, comprehensive in depth, systematic and critical review of

scholarly publication, unpublished scholarly print materials, audiovisual materials and personal communications.

In this study the reviews of literature is presented under following headings:

a) Literature related to urinary calculi and its prevention.

b) Studies related to urinary calculi and its prevention.

Literature related to urinary calculi and its prevention.

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Allie Hamdulay (2006) described that the epidemiology of urolithiasis differs according to geographical

area and historical period: changing socio-economic conditions have generated changes in the incidence and type of

lithiasis in terms of both the site and the physical-chemical composition of the calculi. Reno-ureteral calculosis

typical of adult age and featuring mainly calcium oxalate and phosphate is currently more frequent in economically

developed countries, where the prevalence rate hovers between 4% and 20% and the annual incidence of

hospitalization for calculosis ranges from 0.03 to 0.1%. On the contrary "primitive" vesical calculosis is fairly

widespread in Asia, with calculi composed of ammonium urate and calcium oxalate. Vesical calculosis, due to

malnutrition in the very early years of life, is currently frequent in huge areas of Turkey, Iran, India, China,

Indochina and Indonesia, although the incidence is decreasing in proportion as social conditions gradually improve.

At the beginning of the 20th century primitive vesical calculosis was relatively frequent in Europe also, but in the

course of the last 100 years, there has been a gradual decrease in its incidence, while the reno-ureteral calculosis has

become more common. This trend definited as "stone wave" has been explained in terms of changing social

conditions and the consequent changes in eating habits.

Pinnock (2004) identifies that in Europe, Northern America, Australia, Japan, and, more recently, Saudi

Arabia affluence has spread to all social classes, and with it the tendency to eat "rich" food in large quantities.

Calcium oxalate and/or phosphate stones account for almost The analysis of 322 urinary calculi in adults by

microdissection, infrared spectromorphometry and microchemistry has shown that stones could be classified in

several groups according to their morphology and composition: 8 morphological types have been defined (2 for the

oxalic, 2 for the uric, 2 for the phosphatic and 2 for the cystinstones). Correlations between morphology and

composition have been established dividing the calculi into 10 categories, 4 for the pure forms and 6 for the mixed

forms; the total includes approximately 94% of the calculi analyzed. An 11th category gathering various lithiases

(rare or with multiple components) represents 6% of the cases. Moreover, the study of the localization of the

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component in stones emphasizes the high frequency of phosphates in the nucleus of oxalic lithiases: 80% in mixed

forms, in which the oxalate is the main constituent.

Tiselius HG ( 2003)The majority of stones can be treated with Surgery may be needed to remove the stone

or stones. There are several surgery options. One method involves removing stones through a small, lighted tube

called an endoscope. The endoscope can be passed through the urethra into the body. The urethra is the tube that

carries urine out of the body. The endoscope can then be advanced into the bladder or ureters to see the stone. The

stone can then be removed through the endoscope.

Rodgers AL (2003) In a type of endoscope is larger. It is inserted directly into the kidney through the skin of

the abdomen. Larger stones can one of these methods. If not, traditional or open surgery may be needed. About 90%

of stones 4 mm or less in size usually will pass spontaneously, however 99% of stones larger than 6 mm will require

some form of intervention. There are various measures that can be used to encourage the passage of a stone. These

can include increased hydration, medication for treating infection and reducing pain, and diuretics to encourage

urine flow and prevent further stone formation. Caution should be exercised in eating certain foods, such as starfruit,

with high concentrations of oxalate which may precipitate acute renal failure in patients with chronic renal disease.

Kok DJSome (2002) Types of stones can be dissolved with oral medications. Stones containing calcium

cannot be dissolved using medication. If this type of stone does not exit the body on its own, some other treatment

is required. One type of treatment is lithotripsy, which uses shock waves aimed at the kidney stones from outside

the body. The shock waves often break up the stones into small pieces. The small pieces can then be passed out of

the body in the urine.

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Khan SR (2002) In most cases, a smaller stone that is not symptomatic is often given up to four weeks to

move or pass before consideration is given to any surgical intervention as it has been found that waiting longer tends

to lead to additional complications. Immediate surgery may be required in certain situations such as in people with

only one working kidney, intractable pain or in the presence of an infected kidney blocked by a stone which can

rapidly cause severe complication.

Tsai FJ (2001) After treatment, the pain may return if the stone moves but re-obstructs in another location.

Patients are encouraged to strain their urine so they can collect the stone when it eventually passes and send it for

chemical composition analysis which will be used along with a 24 hour urine chemical analysis test to establish

preventative options.

Hsu CD (2001) Most kidney stones do not require surgery and will pass on their own. Surgery is necessary

when the pain is persistent and severe, in renal failure and when there is a kidney infection. It may also be advisable

if the stone fails to pass or move after 30 days. Finding a significant stone before it passes into the ureter allows

physicians to fragment it surgically before it causes any severe problems. In most of these cases, non-invasive

extracorporeal shock wave lithotripsy (ESWL) will be used. Otherwise some form of invasive procedure is required;

with approaches including ureteroscopic fragmentation (or simple basket extraction if feasible) using laser,

ultrasonic or mechanical (pneumatic, shock-wave) forms of energy to fragment the larger stones. Percutaneous

nephrolithotomy or rarely open surgery may ultimately be necessary for large or complicated stones or stones which

fail other less invasive attempts at treatment.

Chen HY (2000) Ureteral stents vary in length and width but most have the same shape usually called a

"double-J" or "double pigtail", because of the curl at both ends. They are designed to allow urine to drain around any

stone or obstruction. They can be retained for some length of time as infections recede and as stones are dissolved or

fragmented with ESWL or other treatment. The stents will gently dilate or stretch the ureters which can facilitate

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instrumentation and they will also provide a clear landmark to help surgeons see the stones on x-ray. Most stents can

be removed easily during a final office visit. Discomfort levels from stents typically range from minimal associated

pain to moderate discomfort. However, it isn't uncommon for patients to experience severe discomfort too,

especially upon removal of said stent. The use of ureteral stents is of particular significance in the treatment of

ureteral stones. Their use, non use, and circumstances peculiar to stents should be well understood in order to

maximize the benefits.

Ahmadkhan (2001) Uric acid calculi develop with increased urine acidity (urine pH < 5.5), or rarely with

severe hyperuricosuria (urinary uric acid > 1500 mg/day [> 9 mmol/day]), which crystallizes undissociated uric

acid. Uric acid crystals may comprise the entire calculus or, more commonly, provide a nidus on which Ca or mixed

Ca and uric acid calculi can form. Cystine calculi occur only in the presence of cystiuria the presence of a UTI

caused by urea-splitting bacteria (eg, Proteus sp, Klebsiella sp). The calculi must be treated as infected Mg

ammonium phosphate calculi (struvite, infection calculi) indicate foreign bodies and removed in their entirety.

Unlike other types of calculi, Mg ammonium phosphate calculi occur 3 times more frequently in women.

Studies related to urinary calculi and its prevention.

Chen WC, Chen HY, Wu HC, Wu MC, Hsu CD, Tsai FJ.(2003) stuied on Vascular endothelial growth factor

gene polymorphism is associated with calcium oxalate stone disease in Taiwan.Growth factor-related genes regulate

cell growth, differentiation and apoptosis in the kidney in response to cellular injury. One of the theories of stone

formation is that cellular injury, and thus growth factors, play a role. Growth factor-related gene polymorphisms

include the cytochrome P450c17alpha enzyme (CYP17) gene MspA I C/T polymorphism at the 5'-UTR promoter

region, the epidermal growth factor receptor (EGFR) gene Bsr I polymorphism (A to T) at position 2,073, and the

insulin-like growth factor-2 (IGF-2) gene Apa I A/G at exon 9. All four polymorphisms were used as genetic

markers in this study in the search for an association between stone disease and growth factor related genes. The

result revealed a significant difference between normal individuals and stone patients (P=0.0003, Fisher's exact test)

in the distribution of the VEGF gene polymorphism as well as an odds ratio of 1.30 (95% confidence

interval=0.993-1.715) per copy of the "T" allele. Whereas, the IGF-2, EGFR and CYP17 gene polymorphisms did 11

not reveal a significant association with stone disease.the investigeter conclude that the VEGF gene Bst U I

polymorphism is a suitable genetic marker of urolithiasis.

Curhan GC, Willett WC, Rimm EB, Stampfer MJ.(1993) Did a prospective study of dietary calcium and other

nutrients and the risk of symptomatic kidney stones in Boston. A high dietary calcium intake is strongly suspected of

increasing the risk of kidney stones. However, a high intake of calcium can reduce the urinary excretion of oxalate,

which is thought to lower the risk and the relation between dietary calcium intake with the risk of symptomatic

kidney stones in a cohort of 45,619 men, 40 to 75 years of age. After adjustment for age, dietary calcium intake was

inversely associated with the risk of kidney stones; the relative risk of kidney stones for men in the highest as

compared with the lowest quintile group for calcium intake was 0.56 (95 percent confidence interval, 0.43 to 0.73; P

for trend, < 0.001). After further adjustment for other potential risk factors, including alcohol consumption and

dietary intake of animal protein, potassium, and fluid. Intake of animal protein was directly associated with the risk

of stone formation those with the lowest, 1.33; 95 percent confidence interval, 1.00 to 1.77); potassium intake

(relative risk, 0.49; 95 percent confidence interval, 0.35 to 0.68) and fluid intake (relative risk, 0.71; 95 percent

confidence interval, 0.52 to 0.97) were inversely related to the risk of kidney stones. And the study concluded that

high dietary calcium intake decreases the risk of symptomatic kidney stones.

Zuckerman JM, Assimos DG. (2009) Studied on pathophysiology and medical management of Hypocitraturia in

Wake Forest University School of Medicine, Winston-Salem, NC. Low urinary citrate excretion is a known risk

factor for the development of kidney stones. Citrate inhibits stone formation by complexing with calcium in the

urine, inhibiting spontaneous nucleation, and preventing growth and agglomeration of crystals. Hypocitraturia is a

common metabolic abnormality found in 20% to 60% of stone formers. It is most commonly idiopathic in origin but

may be caused by distal renal tubular acidosis, hypokalemia, bowel dysfunction, and a high-protein, low-alkali diet.

Genetic factors, medications, and other comorbid disorders also play a role. Hypocitraturia should be managed

through a combination of dietary modifications, oral alkali, and possibly lemonade or other citrus juice-based

therapy. This review concerns the pathophysiology of hypocitraturia and the management of stone formers afflicted

with this abnormality.

Fazil Marickar YM.(2008) Presented a paper on the occurrence of cystine-related abnormality in the population

of stone patients reporting to the hospitals in Trivandrum, South India, India. Two thousand and eight hundred urine

samples from 1,300 patients attending the urinary stone clinic during the period 2004-2008 were assessed for

cystinuria by performing the nitroprusside test on the early morning urine and random samples on the day of

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attendance. Urinary deposits were also studied in all the patients. Stones retrieved from 800 stone patients were

analysed qualitatively and by Fourier Transform infra red (FTIR) spectroscopy. Cystinuria was identified in only

three patients. None of these patients showed cystine crystals. Three other patients out of the 1,300 showed presence

of cystine crystals in the urine deposit. FTIR spectroscopy of the stones retrieved from the patients showed presence

of cystine in 19 out of the 800 stones analysed (2.375%). It was concluded that all the patients who had positive

cystine, cystine crystals or cystine in stone analysis had other biochemical abnormalities. They were medically

managed with appropriate biochemical corrective chemotherapy and had control of stone disease process. From the

study it was found that cystinuria is a rare entity in South India. It, however, exists in a small percentage of stone

patients.

Sweeney DD, Tomaszewski JJ, Ricchiuti DD, Averch TD.(1996) Performed a study to findout the effect of

carbohydrate-electrolyte sports beverages on urinary stone in Pennsylvania, USA. Gatorade consumption in both

study group increased urinary pH (p = 0.006), urinary chloride (p = 0.044) and urinary sodium (p = 0.008), and

decreased urinary potassium (p = 0.035) and urinary uric acid (p = 0.019) in a statistically significant manner. In

response to Gatorade consumption urinary volume, calcium and citrate were unchanged compared to water

consumption and baseline. The study concluded that Gatorade increased mean urinary sodium and chloride levels

compared to water and baseline.

Sun WD, Zhang KC, Wang JY, Wang XL.(1996) Conducted a experimental study to asses the chemical

composition and ultrastructure of uroliths on Boer goats in China. Male Boer goats were studied using qualitative

chemical analysis, scanning electron microscopy, X-ray diffraction, X-ray energy dispersive spectrometry and

Fourier transform infra-red spectroscopy. The results indicated that the major component of urinary calculi collected

from naturally-occurring and experimentally-induced cases of urolithiasis was struvite (magnesium ammonium

phosphate). The study also identified previously unreported prismatic crystals in the uroliths of goats, similar to

struvite but rich in potassium. The characteristic ultrastructure of struvite uroliths is described along with a brief

discussion of their formation.

um stone formation is still possible.

Bergsland KJ, Coe FL, Gillen DL, Worcester EM.(2009) A studied the hypothesis that the collecting duct

calcium-sensing receptor limits rise of urine calcium molarity in hypercalciuric calcium kidney stone formers in

USA. High deliveries of calcium into the IMCD would be predicted to activate CaSR, leading to reduced membrane

abundance of aquaporin-2, thereby limiting water conservation and protecting against stone formation. We have 13

tested this hypothesis in 16 idiopathic hypercalciuric calcium stone formers and 14 matched normal men and women

in the General Clinical Research Center. Subjects were fed identical diets; we collected 14 urine samples at 1-h

intervals during a single study day, and one sample overnight. Hypercalciuria did not increase urine volume, so

urine calcium molarity and supersaturation with respect to calcium oxalate and calcium phosphate rose

proportionately to calcium excretion. Thus CaSR modulation of urine volume via IMCD CaSR activation does not

appear to be an important mechanism of protection against stone formation.

Hess B, Ryall RL, Kavanagh JP, Khan SR, Kok DJ, Rodgers AL, Tiselius HG (1998) studied on the

Methods for measuring crystallization in urolithiasis in Switzerland. kidney stone formation is a pathologic incident

and reflects a specific form of biomineralization. crystal formation in the urinary tract is distinguished from stone

formation in the kidney by the process of particle retention. This overview aims at critically reviewing the principles

of currently available assay systems for studying crystallization processes involved in stone formationt carefull

designed in vitro studies will always play an important part in urolithiasis research for such studies, it is highly

important to exactly control the appropriate experimental conditions that are relevant to a specific crystallization

process under investigation. Practical guidelines for researchers working with crystallization systems, and the

conducted concluded that international efforts should be made to standardize the terminology a set of basic

experimental parameters (temperature, pH, artificial urine composition), and to adopt simple tests or conditions are

reference points for quality and comparative control.

Fleming DE, Van Riessen A, Chauvet MC, Grover PK, Hunter B, van Bronswijk W, Ryall RL(2003) Studied

on Intracrystalline proteins and urolithiasis inAustralia. The existence of intracrystalline proteins and amino acids in

calcium oxalate monohydrate was demonstrated by X-ray synchrotron diffraction studies. Their presence has

implications for the destruction of calcium oxalate crystals formed in the urinary tract and the prevention of kidney

stones. crystals were grown in human urine and in aqueous solutions containing either human prothrombin (PT),

Tamm-Horsfall glycoprotein (THG), aspartic acid (Asp), aspartic acid dimer (AspAsp), glutamic acid (Glu),

glutamic acid dimer (GluGlu), or gamma-carboxyglutamic acid (Gla). Controls consisted of COM crystals

precipitated from pure inorganic solutions or from human urine that had been ultrafiltered to remove

macromolecules. Synchrotron X-ray diffraction with Rietveld whole-pattern peak fitting and profile analysis was

used to determine nonuniform crystal strain and crystallite size in polycrystalline samples. It was CONCLUDED

that the Selected proteins and amino acids associated with COM crystals are intracrystalline. The mineral bulk

would be expected to affect the rate of crystal growth, they also have the potential to influence the phagocytosis and

intracellular destruction of any crystals nucleated and trapped within the renal collecting system.

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Worcester EM, Coe FL, Evan AP, Parks JH.(1998) Performed a Study on reduced renal function and

benefits of treatment in cystinuria in ASIA. The study included cystine stone formers and routine stone formers; the

former group had a higher requirement for therapeutic procedures, but this was less if they took chelating agents. All

patients had three 24-h urine and blood samples taken to determine the risk of stones before their first clinic visit;

these studies were repeated after therapy was initiated, and at regular intervals to monitor therapy. Cystine was

measured in the urine samples of the cystine SF. All stone-related procedures were recorded, and BP measured at

clinic visits. Creatinine clearances (CCr) were calculated from each set of serum and urine values. Cystine

supersaturation (SS) was directly measured in 16 urine samples collected. The study result showed that Urine

volume and pH were significantly higher in cystine SF than in routine SF, both before and during treatment. Cystine

SS decreased during treatment, consistent with the increase in urine volume and decline in procedure rates during

treatment..

Miyaoka R, Monga M.(2009) Use of traditional Chinese medicine in the management of urinary stone disease

in USA the researcher assessed the evidence-based literature supporting the use of traditional Chinese medicine

Kampo herbal and Acupuncture in stone disease management. Kampo medicine in the treatment of stone disease are

described according to their in vitro and in vivo effects. They also reviewed the role of Acupuncture in urologic

clinical setting as well as its proposed mechanisms of action and results. RESULTS identified that Herbal medicine

has been proven to be free from side-effects and therefore suitable for long term use therapy. Its antilithic beneficial

effects include increased urinary volume, increased magnesium excretion, inhibitory activity on calcium oxalate

aggregation, inhibition of calcium oxalate nucleation and hydroxyapatite internalization, acupuncture, has shown to

be effective as a pre-treatment anxiolytic and analgesic during colic pain and extracorporeal shock wave lithotripsy

treatment, reducing the need for complementary sedative drugs. The investigator concluded that Chinese traditional

medicine is promising as regards its role in stone prevention.

Keeley FX Jr, Assimos DG.(2009) performed a Clinical trials on the surgical management of urolithiasis:

current status and future needs. Investigator reviewed the literature on the surgical treatment of urolithiasis. All

prospective, randomized trials on the surgical treatment of stone disease. Percutaneous nephrolithotomy (PNL) is

superior to shockwave lithotripsy (SWL) or open surgery in the treatment of staghorn calculi. For ureteral stones,

ureteroscopy appears to result in a higher stone-free rate and lower need for retreatment compared with SWL but has

a higher complication rate and increased hospital stay.

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Baumann JM.(1999) Did a Epidemiology study on stone prevention shows that stone formation in most

patients is only a sporadic event, probably resulting from a coincidence of different factors. The hypercalciuria,

hypocitraturia, hyperuricosuria and hyperoxaluria frequently found in calcium stone formers can be influenced

therapeutically and, in affluent societies, seem to be the result of protein over-consumption. In urine, crystallization

of calcium oxalate can only be induced by an extreme supersaturation, a deficient inhibitor activity and promoters of

crystallization. To form a stone, crystals have to be retained in the urinary collecting system. Two mechanisms of

retention are discussed: large crystal aggregates trapped in collecting ducts of renal papillae. It was found that an

excessive oxalate intake combined with a low calcium consumption can produce marked hyperoxaluria.

Hypercalciuria at a low pH favours the aggregation of calcium oxalate, and at a high pH the crystallization of

calcium phosphate, a promoter of heterogeneous nucleation of calcium oxalate. All these factors and further

complex phenomena mentioned in this paper have to be taken in account to perform rational stone metaphylaxis.

Van Drongelen J, Kiemeney LA, Debruyne FM, de la Rosette JJ.(1998) Performed a retrospective study on

the Impact of urometabolic evaluation on prevention of urolithiasis. Objectives of the study was to obtain

information on compliance to therapy and study its effect on recurrences. Over the past 20 years, a selective therapy

protocol has been formed for prevention of urolithiasis recurrence. Result identified that thirty-six percent of the

study population was still compliant to the prescribed therapy after a mean period of 5.3 years of follow-up, patients

were older and had more treatments, more lithiasis-related complaints.These characteristics suggest that patients'

awareness of their disease might improve compliance. Analyses showed that the stone recurrence rate was twice as

high among patients with a history of frequent stones compared with patients with a single stone episode,the.

CONCLUSIONS was the usefulness of urometabolic evaluation and subsequent therapy advice seems questionable.

Compliance to a life-long therapy is needed relatively short follow-up period .

Bardaoui M, Sakly R, Neffati F, Najjar MF, El Hani A.(1999) Conducted a study to identify the effect of vitamin

A supplemented diet on calcium oxalate renal stone formation on rats in Tuisia. Twenty-four male Wistar rats were

randomly divided into three groups of eight rats each. The first group (group A) received a normal diet for six

weeks. The second group (group B) was fed a lithogenic diet by the addition of ethylene glycol 0.5% to drinking

water for three weeks then a normal diet for three weeks. The third group (group C) received the same lithogenic

diet for three weeks then a vitamin A supplemented diet 20 times the normal amount (5.1mg/100g of diet) at the

three last weeks. One day before the end of treatment, each animal was placed for 24h in metabolic cage in order to

collect urine samples and determine the urinary parameters. Results showed that: The glomerular filtration rate and

the urinary excretion of citric acid which fell in group B have been restored in group C. The investigator identified

16

that a vitamin A supplemented diet at the rate of 20 times standard ration could improve the renal function by

restoring the glomerular filtration rate and by increasing the urinary pH and excretion of citric acid.

McNally MA, Pyzik PL, Rubenstein JE, Hamdy RF, Kossoff EH.(2006) Perform a empirical study on the

use of potassium citrate with the ketogenic diet to reduces kidney-stone incidence in USA. Polycitra K was

administered to 198 subjects preventatively overall, 4 (2.0%) of whom developed kidney stones, compared with 11

(10.5%) of 105 who did not receive Polycitra K (P = .003). Successful empiric administration of Polycitra K at KD

onset resulted in a kidney-stone incidence of 0.9% (1 of 106) compared with administration only because of

hypercalciuria, 6.7% (13 of 195; P = .02). Polycitra K resulted in less acidic urine (mean pH: 6.8 vs 6.2; P = .002).

The findings of the study concluded that oral potassium citrate is an effective preventive supplement against kidney

stones in children who receive the KD, achieving its goal of urine alkalinization. Universal supplementation is

warranted.

Rodgers A, Lewandowski S, Allie-Hamdulay S, Pinnock D, Baretta G, Gambaro G.(1991) Investigated

the effect of Evening primrose oil supplementation increases citraturia and decreases other urinary risk factors for

calcium oxalate urolithiasis in South Africa. Eight black and 8 white healthy male subjects ingested 1,000 mg

evening primrose oil (Natrodale, Kuils River, South Africa) daily for 20 days while following a free diet.

Arachidonic acid content was determined by a dietary questionnaire. On days 0, 10 and 20, and 4 days after protocol

24-hour urine samples were collected. Samples were analyzed using routine assays. It was concluded that evening

primrose oil alters membrane fatty acid composition, thereby inhibiting the modulation of protein kinases that lead

to hyperoxaluria. In regard to decreased calciuria we suggest that evening primrose oil modulates delta-5 and/or

delta-6-desaturase, thereby inhibiting the production of arachidonic acid and prostaglandin E2, which influence

calciuria.

Suki WN.(2007) Studied on the effects of diuretics with the kidney stone formation in Texas. They were related to

the shrinkage of extracellular (ECF) volume which signals the kidney to enhance filtrate absorption particularly in

the proximal tubule. Calcium excretion will return to the original elevated level, inspite of continued administration

of the diuretic, when a high salt intake were allowed. Study also showed the opposite, hypercalciuria can be

produced by mineralocorticoid administration if liberal salt intake were allowed, and is prevented by salt restriction.,

the high-ceiling diuretics, unlike the thiazides produce a major increase in Ca2+ excretion suggesting that they exert

their effects at a different site in the nephron, to dilute the concentration of urine by reducing the risk of stone

formation.

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6.3 STATEMENT OF THE PROBLEM

“ A study to determine the knowledge on prevention of urinary calculi among clients in selected urology

Hospital of Bengaluru with a view to prepare self instructional module “

6.4 OBJECTIVES OF THE STUDY.

The objectives of the study are to:-

a. Determine the knowledge on urinary calculi among the clients.

b. Identify the knowledge on prevention of urinary calculi.

c. Find the knowledge on urinary calculi and knowledge on prevention of urinary calculi.

d. Identify the association between the knowledge on urinary calculi and selected demographic variable (Age,

Sex, Education, Occupation, economic status, Food habits…)

e. Identify the association between the knowledge on prevention with selected demographic variable (Age, Sex,

Education, Occupation, economic status, Food habits…)

f. Preparing a self Instructional module.

6.5 HYPOTHESES

H1;- There is significant relationship between knowledge of urinary calculi clients in

selected hospital.

H2;- There is significant association between the knowledge of clients on urinary calculi and

its prevention with selected demographic variables.

6.6. 0PERATIONAL DEFINITION OF TERMS

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DETERMINE

To come to a decision concerning, the knowledge on prevention of urinary calculi, by investigation or

reasoning.

KNOWLEDGE

The fact, information and skills that a person has acquired through experience and education regarding

urinary calculi.

SELECTED DEMOGRAPHIC VARIABLES

It refers to the age, education, occupation, food include, exposures to sunlight, income of the family and source of

information.

6.7 ASSUMPTIONS

Clients have certain knowledge on urinary calculi and its prevention.

Self instructional module can improve the knowledge of adults regarding prevention of urinary calculi.

Restricting certain life style practices can reduce the risk of urinary calculi.

6.8 DELIMITATIONS

The study is delimited to,

Assessment of knowledge only as correct response to the items in the knowledge questionnaire.

Clients those who are admitted in the urology hospital.

Clients who can read and write English or Kannada.

Clients who are willing to participate.

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Clients available during the study period.

Study duration is limited to five weeks

7 MATERIALS AND METHODS

7.1 SOURCES OF DATA

Clients who are present in the selected urology hospital

7.2 METHOD OF DATA COLLECTION

Research method : descriptive study

Research design : Non experimental descriptive design.

Sampling technique : convenient sampling

Sample size : 60 patients from s elected urology Hospitals

Setting of the study : Selected urology hospitals at Bengaluru

7.2.1 CRITERIA FOR SELECTION OF SAMPLES

From selected urology hospitals at Bengaluru

Who can understand and speak or English or Kannada

Who are available at the time of data collection

Who are in the age group of 30 – 55 years

.Who are willing to participate in this study.

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EXCULUSION CRITERIA

This study excludes urinary calculi patients:-

Who are not willing to participate in the study.

Who are in the age above 55 years

Who can’t understand and speak English or Kannada.

Who are not available at the time of data collection.

7.2.2 DATA COLLECTION TOOL

A structural knowledge instructional module will be prepared to assess the knowledge regarding urinary calculi

among the patients. A planned teaching programme will be prepared on urinary calculi. Content validity of the tool

will be ascertained in consultation with guide and experts from various fields like medicine and nursing.

Reliability of the tool will be established by split half method. Prior to the study written permission will be obtained

from the concerned authority. Further consent will be taken from the samples regarding their willingness to

participate in the study. The proposed period of data collection will be August 2010.

7.2.3 DATA ANALYSIS METHOD.

Data analysis will be done by descriptive and inferential statistics. Frequency and percentage distribution will

be done to analyze demographic variables. Mean and standard deviation will be done to assess the knowledge

regarding urinary caculi .A’ t’ test will be done to compare the pre- test and post- test knowledge score of urinary

calculi among the clients in order to evaluate the effectiveness of the structured teaching programme .A chi- squre

21

test (X) will be done to find out association between the mean pre-test knowledge score with selected demographic

variables.

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7.3 DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON CLIENTS OR OTHER HUMAN OR ANIMALS.

YES. Only a planned teaching programme and a structured knowledge instructional module will be used . no

other intervention which causes any physical harm will be used in the study.

7.4 HAS ETHICAL CLRARANCE BEEN OBTAINED ?

YES. a. confidentiality and anonymity of the subjects will be maintained.

b. consent will be taken from the clients before the study.

c. A written permission from the concerned authority will be obtained prior to the study.

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8. REFERENCES

1. Rebentisch G, Berg W. Comparison of methods and guaranteeing quality of analysis of urinary calculi—5th

International Ring Test. Urol Int 1989;44:298-302.

1. Blijenberg BG, Wulkan RW, Zwang L, Liem TL, Leijnse B. Computergestütste Auswertung von

Röntgendiffractometrie-Analysen. J Clin Chem Clin Biochem 1987;25:719-722.

1. Rebentisch G, Berg W, Pirlich W, Hommann D. Assessment and maintenance of the quality of urolith analyses

in a comparison of methods. 4th International Ring Test to check quality. Int Urol Nephrol 1988;20:35-45.

1. Ng LM, Simmons R. Infrared spectroscopy. Anal Chem 1999;71:343-350.

1. Brown SD, Blank TB, Sum ST, Weyer LG. Chemometrics. Anal Chem 1994;66:315R-359R.

1. Gould N, Hallson PC, Kasidas GP, Samuell CT, Weir TB. Rapid computer-assisted infrared analysis of urinary

calculi using photoacoustic detection. Urol Res 1995;23:63-69.

1. Berthelot M, Cornu G, Daudin M, Helbert M, Laurance C. Diffuse reflectance technique for infrared analysis of

urinary calculi. Clin Chem 1987;33:780-783.

1. Oliver LK, Sweet RV. A system of interpretation of infrared spectra of calculi for routine use in the clinical

laboratory. Clin Chim Acta 1976;72:17-32

1. Hesse A, Gergeleit M, Schuller P, Moller K. Analysis of urinary stones by computerized infrared spectroscopy. J

Clin Chem Clin Biochem 1989;27:639-642

1. Hesse A, Sanders G. Atlas of infrared spectra for the analysis of urinary concrements 1988:192 George Thieme

Verlag Stuttgart. .

1. Lehmann CA, McClure GL, Smolen I. Identification of renal calculi by computerized infrared spectroscopy.

Clin Chim Acta 1988;173:107-116.

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1. Hesse A, Sanders G, Döring R, Oelichmann J. Infrarotspektroskopische Harnsteinanalyse. Automatisierte

Spektrenauswertung mit Hilfe de Factoranalyse. Frensenius Z Anal Chem 1988;330:372-373.

1. Volmer M, Bolck A, Wolthers BG, de Ruiter AJ, Doornbos DA, van der Slik W. Partial least-squares regression

for routine analysis of urinary calculus composition with Fourier transform infrared analysis. Clin Chem

1993;39:948-954.

1. Volmer M, Wolthers BG, Metting HJ, de Haan THY, Coenegracht PMJ, van der Slik W. Artificial neural

network predictions of urinary calculus compositions analyzed with infrared spectroscopy. Clin Chem

1994;40:1692-1697

1. Siegel SN, Castellan NJ, Jr. Nonparametric statistics for the behavioral sciences, 2nd ed 1988:58-64 McGraw-

Hill New York. .

62133. Rumelhart DE, Hinton GE, Williams RJ. Learning representation by backpropagation errors. Nature

1986;323:533-536

1. Bos A, Bos M, van der Linden WE. Artificial neural networks as tool for soft-modeling in quantitative analytical

chemistry: the prediction of water content of cheese. Anal Chim Acta 1992;256:133-144.

1. Smits JRM, Melssen WJ, Buydens LMC, Kateman G. Using artificial neural networks for solving chemical

problems. Chemom Intell Lab Syst 1994;22:165-189.

2. Bland JM, Altman DG. Statistical methods for assessing agreements between two methods of clinical

measurement. Lancet 1986;1:307-310

3. Funez AF, Cuerpo GE, Castellanos LF, Barrilero EA, Padilla AS, Palasi VJ. Epidemiology of urinary lithiasis in

our unit. Clinical course in time and predictive factors. Arch Esp Urol 2000;53:343-347.

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9 SIGNATURE OF THE CANDIDATE

10 REMARKS OF THE GUIDE This study helps clients to prevent Urinary calculi which are common in adults.

11 NAME AND DESIGNATION

11.1 GUIDE

11.2 SIGNATURE

11.3 HEAD OF THE DEPARTMENT

11.4 SIGNATURE

Mrs. Sheeba.A

Mrs. Sheeba.A

12 REMARKS OF THE PRINCIPAL Self Instructional module helps clients to

prevent Urinary calculi and lead a better

life.

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