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CHAPTER-I
ABSTRACT

Objective: To determine Sonographic comparison of bilateral versus unilateral renal stones with family history.
Methods: This was cross-sectional analytical study with sample size of 389 patients. Sampling techniques was non-probability convenient sampling. Study was performed in Haqqania Primary Healthy Clinic Radiology Section District Nowshera KPK Pakistan. Study period was 09 months after approval of synopsis. The target was to diagnose bilateral and unilateral renal stones patients with family history. Ultrasound Machine was used Toshiba Capasee II having frequency range from 50-60HZ for scanning technique. The data collection sheet was used to record observed data and individual patient personal data will not be published.
Result: Among the enrolled individuals for kidneys ultrasound patients with certain positive family history for bilateral and unilateral renal stones 118 (19.70 %) females and 480 (80.30%) male, mean age 34.76 ± 15.46 (1 to 60) years. In 600 patients the results shows that 367 patients were suffering from renal calculi due to family history and 230was negative cases.
Conclusion: Ultrasound is very useful for the detection of renal calculi. It is economical as compared to MRI and CT Scan. Easily approachable for Doctors and Patients also. Doppler ultrasound plays a key role in the diagnosis of renal calculi. Ultrasound technology is more affective as compared to other technologies for the diagnosis of renal diseases.
Key words: Ultrasound, Renal calculi, bilateral & unilateral.

CHAPTER – 2
INTRODUCTION

Renal calculi are tiny, solid crystals or deposits that form within your kidneys when salts and other minerals in your urine tie together 1. Renal calculi development progresses in consecutive steps. i) Nucleation: which is the stage of dissolved salts into a solid. Nucleation can be either homogenous when crystal precipitation happens unexpectedly in a supersaturated urine or heterogeneous when it produces at minor degrees of saturation in the presence of nucleating agents (i.e. cells, crystals, urinary proteins or components of the epithelial cells). ii) Retention of the initial nucleus in sites of the urothelium; iii) Crystal’s growth; iv) Crystal’s aggregation 2, 3.
Developing factors are those which develop the formation of renal calculi inside human body.
Stone developing factors are Calcium, Sodium, Oxalate, Urate, Cystine, Tamm-Horsfall protein and Low urine pH 4. Renal calculi inhibiting factors are (Inorganic: Citrate, Magnesium and Pyroophospate) whereas in organic Tamm-horsefall, proteae inhibitor, inter alpha inhibitor, unary prothrombin fragment I, Glyscossaminoglyeans, osteopontin (Uropoontin), Renal Lithsthatine, other bikunin, calgranulin and high urine flow 5.
Renal calculi are classified into 2 categories. Common types are: Calcium Oxalate, Calcium Phosphase, Uric Acid and Struvite Renal calculi. Uncommon types of renal calculi are, calcium carbonate, calcium citrate and ammonium urate. A variety of publications have focused on the possible effect of positive family history for the onset and recurrence as well as for the prevalence of urinary stones. However, the exact relationship between the familial predisposition and the stone formation in primary urolithiasis has been incompletely analyzed. Positive family history has been reported to be present in 17–37% of patients with stone disease when compared with 4–22% of normal healthy control subjects.6 In a well-designed epidemiological study, about 25% of patients with urinary stones have been found to be associated with a positive family history. In another study, it was demonstrated that stone-forming patients with positive family history were affected by the disease at younger ages. In a survey carried out in 380 patients in an outpatients’ stone clinic, a majority of the patients with a documented family history, had experienced frequent recurrences when compared with the others. While in 55.4% of patients at least one first-degree relative suffered from renal stones; positive family history was more common in females (64.7%) than males (51.0%) and in those who had multiple recurrences. In an evaluation of 214 calcium stone patients and 428 age and sex-matched controls; the authors observed a higher frequency of stone episodes among the first-degree relatives of stone patients compared with the relatives of controls. A family history of renal stones was more common among female (45%) and male patients (31%). Finally, the parents and siblings of renal stone patients with positive family history were found to have more calculi than the corresponding relatives of their spouses.7, 8
We aimed to evaluate the possible effect of positive family history on recurrent stone formation and compare the data with stone-forming patients without any positive family history. The overall incidence of positive family history in stone-forming patients was 27%. Female gender seemed to have higher incidence of positive family history than males. Male gender tended to be afflicted by the disease at younger ages than females, which was more pronounced for the cases revealing a positive family history.9 This finding is important because the involvement of one or more members of the family with stone disease may be a good predictor for the onset of the disease at younger ages in next generations. Another important parameter was the number of stone recurrences and the interval between these episodes. Evaluation of the patients with positive family history did clearly show that these patients tended to have higher recurrence rates in relatively shorter periods. Therefore, this finding makes the close follow-up of such cases mandatory. A total of 53.8% of patients with positive family history did have more than two stone episodes at the same period which was significantly higher than the patients without any family history.10
Separate evaluation of both sexes clearly showed that male gender was associated with higher number of stone episodes which might be caused by an earlier onset of the disease in that gender, possibly also associated with an increased biochemical risk. This finding has also been found to be in accordance with the data of many studies regarding the recurrence rates which in turn may emphasize the potential inhibitory role of female hormones in urinary stone formation.11
In the light of all these findings, the higher incidence of recurrences and the early onset of the disease in patients with family history of urolithiasis may lead the clinicians focus on genetic factors playing an important role in such patients as well as families.12
In the light of the multifactorial nature of urolithiasis, our findings show that in addition to dietary and lifestyle factors, a positive family history may also affect the onset as well as the course of urinary stone disease. Early onset of urinary stone formation along with the frequent stone episodes in such cases may make the positive family history predictive of the course of the stone disease and, therefore, these patients should be followed up closely to prevent future recurrences. We also believe that as an important epidemiological factor, a positive family history will add a new perspective to the evaluation and management of patients with urinary stone disease. This might be of particular value for those with severe recurrent stone formation.13
Ultrasound is a correct imaging technique to recognize renal calculi. In adding, this practice also allows the recognition of other types of kidney diseases. The discovery of renal calculi is based on the identification of calculi and the following obstacle of the excretory structure. While the finding of excretory tract is very useful in the perception of kidney, this mark should be observed carefully, as dilatation does not mean barrier, and the level of dilatation does not disclose the severity of barrier.14

ULTRASONIC KIDNEY STONE TEXTURE

Properties of stones in grey-scale and limitations: Stones are identified as hyperechogenic with consequent imaging. The most ordinary limitations of ultrasound are the finding of small renal calculi (

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