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      A Proposed Grading System to Standardize the Description of Renal Papillary Appearance at the Time of Endoscopy in Patients with Nephrolithiasis

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          Abstract

          Background and Purpose: The appearance of the renal papillae in patients with nephrolithiasis can be quite variable and can range from entirely healthy to markedly diseased. The implications of such findings remain unknown. One potential reason is the lack of a standardized system to describe such features. We propose a novel grading scale to describe papillary appearance at the time of renal endoscopy.

          Methods: Comprehensive endoscopic renal assessment and mapping were performed on more than 300 patients with nephrolithiasis. Recurring abnormal papillary characteristics were identified and quantified based on degree of severity.

          Results: Four unique papillary features were chosen for inclusion in the PPLA scoring system— ductal Plugging, Pitting, Loss of contour, and Amount of Randall's plaque. Unique scores are calculated for individual papillae based on reference examples.

          Conclusions: The description and study of renal papillary appearance in stone formers have considerable potential as both a clinical and research tool; however, a standardized grading system is necessary before using it for these purposes.

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          Most cited references 20

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          Contemporary surgical trends in the management of upper tract calculi.

          Upper tract nephrolithiasis is a common surgical condition that is treated with multiple surgical techniques, including shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy. We analyzed case logs submitted to the ABU by candidates for initial certification and recertification to help elucidate the trends in management of upper tract urinary calculi.
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            Mechanisms of human kidney stone formation.

            The precise mechanisms of kidney stone formation and growth are not completely known, even though human stone disease appears to be one of the oldest diseases known to medicine. With the advent of the new digital endoscope and detailed renal physiological studies performed on well phenotyped stone formers, substantial advances have been made in our knowledge of the pathogenesis of the most common type of stone former, the idiopathic calcium oxalate stone former as well as nine other stone forming groups. The observations from our group on human stone formers and those of others on model systems have suggested four entirely different pathways for kidney stone formation. Calcium oxalate stone growth over sites of Randall's plaque appear to be the primary mode of stone formation for those patients with hypercalciuria. Overgrowths off the ends of Bellini duct plugs have been noted in most stone phenotypes, do they result in a clinical stone? Micro-lith formation does occur within the lumens of dilated inner medullary collecting ducts of cystinuric stone formers and appear to be confined to this space. Lastly, cystinuric stone formers also have numerous small, oval, smooth yellow appearing calyceal stones suggestive of formation in free solution. The scientific basis for each of these four modes of stone formation are reviewed and used to explore novel research opportunities.
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              Three pathways for human kidney stone formation.

              No single theory of pathogenesis can properly account for human kidney stones, they are too various and their formation is too complex for simple understanding. Using human tissue biopsies, intraoperative imaging and such physiology data from ten different stone forming groups, we have identified at least three pathways that lead to stones. The first pathway is overgrowth on interstitial apatite plaque as seen in idiopathic calcium oxalate stone formers, as well as stone formers with primary hyperparathyroidism, ileostomy, and small bowel resection, and in brushite stone formers. In the second pathway, there are crystal deposits in renal tubules that were seen in all stone forming groups except the idiopathic calcium oxalate stone formers. The third pathway is free solution crystallization. Clear examples of this pathway are those patient groups with cystinuria or hyperoxaluria associated with bypass surgery for obesity. Although the final products may be very similar, the ways of creation are so different that in attempting to create animal and cell models of the processes one needs to be careful that the details of the human condition are included.
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                Author and article information

                Journal
                J Endourol
                J. Endourol
                end
                Journal of Endourology
                Mary Ann Liebert, Inc. (140 Huguenot Street, 3rd FloorNew Rochelle, NY 10801USA )
                0892-7790
                1557-900X
                01 January 2016
                : 30
                : 1
                : 122-127
                Affiliations
                [ 1 ]Department of Urology, Indiana University School of Medicine , Indianapolis, Indiana.
                [ 2 ]Department of Anatomy and Cell Biology, Indiana University School of Medicine , Indianapolis, Indiana.
                [ 3 ]Section of Nephrology, The University of Chicago , Chicago, Illinois.
                Author notes

                Accompanying video published in Videourology (VID-2015-0023; vol. 29, issue 6; see www.liebertpub.com/vid).

                Address correspondence to: James E. Lingeman, MD, FACS, Indiana University School of Medicine 1801 North Senate Blvd., Suite 200, Indianapolis, IN 46202, E-mail: jlingeman@ 123456iuhealth.org
                Article
                PMC4744462 PMC4744462 4744462 10.1089/end.2015.0298
                10.1089/end.2015.0298
                4744462
                26414908
                Copyright 2016, Mary Ann Liebert, Inc.
                Page count
                Figures: 4, Tables: 2, References: 21, Pages: 6
                Categories
                General Research

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