PARIS — How to adapt the management of urolithiasis in the elderly? During a round table organized during the 118th congress of the French Association of Urology (CFU2024), a geriatrician, a urologist and a nephrologist shared their point of view on the question knowing that, faced with a patient considered fragile, appropriate support must be put in place before surgical treatment with the aim of improving the prognosis [1].
To help these patients cope with invasive treatment and avoid a shift towards dependence, it is recommended in particular to apply upstream “nutritional and functional support, as well as management of comorbidities”, underlined the Dr. Cyrielle Rambaudgeriatrician at the Arnault Tzanck Institute, in Saint-Laurent du Var (83), during his presentation.
Acidification of urine
Stone disease is characterized by the formation of stones in the urinary tract, which usually manifests itself as renal colic. This pathology, which affects 10% of the population in France, is essentially linked to an overly rich diet and insufficient fluid intake. Uricolithiasis is more common in elderly patients.
To illustrate their presentations, the three speakers relied on the case of an 82-year-old patient seen in urology after the fortuitous discovery of a complex stone in an assessment carried out due to diffuse abdominal pain. The patient has several comorbidities, including cardiac arrhythmia, controlled diabetes, and controlled hypertension.
The CT scan reveals a large stone measuring 4.1 cm in length in the left kidney. Its density suggests a uric acid stone. 3D reconstruction makes it possible to determine a volume of 7 cm3i.e. an operating time for fragmentation by percutaneous nephrolithotomy estimated at 139 minutes or 280 minutes by uteroscopy.
“From the age of 60, there is an increase in the proportion of uric acid stones, which is specific to age, but also to the increase in comorbidities,” recalled the Dr. Camille Saint-Jacquesnephrologist at the Charles Mion Foundation, Montpellier (34). The risk of uric acid lithiasis is particularly increased with overweight and type 2 diabetes, which cause acidification of the urine.
Before considering an intervention, it is recommended to reduce the size of the stone by trying to dissolve it in order to have it expelled naturally. Medical care then involves the intervention of the nephrologist. “A metabolic assessment is first carried out to look for risk factors for lithiasis,” specifies Dr. Saint-Jacques.
Alkalization and increased diuresis
In cases of uric acid lithiasis, the urinary pH is generally below 5.5. Note: if the presence of uric acid is high in the blood (hyperuricemia), it conversely remains low in the urine. “The cornerstone of treatment is therefore to act first of all on the pH of the urine and not on the quantity of uric acid.”
Thus, in this patient, alkalization of the urine is first considered by consuming drinking water enriched with bicarbonate (Vichy Saint-Yorre, Célestins, etc.) or, failing that, by ingestion of bicarbonate capsules. sodium (material preparation or Bicafres® off-label). Potassium citrate can also help alkalize urine.
Unlike sodium chloride, “sodium bicarbonate has no effect on blood pressure balance,” said the nephrologist, who is often questioned about this potential risk. There is also no increased risk of calcium lithiasis. “Providing a little more sodium can increase calciuria, but in the elderly, calciuria tends to decrease.”
The objective of alkalization is to obtain a urinary pH of 6.5. “Beyond 7, the risk is to have the formation of other types of crystals around the stone, which then becomes impossible to dissolve.”
In addition to alkalinization, a dilution of uric acid should be sought by aiming for a diuresis > 2 liters/day. If uricuria turns out to be high, “we must look for dietary errors”, for example with too much fructose consumption. Treatment with a xanthine oxidase inhibitor may also be considered.
Stratify the risks associated with the intervention
In the event of failure, therapeutic abstention may be applied in the elderly, nevertheless considering the risk of renal failure and urinary infection, specified the Dr François-René Roustanurologist at the Urovar urology center, in Toulon (83), who presented the clinical case.
-According to a study carried out in patients aged 75 and over, conservative treatment of lithiasis is associated with a rate of deterioration in renal function at two years of 15%.[2]. Furthermore, urosepsis was involved in 7% of deaths.
In the elderly, treatment of lithiasis by percutaneous nephrolithotomy gives fairly similar results compared to younger patients. The intervention is therefore considered in this 82-year-old patient, but the opinion of the geriatrician is required to assess her condition before the operation, underlines the urologist.
Studies show that complications linked to percutaneous intervention tend to increase with age and comorbidities, but this option does not involve repeating the intervention, unlike fragmentation by ureteroscopy, added Dr. Rambaud.
According to the geriatrician, care is defined by the level of fragility of the elderly patient. “Geriatric assessment is a decision-making aid through risk stratification based on treatment. Above all, it aims to improve the prognosis through personalized support to have fewer complications.”
Three categories of patients
The evaluation is modeled on that used in oncogeriatrics. Patients are classified into three categories – dependent, frail or robust – based on their health status and associated comorbidities. “Frail patients represent around 40% of those over 65.”
The so-called robust patient does not present any comorbidity. “He can be treated like a younger patient.” If the stone size is greater than 2 cm, percutaneous intervention is recommended.
In patients presenting one or more frailty criteria (one or more comorbidities, difficulty walking, involuntary weight loss, reduced physical activity, muscle weakness, etc.), a suitable intervention should be offered before the operation to support the operation, including nutritional and functional support.
Concerning the dependent patient, symptomatic treatment is preferred due in particular to the risks of post-operative confusion, decompensation of comorbidities and loss of autonomy associated with surgical intervention.
In these patients, “the comorbidities often pose more problems than the stone disease” and treating them is not necessarily beneficial, believes Dr. Rambaud. They can find themselves bedridden for longer than expected, be malnourished, weaken and ultimately fall into dependence, says the geriatrician.
In the case of the 82-year-old patient, the assessment revealed a state of slight fragility, including difficulty walking linked to being overweight. “We can implement physiotherapy, adapt nutrition and ensure better management of comorbidities.”
She finally underwent percutaneous surgery. “The procedure went well without complications,” said Dr. Roustan. The hospitalization lasted three days. An additional uteroscopy had to be carried out on an outpatient basis to remove a second stone. Again, without major complications.
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