Acute Stone Research Articles

Analgesic Prescribing Patterns for Acute Symptomatic Kidney Stones in Emergency Departments

Aksenov, Leonid I. BS; Wietsma, Ashley C. MD; Lipkin, Michael E. MD; Routh, Jonathan C. MD, MPH; Preminger, Glenn M. MD; Scales, Charles D. MD, MSHS Author Information

Early versus delayed laparoscopic cholecystectomy in acute gall stone induced pancreatitis

Early versus delayed laparoscopic cholecystectomy in acute gall stone induced pancreatitis

Serum procalcitonin level correlates with severity of acute cholecysitits

Introduction: The objective of this study is to evaluate the role of serum procalcitonin level (SPL) in predicting the severity of inflammation and presence of bacteremia in acute cholecystitis patients. Methods: One hundred and forty-five patients who underwent cholecystectomy for acute cholecystitis or gallbladder stones were included in this study. Blood samples were obtained in the emergency room before operation to determine complete blood count and SPL. Severity of cholecystitis was evaluated on the basis of the Tokyo Guidelines 2013 (TG13) and Parkland grading scale. Blood culture was carried out for the patients who presented fever and/or chilling. Results: According to TG13, there were 90 patients classified as grade 1 (mild), 44 as grade 2 (moderate), and 11 as grade 3 (severe). Based on Parkland grading scale, there were 21, 34, 31, 14, and 34 patients in grade 1, 2, 3, 4, and 5 group respectively. SPL was 0.5 ± 2.3, 6.0 ± 11.5, and 19.4 ± 25.8 in TG grade 1, 2, and 3, and the p value was <0.001. SPL in Parkland grade 1, 2, 3, 4, and 5 group was 0.2 ± 0.4, 1.5 ± 6.1, 4.8 ± 16.2, 20.4 ± 35.6, and 8.0 ± 15.7 repectively, and the p value was 0.008. Blood culture was carried out in 108 patients and 18 patients presented bacteremia. At the cutoff value of 0.48, SPL could predict the presence of bacteremia with sensitivity of 66.7% and specificity of 65.2%. Conclusions: SPL was helpful in predicting the severity of acute cholecystitis and was well correlated with TG13 severity assessment criteria and Parkland grading scale.

Pain is Independent of Stone Burden and Predicts Surgical Intervention in Patients with Ureteral Stones

Patients with obstructing ureteral stones typically experience sudden onset, severe pain. We examined the use of the NIH (National Institutes of Health) PROMIS® (Patient-Reported Outcome Measurement Information System) pain instruments in patients with acute ureteral stones. PROMIS pain measures were obtained from a complete cohort of patients who presented to a subspecialty kidney stone clinic after emergency department discharge. Patients were followed longitudinally through the course of care. Raw scores were translated into population normed T-scores with a T-score of 50 indicating the mean pain population in the United States. Objective and patient centered factors were evaluated with reference to T-score thresholds for pain intensity with 60 equal to 1 SD above the mean and pain interference with 70 equal to 2 SD. Multivariable logistic regression in 650 patients demonstrated an absent association between pain scores and stone size or location. Pain scores were associated with patient age, gender and emergency department pain scores (p<0.05). Initial stone surgery was predicted by a stone size less than 4 mm (OR 0.14, 95% CI 0.07-0.3), greater than 6 mm (OR 19.1, 95% CI 0.22-39.58), proximal location (OR 1.75, 95% CI 1.34-2.3) and pain intensity greater than 60 (OR 7.03, 95% CI 3.63-13.6) but not pain interference (p <0.001). Failed attempted stone passage was less likely for stones less than 4 mm (OR 0.26, 95% CI 0.14-0.48, p <0.001) and more likely for proximal stones (OR 1.61, 95% CI 1.21-2.14, p <0.01) and pain intensity greater than 60 (OR 2.74, 95% CI 1.23-6.07, p <0.05). PROMIS pain scores are independent of stone size and location. Attention to emergency department discharge symptom control offers the potential to improve patient care. PROMIS pain intensity is an independent predictor of surgical intervention in patients with ureteral stones 1 cm or less.

Salivary Neutrophil Gelatinase-Associated Lipocalin Sampling Feasibility in Acute Renal Colic.

Neutrophil gelatinase-associated lipocalin (NGAL) levels in the serum and urine are predictive biomarkers of acute kidney injury with correlation to complication and survival in major surgery. Salivary levels of NGAL during acute renal colic may reflect the degree of renal injury as it appears in different compartments encompassing body response in time perspective. Our aim is to evaluate and examine the feasibility and correlation of salivary NGAL with serum and urine levels in acute renal colic event. A prospective controlled study of all patients presenting to the emergency room with acute renal colic event diagnosed with single ureteral stone obstruction by noncontrast CT. Saliva, urine, and blood samples were collected in patients and a control group during the first morning of admission. The study groups consisted of 44 patients and 13 controls, mean age 47 ± 15 years, body mass index 29 ± 6, mean stone size 6 ± 4 mm, mean creatinine levels 1.3 ± 0.7 mg/dL, mean white blood count 10,900 ± 3100 counts per field, and C-reactive protein 29 ± 55. Serum (190 ± 120 ng/mL vs 81 ± 24; p < 0.001) and predominantly salivary (474 ± 185 vs 328 ± 134 ng/mL; p < 0.05) NGAL levels were significantly elevated in patients compared with controls. Salivary NGAL sampling is feasible during the acute phase of renal colic. High levels of salivary NGAL are observed in a single sampling during acute ureteral stone obstruction and may advance clinical decision-making.

Early experience of laparoscopic cholecystectomy in acutely inflamed gallbladder

Gallstones are now among the most important disease in the era of surgery. Definitive treatment of gall stone disease remains cholecystectomy. One of the common causes of emergency surgical referral is acute cholecystitis of which 50-70% cases are seen in the elderly patients.50 patients were treated with laparoscopic cholecystectomy from October 2013 to October 2015. The patient’s age was from 20 to 65 years old with a mean age of 34 ±3 years old. The patients received in the emergency unit and their attack not more than 72 hrs of acute gall stone inflammation were included in this study.From the 50 patients,15 were males (34%) and females were 35 (74%) so the ratio of 1:2of male to female. Problems and complications that facing in this study at time of laparoscopy were mainly adhesions to the adjacent structures like stomach, colon, and omentum. Adhesion into CBD also considered.Early intervention for acute cholecystitis of calculus type by laparoscopy now regarding safe and gold standard approach that should be kept in mind when dealing with such cases.

Renal effects of non-tenofovir antiretroviral therapy in patients living with HIV

A review of literature published regarding non-tenofovir antiretroviral agents causing renal adverse effects was conducted. The literature involving renal adverse effects and antiretroviral therapy is most robust with protease inhibitors, specifically atazanavir and indinavir, and includes reports of crystalluria, leukocyturia, nephritis, nephrolithiasis, nephropathy and urolithiasis. Several case reports describe potential nephropathy (including Fanconi syndrome) secondary to administration of abacavir, didanosine, lamivudine and stavudine. Case reports documented renal events such as acute renal failure, nephritis, proteinuria and renal stones with efavirenz administration. Regarding rilpivirine, a small increase of serum creatinine levels (SCr) was found in clinical trials; however, the clinical significance and impact on actual renal function is unknown. The integrase strand transfer inhibitors and enfuvirtide have a relatively safe renal profile, although studies have shown dolutegravir and raltegravir cause mild elevations in SCr without an impact on actual renal function. This is similar to the reaction observed with cobicistat, the pharmacokinetic enhancer frequently given with elvitegravir.

Urology Consultation and Emergency Department Revisits for Children with Urinary Stone Disease

We determined the association between urology consultation and emergency department revisits for children with urinary stones. This retrospective cohort study included patients 18years old or younger who presented to an emergency department in South Carolina with a urinary stone from 1997 to 2015. The primary exposure was urology consultation during the index emergency department visit. The primary outcome was a stone related emergency department revisit occurring within 180days of discharge from an index emergency department visit. Secondary outcomes included computerized tomography use, inpatient admission and emergent surgery. Of 5,642 index emergency department visits for acute urinary stones 11% resulted in at least 1 stone related emergency department revisit within 180days. Of revisits 59% occurred within 30 days of discharge and 39% were due to pain. The odds of emergency department revisit were highest within the first 48 hours of discharge home (OR 22.6, 95% CI 18.0 to 28.5) and rapidly decreased thereafter. Urology consultation was associated with a 37% lower adjusted odds of emergency department revisit (OR 0.63, 95% CI 0.44 to 0.90) and 68% lower odds of computerized tomography use across all emergency department visits (OR 0.32, 95% CI 0.15 to 0.69). Among patients who revisited the emergency department the frequency of pain complaints was 27% in those with a urological consultation at the index visit and 39% in those without. Urology consultation was associated with decreased emergency department revisits and computerized tomography use in pediatric patients with urinary stones. Future studies should identify patients who benefit most from urology consultation and ascertain processes of care that decrease emergency department revisits among high risk patients.

Emergency Department Switching and Duplicate Computed Tomography Scans in Patients With Kidney Stones

To test whether duplicate imaging relates to a lack of information sharing among providers, we measured the association between emergency department (ED) switching during a kidney stone episode and receipt of a repeat computed tomography (CT) scan. Using the MarketScan Commercial Claims and Encounters Database, we identified adults between the ages 18 and 64 with an ED visit for a diagnosis of kidney stones. Among patients who had an abdominal or pelvic CT scan at their initial encounter, we then determined the subset that made an ED revisit within 30 days of their first, distinguishing between those to the same vs a different ED. Finally, we fit multivariable logistic regression models to estimate the risk of receiving a repeat CT scan associated with ED switching. Twelve percent of patients who received a CT scan at their initial ED encounter had a revisit within 30 days of discharge. One-third of their revisits were made to a different ED than the index one. Duplicate CT scans were obtained at nearly 40% of all revisits. On multivariable analysis, the risk of receiving a repeat CT was 12% higher if this revisit was made to a different ED (risk ratio, 1.12; 95% confidence interval, 1.03-1.21; P = .010). Our study reveals that ED switching during an acute kidney stone episode is associated with higher levels of repeat CT imaging. These findings support the role of better health information exchange among providers to help reduce waste in the health-care system.

Percutaneous transcystic balloon dilation for common bile duct stone removal in high-surgical-risk patients with acute cholecystitis and co-existing choledocholithiasis

BackgroundPercutaneous procedures to treat common bile duct (CBD) stones typically require access via intrahepatic bile ducts. This study aimed to describe the outcomes of a percutaneous transcystic approach that expelled the CBD stones into the duodenum after percutaneous transcystic balloon dilation of the ampulla (PTCBDA) for high-risk patients who present with acute cholecystitis and CBD stones. MethodsPatients diagnosed with acute cholecystitis and CBD stones who were deemed too high-risk for surgery or general anesthesia and were treated with PTCBDA and CBD stone removal between March 2010 and November 2015 were included for further analysis. Patients underwent emergency percutaneous transhepatic gallbladder drainage under ultrasound. Staged PTCBDA and CBD stone expulsion were performed. Outcomes evaluated included the success rate, causes of failure, and complications. ResultsEighteen patients met the inclusion criteria. CBD stones were successfully expelled in 16 patients. A second procedure was performed in one patient because of residual stones. The procedure failed in two patients because their stones were large. One patient developed bile peritonitis and underwent percutaneous catheter drainage. DiscussionPercutaneous transcystic anterograde expulsion of CBD stones may be a feasible and effective method for treating high-risk surgical patients with acute cholecystitis and co-existing CBD stones.

Patient-Reported Outcomes in Nephrolithiasis: Can We Do Better?

Nephrolithiasis contributes significantly to the worldwide healthcare burden. Patient-reported outcome measures (PROMs) are widely recognized as important outcome measures for patient-centered care. We sought to summarize what is currently known about PROMs in urinary stone disease and to characterize use of PROMs in randomized controlled trials (RCTs) for nephrolithiasis. Health-related quality of life (HRQOL) in patients with nephrolithiasis is reviewed. A search of both MEDLINE and EMBASE databases for RCTs in nephrolithiasis was performed to assess utilization of PROMs in these trials. All searches were for articles published between 1990 and 2014. Two independent reviewers reviewed all abstracts to determine inclusion for full-text review, with disagreements reviewed by a separate arbitrator. Validated methods for collecting PROMs include symptom diaries, pain scales, and validated HRQOL instruments. HRQOL is impacted in patients with nephrolithiasis and may be related to gender, proximity of a recent colic episode, or treatment modality. One validated instrument has been created in the nephrolithiasis population, while a treatment-specific questionnaire on ureteral stents has also been developed. PROMs are variably reported in RCTs for nephrolithiasis. Few trials utilize validated HRQOL instruments and none utilizes a disease-specific instrument. HRQOL is diminished in patients with urolithiasis, especially in times near to an acute stone event. Only one validated HRQOL instrument exists specific to nephrolithiasis. No validated instrument exists to assess the outcomes from different management options for renal and ureteral stones. Development of condition-specific PROMs instruments should aim to account for the heterogeneous and episodic nature of the disease and its treatment. Effective reporting of PROMs is lacking in the RCTs for nephrolithiasis. Future RCTs for urolithiasis standardize reporting of PROMs.

59 - Simple plain XR KUB for all patients with acute ureteric stones: Optional or Necessity - Results from a University Hospital

59 - Simple plain XR KUB for all patients with acute ureteric stones: Optional or Necessity - Results from a University Hospital

The "Acute" Stone Clinic Effect: Improving Healthcare Delivery by Reorganizing Clinical Resources.

To determine the time to specialist urologic consultation and definitive management after establishing a subspecialist administered acute stone clinic (ASC) for adults with symptomatic upper tract stones in a publically funded universal healthcare system. We retrospectively reviewed 337 adult referrals for stone management. Three distinct 9-week periods were assessed. Group 1 patients were seen/treated by their individual urologist before inception of a general urology emergency clinic (pre-EC). Group 2 patients were seen in a pooled EC and Group 3 patients were seen in the ASC. A total of 337 patients (75, pre-EC; 91, EC; 171, ASC) were reviewed. Mean time to consultation for pre-EC, EC, and ASC cohorts was 29, 7, and 7 days, respectively (p < 0.05), whereas loss to follow-up decreased from 13% to 5% (p < 0.05). On average, the number of patients seen per week increased from 9 to 20. Mean time to stone surgery from date of referral was 75 days pre-EC, 43 days EC, and 25 days ASC (p < 0.05). The percentage of patients undergoing surgery was between 59% and 63% per cohort; however, the number of patients increased from 5 to 11 per week. By reorganizing clinical resources, a dedicated ASC was able to increase patient capacity, reduce time to urologist consultation and reduce surgical wait times.

Rational use of antibiotics and its guidelines in surgical patients-a retropspective study

Introduction: Rational use of drugs means to prescribe the appropriate drugs in correct dose over an adequate period of time at a lower cost. Irrational use of antibiotic is harmful both for the patient and the society and hence the top cause of mortality and morbidity around the world. So the aim of the present study is to - 1. Avoid adverse effect of irrational use of antibiotics on patient. 2. Avoid emergence of antibiotic resistance. 3. Avoid unnecessary increase of cost of health care. Methods: The study was conducted at the Surgery Unit II of the ESI-PGIMSR and ESIC Medical College, Joka, Kolkata- 700104, West Bengal. The Data was collected on random basis and the SSI was observed between the control and test group after rational and non rational treatment with antibiotics in some selected surgical patient. Results: It was found that in some diseases like acute gall bladder stone, cholecystitis, appendicitis, pancreatitis if some other antibiotics are additionally used besides the recommended as usual antibiotics the significant betterment is achieved in relation to quick recovery of the patients along with minimization of surgical site infection with no other complications. On the other hand in some other diseases like Diabetes foot, hernia, etc. use of antibiotics beyond the recommended antibiotics aggravates some other complications in the patients along with no significant betterment of surgical site infection in Test group. Conclusion: To conclude finally antibiotic resistance is a major problem worldwide and is inevitable and hence its rational use in proper guidelines is the only way of prolonging the useful life of the patients requiring antibiotics.

Pharmacologic interventions to treat renal colic pain in acute stone episodes: Systematic review and meta-analysis

To assess effectiveness of pharmacologic interventions to relieve pain in patients suffering an acute stone episode. Relevant trials that included patients with acute renal colic and radiological findings of urinary stones were identified in four databases. The main outcome was pain relief evaluated by Visual Analogue Scale score (VAS). In overall, diclofenac was superior to other NSAIDs for pain relief (MD of -12.57 [95% CI: -19.26, -5.88]). Paracetamol was superior to morphine for pain reduction at 30minutes (MD of -3.92 [95% CI: -6.41, -1.43]) and also to placebo at 15minutes (MD of -24.77 [95% CI: -33.19, -16.35]) and at 30minutes (MD of -16 [95% CI:-29, -2.96]) after drug administration. Finally, diclofenac was superior to paracetamol for pain reduction at 60 (MD of 6.60 [95% CI: 4.37, 8.83]) and 90minutes (MD of 3.4 [95% CI: 2.01, 4.79]). Diclofenac was superior to other NSAIDs and paracetamol for diminishing pain in patients suffering an acute stone episode. Paracetamol was superior to morphine and placebo for short pain relief. Future trials should address the role of paracetamol in the management of pain in patients suffering an acute stone episode.

Patient-Reported Outcomes Measurement System (PROMIS®) for Patients with Urolithiasis: Initial Report.

Health related quality of life is increasingly important in quality improvement efforts for medical conditions. However, it has proved challenging to measure health related quality of life for urolithiasis, given the distinct chronic and acute phases of this disease. We evaluated the use of PROMIS® (Patient-Reported Outcomes Measurement System) to assess the patient experience through acute stone episode stages. PROMIS pain measures (intensity and interference) were obtained from patients at a subspecialty kidney stone clinic. Four types of clinical encounters were considered, including emergency department followup, trial of passage, stent removal and 1-month postoperative findings. Raw scores were translated into population normed T-scores with a T-score of 50 considered the reference population mean and a score of 60 considered 1 SD above the mean. T-scores were compared across encounter types on univariate and multivariate analysis. A total of 2,018 complete surveys were available from 1,162 patients. Mean pain intensity and pain interference T-scores differed significantly by encounter type (p <0.001). On multivariate analysis the OR of T-scores greater than 60 was higher for pain intensity and interference for all encounter types relative to postoperative findings, including emergency department followup 37.9 vs 124.9, passage trial 5.4 vs 10.5 and stent removal 9.4 vs 30.2 (p <0.001). Additionally, female gender and younger age were independent risk factors for T-scores greater than 60. PROMIS pain measures are responsive to the phase of care during symptomatic stone events. Further application of this instrument holds great potential as a valuable tool to improve the quality of urolithiasis care.

Prevalence and complications of hypouricemia in a general population: A large-scale cross-sectional study in Japan.

BackgroundsHypouricemia was reported as a risk factor for exercise-induced acute renal injury (EIAKI) and urinary stones. However, the prevalence of kidney diseases among hypouricemic subjects has not been evaluated. This study was conducted to clarify the prevalence of hypouricemia and the association of hypouricemia with kidney diseases by using a large-scale Japanese population data.MethodsThis study is a retrospective cross-sectional study at the Center for Preventive Medicine, St. Luke’s International Hospital, Tokyo, Japan, and Sanin Rousai Hospital, Yonago, Japan. We analyzed the medical records of 90,143 Japanese subjects at the center in St. Luke’s International Hospital, Tokyo, and 4,837 subjects in Sanin Rousai Hospital, Yonago, who underwent annual regular health check-up between January 2004 and June 2010. We defined hypouricemia as serum uric acid level of ≤2.0 mg/dL. We checked the medical history of all the study subjects and compared the rates of complications including urinary stones and kidney diseases among those with or without hypouricemia.ResultsThe prevalence of hypouricemia was 0.19% in St. Luke’s International Hospital, Tokyo, and 0.58% in Sanin Rousai Hospital, Yonago. The prevalence of hypouricemia in women was larger than that in men both in Tokyo (0.31% vs 0.068%, p<0.001) and in Yonago (1.237% vs 0.318%, p<0.001). Among 172 hypouricemic subjects (30 men), the rates of previous urinary stones and kidney diseases (including nephritis/nephrosis) were 1.2% (3.3% men, 0.7% women) and 2.3% (10% men, 0.7% women), respectively. Hypouricemic men had a 9-fold higher rate of previously having kidney diseases compared to non-hypouricemic men (p<0.001). However, the rates of other diseases including urinary stones were not significantly different between the two groups.ConclusionsHypouricemia was associated with a history of kidney disease especially in men.

Single incision laparoscopic cholecystectomy with conventional instruments and ports: Initial experience at tertiary care public sector Hospital.

Objective:To find out safety and feasibility of single incision laparoscopic cholecystectomy (SLIC) using conventional instruments.Methods:This study was conducted at surgical department of LUMHS Jamshoro Pakistan from Jan: 2014 to Dec: 2015. All cases of symptomatic cholelithiasis that consented for laparoscopic surgery were included. The exclusion criteria were acute cholecystitis, acute gall stone pancreatitis, common bile duct stones and patients with co-morbid. A midline 3cm incision made supraumbilically and 10mm port placed. Two 5mm ports placed on either side of umbilicus slightly superior and laterally in or-der to triangulate. A 2/0 prolene suture placed through the infundibulum of the gall bladder to achieve retraction. The rest of the procedure is like standard 4 ports laparoscopic cholecystectomy.Results:Total no of cases were 50. The age ranged from 30-59 years (mean 35.20 years ±4.886.) There were 43(86%) females and 07(14%) males. The mean operating time was 80 minutes (range 50-120 ±16.020). Four (8%) cases were converted to standard four ports laparoscopic cholecystectomy due to bleeding and difficult dissection in Calot’s triangle. Minimal blood loss was observed during the procedure with no postoperative complications. The range of hospital stay was 1-2 days (mean 1.08 ±0.274).Conclusion:SILC is a safe and feasible procedure with conventional laparoscopic instruments without additional cost of single port and articulated instruments. The cosmetic results are excellent with minimal increase in the operating time.

An overview of kidney stone imaging techniques.

Kidney stone imaging is an important diagnostic tool and initial step in deciding which therapeutic options to use for the management of kidney stones. Guidelines provided by the American College of Radiology, American Urological Association, and European Association of Urology differ regarding the optimal initial imaging modality to use to evaluate patients with suspected obstructive nephrolithiasis. Noncontrast CT of the abdomen and pelvis consistently provides the most accurate diagnosis but also exposes patients to ionizing radiation. Traditionally, ultrasonography has a lower sensitivity and specificity than CT, but does not require use of radiation. However, when these imaging modalities were compared in a randomized controlled trial they were found to have equivalent diagnostic accuracy within the emergency department. Both modalities have advantages and disadvantages. Kidney, ureter, bladder (KUB) plain film radiography is most helpful in evaluating for interval stone growth in patients with known stone disease, and is less useful in the setting of acute stones. MRI provides the possibility of 3D imaging without exposure to radiation, but it is costly and currently stones are difficult to visualize. Further developments are expected to enhance each imaging modality for the evaluation and treatment of kidney stones in the near future. A proposed algorithm for imaging patients with acute stones in light of the current guidelines and a randomized controlled trial could aid clinicians.

Assessment of Urine Proteomics in Type 1 Primary Hyperoxaluria

Background: Primary hyperoxaluria type 1 (PH1) and idiopathic hypercalciuria (IHC) are stone-forming diseases that may result in the formation of calcium (Ca) oxalate (Ox) stones, nephrocalcinosis, and progressive chronic kidney disease (CKD). Poorer clinical outcome in PH1 is segregated by the highest urine (Ur)-Ox (UrOx), while IHC outcomes are not predictable by UrCa. We hypothesized that differences would be found in selected Ur-protein (PRO) patterns in PH1 and IHC, compared to healthy intra-familial sibling controls (C) of PH1 patients. We also hypothesized that the PRO patterns associated with higher UrOx levels would reflect injury, inflammation, biomineralization, and abnormal tissue repair processes in PH1. Methods: Twenty four-hour Ur samples were obtained from 3 cohorts: PH1 (n = 47); IHC (n = 35) and C (n = 13) and were analyzed using targeted platform-based multi-analyte profile immunoassays and for UrOx and UrCa by biochemical measurements. Results: Known stone matrix constituents, osteopontin, calbindin, and vitronectin were lowest in PH1 (C > IHC > PH1; p < 0.05). Ur-interleukin-10; chromogranin A; epidermal growth factor (EGF); insulin-like growth factor-1 (IGF-1), and macrophage inflammatory PRO-1α (MIP-1α) were higher in PH1 > C (p = 0.03 to p < 0.05). Fetuin A; IGF-1, MIP-1α, and vascular cell adhesion molecule-1 were highest in PH1 > IHC (p < 0.001 to p = 0.005). Conclusion: PH1 Ur-PROs reflected overt inflammation, chemotaxis, oxidative stress, growth factors (including EGF), and pro-angiogenic and calcification regulation/inhibition compared to the C and IHC cohorts. Many of the up- and downregulated PH1-PROs found in this study are also found in CKD, acute kidney injury, stone formers, and/or stone matrices. Further data analyses may provide evidence for PH1 unique PROs or demonstrate a poorer clinical outcome.