Friday, March 7, 2014

Kidney Stones in the Elderly

Historically kidney stones affect adults aged 20-60 years-old.  However, 10-20% of patients presenting with stones are >65 years-old and as the population ages and the older demographic increases, it is important to understand how to evaluate, treat and prevent kidney stones in this population.[1-4]  Especially as older patients have higher risk of infectious complications and overall morbidity following treatment of stones.[5]  Here we review the important epidemiology and clinical management considerations for the elderly patient with kidney stones.


Epidemiological Considerations


  • Historic estimates for stone disease in the elderly were 2%; contemporary estimates are closer to 12% (which is equivalent to the general population). [6]
  • Elderly patients are more likely to have bladder stones (due to benign prostatic hyperplasia and obstructive symptoms in men).
  • Stone size, laterality, location and recurrence rates do not vary with age.[3,7]
  • Among all age groups, men are two to three times more likely than women to develop kidney stones.  
    • Male predominance is most pronounced in middle-aged men (2.8x for age 5-59).
    • Male predominance decreases with age:
      • 2.49x compared to women for age 60-69
      • 2.23x for age 70-79
      • 1.8x for age 80-89
      • 1.6x for age 90 or greater [8]
    • Estrogens are known to have a protective effect on the formation of kidney stones and hypothesized to explain the narrowing of the gender-gap in post-menopausal age range.[9,10]

Clinical Presentation 

  • Struvite and uric acid stones are more common in older patients calcium and cysteine stones are less common.
    • Calcium stones: >80% of stones in patients 20-60 years-old; <50% in patients >80.[8]
    • Struvite stones: 2% age <30 years-old; >30% in patients >80.[3,8]
  • The most common metabolic profile in older patients is hypercalciuria, however elderly patients secrete less calcium than younger patients.[11]
    • Hypocitraturia and hypernatriuria are the most common abnormalities in elderly men.[12]
  • Elderly patients are more likely to: 
    • present without symptoms or with atypical symptoms (fever, pyuria, diarrhea).
    • have multiple comorbidities
    • have urinary tract infections and bacteremia
    • be hospitalized (2x)
  • Elderly patients are less likely to receive pain medications or medications for medical expulsive therapy.[7,13]

Preventive Therapies and Dietary Modifications in the Elderly

  • For elderly patients, low urine output and low fluid intake may contribute to stone formation.
    • Increased fluid intake (goal 2L urine daily) may lower the incidence of stone formation and decrease recurrence rates.[14,15]
  • To combat the hypocitraturia and hypernatriuria common in elderly men, decreasing salt and protein intake while increasing citrate intake will promote a balanced intracellular pH.
  • Vitamin C supplementation increases the risk of kidney stones in older men; compared to men who take <90mg/day:
    • men who take 250-500mg/day have a 20% increased risk of stones
    • men who take >1000mg/day have a 40% increased risk [16]
  • Many elderly patients have osteopenia and osteoporosis for which they take calcium supplementation.
    • It is well established that a diet of increased calcium and restricted animal protein and sodium decreases recurrence rates in known stone-formers,[17] however routinely checking 24-hour urinalyses may help balance the risks of bone disease and kidney stone formation.  
  • Weight reduction is a non-age-specific intervention that is proven to reduce stone formation.[18]

Treatment Considerations for Elderly Patients

  • Older patients are more likely to fail medical expulsive therapy.[13]
  • Complication rates of percutaneous nephrolithotomy (PCNL) can be significant and morbid in the elderly.
    • Transfusion rates were higher in the elderly, but have declined among all age groups over the past 20 years.[19-21]
    • Stone-free rates are similar among all age groups undergoing PCNL.[22-24]
  • Extracorporeal Shock Wave Lithotripsy (ESWL) has a 52-71% stone clearance rate in the elderly with low rates of major complications.[25,26]
  • Ureteroscopy and laser lithotripsy has a higher stone-free rate but higher complication rate in the elderly.[27]

Elderly patients are an increasing demographic in the management of kidney stones.  These patients can present with different symptoms, different stones and metabolic abnormalities than their younger counterparts and therefore warrant different consideration when applying behavioral and medical therapies.  In addition, the morbidity profile of PCNL, ESWL and ureteroscopy is different for the older patient and while each approach is valid, the risk-benefit profile should be considered on an individual basis.

Max Kates, MD
Brian Matlaga, MD
This blog entry is extracted from "Stones in the Elderly," which appears in Current Geriatric Reports, by Max Kates and Brian Matlaga.  The entire publication is available at link.springer.com.
Max Kates, MD is a resident at the Brady Urological Institute at Johns Hopkins.  Brian Matlaga, MD, is an Associate Professor of Urology, Director of Stone Disease and Director of Ambulatory Care at the Brady Urological Institute at Johns Hopkins.





1. Bartoletti R, Cai T, Mondaini N, et al. Epidemiology and risk factors in urolithiasis. Urol Int. 2007;79 Suppl 1:3–7. 
2. Knoll T, Schubert AB, Fahlenkamp D, Leusmann DB, Wendt-Nordahl G, Schubert G. Urolithiasis through the ages: data on more than 200,000 urinary stone analyses. J Urol. 2011;185:1304–11.
3. Usui Y, Matsuzaki S, Matsushita K, Shima M. Urolithiasis in geriatric patients. Tokai J Exp Clin Med. 2003;28:81–7.

4.Yoshida O, Terai A, Ohkawa T, Okada Y. National trend of the incidence of urolithiasis in Japan from 1965 to 1995. Kidney Int. 1999;56:1899–904.
5. Worcester E, Parks JH, Josephson MA, Thisted RA, Coe FL.Causes and consequences of kidney loss in patients with nephrolithiasis. Kidney Int. 2003;64:2204–13.
6. Gentle DL, Stoller ML, Bruce JE, Leslie SW. Geriatric urolithiasis. J Urol. 1997;158:2221–4.
7. Arampatzis S, Lindner G, Irmak F, Funk GC, Zimmermann H, Exadaktylos AK. Geriatric urolithiasis in the emergency department: Risk factors for hospitalisation and emergency management patterns of acute urolithiasis. BMC Nephrol. 2012;13:117-2369-13-117.
8. Daudon M, Dore JC, Jungers P, Lacour B. Changes in stone composition according to age and gender of patients: a multivariate epidemiological approach. Urol Res. 2004;32:241–7.
9. Heller HJ, Sakhaee K, Moe OW, Pak CY. Etiological role of estrogen status in renal stone formation. J Urol. 2002;168:1923–7.
10. Yasui T, Iguchi M, Suzuki S, et al. Prevalence and epidemiologic characteristics of lower urinary tract stones in Japan. Urology. 2008;72:1001–5.
11. Goldfarb DS, Parks JH, Coe FL. Renal stone disease in older adults. Clin Geriatr Med. 1998;14:367–81.
12. Freitas Junior CH, Mazzucchi E, Danilovic A, Brito AH, Srougi M. Metabolic assessment of elderly men with urolithiasis. Clin (Sao Paulo). 2012;67:457–61.
13. Krambeck AE, Lieske JC, Li X, Bergstralh EJ, Melton 3rd LJ, Rule AD. Effect of age on the clinical presentation of incident symptomatic urolithiasis in the general population. J Urol. 2013;189:158–64.
14. Curhan GC, Willett WC, Rimm EB, Stampfer MJ. A prospective study of dietary calcium and other nutrients and the risk of symptomatic kidney stones. N Engl J Med. 1993;328:833–8.
15. Borghi L, Meschi T, Amato F, Briganti A, Novarini A, Giannini A. Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized prospective study. J Urol. 1996;155:839–43.
16. Taylor EN, Curhan GC. Diet and fluid prescription in stone disease. Kidney Int. 2006;70:835–9.
17. Heaney RP. Calcium supplementation and incident kidney stone risk: a systematic review. J Am Coll Nutr. 2008;27:519–27.
18. Obligado SH, Goldfarb DS. The association of nephrolithiasis with hypertension and obesity: a review. Am J Hypertens. 2008;21:257–64.
19. Stoller ML, Bolton D, St Lezin M, Lawrence M. Percutaneous nephrolithotomy in the elderly. Urology. 1994;44:651–4.
20. Sahin A, Atsu N, Erdem E, et al. Percutaneous nephrolithotomy in patients aged 60 years or older. J Endourol. 2001;15:489–91.
21. Kuzgunbay B, Turunc T, Yaycioglu O, et al. Percutaneous nephrolithotomy for staghorn kidney stones in elderly patients. Int Urol Nephrol. 2011;43:639–43.
22. Kane CJ, Bolton DM, Stoller ML. Current indications for open stone surgery in an endourology center. Urology. 1995;45:218–21.
23. Matlaga BR, Assimos DG. Changing indications of open stone surgery. Urology. 2002;59:490–3. discussion 493-4.
24. Paik ML, Wainstein MA, Spirnak JP, Hampel N, Resnick MI. Current indications for open stone surgery in the treatment of renal and ureteral calculi. J Urol. 1998;159:374–8. discussion 378-9.
25. Sighinolfi MC, Micali S, Grande M, Mofferdin A, De Stefani S, Bianchi G. Extracorporeal shock wave lithotripsy in an elderly population: how to prevent complications and make the treatment safe and effective. J Endourol. 2008;22:2223–6.
26. Philippou P, Lamrani D, Moraitis K, Bach C, Masood J, Buchholz N. Is shock wave lithotripsy efficient for the elderly stone formers? Results of a matched-pair analysis. Urol Res. 2012;40:299–304.
27. Aboumarzouk OM, Kata SG, Keeley FX, Nabi G. Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi. Cochrane Database Syst Rev. 2011;(12):CD006029.

23 comments:

  1. Hello..!
    Nice post
    if you know about kidney stones treatment

    ReplyDelete
    Replies
    1. Hello everyone i am Mudaf Kyle from MALARIA , i am here to give my testimony about a great spell caster called Dr OLU, I was heartbroken and disappointed because i had very small penis, not big enough to satisfy or pregnant a woman, i have been in so many relationship, but cut off because of my small penis situation, i have used so many product,drugs,vaccines,herbs which doctors prescribe for me, but none could offer me the help i searched for. one faithful day i saw some few comments on the internet about how this great specialist called Dr OLU has been helping men enlarge their penis size ,pregnant woman and last longer in bed and i decided to email him on his email i saw on the internet,(drolusolution@gmail.com) i also visited his website http://droluherbs.clan.su/ ,so I decided to give his herbal product a try. i emailed him and he got back to me, he gave me some comforting words and steps to follow which i did with his herbal pills for Penis Enlargement, Within 1 week of it, i began to feel the enlargement of my penis, " and now it just 1 weeks of using his products my penis is about 10.5 inches longer in erection , and i had to settle out with my Ex girlfriend Stephanie, i was surprised when she opened her mouth and said that i almost killed her and she is satisfied with my sex and i have got a very Big penis now.
      Am so happy, thanks to Dr OLU I also learn that Dr OLU also help with
      penis enlargement
      weak erection
      erectile dysfunction
      breast pills and enlargement bums,
      pregnancy
      herpes cure
      diabetes type 1 / 2
      fat belly and swollen stomach
      Abortion
      malaria/lassar fever
      heart failure
      kidney problem
      human papiloma virus (HPV)
      tigthling and enlarging of vagina
      spell of all kinds(ex boyfriend/husband/girlfriend back,lottery spell,win a court case spell,job promotion or boom,marriage spell,breakup spells,cancel a divorce spell,Death spell and so many more

      so if you have any of this problem or other do not hesitate to contact Dr.OLU now for help on his email via (drolusolution@gmail.com or website http://droluherbs.clan.su/ [drolusolutionhome@gmail.com] or you can call him on his mobile number +2348140654426 .........for more information and advice contact my email mudafkyle@gmail.com THANKS

      Delete
  2. I never know natural way of dealing with this problem was really available until i came across the post of Dr Alaska John how he got someone cured of the kidney problem with his spell power. I quickly contacted him and told him all i have been suffering in the hands of kidney i was told what to do and i actually got the cured with 6 days of the kidney problem as promise by him. Today am living well and healthy what doctors could not do an ordinary spell caster did it. Am free from kidney problem today for his help contact him. Dralaskajohn@gmail.com

    ReplyDelete
  3. I never know natural way of dealing with this problem was really available until i came across the post of Dr Alaska John how he got someone cured of the kidney problem with his spell power. I quickly contacted him and told him all i have been suffering in the hands of kidney i was told what to do and i actually got the cured with 6 days of the kidney problem as promise by him. Today am living well and healthy what doctors could not do an ordinary spell caster did it. Am free from kidney problem today for his help contact him. Dralaskajohn@gmail.com

    ReplyDelete
  4. Loving this blog, great content and will be coming back to find out more for sure!

    Buy online cancer medicines ludhiana

    ReplyDelete
  5. My husband left me and our 6 month old daughter at the end of last month. I was and still am devesated. He said he fell out of love with me and that we were no good for each other since all we did was argue and fight. He then changed his story before he left saying he would come back for us after 2 weeks of working and saving up and move us all down to flordia to live so we could raise our daughter without my family’s meddling in our business. Well once he was down there I found this wasn’t true. He told me it was over and that he wanted to sign his rights away to our daughter and he wants to divorce. He claims he is very happy down there and I am happy for him. Turns out I found from one of his friends that he had no intention of coming back and he said that stuff so I wouldn’t over react and cause a scene. I miss him so terribly much..we’ve only been married since Septmeber 2014 and he’s about to turn 21 next month and I am 22. My family says it’s his age that caused this and that he’s scared. I’ve prayed to god every single night to be there for him and to help him grow up and understand what it is he’s doing. Meanwhile my heart..it’s not feeling broken like it first was..yes I’m sad and miss my husband terribly but it’s like my heart is full of hope..even after us bickering on the phone 2 days ago I still feel hope that things will get better and we can save our marriage and Dr.OOMIRIMIRI spell brought smile back in our marriage contact him today on his email: OOMIRIMIRI@GMAIL.COM OR CALL +2349073244122

    ReplyDelete
  6. R U SUFFERING FROM KIDNEY STONE (RENAL CALCULUS),PAIN ABDOMEN,GOING TO SURGICAL MANAGEMENT.BEFORE MAKING FINAL DECISION CONSULT TO US.KIDNEY STONE UPTO 20MM IS REMOVABLE WITHOUT SURGERY.YES IT IS TRUE.IT IS ALSO TRUE THAT THERE IS NO MEDICINAL TREATMENT TO REMOVE KIDNEY STONES IN ALLOPATH WITHOUT SURGERY.BUT NOW..SAY NO TO SURGERY4KIDNEY STONE..ONLY SAY YES2India's WELL KNOWN ... RISHI SEVA SADAN.UR STONE CAN BE REMOVED IN JUST6WEEKS WITH HERBAL MEDICINES WITHOUT ANY SIDE EFFECT,NO OPERATION,NO HOSPITALISATION,NO HIGH COST OF TREATMENT.TREAT U AT UR HOME.GET MEDICINE AT HOME BY COURIER/SPEED POST.COST OF COMPLETE course of treatment 2000/-INR.If u've any query then contact to..Dr R.K.RISHI,BAMS,MD .A.MEDICINE.VARANASI.Mob.No.+919889971201
    FOR MORE INFORMATION KINDLY CLICK HERE

    ReplyDelete
  7. Without surgery remove kidney stone. Dissolve Renal calculus(kidney stones/Nephrolithiasis)with pure herbal medicines.Are you suffering from U.B.,Ureter,KIDNEY stones?Everyone knows that kidney stone is an excrutiating painful problem n surgery is the only solution for get ridoff,but now-a-days it is not true.India's well known Ayurvikalpa Rishi Seva Sadan( kidney stone treatment n research center)has already treated more than 5000 patients successfully.There r no need of Lithotripsy or open surgery.
    This medicine is available in powder form n have no any side effect.After yrs.of research,we present a miracle stone dissolving package,cost 2000/-for complete course of 6 weeks treatment. Our medicine doesn't only dissolve kidney stones,instead it destroy the root causes n we guarantees that u will never get Kidney stone again in ur rest of life.If u have any query then Contact to...Dr.R.K.Rishi,BAMS,MD(A.Medicine).Varanasi. Mob. 09889971201
    FOR MORE INFORMATION KINDLY CLICK HERE

    ReplyDelete
  8. Minerals and salts which are available in our pee once in a while stick together in a few people and afterward form into little kidney stones.
    http://whereareyourkidneys.org/what-does-a-kidney-stone-look-like/

    ReplyDelete
  9. New Diet Taps into Revolutionary Idea to Help Dieters LOSE 23 Pounds within Only 21 Days!

    ReplyDelete
  10. Drinking plenty of fluids is a vital part of passing kidney stones and preventing new stones from forming. Not only does the liquid flush out toxins, it helps move stones and grit through your urinary tract. There are some simple natural remedies that may help soothe the discomfort of kidney stones and speed up the body’s natural healing processes. visit http://kidneystonemedicine.com/kidney-stones/

    ReplyDelete
  11. Dr. Sam has really made me so much believe in him by getting me cured with his herbal treatment. i really appreciate you Dr.Sam for bringing back happiness to my life again. thanks you so much,friends join me to thank him for what he has actually done for me i pray to you all for a good life and good health, and most especially to you Dr. Sam THANKS.

    I have been suffering from (HERPES SIMPLEX VIRUS) disease for the past four years and had constant pain, especially in my knees. During the first year,I had faith in God that i would be healed someday.This disease started circulating all over my body and i have been taking treatment from my doctor, few months ago i came on search on the internet if i could get any information concerning the cure of this disease, on my search i saw a testimony of someone who has been healed from (HERPES SIMPLEX VIRUS) by this Man Dr Sam and she drop the email address of this man and advise we should contact him for any sickness that he would be of help, so i wrote to Dr. Sam telling him about my (HERPES Virus) well after all the procedures and remedy given to me by this man few weeks later i started experiencing changes all over me. I am now here to testify that i am not longer a herpes patient, I have experience a total transformation in my life,for all herpes patients get your herbal medicine to cure your sickness. And there has being rapid improvement in my health, I no longer feel pains and I wake up each morning feeling revived. So friends my advise is if you have such sickness or any other at all,you can contact him. (Supremecurehome@gmail.com) Wbesite: http://www.supremecurehome.blogspot.com
    CANCER
    EPILEPSY.
    GENPILENCIN.
    HIV AIDS.
    DIABETICS
    STROKE.
    EXPANDS OF PENIS BREAST
    H.P.V TYPE 1 TYPE 2 TYPE 3 AND TYPE 4. TYPE 5.
    HUMAN PAPAILOMA VIRUS.
    HERPES.
    SYPHILIS.
    HEPATITIS A B and C.

    Email: Supremecurehome@gmail.com WhatsApp number +2347087462033

    ReplyDelete
  12. We are urgently in need of KlDNEY donors for the sum of $500,000.00 USD, WhatsApp or Email for more details:
    hospitalcarecenter@gmail.com
    WhatsApp +91 779-583-3215

    ReplyDelete
  13. The doctors said Herpes virus do not have medical cure because the virus is capable of hiding within the human cells, it remains protected from your immune system. Herpes isn’t a special virus – your immune system has the tools to fight it back. But because it is able to lay dormant in protected cells, your immune system is unable to remove it from your body,But with strong reactive herbal medication is capable of getting rid of the virus gradually and totally from your body without damaging any of your cells,natural herbs kills the virus totally not just reducing the out break. Get natural herbs cure from Dr. Oshuku (droshuku@gmail.com) or WhatsApp number +2348130419838

    ReplyDelete
  14. Kidney - The organ that filters waste product from blood. Dr. Niren, is the best kidney doctor in delhi tells about various chronic diseases- kidney stone, cancer & transplant

    ReplyDelete
  15. Kidney stone hinders our day to day life. In order to get free from such troubles, you should look for kidney stone Treatment. The clinic run by Dr. Niren Rao is a specialized one for Kidney Stone Treatment in South Delhi. If you are facing troubles of kidney and related disorder, then come to the clinic of Dr. Niren Rao and seek his expert consultation for the same. Call on 9811144680 for booking instant appointments

    ReplyDelete
  16. Hello everyone i am Mudaf Kyle from MALARIA , i am here to give my testimony about a great spell caster called Dr OLU, I was heartbroken and disappointed because i had very small penis, not big enough to satisfy or pregnant a woman, i have been in so many relationship, but cut off because of my small penis situation, i have used so many product,drugs,vaccines,herbs which doctors prescribe for me, but none could offer me the help i searched for. one faithful day i saw some few comments on the internet about how this great specialist called Dr OLU has been helping men enlarge their penis size ,pregnant woman and last longer in bed and i decided to email him on his email i saw on the internet,(drolusolution@gmail.com) i also visited his website http://droluherbs.clan.su/ ,so I decided to give his herbal product a try. i emailed him and he got back to me, he gave me some comforting words and steps to follow which i did with his herbal pills for Penis Enlargement, Within 1 week of it, i began to feel the enlargement of my penis, " and now it just 1 weeks of using his products my penis is about 10.5 inches longer in erection , and i had to settle out with my Ex girlfriend Stephanie, i was surprised when she opened her mouth and said that i almost killed her and she is satisfied with my sex and i have got a very Big penis now.
    Am so happy, thanks to Dr OLU I also learn that Dr OLU also help with
    penis enlargement
    weak erection
    erectile dysfunction
    breast pills and enlargement bums,
    pregnancy
    herpes cure
    diabetes type 1 / 2
    fat belly and swollen stomach
    Abortion
    malaria/lassar fever
    heart failure
    kidney problem
    human papiloma virus (HPV)
    tigthling and enlarging of vagina
    spell of all kinds(ex boyfriend/husband/girlfriend back,lottery spell,win a court case spell,job promotion or boom,marriage spell,breakup spells,cancel a divorce spell,Death spell and so many more

    so if you have any of this problem or other do not hesitate to contact Dr.OLU now for help on his email via (drolusolution@gmail.com or website http://droluherbs.clan.su/ [drolusolutionhome@gmail.com] or you can call him on his mobile number +2348140654426 .........for more information and advice contact my email mudafkyle@gmail.com THANKS

    ReplyDelete
  17. Thanks for sharing, nice post! Post really provice useful information!

    Giaonhan247 chuyên dịch vụ mua nước hoa Coco Mademoiselle hay mua vòng tay pandora chính hãng với dịch vụ nhận mua và ship hàng từ mỹ về việt nam cùng với giá cước vận chuyển hàng đi mỹ cho dịch vụ mua hàng ebay việt nam uy tín.

    ReplyDelete
  18. Do you want to have power and influence over others, To be charming and desirable, To have wealth, health, without delaying in a good human posture and becoming an immortal? If yes, these your chance. It's a world of vampire where life get easier,We have made so many persons vampires and have turned them rich, You will assured long life and prosperity, You shall be made to be very sensitive to mental alertness, Stronger and also very fast, You will not be restricted to walking at night only even at the very middle of broad day light you will be made to walk, This is an opportunity to have the human vampire virus to perform in a good posture. If you are interested contact us on Vampirelord7878@gmail.com

    ReplyDelete
  19. HELLO EVERYONE.. FEW MUNINETS TO REDY THIS INFOR ON HERPES CURE 2018..
    2017 MY MOTHER WAS DIAGNOSED OF HERPES/ KNOWN AS GENITAL WARTS ,I SPENT A LOT OF MONEY ON HER MEDICATION TILL A POINT I EVEN LOST HOPE,BECAUSE MY MOTHER WAS GRADUALLY DYING AND LOST HER MEMORY TOO, I WAS SO DESPERATE TO GET MY MOTHER BACK TO NORMAL, ONE DAY MY UNCLE WHO LIVES IN LONDON UNITED KINGDOM TOLD ME ABOUT DR OLIHA ,WHO HELPED HIM GET RID OF HERPES /GENITAL WART WITH HERBAL MEDICINE AND HIS HERBAL SOAP ,I WAS SO SHOCKED WHEN HE TOLD ME ABOUT THIS ,ALTHOUGH I NEVER BELIEVE IN HERB BUT, I KEEP TO BELIEVE BECAUSE MY UNCLE CAN'T TELL ME LIES WHEN IT COMES TO HEALTH CONDITION I CONTACTED DR OLIHA VIA HIS EMAIL; OLIHA.MIRACLEMEDICINE@GMAIL.COM , YOU CAN TALK TO HIM VIA CALL OR WHATSAPP MESSENGER ON +2349038382931 , HE REPLIED AND ASK ME TO SEND MY HOME ADDRESS AND MY MOTHER'S DETAIL AND THEN I PURCHASED THE HERBAL MEDICINE,SENT ME THE HERBAL MEDICINE THROUGH COURIER SERVICE, WHEN I RECEIVED THIS HERBAL MEDICINE USED IT FOR 2 WEEKS, AND 4 DAYS OF USAGE THE WARTS FELL OFF, MY MOTHER I NOW TOTALLY CURED AND MY MOTHER IS LIVING FREE AND HAPPY AGAIN. YOU CAN TALK TO DR VIA HIS MOBILE NUMBER OR WHATS APP HIM ON +2349038382931.ALL THANKS TO DOCTOR DR OLIHA

    ReplyDelete
  20. I really like your Blog. Thanks to Admin for Sharing such useful information. Addition to this here I am sharing One more similar Story Kidney Stone Symptoms & Home Remedies to pass quickly.

    ReplyDelete
  21. If you are suffering from kidney stone problem and looking for the best Surgeon in Moga for kidney stone removal then visit us. Dr Ashish Koura provides the best kidney stone removal at an affordable price. You can visit us or check our website for more details.

    ReplyDelete
  22. Hello viewers around the Globe, I was despondent because i had a very small penis, about 2.5 inches soft and 4 inches hard not nice enough to satisfy a woman, i have been in so many relationship, but cut off because of my situation, i have used so many product which doctors prescribe for me, but none could offer me the help i searched for. i saw some few comments on the internet about this specialist called Dr, OLHIA and i decided to contact him on his {oliha.miraclemedicine@gmail.com} so I decided to give his herbal product a try. i emailed him and he got back to me, he gave me some comforting words with his herbal pills for Penis Enlargement, Within 3 week of it, i began to feel the enlargement of my penis, " and now it just 4 weeks of using his products my penis is about 9 inches longer, and i had to settle out with my Ex girlfriend Ella, i was surprised when she said that she is satisfied with my sex and i have got a large penis. Am so happy, thanks to Dr OLIHA I also learn that Dr OLIHA also help with Breast Enlargement Hips and Bums Enlargement etc.. If you are in any situation with a little Penis, weak ejaculation, small breast_hips_bums do get to Dr OLIHA now for help on his email {oliha.miraclemedicine@gmail.com} or whats app him number: +2349038382931
    .........

    ReplyDelete