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January 27, 2011

Epidemiology 1/685 pediatric admissionsLower incidence than adults

Higher crystal formation inhibitors in urine

M>FMost common stones

Calcium oxalate Calcium phosphateStruviteCystine Uric Acid

Risk FactorsPresent in 75-85% of childrenUrinary metabolic abnormality

Hypercalciuria*HyperoxaluriaHyperuricosuriaHypocitraturia

UTIStructural renal or urinary tract abnormality

Nephrolithiasis PresentationAbdominal or flank pain

Wide variabilityGross hematuriaDysuriaUrgencyNausea/vomiting 15-20% asymptomatic

Younger patients

Other HistoryPrevious historyFamily historyUnderlying renal and urinary tract structural

abnormalitiesUnderlying metabolic conditionsMedication useHistory of UTI

Especially with urease-producing organisms Proteus or Klebsiella

Physical ExamGrowth parameters

Congenital or chronic conditionTemperature

UTIBlood pressure

Glomerular disease Edema

AbdomenTendernessMass

Obstruction

Lab EvaluationUA

Sediment Cystine crystals Calcium oxalate Calcium phosphate Uric acid Phosphate

Urine Culture

DiagnosisConfirmation

Imaging Non-contrast helical CT Ultrasonography

Stones >5mm Location

Plain abdominal radiography Radiopaque only Not good for small stones

Retrieval

TreatmentHospitalization

Nausea/vomitingSevere painUrinary obstructionSolitary kidneyInfection

TreatmentPain control

NSAIDsOpiod therapyCombination may be

superiorPassage

<5 mmHydrationStrain urine

Stone analysis

TreatmentUrologic intervention

Unremitting severe painUrinary obstructionInfection Renal insufficiency>5mm stoneStruvite calculi>2 weeks of conservative treatment

TreatmentUrological

interventionExtracorporeal shock

wave lithotripsy Small <1cm

Percutaneous nephrostolithotomy >2cm Structural

abnormalities Harder stones

Ureteroscopy

PreventionRecurrent stone disease frequently occurs in

children>50% of children with nephrolithiasis will

have an underlying metabolic abnormalityReduce

PainSchool absenteeismLoss of work for parentsClinical costs

PreventionStone analysis

Focus metabolic evaluation

Metabolic evaluationAt homeFully ambulatoryRegular dietFree of infection

PreventionSerum testing

CalciumPhosphorusBicarbonateCreatinineMagnesiumUric Acid

PreventionUA

SpGrpHCrystals

Urine solute excretion24h vs singleVolume and creatinine

PreventionFluid intake

Metabolic interventionsTargeted to correct the specific abnormality

Infants >750ml/day<5y >1L/day

5-10y >1.5L/day>10y >2L

MonitoringImaging

New formation or increasing size of previous stones

U/SFrequency depends on risk

Lab evalAssess response to preventative therapy6-8 weeks, 6 months, yearly