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Pediatric Stone Disease

Pediatric Stone Disease. Overview. Epidemiology. 4 Reasons Stones Form. Diagnostic Tests. The Menu of Stones. Pediatric Urolithiasis How is it compare to adult stone disease?. LESS COMMON. 1/50 th the rate No “Stone Belt” Increasing Incidence. GENDER EQUALITY. No male predominance.

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Pediatric Stone Disease

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  1. Pediatric Stone Disease

  2. Overview Epidemiology 4 Reasons Stones Form Diagnostic Tests The Menu of Stones

  3. Pediatric UrolithiasisHow is it compare to adult stone disease? LESS COMMON 1/50th the rate No “Stone Belt” Increasing Incidence

  4. GENDER EQUALITY No male predominance

  5. SIMILAR PASSAGE RATES Similar spontaneous passage (8-50 %)

  6. SIMILAR RECURRENCE Similar Recurrence (~ 50 %)

  7. MORE VARIED CAUSES More secondary etiologies

  8. The Bigger the Stone, The Less Likely it Passes % mm

  9. Presenting Features of Pediatric Stone Disease by Age(Sums exceed 100% due to multiple presenting features) Milliner, Murphy, Mayo Clin Proc, 1993

  10. Primary Etiology of Pediatric Stones(20% have multiple causes) Polinsky 1993; Robertson, 1978, Basaklar, 1991

  11. Types of Pediatric Stones

  12. Acute Management Imaging Decide if Urology needs to be called Pain Control Fluids

  13. Imaging • X-Ray • Non-radioopaque (uric acid) • Mildly radioopaque (cystine) • Radio-opaque (calcium) • IVP • US • CT Scan – imaging of choice

  14. Non-Medical Treatment • Indications • > 5 mm • Staghorn • Struvite stones • Infection • Obstruction

  15. Acute Management of Stones • Hydration • Pain Control Oral better than IV NSAIDS better than opioids

  16. Use of Alpha Blockers and Stone Passage Rates % mm

  17. ESWL vs Laser Lithotripsy • ESWL • Pros • Great for CaOx and Urate stones • Non-invasive • Cons • GETA for kids < 8 y • Can’t break up Cystine stones • Poor success rate with BIG stones (> 1 cm) • Hemorrhage and edema post-ESWL

  18. Overview Epidemiology 4 Reasons Stones Form Diagnostic Tests The Menu Of Stones

  19. The 4 Quadrants of Stone Formation Too Much Solute Too Little Solvent Too Many Promoters Too Few Inhibitors

  20. Too Much Solute Low sodium diet Enhance reabsorption Low dietary intake of solute

  21. Too Little Solvent Most stones prevented with > 2 L/m2/day

  22. Too Many Promoters pH Uric Acid

  23. pH and Stone Risk High pH CaPO4 Struvite Low pH CaOx Uric Acid Cysteine

  24. Too Few Inhibitors Most important inhibitors Citrate Magnesium Natural (but clinically insignificant) Inhibitors Tamm-Horsfall Protein Osteopontin Prothrombin fragment 1

  25. Lemonade Therapy • 4 oz of lemon juice in 2 Liters of water • Can restore normal citrate levels Urology, 2007

  26. Overview Epidemiology 4 Reasons Stones Form Diagnostic Tests The Menu Of Stones

  27. Timed Urine Collection • A variety of units • Mg/kg/day (calcium, magnesium) • Mg/m2/day (oxalate) • Mg/1.73m2/day (uric acid) • Mg/g creatinine (cystine, citrate) • Other measures • saturation indices • Mg/Ca and Citrate/Ca ratios

  28. What’s So Special About the Orange Jug? • Thymol – prevents change in pH, citrate, uric acid, sulfate, sodium, potassium, and cAMP • HCl or Boric Acid – prevents change in Ca, Mg, PO4, Ox, ammonium, creatinine

  29. Spot Urine Solutes • Solute : Creatinine • Ca / Cr < 0.22

  30. Urinalyses: Crystals

  31. Diamonds

  32. Pink Junk Uric Acid Crystals

  33. Coffin Lids

  34. Hexagons

  35. Spectroscopy of Stone

  36. Overview Epidemiology 4 Reasons Stones Form Diagnostic Tests The Menu Of Stones

  37. A MENU OF STONE DISEASES Look what I passed!

  38. Hypercalciuria Facts • 50% of identified metabolic abnormalities • 50% are inheritied (Autosomal Dominant) • 10-16% of untreated kids get stones in 1-4 y • 72% within 15 yrs (retrospective Hungarian) • Idiopathic #1 cause • Renal or GI subtypes (clinically unimportant) • 70% of kids have + Family Hx • Can be associated with low bone density

  39. Secondary Causes of Hypercalciuria • Ketogenic Diet • Vitamin D intoxication • Medication (steroids, loop diuretics) • Immobilization • Acidosis • Hypercalcemia • Thyroid disorders • Dent’s Disease • dRTA • CaSR Mutations • Familial hypomagnesemia-hypercalciuria • Bartter’s syndrome • Medullary Sponge Kidney

  40. Medullary Sponge Kidney

  41. Upper Limit of Normal forSpot Ca:Cr Ratios

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