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RENAL STONE IN CHILDREN

RENAL STONE IN CHILDREN. Ali Derakhshan MD Shiraz university of Medical Sciences Shiraz-Iran بهمن 96 26.

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RENAL STONE IN CHILDREN

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  1. RENAL STONE IN CHILDREN Ali Derakhshan MD Shiraz university of Medical Sciences Shiraz-Iran بهمن 9626

  2. Case18 mo old baby presented with irritability, an US →19 mm stone in LP of LT kidney,since his older brother was a case of cystine stone , urine sample →+nitroprusside test for cystine Urologic consult →can wait on medical Rx since non-obstructive Combination Rx with polycitra-K+ captopril+ vit. B6+ D-penicillamine, 6 weeks later stone size  to 12 mm and Rx continued with a 3mo F up At this time US was entirely NL.

  3. CASE 2 3yrs old♀, fever and abdominal pain,active UA,UC to follow, Past Hx:open surgery for a Lt.pelvic stone 1yr ago with composition85% cystine but no follow up Rx. US 8mm stone in lt proximal ureter +hydronephrosis +2other 6mm and 5 mm stone in lt U and Lower pole.

  4. Case 3 45days old♂ with colicky pain,an US revealed a few gravel 1-1.5 mm in each kidney NL UA -----------------------------

  5. Urinary tract obstruction Common cause of acute and chronic renal failure Potentially curable form of kidney disease

  6. Our ESRD children 1990-1999116 children on hemodialysis Major causes of ESRD in order of frequency were glomerulopathies 23 (19.83%), reflux 15 (12.93%), chronic pyelonephritis without reflux 11 (9.5%), cystic diseases 10 (8.62%), neurogenic bladder 10 (8.62%) stone disease 9 (7.75%), posterior urethral valve 7 (6.03%) ureteropelvic junction obstruction 7 (6.03%)= total obst:29%UTO

  7. Epidemiology Rate of symptomatic stone formation was 7.9/10000 in 1996, increased to 18.5/10000 in 2007. Adult rate : Asia 1-5% Europe 5-9% North America 13% Saudi Arabia 20%

  8. Causes of increase incidence: The causes of increase incidence is unknown but obesity, higher salt intake, lower water intake, low Ca diet and high rate of using antibiotics may be considered.

  9. Predisposig Factors • 1. Peak Age (20- 40 yr),Adolescents 10 times more symptomatic stone than< 3 yr • 2. Sex (M>F) • 3. Race • 4. Environmental and Socioeconomic Factors • 5. Genetic Factors, Obesity • 6. Dietary Habits

  10. Renal stone Composition • Ca is found in 90% • Ca-oxalate(40-60%) • ca-phosphate(15-25%) • Ca-oxalate + Ca-phosphate(10-25%) • Struvite(17-30%) • Uric acid(2-10%) • Cystine(6-8%) • xanthin, Hypoxanthin, Drugs,……

  11. Stone Composition With increasing age : Ca-oxalate stone increases while P and struvite stones decrease.

  12. Mechanism of stone formation • Supersaturation • Infection - crystals(formation, growth, aggregation, adherence to epithelial cells), presence of matrix & absence of inhibitors. • Foreign body or urinary stasis • Urine PH

  13. Why stones form… 1. Decreased urine volume… Urine concentrates, supersaturates & crystals precipitate. 2. Urine pH affects solubility… Acidic urine: Uric acid, Cystine, Ca Oxalate Alkaline urine: Ca phosphate, struvite Promotes precipitation of:

  14. Why stones form… 3. Absence of inhibitors Citrate, glycosaminoglycans and Tam Horsfallproteins,Zn and Mg. 4. Infection: Urea-splitting organisms (Proteus, Klebsiella, E.coli,….) generate ammonia and alkalinize urine Proteus Urease Staghorn calculi (struvite)

  15. Underlying Causes(75%) Hypocitraturia(15-63%) • Primary • Secondary (acidosis, ↑protein intake, severe exercise, ↑Na intake, ↓urine Mg, UTI, chronic diarrhea, thiazides, hypokalemia) • Structural abnormalities(32%) • Hyperoxaluria, Cystinuria, RTA Hyperuricosuria, Hypercalciuria(the most common 50%),other rare causes

  16. Management of renal stone Paraclinicalevalution indicated in all children since: Once stone always stone 24 hrs. urine for Ca, Cr, Uric acid, Mg, Cystine, citrate and oxalate,urine PH - VBG -BUN,Cr,Na,K,Ca,P,UA,Mg,AG - Stone analysis if any -Some may need genetic evaluation for primary hyperoxaluria

  17. Treatment • Pain control • Alpha adrenergic blockers (Tamsulosin) ,Ca Channel Blockers • Hydration • Control of UTI • Medical, surgical or ESWL • Prevention

  18. Medical treatment • Non-pharmacological medical therapy in all children • Pharmacological therapy in children with multiple stones at presentation or recurrence of stone during one year.

  19. Renal stone Rate of another stone formation >50% in 5yrs How long to continue medical Rx Depends on the cause for cystine it is mentioned lifelong ?? for other causes 3-6 mo after clearance but at least 5 yrs. FUP

  20. Special indications for drug therapy • Hypercalciuria (the most common) • RTA • Cystinuria • Hyperuricosuria • Hypocitraturia • Hyperoxaluria • Hypomagnesuria Citrate compounds HCTZ………… Citrate is recommended for all types of stone except for phosphate & infectious stone

  21. Non-pharmacological Non-surgical therapy • ↑Water intake • Prevention of heavy exercise • ↓Na intake • ↓Protein intake (↓urine Ca, ↑Urine PH, ↓Urine uric acid, Effect on urine citrate) • Ca-intake (regular or even ↑) • ↓Lipid intake • ↓Intake of oxalate containing drinks or foods.

  22. Recurrence of renal stone • Rcurrence occurs frequently • It is higher in children with metabolic abnormalities • It is about 5-10% each year • So, long term FU and periodic reassessment is indicated • Frequency of imaging depends on type, number of stones, severity of metabolic abnormalities, UTI andsymptoms.

  23. Sarv Abarkooh Gonbade Ali Abarkooh

  24. Results of study in Shiraz • 153 children <18 Yr (M/F=1.1) • <2 Yr: 37%, 2-6 Yr: 36.6%, >7 Yr: 26% • F HX: about 50% positive • Stone size <5 mm: 70%, >10 mm: 2.5%. • Stone No: 40.5% =1 stone, 42.5%= 2-3 & 17%>3 stones. • Bilateral in 37%

  25. 24 Hr. Urinary Findings • 90.8% had at least one metabolic abnormality • Hypomagnesuria 60.8% • Hypocitraturia 52.9% • Hypercalciuria 47.1% • Hyperuricosuria 37.3% • Hyperoxaluria 17% • Cystinuria 2%

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