FRW Renal Stones in Children Renal Stones in Children Frank Willis Frank Willis Renal Unit Renal Unit RHSC RHSC - - Yorkhill Yorkhill Glasgow Glasgow Scottish Scottish Paediatric Paediatric Renal Renal & & Urology Urology Network Network May 2009 May 2009
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Renal Stones in Children Renal Stones in Children Frank Willis Renal Unit RHSC -Yorkhill Glasgow Scottish Paediatric Renal & Urology Network May 2009 FRW Aetiology Differs from adults
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Renal Stones in ChildrenRenal Stones in Children
Frank WillisFrank Willis
Renal UnitRenal Unit
RHSCRHSC--YorkhillYorkhill
GlasgowGlasgow
Scottish Scottish
PaediatricPaediatric
RenalRenal & &
Urology Urology
NetworkNetwork
May 2009May 2009
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AetiologyAetiology
�� Differs from adultsDiffers from adults
�� Varies with geography & over timeVaries with geography & over time
�� Most have primary Most have primary ‘‘metabolicmetabolic’’ risk factorsrisk factors
�� Some have Some have ‘‘otherother’’ risk factorsrisk factors
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Aim to discussAim to discuss
�� Stones in the UK childrenStones in the UK children
�� Stones in Australian Aboriginal childrenStones in Australian Aboriginal children
�� Stones in other geographical settingsStones in other geographical settings
�� Management StrategiesManagement Strategies
�� Local examples Local examples -- Infection StonesInfection Stones
-- Urate StonesUrate Stones
-- Cystine StonesCystine Stones
-- Standing StonesStanding StonesCalcium Calcium
oxalate oxalate
stonesstones
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Paediatric Stones in the UKPaediatric Stones in the UK
�� Incidence seems to be increasing, esp. in young Incidence seems to be increasing, esp. in young females (F females (F ≤≤ M)M)
�� Younger age at 1Younger age at 1stst stonestone
�� In children, commoner in younger patients In children, commoner in younger patients (esp. 0(esp. 0--5 yrs)5 yrs)
�� Associated with subAssociated with sub--optimal growthoptimal growth
VanVan’’t Hoff W. Aetiology of Paediatric Renal Stones. ICH, London, Mt Hoff W. Aetiology of Paediatric Renal Stones. ICH, London, March 2009 (Lecture)arch 2009 (Lecture)
South Uist
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Paediatric Stones in the UKPaediatric Stones in the UK
�� Approx 50% have identifiable metabolic abnormality Approx 50% have identifiable metabolic abnormality (GOS 1997(GOS 1997--2005, n=250)2005, n=250)
�� Other Oxaluria (e.g. Enteric) 6%Other Oxaluria (e.g. Enteric) 6%
�� Risk of metabolic cause greater if bilateral stones Risk of metabolic cause greater if bilateral stones (OR 2.7)(OR 2.7)
VanVan’’t Hoff W. Aetiology of Paediatric Renal Stones. ICH, London, Mt Hoff W. Aetiology of Paediatric Renal Stones. ICH, London, March 2009 (Lecture)arch 2009 (Lecture)
Lewis
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Presenting FeaturesPresenting Features
�� Haematuria Haematuria 60%60%
�� Abdominal PainAbdominal Pain 55%55%
�� UTIUTI 44%44%
�� VomitingVomiting 22%22%
�� AsymptomaticAsymptomatic 16%16%
�� Note Note 40% didn40% didn’’t have haematuriat have haematuria
45% didn45% didn’’t have abdo. paint have abdo. pain
VanVan’’t Hoff W. Aetiology of Paediatric Renal Stones. ICH, London, Mt Hoff W. Aetiology of Paediatric Renal Stones. ICH, London, March 2009 (Lecture)arch 2009 (Lecture)
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Theories about Lifestyle & StonesTheories about Lifestyle & Stones
�� ? Diet changes relate to ? Diet changes relate to ↑↑--ed stone frequencyed stone frequency
e.g. e.g. ↑↑ protein, refined sugars, purines & sodiumprotein, refined sugars, purines & sodium
→→ ↑↑--ed urine Ca, uric acid, oxalate & Naed urine Ca, uric acid, oxalate & Na
↓↓ urine citrateurine citrate
�� Increased antibiotic use Increased antibiotic use →→ altered gut floraaltered gut flora
Baldwin DN, Spencer JL, JeffriesBaldwin DN, Spencer JL, Jeffries--Stokes CA. Carbohydrate intolerance & kidney Stokes CA. Carbohydrate intolerance & kidney stones in children in the Goldfields. J Paediatr. Child Health stones in children in the Goldfields. J Paediatr. Child Health (2003) 39, 381(2003) 39, 381--85.85.
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Personal ObservationsPersonal Observations
�� Recurrently unwell young childrenRecurrently unwell young children
�� DxDx--ed when admitted ed when admitted ‘‘sicksick’’
�� Seen on US, not seen on xSeen on US, not seen on x--rayray
�� Often multiple & smallOften multiple & small
�� Usually asymptomaticUsually asymptomatic
�� Most get better with time, good health and nutrition Most get better with time, good health and nutrition +/+/-- urinary alkalinisation urinary alkalinisation
�� Low recurrence rate (Low recurrence rate (=> => unlikely due to persistent unlikely due to persistent metabolic or anatomical factors)metabolic or anatomical factors)
�� Hypercalciuria next commonestHypercalciuria next commonest
�� Recurrent in 39%Recurrent in 39%
VanDervoort et al. Ped. Urology 2007 June ; 177(6): 2300VanDervoort et al. Ped. Urology 2007 June ; 177(6): 2300--5.5.
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Melamine Stones in Chinese ChildrenMelamine Stones in Chinese Children
�� Recent epidemic related to contaminated baby milkRecent epidemic related to contaminated baby milk
4 reported deaths in China by September 20084 reported deaths in China by September 2008
�� 15 patients from Hong Kong, aged 315 patients from Hong Kong, aged 3--31 months31 months
�� 2/3 were asymptomatic (Dx2/3 were asymptomatic (Dx--ed on US)ed on US)
�� Stones varied from 2.5 Stones varied from 2.5 --18mm, 9/15 bilateral, 18mm, 9/15 bilateral, soft & friablesoft & friable
�� None had UTINone had UTI
�� 8/14(?) had predisposing lithogenic factors e.g. 8/14(?) had predisposing lithogenic factors e.g. hyperuricosuria (commonest),hyperuricosuria (commonest),
hypercalciuria, hyperoxaluria and acid urine.hypercalciuria, hyperoxaluria and acid urine.
Lam C-W, et al. Diagnosis & spectrum of melamine-related renal disease.
-- Choice based on location, hardness or softnessChoice based on location, hardness or softness
�� Open surgery occasionallyOpen surgery occasionally
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Investigate for cause Investigate for cause RHSCRHSC--Yorkhill stone workup Yorkhill stone workup
1. Ultrasound and abdominal x1. Ultrasound and abdominal x--ray ray
2. Biochemical stone analysis when possible. 2. Biochemical stone analysis when possible.
–– If the biochemical stone analysis suggests a cystine stone, the If the biochemical stone analysis suggests a cystine stone, the key key investigation is urinary amino acid chromatography. investigation is urinary amino acid chromatography.
–– If analysis suggests a uric acid stone the key investigations arIf analysis suggests a uric acid stone the key investigations are urinary e urinary urate/creatinine ratio, plasma urate, plasma HGPRT and APRT (enzurate/creatinine ratio, plasma urate, plasma HGPRT and APRT (enz. def.s). . def.s).
–– If analysis suggests a struvite stone, metabolic evaluation is uIf analysis suggests a struvite stone, metabolic evaluation is unnecessary. nnecessary.
3. If the biochemical stone analysis suggests calcium oxalate/ca3. If the biochemical stone analysis suggests calcium oxalate/calcium lcium phosphate or if there is no stone recovered, the following invesphosphate or if there is no stone recovered, the following investigations tigations should be carried out. should be carried out.
1.1. Urinalysis and pH Urinalysis and pH
2.2. Urine Culture Urine Culture
3.3. Urinary calcium, oxalate and urate / creatinine ratios Urinary calcium, oxalate and urate / creatinine ratios
4.4. Urinary amino acid and organic acid screen Urinary amino acid and organic acid screen
5.5. If spot urines are abnormal, a second voided EMU should be takenIf spot urines are abnormal, a second voided EMU should be taken and and subsequently a 12subsequently a 12--14hr collection14hr collection
Reviewed: February 2006 Reviewed: February 2006
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Stone TypesStone Types
�� North American data of analysed stones North American data of analysed stones suggest the frequency and composition of suggest the frequency and composition of urinary tract stones as: urinary tract stones as: