More children are getting kidney stones.
The clinical presentation of urolithia sis in children is often different from that in adults, so physicians are frequently caught off guard.
"The diagnosis of kidney stones is often not the first thing on the differential diagnosis list--or even on the list--for a child with abdominal pain," Dr. Beth A. Vogt observed at the meeting.
The younger the child with a kidney stone, the more likely the clinical presentation will be nonspecific abdominal pain rather than the flank pain or renal colic typical in affected adults, said Dr. Vogt, a pediatric nephrologist at Case Western Reserve University, Cleveland.
Thus, in the child with nonspecific abdominal pain, it's important to add urolithiasis to the differential diagnosis list, which has included viral gastroenteritis, appendicitis, cholecystitis, intussusception, and food poisoning, she said.
Gross hematuria is present in 30%-40% of children who present with kidney stones. Dysuria is also common. In addition, asymptomatic kidney stones are frequently detected incidentally in children undergoing ultrasound or CT following traumatic injury.
The primary care physician's role in pediatric urolithiasis is to make the diagnosis, begin acute management with hydration and pain control, hospitalize if necessary, and refer the patient to urology for intervention if the stone is so large it's unlikely to pass.
Referral to a nephrologist is recommended after a first-ever stone has passed and the child has resumed normal activities. The nephrologist must figure out why the child is forming stones and come up with a specific prevention plan (for example, a low-sodium diet in patients with hypercalciuria, or antibiotics in children with infection-related struvite stones), Dr. Vogt said.
"In adults, the standard practice is to wait until they prove to be recurrent stone formers before doing a work-up. That's not the case in children. Don't wait until after a child has had several stones to refer to nephrology. We find something metabolically wrong in about 75% of the kids," she said.
The diagnosis of pediatric urolithiasis is suggested by the combination of abdominal or flank pain, hematuria on a urine dipstick test, and crystals in the urine upon microscopic examination. A couple of caveats, though: Studies indicate that up to 15% of children with active stone disease have a negative urinalysis, so urolithiasis can't be ruled out on the basis of a negative urine dipstick. Also, many children who don't have kidney stone disease have crystals in their urine.
The best initial diagnostic imaging study is kidney ultrasound. It doesn't involve radiation, which is an important advantage because some young patients will continue making stones and will therefore need to undergo imaging many times.
Ultrasound is very good at identifying stones in the renal parenchyma, but not ureteral stones or very small stones. So if the clinical picture and laboratory re suits suggest urolithiasis but the ultrasound is negative, it's time to move on to CT without contrast, by far the most sensitive test. It is ordered by requesting a "CT stone protocol."
Acute management of stone disease entails oral or intravenous hydration to push the stone through the urinary tract. Pain medication is important. Tamsulosin (Flomax) is prescribed off label to induce ureteral relaxation and assist in the stone's passage. It's useful to have the patient use a urine-straining device to try to catch the stone for later analysis.
Urologists consistently recommend a 4to 6-week trial of spontaneous passage, provided the child doesn't have a urinary tract infection, is able to hydrate orally, and obtains pain control with oral medications. "When you tell that to parents, they say, Are you kidding?' That's a long, long time. Parents don't like it," Dr. Vogt said.
A stone larger than 10 mm is so unlikely to pass spontaneously that Dr. Vogt recommends going straight to urologic intervention. A stone less than 5 mm will usually pass spontaneously, even in a child.
Urologists will typically place a ureter-long stent in a patient with refractory nausea and vomiting or an infection. This allows urine to bypass an obstructive stone. "'It buys you time. It gets the patient out of the cycle of pain, vomiting, and renal colic," she explained.
A week or two later, the urologist will take out the stent and remove the stone, most often by ureteroscopy. This involves inserting the ureteroscope through the bladder and capturing the stone in a basket, sometimes after breaking it into fragments via laser lithotripsy.
Extracorporeal shock wave lithotripsy is still widely performed in adults. It is less popular in children because of the theoretical risk of damaging nearby healthy tissues, which might then result in hypertension or diabetes.
Although most cases of pediatric urolithiasis are managed on an outpatient basis, today roughly 1 in 1,000 pediatric hospitalizations is for kidney stones. The explanation for the increase over the past decade isn't entirely clear. Increased consumption of salty, high-protein, processed foods and decreased water intake have been implicated.
Prevention measures include ample fluid intake--more than 2 L daily in teens--and liberal consumption of fruits and vegetables to increase excretion of stone-inhibiting citrate into the urine. Restriction of dietary calcium is not recommended, even in calcium stone formers.
"I usually tell patients to drink enough fluids that their urine looks very dilute. You don't want dark yellow urine," said Dr. Vogt, who indicated that she had no conflicts of interest to report.
BY BRUCE JANCIN
EXPERT ANALYSIS FROM A MEETING ON PRACTICAL PEDIATRICS SPONSORED BY THE AMERICAN ACADEMY OF PEDIATRICS
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|Title Annotation:||KIDNEY DISEASE|
|Publication:||Family Practice News|
|Date:||Mar 1, 2012|
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