Kids with Kidney Stones

Kids with Kidney Stones

Kidney stones are a relatively common entity encountered on the adult side of the ED, but while kids are not just little adults, some will develop adult-like problems. There has been an increase in incidence of renal stones in children (as well as adults) over the past few decades. (http://www.reuters.com/article/)

But, let’s not get carried away, it is still a relatively unusual condition in children… so how do we find this needle in the haystack? The answer is the same as with all conditions: a good H+P and avoiding premature closure of your differential.

Increases risk of renal calculi (the abridged list):

  • Diet (likely why we’ve seen an increase in stones – I’m surprised we don’t see more)
    • High animal protein, salt, and refined carbohydrates (can you say Fast Food)
    • Soft drinks (because of phosphoric acid) [Another strike against Fast Food joints]
  • Anatomic Anomalies
    • Examples = Vesicoureteral reflux, UPJ obstruction, neurogenic bladder
    • Lead to urinary stasis and predispose to infection
  • Medications
    • Prolonged steroids (asthma pt with flank pain?)
    • Chemotherapy (because our pts with cancer don’t have enough problems)
    • Anticonvulsants
    • Loop Diuretics
    • Antacids
  • Medical Problems
    • Inflammatory Bowel Disease and GI Malabsorption
    • Seizure D/O being treated with Ketogenic Diet
    • Leukemia/Lymphoma (plus they get chemo)
    • Hyperparathyroidism
    • Cystic Fibrosis
    • HTN
    • Diabetes
    • Rickets
    • Renal Tubular acidosis
    • Recurrent urinary tract infections
    • Immobilization (recent ortho procedure?)
  • Family Medical History (~75% will have family hx: you can’t outrun your genetics)

Presentation

  • As with all pediatric conditions – it depends on age
    • Older children typically present, as adults, with typical colicky flank pain and hematuria
    • Younger kids will more likely have nonspecific vomiting and irritability
  • One study found:
    • Prior urolithiasis, nausea, vomiting, lack of dysuria, and microscopic hematuria to be significantly associated with urolithiasis.
    • Fever, dysuria, and CVA tenderness to be inversely associated with urolithiasis
  • Put Kidney Stones on the DDx when you are considering:
    • Urinary tract infection
    • Constipation
    • Gastroenteritis
    • Torsion (Testicular or Ovarian)
    • Intussusception
    • Appendicitis
  • Consider with c/o abdominal pain, +/- vomiting, and without another clear etiology

Evaluation

  • Labs
    • No lab makes the Diagnosis
    • BUN/Cr useful to define renal function
    • Microscopic hematuria (2-5 RBCs/HPF) often present, but may be absent in ~15%
  • Imaging
    • “Dry”/Non-contrast CT is gold standard now as it can detect renal and ureteral stones
    • U/S is good for detecting renal stones, but terrible at finding ureteral stones
    • Consider starting with U/S, but if negative may need to proceed to Dry CT.

Schissel BL, Johnson BK. Renal Stones: Evolving Epidemiology and Management. Pediatric Emergency Care: 27(7), July 2011, pp.676-681

Sas DJ. An Update on the Changing Epidemiology and Metabolic Risk Factors in Pediatric Kidney Stone Disease. Clin J Am Soc Nephrol. 2011, Aug; 6(8); pp.2062-8.

Persaud AC, Stevenson MD, McMahon DR, et al. Pediatric Urolithiasis: Clinical Predictors in the Emergency Department. Pediatrics. 2009;124:888-894.

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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1 Response

  1. December 16, 2012

    […] illnesses are now increasing in incidence in children.  We have discussed how the prevalence of Kidney Stones in children is increasing, and not to be outdone, gallstones are are no longer simply an adult […]

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