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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.

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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