1. Renal stones in children
treatment?

2. LOCATION OF STONES IN KIDNEY

3. Types of Renal Calculi

4. Ureteroscopy (URS)

5. Nephrostomy

6. Percutaneous Nephrostomy

7. Introduction
▪ Global management
1. Treatment of renal colic
2. Prevention measures
3. Indications for surgery
4. Specific treatment of the primary disease

8. Management of renal colic
Priority: i.v. route as long as pain is present
▪ Anti-inflammatory treatment
▪ E.g., Ibuprofen, 1 mg/kg per 8 h if required
▪ [Sometimes methylprednisolone, 2 to 4 mg/kg per day]
▪ Alpha-adrenergic blockers (tamsulodin)
▪ Non-specific analgesics
▪ Paracetamol, 15 mg/kg/6 h
▪ Morphine (nalbuphine 0.2 mg/kg per 6 h)
▪ Hydration

9. mmol
L
↓
↑
Calcium Na, [thiazide]
Oxalate Pyridoxine
Cystine D-penicillamin
Uric acid Allopurinol
Water
Water
Water
Water
2 to 3 L/m²
over 24 h
Struvite < 7
pH Uric acid > 6
Cystine > 7
Goals: Calcium < 4 mmol/L – Oxalate < 0.4 mmol/L – Cystine < 1 mmol/L
Prevention: A question of ratio in urine!

10. Hydration: practical aspects
▪ Goal: urine volume 2 to 3 L/m² per 24 hours
▪ Distribution of water intake all over day and night
▪ Children & adolescents Drink after each micturation
▪ Infants & small childrenTube feeding sometimes mandatory

11. Renal Calculi
 Medical Management:
 Acute: treat pain, infection, obstruction
 Narcotics, for fluids—IV and po, strain urine
 Evaluate cause of stone formation: history, stone analysis
 Adequate hydration, dietary NA+ restriction, dietary changes, medication
 Treatment of struvite stones: control of infection

12. Renal Calculi
prevention
 Foods high in purine, calcium, or oxalate:
 Purine:
 High: Sardines, herring, mussels, liver, kidney, goose,
venison, meat soups sweetbreads
 Calcium: milk, cheese, ice cream, yogurt, sauces
containing milk, all beans (except green beans),
lentils, fish with fine bones (sardines, kippers
herring, salmon); dried fruits, nuts, chocolate,
cocoa, Ovaltine
 Oxalate: spinach, rhubarb, asparagus, cabbage,
tomatoes, beets, nuts, celery, parsley, runner beans,
chocolate, cocoa, instant coffee, Ovaltine, tea;
Worcestershire sauce

13. Renal Calculi
Removal
 Indications for Endourologic, lithotripsy or open surgical stone removal:
 Stones too large for spontaneous passage
 Stones associated with bacteriuria or symptomatic infection
 Stones causing impaired renal function
 Stones causing persistent pain, nausea, or ileus
 Inability of patient to be treated medically
 Patient with one kidney

14. Surgery/endoscopic procedures
Avoid open surgery
Give priority to
▪ Stones < 10-20 mm Ureterorendoscopy/retrograde intrarenal surgery
▪ Stones > 10-20 mm Mini-percutaneous nephrolithotomy
▪ Limited indication External shock-wave lithotripsy
Sometimes
▪ Percutaneous nephrostomy
▪ JJ tube
Baretto Cochrane Library 2018, Zanetti PLoS ONE 2018

15. Renal Calculi
Removal
 Endourological Procedures
 Cystoscopy – remove stones from bladder
 Cystolitholapaxy – cysto with lithotrite (stone crusher) – then flushed out of bladder
 Cystoscopic lithotripsy – cysto with pulverize stones
 Flexible ureteroscopes: remove stones from ureter, kidney pelvis – may be used with
ultrasound, electrohydraulic, or laser lithotripsy
 Percutaneous nephrolithotomy -- nephrostomy tube left in place for a period of time

16. Stone formation: a desequilibrium
Promoters Inhibitors
Calcium Citrate
Oxalate Magnesium
Uric acid, xanthine Phosphate
Cystine Proteins (uropontine, uromoduline, etc.)
Drugs
Cell debris
Urine volume – Urine pH

17. Stone composition
Structure Disease
PO4-NH3-Mg (struvite) UTI
Calcium phosphate
Hypercalciuria
Calcium oxalate, dihydrated
Calcium oxalate, monohydrated Hyperoxaluria
Cystine Cystinuria
Uric acid Purine synthesis disorder
2,8-dihydroxyadenine APRT deficiency
Xanthine Xanthinuria

18. Tubulopathies with hypercalciuria
▪ Bartter syndrome(s)
▪ Distal renal tubular acidosis (dRTA)
▪ Dent disease
▪ Familial hypomagnesemia, hypercalciuria & nephrocalcinosis
▪ Hypophosphatemic rickets with hypercalciuria
▪ Lowe syndrome

19. Hypercalciuria: Global management
▪ Cornerstone: hydration + adherence
▪ Normal dietary calcium intake
▪ Limited dietary sodium intake (UCa parallels UNa)
▪ Increased dietary potassium intake (reduces UCa)
▪ In case of hypocitraturia, K citrate (100 to 150 mg/kg/day)
▪ [Sometimes thiazides, 1 to 2 mg/kg/day (reduces UCa)]

20. Hypercalciuria: Specific treatments
▪ Bartter syndrome
▪ Indomethacin, 1 to 3 mg/kg per day
▪ Increased sodium intake, to maintain high blood volume
▪ Potassium chloride - Goal: K > 2.5 mmol/L
Sometimes - K-sparing diuretics (spironolactone, 5 mg/kg/day)
- ACE inhibitors (enalapril)
▪ Antenatal Bartter syndrome: neonatal ICU
▪ Distal RTA
▪ Sodium bicarbonate (± citrate)
▪ Goal: plasma bicarbonate > 22 mmol/L

21. Conclusion
▪ The renal prognosis relies on
▪ Nephrocalcinosis
▪ Treatment adherence
▪ Number and severity of infection and obstruction events
▪ Need for repeated surgical procedures
▪ The general prognosis relies on
▪ Degree of extrarenal involvement
▪ Mainly in primary hyperoxaluria type 1 and Lesch-Nyhan syndrome
▪ Urologists should be educated since they use to be first actors

22. But...
Baretto Cochrane Library 2018

23. T H A N K S