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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 4  |  Page : 762-771
Pediatric urolithiasis in the central coast of Tunisia: Epidemiologic changes over the past twenty-five years

1 Department of Biochemistry and Toxicology, Fattouma Bourguiba Hospital, Monastir, Tunisia
2 Department of Pediatric Surgery, Fattouma Bourguiba Hospital, Monastir, Tunisia

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Date of Web Publication26-Jun-2010


The incidence of Pediatric urolithiasis has been constantly decreasing during the past twenty-four years (1982-2007) in Tunisia as well as in other Mediterranean countries. This study was undertaken to observe the incidence of stone disease and its composition in children. Our study shows a downward trend of incidence of urolithiasis in pediatric patients over the last 25 years. The prevalence of calcium oxalate stones has constantly increased with decrease in the stones related to infections Whewellite (calcium oxalate) was more frequent in children of school age. In conclusion, the decrease in struvite frequency in children patients during the past twenty­five years and the stabilization of calcium phosphate stones are the result of a significant im­provement of diagnostics and the treatment of urinary tract infections in the young children in our country.

How to cite this article:
Najjar M F, Alaya A, Nouri A. Pediatric urolithiasis in the central coast of Tunisia: Epidemiologic changes over the past twenty-five years. Saudi J Kidney Dis Transpl 2010;21:762-71

How to cite this URL:
Najjar M F, Alaya A, Nouri A. Pediatric urolithiasis in the central coast of Tunisia: Epidemiologic changes over the past twenty-five years. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Jun 1];21:762-71. Available from: http://www.sjkdt.org/text.asp?2010/21/4/762/64658

   Introduction Top

The geographical pattern of childhood uroli­thiasis varies widely in terms of prevalence, location, stone composition and predisposing etiological factors. Its frequency is steadily de­creasing in developing countries; but it is still endemic in some parts of the world. In 1969 first Tunisian study of pediatric nephrolithiasis highlighted the importance of this pathology in the country. [1] Several studies have been under­taken since then. [1],[2],[3],[4] However, during the past twenty-five years, lifestyle and dietary habits have been dramatically changed in Tunisia. To examine if these factors are relevant to neph­rolithiasis we studied children treating in the same centres over the past twenty-five years.

   Patients and Methods Top

Between 1982 to 2007, 414 pediatric patients (293 boys and 121 girls) with urolithiasis were evaluated, treated, and followed in the depart­ment of pediatric surgery in Fattouma Bourguiba Teaching Hospital in Monastir.

Patients were from the central coast of Tu­nisia (region of Mahdia and Monastir). Full documentation included recording of age, sex, residence, age of onset of symptoms, age of diagnosis of stone disease, clinical presenta­tion, past medical and surgical history, family history of stone disease and recurrence. In most pediatric cases stones were imaged by excre­tory urography, although plain X-ray was per­formed to monitor stones that were radio­paque. Stone analysis and composition were done in 385 patients (92.9%). A 24-hour urine collection and serum chemistry studies were performed in 344 patients (83.0%).

The software SPSS 11.0 for Windows was used for data entry and analysis. Chi-Square test was used to compare between different results. P values < 0.05 were considered signi­ficant.

   Results Top

Of the 414 children with urolithiasis, 293 (70.8%) were males and 121 (29.2%) were fe­males; Children's median age at presentation was 78 months (5-192 months) and 66% of the study group was below 5 years of age [Figure 1]. The incidence of urolithiasis remained re­latively constant over the past 25 years for children below 5 years old, however there was a continuous increase after the age of 10 since the eighties. An incidence of 0.7/1000 admi­ssions per year has been observed in our region (0.68/10 000 of the child population (region of Mahdia and Monastir) per year. The incidence of pediatric urolithiasis in central Tunisia has also steadly decreased from 0.7/10000 of the child population/year in 1991-1994 to 0.1 cases/ 10000 children/year in 2007 [Figure 2], accom­panied by the decrease in the male to female ratio of 3.1 in 1982-1986 to 1.7 in 2003-2007 [Table 1]. Boys seem less affected by this pa­thology in our area [Figure 3], however they are prevalent in baby (P< 0.001) with a sex­ratio of 3.7 [Figure 4]. Teenage Children are increasingly affected by this pathology [Figure 5].

The most frequent symptom on presentation was hematuria, which occurred in 37.9% of cases [Figure 8]. Additional symptoms included urinary tract infection in 36.4% and abdominal pain in 30.7%, which was prevalent in school age child [Figure 9]. A positive family history of urolithiasis was recorded for 25 patients (n=280). Of the patients 27 (9.6%) (27/280) had an underlying anatomic abnormality, in­cluding uretropelvic junction obstruction in 11 cases [Table 2]. Metabolic disorders were re­corded in 344 children (83%). The 24-hour urine collections were normal in the majority of ca­ses but hypercalciuria was found in 33 cases (9.59%) and hyperoxalurie in 59 cases (17.15%). These hyperoxaluria was moderate (0.5-1 mmol/ 24 hours) excluding the primary hyperoxaluria. In addition cystinuria was found in 3 cases (0.8%) (the concentration observed was higher than 120 ΅mmol/mmol creatinine in the two ca­ses), and normal (16 ΅mol/mmol creatinine) in one case. Finally hyperuricosuria was observed in 10 cases (4.9%). The location of the stone was the upper urinary tract in 68.6% of cases (Kidney: 51%; ureters: 17.6%). Bladder stone accounted for 25.4%. Incidence of kidney stones remained relatively constant over the past 25 years, but there was a continuous decrease in bladder stone [Figure 6], which was more fre­quent in younger than teenagers (P<0.01), [Figure 7].

Of the 385 stones analysed (92.9%), one false stone was noted. Stone analysis revealed the composition to be homogeneous in 31.4% of cases. The main component (> 50% of stone composition), was calcium oxalate stones in 36.4% of the cases [Figure 10], [Table 3] and whe­wellite (calcium oxalate) represent it's most frequent form: 67.5% [Figure 11]. Since the eighties the increase of oxalate stones was accompanied by a decline in the purine and struvite stones [Figure 12].

Stones were treated by open surgery in 268 cases (95.7%). An endoscopy associated with a ballistic endocorporel lithotripsy was performed on 2 cases. Complete stone clearance was achieved in 95% of all patients.

Of 280 subjects had a followed up documen­ted, 8 (2.8%) experienced recurrences after an initial diagnosis of stone disease during their lifetime. Disease recurrence occurred at me­dian 5 years after the initial diagnosis.

   Discussion Top

Since the sixties, all the studies carried out in our country were focused on the study of etiological and chemical data collected from a limited number of urolithiasis patients. [1],[2],[3],[4] The epidemiology of pediatric nephrolithiasis appears to have changed in the past 25 years in Tunisia as evident from our study.

Available publications on the incidence of Pediatric urolithiasis varies greatly depending on the year that the article was published as well as its country of origin, [Table 3]. Most epidemiological studies of urolithiasis were based on hospital statistics, general practice surveys or selected group surveys for deter­mining the prevalence and incidence of this pathology.

In North Africa, prevalence varies between 3.76 and 16.3 % according to Joual et al. [5] It was difficult to determine the true prevalence of urolithiasis in our country. Since the sixties and during the eighties an incidence of 30 cases/year was reported. [1],[4] Study by Alaya et al [6] an incidence of 0.7/ 1000 admissions/year was observed in our region (either 0.68/10 000 population of children. [7] /year); which is lower than the data collected in Thailand, India, Iraq and Egypt but remains higher than those ob­served in Saudi Arabia and in the United States of America. [8] There was a continuous decrease since the eighties and incidence represents currently 0.4 case/1000 admission/year which is significantly lower than those observed in Asia where it ranges between 71.9 and 180/1000 pediatric admission/year, respectively in Pakistan and Afghanistan. [9],[10] However, this frequency is closer to the data published in the Arabian Peninsula where it was 2.9/1000 pediatric ad­missions/year in Jordan. [11]

Chronological changes in the incidence of urinary lithiasis can be explained by the deve­lopment of several national programs of chil­dren's health, better care for children suffering from this disease in our country. [7] As shown in some papers, [12] prevalence and incidence cha­nges jointly, so we can think that the pre­valence of Pediatric urolithiasis in Tunisia had already decreased, but that remains to be con­firmed.

The well-known male preponderance has been confirmed in our study, however this predo­minance is progressively decreasing compared to results previously published in 1969 (M/F: 12.4). [1] This aspect can be explained by an tra­ditional gender preference where family paid more attention to boys than girls. This has changed during these recent years as expressed by a sex-ratio of only 0.5 for the general medicine consultations. [13]

According to some publications urolithiasis mainly affects children of age < 2 years [14],[15],[16] where boys predominate with a sex ratio from 5 to 6/1, but decreases with advancing age to 1.5/1. [17]

In Tunisia, urolithiasis in age < 2 years was reported for the first time by Nahlovsky in the area of Sousse, [1] where a frequency of 31.4% was recorded. Ten years later, in the same area, Najjar et al [4] reported a frequency of 37.8%. During the past 25 years, this frequency truly did not change in the central coast of Tunisia and it currently accounts for 28.6%. These data confirm the work of Jellouli et al [18] (24.9%) and reflect urolithiais in age < 2 years in different regions of our country to be around 29.7% in the central area (Sfax) [19] and 33.3% in the North (Tunis). [2] These results are far from those described in Kuwait [20] where urolithiasis in age < 2 years accounts for 55% of cases. Our results are also similar to Coward et al [21] and translates the influence of external factors such as food intake. [22]

In Europe, urinary stones are mainly located in the upper urinary tract. [21],[23] Renal pelvis was affected in 66% of cases and ureters in 33%. [24],[25] Bladder stones are rare in Europe and North America, it represents between 1 and 4% of the cases in Europe [26],[27] whereas it accounts for 7% in Turkey [28] 13% in Armenia. [29]

Developing countries have been known for the high incidence of endemic bladder stones, where it accounts for 35.3% of the cases. [30] Socioeconomic and geographical factors play important roles in determining the prevalence of bladder stones. In Sub Saharan Africa, bla­dder stones accounts for 50 to 71% of the ca­ses, [31],[32] whereas it's less prevalent in the Arab world (about 50% compared to 6% respec­tively). [15],[20],[33],[34],[35],[36] In our study bladder stones accounted for 25.4% The stone localisation is also different according to the age of the subjects. In Europe, frequency of bladder stones increases with the age in adult population [37] compared to children where bladder stones are less frequent in children below the age of ten years, [38] similar to our study.

Majority of our pediatric patients had hema­turia and urinary tract infections as presenta­tion, nevertheless the school age children pre­sented more with abdominal pain.

Urinary tract stones in 90 to 95 % have a mixed composition. [39] In our study, they were homogeneous in 31.4% of cases, which is higher than that described in Algeria (9.8%), [34] but similar to European data (31% in Greece) [40] and Asian (28% in Pakistan), [9] In agreement with large series already published, calcium oxalate was the most frequent component of urinary, and Whewellite represents the most frequent crystalline phases detected in 65.7% of cases.

The main stone component reflects the uri­nary environment and disorder acting on stone nucleation and growth. [41] Comparing our main component data with those already published [Table 3], we found almost similar results.

In our study phosphate stones pre-dominated and represent the main stone composition in 43.5 % of cases (Carbapatite: 20.8% + Struvite: 22.7%), which agree with the results described in Europe. [42] This equivalence with the French data was also observed for calcium oxalate and purine stones. The high frequency of phosphates can be explained by the high frequency of the urinary tract infections in our area which accounted for 36.4% of the cases. The importance of the hypercalciuria, as well as urinary pH, were shown to participate in the stone phos-phate formation, [43] but the lack of biological data in our study did not allow us to confirm this information.

In our study, struvite were present in 28.4% of cases and was the main component in only 20.7% of stones which is higher than those reported in our region [34],[35] probably represen­ ting more prevalent urinary tract infections. The purine (urate) stone occurs frequently in developing countries. [31],[38] Chronic diarrhea with subsequent acidosis during the first months of life and simultaneous phosphorus deficiency can explain a high urine excretion of ammo­nium ions able to form urate ammonium by combining with urate ions which are also abundant in infant urine. [3] In our country purine stone represent 19.3% of cases somewhat less than other countries in the region and higher than the European data [9],[10],[11],[31]

We observed the rise in the frequency of of calcium oxalate stones in the eighties and a progressive decline in the uric acid stones. This period was also characterised by a high frequency of struvite stones which accounted for 39.4%. [4] The frequency of calcium oxalate has followed a continuous increase during the past 45 years possibly due to the improvement in socioeconomic status as suggested by An­ derson. [44],[45] However, the persistence of stru­vite stones in our region reflects a slower progression of the standard of living in our country.

The evolution of stone composition in our region may be dependent on several factors. Major factor being the changes in the dietary habits. Indeed, according to the epidemiolo­gical study conducted by Ben Romdhane et al, [22] dietary habit of Tunisian people, in the Sixties, was based on cereals specially in the rural areas, with low consumption of dairy products which represent below 5% of the average budget of the Tunisian family. During the same period low protein intake was also associated with lower incidence of purine stone in our region. [1] The urbanization since the end of the Eighties (36% in 1956 vs 65% in 2004) following the economic development changed the life style and dietary habits. [22],[46] These data can explain in party this prog­ression of calcium oxalate stones [47] and the sta­bilization of the ammonium urate stones in our country.

In conclusion, our region, since the sixties, has experienced change in the several epide­miologic characteristics of the urinary lithiasis (sex, age, localization and composition).

The nutritional practices and the regression of the culinary traditions introduce new risks of urolithiasis characterized by the emergence of calcium oxalate stones.

   References Top

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Correspondence Address:
A Alaya
Department of Biochemistry and Toxicology, Fattouma Bourguiba Hospital, 5000 Monastir
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]

  [Table 1], [Table 2], [Table 3]

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