RENAL DATA FROM THE ASIA - AFRICA
Year : 2010 | Volume
: 21 | Issue : 1 | Page : 181--184
Clinical manifestations and etiology of renal stones in children less than 14 years age
Mohsen Akhavan Sepahi1, Akram Heidari2, Ahmad Shajari3,
1 Department of Pediatric Nephrology, Clinical Research Development Center, Iran
2 Department of Epidemiology, Qom University of Medical Sciences, Qom, Iran
3 Department of Pediatric Nephrology, Yazd University of Medical Sciences, Yazd, Iran
Mohsen Akhavan Sepahi
Pediatric Nephrologist, Clinical Research Development Center of Qom University of Medical Sciences, Qom
Urolithiasis is one of the commonest problems in pediatric nephrology. Prevalence of urolithiasis in pediatric patients is increasing. The purpose was to properly diagnose and treat with the special attention to the risk factors. This study is case-series and was performed on 100 pediatric patients for evaluation of clinical manifestation and etiology of renal stone in Qom. Hundred Children, fewer than 14 years old with mean age of 3.32 years, were included (54% male). Etiology of urolithiasis in 5% was unclear. Metabolic disorders found in patients were mainly: Hypocitraturia in 54, hyperoxaluria in 14, hyperuricosuria in 25, cystinuria in 6, hypercalciuria in 28 and phosphaturia in 8 patients. The main clinical presentation was fever, pain, irritability, dysuria and hematuria. Family history of urolithiasis was found in 23% of patients and 54% presented with urinary tract infection (UTI). We conclude that majority of patients were symptomatic and hypocitraturia was the commenest risk factor among others.
|How to cite this article:|
Sepahi MA, Heidari A, Shajari A. Clinical manifestations and etiology of renal stones in children less than 14 years age.Saudi J Kidney Dis Transpl 2010;21:181-184
|How to cite this URL:|
Sepahi MA, Heidari A, Shajari A. Clinical manifestations and etiology of renal stones in children less than 14 years age. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Feb 22 ];21:181-184
Available from: http://www.sjkdt.org/text.asp?2010/21/1/181/58801
Urolithiasis is increasingly recognized in pediatric patients and is encountered in a variety of clinical settings. ,
The wide geographic variation in the incidence of urolithiasis in childhood is related to climatic, dietary, and socioeconomic factors. Approximately 7% of urinary calculi occur in children younger than 16 years of age. ,,
Many children with stone disease have a metabolic abnormality. ,,
Although stone disease is one of the most common afflictions of modern society, it has been described since antiquity. With westernization of global culture, however, the site of stone formation has migrated from the lower to the upper urinary tract and the disease once limited to men is increasingly gender blind. Revolutionary advances in the minimally invasive and noninvasive management of stone disease over the past 2 decades have greatly facilitated the ease with which stones are removed. Given the frequency with which stones recur, the development of a medical prophylactic program to prevent stone recurrences is desirable. ,,
The lifetime prevalence of kidney stone disease is estimated at 1% to 15%, with the probability of having a stone varying according to age, gender, race, and geographic location. ,,
Stone disease typically affects boys more commonly as much as two to three times more frequently than females. , Upper urinary tract stones occur more commonly in boys than girls by a ratio of 1.4:1 to 2.1:1. ,,
The physical process of stone formation is a complex cascade of events that occurs as the glomerular filtrate becomes supersaturated with respect to stone-forming salts, such that dissolved ions or molecules precipitate out of solution and form crystals or nuclei. Once formed, crystals may flow out with the urine or become retained in the kidney at anchoring sites that promote growth and aggregation, ultimately leading to stone formation. Most "spontaneous" stones are composed of calcium, oxalate, or phosphate crystals; others are due to uric acid, cystine, or ammonium crystals, or phosphate crystals, or a combination of these substances. However, the presence of molecules that raise the level of supersaturation needed to initiate crystal nucleation or reduce the rate of crystal growth or aggregation, prevents stone formation from occurring on a routine basis. ,, Renal calculi develop from crystals that form on the calyx and aggregate to form a calculus.
Urine must be supersaturated for stones to form. Supersaturation alone is not sufficient for crystallization to occur in urine, owing to the presence of urinary inhibitors. Citrate, diphosphonate, magnesium ion, nephrocalcin, uropontin, and Tamm-Horsfall protein are important inhibitors of crystal nucleation, growth, or aggregation. ,
To this end, we wanted to understand the etiology, epidemiology, and pathogenesis of pediatric urinary tract stone disease in Qom.
We studied 100 children aged less than 14 years, from inpatient as well as out patient pediatric clinics in the region of Qom, Iran presenting with urolithiasis from December 2007 to September 2008.
Demographic variables, sex and age of each patient were recorded in a data form. After recruitment, all patients underwent physical examination and laboratory tests.
Following laboratory investigations were performed:
ABG, serum Na, Ca, Phos, K, Alkaline phosphatase, Albumin, uric acid and urine 24 hour for Na, Ca, Phoa, K, uric acid, Creatinine, Oxalate, Citrate and Cystine.
This study was approved by the Clinical Research Development Center and Ethics Committee of Qom University of Medical Science.
Among the Hundred patients, 54 were boys (54%) and 46 were girls (46%) [Table 1], with ages ranging from 20 days to 14 years, Male to female ratio was 1.19:1.The median age for the group under study was 3.32 years [Table 2].
Etiology of urolithiasis was multifactorial in 73.7% (70 patients), monofactorial in 26.3% (25 patients) and the cause of 5% (5 patients) was unclear.
Metabolic disorders are shown in [Table 2] majority (68%) having hypocitraturia.
The main clinical presentation was hematuria [Table 3].
Family history of urolithiasis was found in 23% of patients. Among total of 100 urolithiasis patients studied, 54% presented with UTI.
An increasing incidence of urolithiasis overall in recent decades has been noted in population-based studies in industrialized countries. ,
There is a wide variation in prevalence of urolithiasis in different countries. The lifetime prevalence of kidney stone disease is estimated at 1% to 15%. With westernization of global culture, prevalence of urolithiasis in Iran like other countries has increased, so we decide to evaluate prevalence and etiology of urolithiasis in Qom region.
Early diagnosis of urolithiasis is necessary to decrease the morbidity rate. These study included 100 children with documented urolithiasis by ultrasonography. Results of our study show that: among the 100 patients, boys had a mild preponderance for stone disease overall similar to other studies from United States, United Kingdom, Brazil, and Armenia. ,,,,
Hypocitraturia was the main cause of urolithiasis in our study. Citrate is a naturally occurring inhibitor of calcium oxalate and calcium phosphate crystallization. , In a study of pediatric patients by Tekin and colleagues, urinary citrate excretion was significantly lower in calcium stone former than in a control group of healthy children,  Hyperoxaluria accounted for 14.7% of our patients' cause for urolithiasis similar to other reported prevalence of 2 to 20%. 
In our study hyperuricosuria was present in 26.3% a higher percentage than 2 to 10% reported in other studies. ,,, Hypoasthenuria is thought to promote increase uric acid excretion but this needs to be further clarified in our population.
Cystinuria was identified in 6.3% of patients, similar to other reports of 2 to 7% in children with stones. An inherited defect in the renaltubular reabsorptive transport of cystine and the dibasic amino acids accounts for the high concentration of cystine in the urine of patients with this disorder.
In our study hypercalciuria was 29.4% (28 patients) similar to the reported prevalence of 30 to 50% of identified metabolic factors in children and adolescents with urolithiasis. ,,,
Rarely urolithiasis is asymptomatic. ,, In our study 90% (90 patients) were symptomatic.
Symptoms of renal colic and gross hematuria, pathognomonic of urolithiasis in adults, are less reliable in children. Flank or abdominal pain or hematuria was the main initial presenting feature in our patients similar to other reports however is present in just 56% of children from birth to 5 years of age. ,,,
In conclusion, common clinical manifestation and symptoms of urolithiasis in our patients were hematuria, dysuria, fever, pain. Hypocitraturia being the commonest cause of urolithiasis followed by other known factors.
It is therefore recommended that in any child suspected of urolithiasis, prompt medical work up including sonography should be performed.
We thank other pediatricians in the children hospital and Dr. Hejazee, for allowing us to study their patients and for reviewing clinical notes.
|1||Larsen R, Kronenberg HM, Melmed S. Williams's textbook of endocrinology. Bunders, Philadelphia, 2003:1534-76.|
|2||Pearle MY. Urinary Lithiasis. In: Wein, Kavoussi L, Novick A, (eds). Campbell-Walash urology, volume 2. Sunders, Philadelphia, 2007:1363-525.|
|3||Soller ML. Urinary stone disease. In: Tangho EA, Mcaninch JH, Smiths (eds). General urology. Mcgraw-Hill companies, New York, 2004: 256-90.|
|4||Milliner DS. Urolithiasis, In: Avner E, Harmon W, Niaudet P (eds). Pediatric Nephrology. Lippincott Williams& Wilkins, Philadelphia, 2004:931-7.|
|5||Elder JS. urinary lithiasis. In: Behrman RE, Kliegman RM, Jenson HB (eds). Nelson Textbook of pediatrics, 17th edn. Philadelphia, Saunders, 2007:1822-6.|
|6||Henry JB. Clinical Diagnosis and management by Laboratory Methods, 21st edn. Sunders, Philadelphia, 2007:394-424.|
|7||Edward D, Harri S Jr. Kelley's textbook of rheumatology. Elsevier Sunders, Philadelphia, 2005:1043-62.|
|8||Schrier RW. Disease of the kidney and urinary tract. Lippincott Williams Wilkins, Philadelphia, 2001:2083-116.|
|9||Wallach J. Interpretation of Diagnosis tests. Lippincott Williams and Wilkins, Philadelphia, 2000:727-8.|
|10||Massry and Glassock's. textbook of Nephrology. Lippincott Williams Wilkins, Philadelphia, 2001:874-94.|
|11||Kaplan BS, Meyers KE. Pediatric Nephrology and Urology. Elsevier Mosby, 2004:361-74.|
|12||Erbagci A, Erbagci AB, Yilmaz M, et al. Pediatric Urolithiasis evaluation of risk factors in 95 children. Scand J Urol Nephrol 2003;37(2): 129-33.|
|13||Bartosh SM. Medical management of pediatric stone disease. Urol Clin North Am 2004;31 (3):575-87.|
|14||Wagner U, Balzar E, Ponhold W, Khoss A, Latal D, Zwiauer K. Urolithiasis in pediatrics, analysis of 34 patients. Urol Nephrol 1987;80 (9):505-11.|
|15||Behrman RE, Kliegman RM. Nelson Essentials of Pediatrics 4th edition. Saundersco, chap 16. 2002.|
|16||Phillips MT. Pyelonephritis the relation between infection, renal scaring and antimicrobial therapy. Kidney Int 1981;19:654.|
|17||Edelman CM. Pediatric kidney Disease, 2nd ed. Little, Brown Company, 1992:1967-70.|
|18||Abbott G D, Urinary tract infection in children, In: Cattell WR (ed). Infections of the kidney and urinary tract, 1st edn. Oxford New York, 1992:158-85.|
|19||Elder JS. Urologic disorders in infants and children. In: Behrman RE, Kleigman RM, Arvin AM, (eds). Nelson Textbook of pediatrics, 16th edn. W.B. Sanders Philadephia, 2000:1619-29.|
|20||Travis LB, Broubard BH. Infections of the urinary tract. In: Rudolph AM, Hoffman JI, Rudolph CD, (eds). Rudolph s pediatrics, 20th edn. Appleton& Lange Norwalk, 1996:1388-92.|
|21||Robert JA. Pathogenesis of non obstructive UTI in children. J Urol 1990;144:475-9.|
|22||Andrich MP, Majd M. Diagnostic imaging in the evaluation of the first urinary tract infecion in infants and young children. Pediatric 1992;90:439-41.|
|23||Husain A, Usama NR. Etiological& clinical patterns of childhood urolithiasis in Iraq. 18th international congress of pediatrics, Tehran, Iran, 27 oct 7 No. 2005.|
|24||Tekin A, Tekgul S, Atsu N, Sahin A, Ozen H, Bakkaloglu M. A study of the etiology of idiopathic calcium urolithiasis in children: Hypocitruria is the most important risk factor. J Urol 2000;164(1):162-5.|
|25||Schrier RW. Diseases of the kidney and urinary tract, 8th edn. Philadelphia, Lippincott Williams& Wilkins, 2005:3139-76.|