1. Good Morning and Welcome Applicants! January 27, 2011

3. Epidemiology • 1/685 pediatric admissions • Lower incidence than adults • Higher crystal formation inhibitors in urine • M>F • Most common stones • Calcium oxalate • Calcium phosphate • Struvite • Cystine • Uric Acid

4. Risk Factors • Present in 75-85% of children • Urinary metabolic abnormality • Hypercalciuria* • Hyperoxaluria • Hyperuricosuria • Hypocitraturia • UTI • Structural renal or urinary tract abnormality

5. Nephrolithiasis Presentation • Abdominal or flank pain • Wide variability • Gross hematuria • Dysuria • Urgency • Nausea/vomiting • 15-20% asymptomatic • Younger patients

6. Other History • Previous history • Family history • Underlying renal and urinary tract structural abnormalities • Underlying metabolic conditions • Medication use • History of UTI • Especially with urease-producing organisms • Proteus or Klebsiella

7. Physical Exam • Growth parameters • Congenital or chronic condition • Temperature • UTI • Blood pressure • Glomerular disease • Edema • Abdomen • Tenderness • Mass • Obstruction

8. Lab Evaluation • UA • Sediment • Cystine crystals • Calcium oxalate • Calcium phosphate • Uric acid • Phosphate • Urine Culture

9. Diagnosis • Confirmation • Imaging • Non-contrast helical CT • Ultrasonography • Stones >5mm • Location • Plain abdominal radiography • Radiopaque only • Not good for small stones • Retrieval

10. Treatment • Hospitalization • Nausea/vomiting • Severe pain • Urinary obstruction • Solitary kidney • Infection

11. Treatment • Pain control • NSAIDs • Opiod therapy • Combination may be superior • Passage • <5 mm • Hydration • Strain urine • Stone analysis

12. Treatment • Urologic intervention • Unremitting severe pain • Urinary obstruction • Infection • Renal insufficiency • >5mm stone • Struvite calculi • >2 weeks of conservative treatment

13. Treatment • Urological intervention • Extracorporeal shock wave lithotripsy • Small <1cm • Percutaneousnephrostolithotomy • >2cm • Structural abnormalities • Harder stones • Ureteroscopy

14. Prevention • Recurrent stone disease frequently occurs in children • >50% of children with nephrolithiasis will have an underlying metabolic abnormality • Reduce • Pain • School absenteeism • Loss of work for parents • Clinical costs

15. Prevention • Stone analysis • Focus metabolic evaluation • Metabolic evaluation • At home • Fully ambulatory • Regular diet • Free of infection

16. Prevention • Serum testing • Calcium • Phosphorus • Bicarbonate • Creatinine • Magnesium • Uric Acid

17. Prevention • UA • SpGr • pH • Crystals • Urine solute excretion • 24h vs single • Volume and creatinine

20. Prevention • Fluid intake • Metabolic interventions • Targeted to correct the specific abnormality

21. Monitoring • Imaging • New formation or increasing size of previous stones • U/S • Frequency depends on risk • Lab eval • Assess response to preventative therapy • 6-8 weeks, 6 months, yearly