we present the updated management of renal stone

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