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treament of renal stone with children

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treament of renal stone with children

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Renal stones in children
treatment?
LOCATION OF STONES IN KIDNEY
Types of Renal Calculi
Ureteroscopy (URS)
Nephrostomy
Percutaneous Nephrostomy
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treament of renal stone with children

  • 1. Renal stones in children treatment?
  • 2. LOCATION OF STONES IN KIDNEY
  • 3. Types of Renal Calculi
  • 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
  • 23. T H A N K S