This document discusses the treatment of renal stones in children. It covers types of renal stones, medical management including treating pain and preventing future stone formation. Surgical and endoscopic procedures for stone removal are also discussed. Prevention focuses on adequate hydration and dietary modifications based on the stone composition. The prognosis depends on factors like nephrocalcinosis, treatment adherence, number of infections and procedures required. Close collaboration between urologists and nephrologists is important for managing these young patients.
Management Of Nephrotic Syndrome
Objectives
To briefly review the definition & etiology of nephroticsyndrome.
To understand the terminology pertaining to clinical course of nephroticsyndrome.
To understand the management of nephroticsyndrome:Specific management & Supportive care and management of complications
Management of congenital nephrotic syndrome
Management Of Nephrotic Syndrome
Objectives
To briefly review the definition & etiology of nephroticsyndrome.
To understand the terminology pertaining to clinical course of nephroticsyndrome.
To understand the management of nephroticsyndrome:Specific management & Supportive care and management of complications
Management of congenital nephrotic syndrome
Urolithiasis Is the process of forming stones in the kidney, bladder or urethra
Kidney stones(calculi) are formed of minerals deposits commonly calcium oxalate and calcium phosphate; however uric acid, struvite and cystine are also calculus formers.
Gouty Arthritis/Gout is a type of crystal arthropathy characterized by recurrent attacks of acute arthritis.
Pathophysiology, clinical features, investigations, treatments modalities and complications
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The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
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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
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
