Pediatric nephrolithiasis (kidney and ureteral stones)

What is pediatric nephrolithiasis (kidney and ureteral stones)?

Pediatric kidney stones vary in shape and size, from the size of a grain of sand to the size of a golf ball (in extreme cases). When these stones are larger than the urinary tube, they can get lodged in the urinary tract and cause intense pain. 

Stones pass from the kidney to the ureter (the tiny tube that connects the kidney to the bladder).

Some kidney stones are small enough to pass without being noticed. Others are larger than the tube and become stuck when trying to pass through. This leads to a urine backup in the kidney, ureter, bladder or the urethra (which takes urine from the bladder out of the body) – wherever the stone is stuck.

What are the different types of pediatric nephrolithiasis (kidney and ureteral stones)?

• Calcium stones are the most common type of kidney stone in children is made of calcium oxalate or calcium phosphate. Calcium in the diet does not increase the risk of this type of stone.

• Cystine stones are a side effect of a genetic disorder called cystinuria. The child’s kidneys leak large amounts of an amino acid called cysteine. Cysteine crystals can form stones.

• Struvite stones can form after an infection in the upper urinary tract. They develop suddenly and become large quickly. They often affect children whose urinary tracts did not develop normally.

• Uric acid stones form when a child’s urine contains too much uric acid, due to inherited conditions or diet. The body creates uric acid when it breaks down substances called purines, a natural chemical compound found in many foods and drinks.

What are the signs and symptoms of pediatric nephrolithiasis (kidney and ureteral stones)?

• Pain in the back, side, lower abdomen or groin

• Blood in urine

• Nausea and vomiting

• Cloudy or bad-smelling urine

• Fever and chills 

• Frequent urge to urinate or inability to urinate 

• Irritability 

• Pain while urinating

How is pediatric nephrolithiasis (kidney and ureteral stones) diagnosed?

• Analysis of kidney stones that have passed

• Blood test

• Imaging

  • Ultrasound

  • Abdominal x-ray

  • CT scan

• Urine test

What are the causes of pediatric nephrolithiasis (kidney and ureteral stones)?

There are many causes of kidney stones, but the most common reason is eating too much salt and not drinking enough water. In fact, the formation of a kidney stone is actually multiple small salt crystals sticking together and growing until it becomes a visible stone.

To describe how kidney stones form, ask your child to imagine sea water evaporating and leaving salt crystals behind. When these stones become large enough to become painful, they may even block the kidneys or the tubes (ureters) that carry urine.

Other causes may include:

• Dehydration 

• Medications like diuretics (pills that help rid the body of water) or calcium-based antacids, can lead to kidney stones.

• Metabolic disorders - If the body doesn’t break down food properly, it can lead to concentrated levels of oxalate or cysteine in the urine. 

• Other health conditions - This can be from genetic conditions that change the shape of the urinary tract, like cystic fibrosis and cystic kidney disease.

• Non-genetic conditions also play a role, such as repeated urinary tract infections, an inflamed bowel or gout (a type of arthritis).

• Sodium - A diet high in sodium adds extra minerals to the urine that can become kidney stones. 

• Sugary foods and drinks - Ingesting too much fructose (sugar) correlates with increasing risk of developing a kidney stone. Fructose can be found in table sugar and high fructose corn syrup.

How is pediatric nephrolithiasis (kidney and ureteral stones) treated?

Depending on the size and severity of your child’s kidney stone, we typically recommend this series of treatment options:

• If there is a chance the stone will pass on its own, we will prescribe medicines to relax the ureter to help stone passage, prevent nausea and vomiting, and relieve pain.  

• We will recommend specific changes in diet, especially increasing the amount of water your child drinks each day.

Prevention

Many things have been recommended to prevent kidney stones in adults, including changing intake of water, sodium salt, acidity (pH), calcium, citrate, and oxalate. But children are not just “little adults”. Before any dietary changes are made, it is extremely important to have 24 hour urine testing to find out the best dietary recommendations for your child’s specific case.

This is extremely important, as some dietary recommendations to prevent stones in adults can actually hurt children and can even make the child create MORE kidney stones. And children are growing, so their dietary needs for normal growth must be considered in the prevention recommendations.

Along with any relevant medical history, results from initial blood and urine tests will guide the pediatric urologists and nephrologists to recommend any additional testing or medications to prevent future stones.

Surgery

• Ureteroscopy with laser lithotripsy - a procedure that allows the surgeon to see inside the bladder and ureter and then, by using a small laser, break up the stone into small pieces that can be removed or passed during urination.

• Extra-corporeal shock wave lithotripsy (ESWL) -  From the ESWL machine, high-energy sound waves go thru the skin to the stone to break it up into small pieces that can be passed during urination. 

• Percutaneous nephrolithotomy - a surgical procedure through a small skin cut on the back. A temporary tube is inserted through the skin into the kidney and the pediatric urologist is able to grind up and suction out the stone through the tube. Once safe, the kidney tube (nephrostomy) is removed.

The procedures will be discussed in more detail at your clinic visit. Sometimes, a temporary hollow drainage tube the size of a spaghetti noodle (called a double J stent) needs to be placed before or after the surgery.