Clinical Review & Education

Review

Current Trends, Evaluation, and Management

of Pediatric Nephrolithiasis
Joel D. Hernandez, MD; Jonathan S. Ellison, MD; Thomas S. Lendvay, MD

Related article page 980

The incidence of pediatric nephrolithiasis has been steadily increasing for the past several
decades, with a concomitant concerning increase in health care costs and burden to children
with this disease. Recent population-based studies have also demonstrated a change in the
current trends of pediatric nephrolithiasis that is characterized by a significant increase in the
number of girls now being affected. While changes in diet and lifestyle, obesity prevalence,
and even imaging practices have been proposed to contribute to the recent increase in
pediatric nephrolithiasis, a definite underlying cause remains elusive. This situation is
complicated by the fact that, unlike in adults, the trends occurring in pediatric nephrolithiasis
have not been studied rigorously, which contributes to the paucity of data in children. The
level of concern with the increasing incidence is raised by factors unique to pediatric
nephrolithiasis that could expose an affected child to more complications. Factors such as
variable clinical presentation, high recurrence of kidney stones associated with abnormalities
of metabolism and the urinary tract, and the possible presence of rare genetic kidney stone
diseases would require physicians to comprehensively evaluate patients presenting with
kidney stones. The goal of evaluation is to identify modifiable risk factors and abnormalities
for which targeted therapy can be prescribed. The goals of medical and surgical treatments
are to eliminate the burden of kidney stones and prevent recurrence while simultaneously
minimizing complications from interventions. Patients at high risk may benefit from a
specialized kidney stone clinic staffed by a pediatric nephrologist, urologist, dietitian, and
clinical nurse. Such a multidisciplinary clinic can help provide the medical and surgical support
needed for patients at high risk and offer key opportunities to learn more about pediatric
nephrolithiasis, thereby fueling the much-needed research in this field.
JAMA Pediatr. 2015;169(10):964-970. doi:10.1001/jamapediatrics.2015.1419
Published online August 24, 2015.

ediatric nephrolithiasis is an important kidney disorder

encountered in clinical practice. Although nephrolithiasis is
less common in children than in adults, its incidence in children is rising and can cause complications and lead to significant
medical costs. Metabolic abnormalities associated with nephrolithiasis are more common in children than in adults and can result in
frequent kidney stone recurrence. However, to our knowledge,
there is a lag in quality data on nephrolithiasis in children compared
with data on adults. This review examines the current state of
evaluation and treatment of children with nephrolithiasis based on
the relevant literature.

Current Trends and Risk Factors

Previously reported incidences of pediatric nephrolithiasis in
the United States have ranged from 1 in 1000 to 1 in 7600 hospital admissions from 1970 to 1990.1-3 A recent study reported
that the rate of hospitalization increased to 1 in 685 admissions
from 2002 to 2007.4 Based on a published case series, nephrolithiasis is historically more common in boys than in girls. 5
Population-based studies are showing an increasing incidence of
964

Author Affiliations: Division of

Pediatric Nephrology, Seattle
Childrens Hospital, Seattle,
Washington (Hernandez); Division of
Pediatric Urology, Seattle Childrens
Hospital, Seattle, Washington
(Ellison, Lendvay).

kidney stones in children, with a significant rise now being demonstrated in girls.4-7 These observational studies have not yet
been able, however, to establish the cause of these increases.
In a retrospective series from Schneider Childrens Hospital in
New York, VanDervoort et al8 reported a 5-fold increase in the number of children diagnosed with nephrolithiasis from 1994 to 2005.
Similarly, emergency department data from South Carolina demonstrated a dramatic increase in the incidence of nephrolithiasis in children between 1996 and 2007.6 The incidence in 1996 was approximately 8 per 100 000 children and increased to approximately 18
per 100 000 children in 2007. The ratio of boys to girls was 1:1.4,
with the discrepancy in sex distribution becoming more obvious in
the adolescent age group. An increased number of adolescents were
diagnosed with kidney stones at age 14 to 18 years. Because the
symptoms of nephrolithiasis in this age group are not subtle, the
trends are not likely to be a result of reporting bias.
Routh et al7 conducted a study using the Pediatric Health Information System national database and demonstrated an increased incidence of nephrolithiasis in children. The data from 1999
to 2008 included all inpatient admissions, ambulatory short-stay

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Trends, Evaluation, and Management of Pediatric Nephrolithiasis

areas, and emergency departments involving patients younger than

18 years with nephrolithiasis. Sex distribution was almost equal; however, with age stratification, more kidney stones were seen in younger
boys but greater proportions of girls aged 12 to 18 years had kidney
stones. After correcting for patient volume, the incidence of nephrolithiasis was 18 per 100 000 patients in 1999 and increased to 57
per 100 000 patients in 2008. The mean annual increase was 10.6%.
This is an alarming increase and could be explained in part by practice pattern changes in that adult urologists are now more likely to
refer patients to pediatric centers as opposed to treating the patients themselves. This shift would account for some of the increase observed in the childrens hospitals that were registered in
the database but is unlikely to represent the complete explanation.
IntheRochesterEpidemiologyProjectinMinnesota,childrenwith
nephrolithiasis were identified from 1984 to 2008, with increased incidence confined to the adolescent population aged 12 to 17 years.9
The overall incidence increased by an average of 4% annually. The ageadjusted incidence rate increased from 7 per 100 000 person-years
between 1984 and 1990 to 14.5 per 100 000 person-years between 2003 and 2008. Girls in the second decade of life are admitted and hospitalized more frequently for kidney stones.4,5,7 This trend
parallels the increasing number of adolescents with obesity observed in pediatric studies, suggesting a possible association with
nephrolithiasis. Rising prevalence of female obesity has been linked
to increasing risk of nephrolithiasis based on adult data.10 Abnormalities predisposing individuals to nephrolithiasis in adult studies include increased urinary sodium and uric acid excretion and low urine
pH. However, evidence is not strong in pediatric patients, and there
are limited data available linking obesity with nephrolithiasis in children. In the 25-year population-based study by Dwyer et al,9 for instance, no correlation was found between increased incidence of kidney stones and body mass index.
Changing patterns of fluid consumption in children, specifically
a decrease in water intake, may be an important contributing factor
to the increase in pediatric nephrolithiasis.11 It is well established that
increased supersaturation of urinary calcium, oxalate, and phosphate related to low urine volume and inadequate hydration are important risk factors for nephrolithiasis. Intake of dietary sodium has
also increased above the recommended dietary allowance in US
children.12 The higher intake of sodium is coupled with increased excretion of urinary calcium. Decreased intake of dietary calcium also
has been proposed as another factor contributing to nephrolithiasis
in older children, with increased consumption of sugary drinks replacing intake of milk.6 Adequate intake of calcium prevents increased intestinal absorption of oxalate, limiting its urinary excretion. Last, the increased use of computed tomography (CT) for
diagnosing nephrolithiasis in children has been cited as a possible reason for the increased incidence of nephrolithiasis.9 Because of the high
specificity and sensitivity of CT scanning for detecting kidney stones,
the perceived increase in incidence may be related to the decrease
in the number of diagnoses that would have been missed if other
imaging modalities were used.
The increasing incidence of pediatric nephrolithiasis is concerning. The level of concern is raised by findings that children with kidney stones represent a group with high risk of recurrence, which
ranges from 16% to 44%.13-17 Recurrence is usually more common in
children with metabolic, genetic, and urinary tract abnormalities. Increased risk of recurrence is linked to metabolic factors such as hyjamapediatrics.com

Review Clinical Review & Education

At a Glance
The incidence of pediatric nephrolithiasis has been steadily
increasing, with a concerning increase in health care costs and
patient burden.
The underlying cause for the recent trends in pediatric
nephrolithiasis remains elusive and is compounded by the lack of
studies in children.
Evaluation aims to identify modifiable risk factors that could be
amenable to medical and surgical treatments prescribed to
eliminate the burden of kidney stones and prevent recurrence.
Advances in technology have allowed a shift from open surgery
for kidney and ureteral stones in children to minimally invasive
management.
Conservative management should be the first-line medical
treatment for patients with kidney stones and is composed of
altering diet and fluid intake.

percalciuria, hypocitraturia, hyperoxaluria, hyperuricosuria, cystinuria, and changes in urine pH that, together with low urine volume,
contribute to nephrolithiasis. This risk is more significant in younger
patients (<10 years) because 50% of patients with nephrolithiasis in
this age group also have metabolic abnormalities.18-21 Hypercalciuria
is the most common, accounting for 34% to 50% of metabolic abnormalities, while hyperuricosuria, cystinuria, hypocitraturia, and
hyperoxaluria make up 2% to 20%, 5% to 20%, 10%, and 10% to
20%, respectively, of the abnormalities in pediatric series of
nephrolithiasis.16,18,22-24 The ability of these factors to predict recurrence, however, is yet to be characterized and may be affected by the
fact that the commonly used definitions for these metabolic abnormalities are based on statistical cutoffs (>95th percentile for the study
population) and not on clinical outcome (nephrolithiasis).25 In children with recurrent nephrolithiasis, there is also a need to consider
inherited monogenic disorders such as adenine phosphoribosyltransferase deficiency, cystinuria, Dent disease, familial hypomagnesemia
with hypercalciuria and nephrocalcinosis, and primary hyperoxaluria.
Development of chronic kidney disease can be associated with these
rare inherited disorders and the delay in diagnosis related to underrecognition compounds the risk of developing chronic kidney disease.
Although recurrence of nephrolithiasis is common in children, the
recurrence rate is lower than that in adults.26 However, Tasian and
Copelovitch27 arguedinarecentreviewthatstudiesofrecurrencerates
in children were conducted in the past, when reported incidence rates
were much lower, and that contemporary recurrence rates may now
be different given the changing incidence of nephrolithiasis. The increasing incidence in children could translate into increasing disease
burden and the rising cost of medical evaluation and treatment. Lack
of studies and guidelines in children compound the problems in evaluation and management. The annual cost of kidney stone treatment
in the adult population was estimated to be almost $2 billion in
2000.28 In South Carolina alone, where increased incidence of nephrolithiasis in children has been reported, the health care dollars spent
for kidney stone management in children nearly quadrupled from $3.4
million in 1996 to $12.6 million in 2007.6

Clinical Presentation
The presentation of nephrolithiasis in children is variable, depending on the age of the patient.23 Severe colicky abdominal pain is common in adolescents and school-aged children. Nonspecific symp(Reprinted) JAMA Pediatrics October 2015 Volume 169, Number 10

Copyright 2015 American Medical Association. All rights reserved.

965

Clinical Review & Education Review

Trends, Evaluation, and Management of Pediatric Nephrolithiasis

toms of abdominal pain, nausea, vomiting, and irritability, rather than

the typical renal colic, are seen in younger children. Gross hematuria
is a common presenting sign. In patients younger than 5 years, kidney stones are frequently discovered following a urinary tract infection or as an incidental finding.23 Patients also may be asymptomatic, with nephrolithiasis incidentally discovered in an imaging study
conducted for other indications.16 In North American children, stones
are mostly located in the kidneys and upper urinary tract.
As reported in several pediatric series, most kidney stones in children are calcium based.2,16,23,29,30 Calcium oxalate is most common and accounts for 40% to 60% of cases of pediatric nephrolithiasis while calcium phosphate accounts for 10% to 20%. Mixed
stones composed of both calcium oxalate and calcium phosphate
constitute 10% to 25% of cases of pediatric nephrolithiasis. Magnesium ammonium phosphate (struvite or infection-related) stones
are seen in 17% to 30% of cases. Infection-related stones are less
common today because of improvements in antenatal screening and
management of congenital anomalies of the urinary tract.31 Cystine stones are found in 6% to 10% of cases of pediatric nephrolithiasis while uric acid stones make up 2% to 10% of cases. Rare stones
to consider include those composed of xanthine and
dihydroxyadenine.32

Evaluation
Evaluation includes a complete medical history and physical examination complemented by appropriate laboratory and imaging studies. The goal of evaluation is to identify modifiable risk factors and
abnormalities for which targeted therapy can be prescribed to decrease recurrence and complications of nephrolithiasis. Screening
for rare hereditary causes of kidney stones should be considered in
the appropriate clinical setting to prevent missed diagnosis. Prompt
evaluation is needed to rule out urinary tract obstruction and urinary tract infection.

Medical History and Physical Examination

The medical history should focus on diet, fluid intake, medications,
family history, and presence or absence of specific disorders that can
lead to nephrolithiasis. A detailed dietary history should be obtained, including information regarding the amount of fluid and dietary sodium intake. The ketogenic diet is a risk factor for formation of uric acid stones and may be associated with hyperuricosuria,
hypocitraturia, and low urine pH. Excessive animal protein intake has
been associated with increased urinary excretion of calcium and uric
acid and decreased urinary excretion of citrate, resulting in calcium
oxalate and uric acid stones.
Medications and supplements associated with nephrolithiasis
include vitamin D, calcium supplements, vitamin C, diuretics (furosemide and acetazolamide), seizure medications (felbamate, topiramate, and zonisamide), steroids, uricosuric drugs, and antibiotics (indinavir sulfate and ceftriaxone sodium). Information should
be obtained on all supplements or herbal preparations a patient is
taking.
A positive family history is present in 22% to 75% of cases of
nephrolithiasis.33 In one case series in the United Kingdom, 16% of
children had a first-degree relative and 33% had both first- and second-degree relatives with kidney stones.22 Familial recurrence of
nephrolithiasis, however, does not necessarily indicate a genetic
cause, as shared environmental factors and dietary habits can con966

tribute to a familial predisposition. Features in a patients history suggestive of a possible hereditary etiology would include infantile or
early childhood presentation; parental consanguinity; positive family history with unexplained renal insufficiency; recurrent kidney
stones; signs and symptoms of tubular dysfunction with associated polyuria, acidosis, rickets, growth retardation, or renal insufficiency; nephrocalcinosis; and dysmorphism.33,34 Specific disorders or conditions predisposing a patient to nephrolithiasis would
include urinary tract obstruction, vesicoureteral reflux, inflammatory bowel disease, short gut syndrome, cystic fibrosis, seizure disorder, and immobilization. Key elements of the physical examination include documentation of blood pressure, growth parameters,
bony deformities, abnormal calcifications, rickets, abnormal genitalia, and immobility.

Laboratory Evaluation
Results of urinalysis provide information regarding specific gravity,
urine pH, and the presence of hematuria or pyuria. Tubular dysfunction may be present if the results of urinalysis show glucosuria and
proteinuria. A diagnosis of infection accompanying acute kidney
stone episodes may be supported by the presence of pyuria. Urine
should be obtained for culture as part of the evaluation for nephrolithiasis. Microscopic analysis can demonstrate the presence of cystine crystals in cystinuria. Xanthine and dihydroxyadenine crystals
can be seen by microscopic examination of the urine, providing the
initial indication of adenine phosphoribosyltransferase deficiency.
Low-molecular-weight proteinuria in boys with kidney stones or
nephrocalcinosis can establish the diagnosis of Dent disease.
It is essential that kidney stone material be retrieved and analyzed whenever possible. Kidney stone composition can narrow the
differential diagnosis and help tailor evaluation and management.
For instance, identification of a uric acid stone should prompt investigation for inborn errors of purine metabolism, given the rarity
of this stone in children.
Metabolic evaluation should incorporate measurement of electrolyte levels, including calcium, magnesium, and phosphorous. Creatinine levels should be measured to assess overall renal function.
If hypercalcemia is present, measuring the parathyroid hormone level
can help diagnose hyperparathyroidism. High levels of vitamin D can
cause hypercalciuria, requiring measurement of the 25hydroxyvitamin D level. Presence of vitamin D deficiency should be
determined and corrected.
Since children with kidney stones have a high risk of recurrence associated with metabolic abnormalities, 24-hour urine collection is the mainstay of the workup for pediatric nephrolithiasis,
as it is in adults. Because of significant intra-individual variability related to diet and environment, two 24-hour urine collections are recommended. There are no studies regarding the appropriate number of urine collections in children, but adult studies support 2 urine
collections on initial evaluation.35-37 Urinary excretion of calcium, oxalate, uric acid, citrate, magnesium, phosphorus, sodium, and potassium should be assessed. Valuable information that can be obtained from the urine collection also includes pH, volume, creatinine,
sulfate, and urea nitrogen levels, and supersaturation. When patients are unable to give 24-hour urine samples, spot urine samples
can be collected, especially in young patients who are not toilet
trained. Normal values for spot urine samples and 24-hour urine collection are given in Table 138-41 and Table 2.32,41-44

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Trends, Evaluation, and Management of Pediatric Nephrolithiasis

Table 1. Normal Urinary Values in Spot Urine Samples38-41

Urine Constituent

Calcium

Review Clinical Review & Education

Table 2. Normal Urinary Values in 24-Hour Urine Collection32,41-44

Age

Value (mg/mg Creatinine)

Urine Constituent

Age

Timed Collection

<7 mo

<0.86

Calcium

All ages

<4 mg/kg

7-18 mo

<0.60

Oxalate

>2 y

<0.45 mg/1.73 m2

19 mo-6 y

<0.42

All ages, male

>365 mg/1.73 m2

All ages, female

>310 mg/1.73 m2

Citrate

>6 y

<0.20

<6 mo

<0.29

Cystine

All ages

<60 mg/1.73 m2

6 mo-2 y

<0.20

Uric acid

All ages

<815 mg/1.73 m2

>2-5 y

<0.11

3-5 y

12-20 mg

6-12 y

<0.06

6-13 y

15-25 mg

<5 y

>0.42

14-18 y, male

18-27 mg

>5 y

>0.25

14-18 y, female

17-24 mg

Cystine

All ages

<0.075

Uric acid

All ages

<0.56 perGFRa

Oxalate

Citrate

Creatininea

Adequacy of urine collection can be assessed by checking urinary creatinine

excretion based on age and sex.

Abbreviation: GFR, glomerular filtration rate.

a

Calculated by multiplying the ratio of uric acid to creatinine (mg/mg) with

serum creatinine (mg/dL).

Imaging
In adults, CT without contrast is the criterion standard for diagnosing nephrolithiasis and urinary tract calculi because of its high sensitivity and specificity. The ability of CT scanning to localize kidney
stones and its characteristic high spatial resolution provide anatomical detail that can be useful for surgical planning. In children, radiation exposure has been a major concern, resulting in recommendations supporting the initial use of renal ultrasound (US) with or
without radiographs to limit radiation exposure.45-47 However, in centers with the capability to adjust CT radiation dose based on the patients size and weight, low-dose CT without contrast continues to
be the initial imaging study in children with suspected renal colic.48,49
The concern regarding radiation exposure is starting to be recognized in the adult population. In a recent study by Smith-Bindman
et al,50 no difference in serious outcome arising from a missed or delayed diagnosis was demonstrated between the use of US and CT
as the initial imaging studies in adults with suspected nephrolithiasis. This finding, together with the lower cumulative radiation exposure over 6 months from multiple imaging tests that followed the
initial use of US, supports the conclusion that US can be considered
as an initial imaging study of choice.

Acute Management
The first step in the management of acute renal colic is determining
the need for emergency urinary decompression. Renal calculi are
generally nonobstructing and acute decompression is not indicated. Obstructed ureteral calculi require acute decompression with
either a ureteral stent or percutaneous nephrostomy tube in obstructed pyelonephritis, acute kidney injury, or intractable pain. Both
methods are equally effective, although size and location of the calculus, the patients hemodynamics, and availability of interventional radiology procedures may influence the choice of
decompression.51 Even in the setting of well-controlled pain and nausea, the combination of infection and an obstructing kidney stone
constitutes an emergency necessitating prompt urologic evaluation and intervention.
Most patients with acute renal colic can be managed without
hospital admission, with an emphasis on presentation on the imjamapediatrics.com

portance of adequate analgesia.52 While literature specific to children is lacking, studies of pain control in acute renal colic in adults
have shown acetaminophen, nonsteroidal anti-inflammatory drugs,
and narcotics to be equally effective analgesics, with combination
therapy being superior to single agents.53,54
Renal and ureteral stones pass spontaneously in children 32% to
50% and 41% to 63% of the time, respectively, so most cases can be
managed successfully by watchful waiting.17,55 Medical expulsive
therapy is a well-established treatment for ureteral calculi in adults that
uses -blockers (tamsulosin, terazosin, doxazosin, prazosin) or calcium channel blockers (nifedipine) to relax ureteral smooth muscle,
resulting in increased rates of stone passage, decreased time to stone
passage, and improved analgesia.56 Although limited data exist in children, tamsulosin use for nephrolithiasis has increased in pediatric
hospitals.4 Two recent studies demonstrated the benefit of tamsulosin in children with ureteral calculi, with tamsulosin reported to have
up to a 3-fold increase in rate of stone passage.57,58 Health care professionals should be aware that the use of medical expulsive therapy
is off-label and beneficial only for ureteral calculi. Stone passage may
take 4 to 6 weeks and confirmation of passage by either repeated
imaging or visualization of the passed calculus is mandatory.

Surgical Management
Up to 22% of children with nephrolithiasis will require surgical
intervention within 6 months of presentation, with 25% requiring
more than 1 procedure.59 Surgical options for pediatric nephrolithiasis include extracorporeal shock wave lithotripsy, ureteroscopy with lithotripsy and/or kidney stone extraction, percutaneous nephrolithotomy, and minimally invasive or open
pyelolithotomy. The choice of specific surgical procedure
depends on multiple factors. Ureteroscopy and extracorporeal
shock wave lithotripsy are classically used for smaller calculi
within the ureter or kidney and, in most cases, they are considered to be relatively equivalent in the rate of success.60,61 While
the choice of ureteroscopy or extracorporeal shock wave lithotripsy may be determined in part by kidney stone characteristics,
the availability of equipment and surgeon preference also play
significant roles in the choice of surgical treatment.62 Percutaneous nephrolithotomy and pyelolithotomy are generally reserved
for large calculi.63 Historically, pyelolithotomy was the treatment
of choice for large kidney stones.64 However, with the advent of
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Clinical Review & Education Review

Trends, Evaluation, and Management of Pediatric Nephrolithiasis

Table 3. Comparison of Treatment Modalities for Surgical Management of Pediatric Nephrolithiasis

Treatment

Indication

Stone-Free Rate, % Limitations

Complications

Extracorporeal shock wave

lithotripsy

Smaller stones, ureter and

kidney

80-8368,69

Lacks direct visualization of stone, high

retreatment rate

Steinstrasse, perirenal
hematomaa

Ureteroscopy

Smaller stones, ureter and

kidney

85-8870

Adult-sized instruments, surgical

expertise needed

Infection, ureteral obstruction,

ureteral stricture

Adult-sized instruments, surgical

expertise needed, higher complication
rate, inpatient procedure

Bleeding (8%-16% require

blood transfusion), urine leak,
urinary obstruction, sepsis

Invasive, long postoperative

convalescence

As for any open surgery

Surgical expertise needed, learning

curve

As for any minimally invasive

surgery

Percutaneous nephrolithotomy

Larger stones, abnormal

anatomy

70-97

Open pyelolithotomy

Larger stones

79-9863,74

Minimally invasive
pyelolithotomy
a

71-73

Larger stones

No data

Steinstrasse is a collection of stone fragments that become obstructed within

the ureter following lithotripsy.

Hypercalciuria

Conservative Management

Medications

Increase fluid intake

Potassium citrate

Limit dietary sodium intake

Thiazides

Consume RDA of dietary

calcium
Avoid excessive protein
intake
Normalize vitamin D status

Hypocitraturia

Encourage intake of dietary

citrate

Potassium citrate

Increase intake of fruits and

vegetables

Bicarbonate

Avoid excessive protein

intake
Increase fluid intake

Hyperoxaluria

Potassium citrate

Reduce dietary oxalate

Pyridoxine

Consume RDA of dietary

calcium

Neutral phosphate

Treat fat malabsorption, if

present

Magnesium

Probiotics

Hyperuricosuria

Cystinuria

Increase fluid intake

Potassium citrate

Decrease intake of
purine-rich foods

Bicarbonate

Avoid excessive protein

intake

Allopurinol

Increase fluid intake

Tiopronin

Limit dietary sodium intake

Penicillamine
Captopril

Abbreviation: RDA, recommended dietary allowance.

endoscopic techniques, open pyelolithotomy in the management

of patients with kidney stones has been minimized.63,65 Laparoscopic and robotic-assisted kidney stone removal may prove to
be the future of kidney stone surgery in children, if indeed these
procedures can improve on kidney stonefree rates seen in endoscopic techniques while providing equal convalescence and pain
control postoperatively.66,67 Recent advances in instrumentation
have shifted surgical management from open surgery to minimally invasive surgical techniques and endoscopic treatments.
The burden of health careassociated costs for children requiring
surgery is high, highlighting the need to facilitate kidney stone
passage and prevent kidney stone recurrences with medical
968

Case reports on minimally invasive pyelolithotomy are few, which limits the
comparison of stone-free rates.

interventions. 59,62 Surgical options for children with kidney

stones, including indications and complications, are summarized
in Table 3.63,68-74

Table 4. Treatment of Metabolic Abnormalities

in Pediatric Nephrolithiasis
Metabolic Abnormality

Prevention and Medical Management

Preventive measures for kidney stone recurrence should focus on
modifying risk factors. Limiting dietary sodium intake can decrease
hypercalciuria. Patients should be encouraged to maintain adequate
fluid intake to help decrease urinary supersaturation of calcium, oxalate, and uric acid and maintain urine flow rate. A minimum fluid intake of 1.5 to 2 L/m2/d is recommended. The volume of fluid intake
should be adjusted to maintain urine volume greater than 750 mL/d
in infants, greater than 1000 mL/d in children younger than 5 years,
greater than 1500 mL/d in children between 5 and 10 years, and
more than 2000 mL/d in children older than 10 years.32 Discontinuation or weaning of medications that can cause kidney stones
should be part of treatment. Dietary calcium restriction is not recommended since it can increase intestinal oxalate absorption and
risk of nephrolithiasis.75 Children should consume the recommended dietary allowance of calcium. A low vitamin D level
would need correction to maintain bone health. Excessive protein
intake should be avoided since the acid load from protein
metabolism can cause hypercalciuria and hypocitraturia. Protein
restriction is also not recommended because of concerns regarding its effects on growth. Children should be encouraged to
increase their intake of vegetables and fruits, which are excellent
sources of citrate and potassium. Both citrate and potassium in
the urine act as kidney stone inhibitors.
Medications should be considered in children with recurrent kidney stones, obstruction in a solitary kidney, and genetic kidney stone
diseases. The primary medications used in children with nephrolithiasis include potassium citrate and thiazide and potassium-sparing diuretics. Potassium citrate can be used to treat hypocitraturia and increase urine pH to prevent uric acid crystallization in hyperuricosuria.
Thiazides, which work by reducing urinary calcium excretion, should
be considered in patients with persistent hypercalciuria and recurrentkidneystones.Potassium-sparingdiuretics,suchasamiloride,may
enhance calcium reabsorption when combined with thiazides. Treatment of hyperoxaluria should focus on limiting oxalate absorption and
preventing calcium oxalate crystallization in the urine. Pyridoxine can
be given empirically if primary hyperoxaluria is suspected. Tiopronin
and penicillamine can be used in cystinuria to increase cystine solubility. Allopurinol can be prescribed to help treat patients with a de-

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Trends, Evaluation, and Management of Pediatric Nephrolithiasis

fect in purine metabolism. Conservative management should be the

first-line treatment for patients with kidney stones and is composed
of altering diet and fluid intake. Table 4 provides a summary of medical treatment strategies.
The need for a multidisciplinary approach to prevent and treat
kidney stones has resulted in an increasing number of dedicated kidney stone clinics for children. The combined expertise of a pediatric nephrologist, urologist, dietitian, and clinical nurse aims to provide comprehensive and coordinated care to children with kidney
stones. Outcome studies supporting the benefits of a dedicated center are lacking in children but have been published in the adult
literature.76

Conclusions
The changing current trends, rising medical costs, and limited
studies in children with nephrolithiasis highlight the need for
evidence-based research in this population. Meticulous medical
management together with less invasive surgery are essential in
eliminating kidney stone burden and recurrence in children.
Although technologies to treat nephrolithiasis are becoming more
focused on pediatric patients, our primary efforts should be
directed toward modifying the risk factors that led to nephrolithiasis in the first place.

9. Dwyer ME, Krambeck AE, Bergstralh EJ, Milliner

DS, Lieske JC, Rule AD. Temporal trends in
incidence of kidney stones among children. J Urol.
2012;188(1):247-252.

ARTICLE INFORMATION
Accepted for Publication: May 5, 2015.
Published Online: August 24, 2015.
doi:10.1001/jamapediatrics.2015.1419.
Corresponding Author: Joel D. Hernandez, MD,
Division of Pediatric Nephrology, Seattle Childrens
Hospital, 4800 Sand Point Way NE, Seattle, WA
98105 (joel.hernandez@seattlechildrens.org).
Author Contributions: Drs Hernandez and Ellison
had full access to all the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data:
Hernandez, Ellison.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important
intellectual content: All authors.
Administrative, technical, or material support: All
authors.
Study supervision: Hernandez, Lendvay.
Conflict of Interest Disclosures: None reported.
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2. Walther PC, Lamm D, Kaplan GW. Pediatric
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