CASE REPORT

NEPHROLITHIASIS
IN CHILDREN
Supervised by: dr. Nurifah, Sp.A
Presented by: Shofa Samiroh Adli
(41181396100010)
01
About the Patient
You could enter a subtitle here if you need it
 PATIENT’S IDENTITY

NAME ADDRESS
An. EAH Pekayon, Pasar Rebo

MEDICAL R E C O R D DATE OF HOSPITAL ADMISSION

1092551 5 Januari 2020

DATE OF BIRTH DATE OF PATIENT CHECKED

Jakarta, 23 April 2008 9 Januari 2020

GENDER
Female
 ANAMNESIS
Autoanamnesis and alloanamnesis at Hardja 2a, 18 November 2019

CHIEF COMPLAINT
Abdominal pain since 3 months prior to hospital
admission

ADDITIONAL COMPLAINT
Nausea
 HISTORY OF PRESENT ILLNESS
Abdominal pain since pain felt spread from the
3 months prior to lower left to until the back the pain is felt
hospital admission of the waist to disappear

The patient also feels irritating if sitting

complained of nausea, for a long time,
Urinate and defecate but the patient did not improved when lying
Normal complain of vomiting down
 HISTORY OF
CHILDBIRTH
HISTORY OF
PAST ILLNESS • BW: 3200 gr, BL: 50 cm
• spontaneous, enough
None months, helped by the
doctor.
HISTORY

HISTORY OF
HISTORY OF GROWTH &
FAMILY ILLNESS DEVELOPMENT
Similar current illness (-) Delayed growth and
Other illness (-) development (-)
 HISTORY OF
FEEDING
 ASI until 6 months
HISTORY OF
 Formula milk and Eat
porridge after 6 month HABIT
 Eat family food after 1 y.o
HISTORY • Rarely drink water (±1200
ml/day)
• More often taste drinks
like thai tea, greentea,
HISTORY OF and others
IMMUNIZATION • Often hold back urination
while at school
Basic immunization:
Complete
 PHYSICAL EXAMINATION

Awareness Tension Heart Rate Respiratory Rate

Composmentis 100/75 mmHg 96 x/minute 22 x/minute

Temperature Weight Lenght

36,5 °C 30 kg 161 cm
 ANTROPOMETRIC STATUS

Age : 12 yo

WFA : 30/42 x 100% = 71,4% (underweight)

HFA : 161/151 x 100% = 106% (normal height)

WFH : 30/50 x100% = 60% (underweight)

 Physical Examination

Head: Normocephal Vesicular breath Regular 1st and 2nd Look flat, Bowel CVA
Eyes: CA -/-, SI -/-, sounds +/+, ronkhi - heart sound, murmur sounds 7x/min, (Costovertebra
Ears: Deformity (-), /-. Wheezing -/- (-), gallop (-) Supple, tenderness Angle) sign -/-
Discharge (-) (-), liver and spleen
Nose: Deformity (-), Nasal not palpable, rapid
flaring (-) turgor
Mouth: Dry lips (-), coated
tongue(-)
Neck: Lymph node
enlargement(-)
 Physical Examination

Genital: Normal Warm Rovsing sign: Negatif

CRT < 2sec Obturator sign: Negatif
No edema Psoas sign : Negatif
 LABORATORY

Pemeriksaan Hasil Nilai Rujukan Satuan

Hematologi 5 Januari 2020
Hemoglobin 12,7 12-14 g/dl
Leukosit 6.700 5.000-10.000 /ul
Hematokrit 37 37-43 %
Trombosit 288 150.000-400.000 /ul

Eritrosit 4,73 4-5

 Urine Lengkap 5 Januari 2020
Warna Kuning
Kejernihan Jernih
Reaksi / pH 7.0 5-8.5
Berat jenis 1005 1000-1030
Protein - Negatif
Bilirubin - Negatif
Glukosa - Negatif
Keton - Negatif
Darah / Hb - Negatif
Nitrit - Negatif
Urobilinogen 0.1 0.1-1.0 IU
Leukosit - Negatif
Sedimen:
Leukosit 0-1 0-5 /LPB
Eritrosit 0-1 1-3 /LPB
Sel epitel +
Silinder - /LPK
Kristal -

Lain-lain -
Pemeriksaan Hasil
USG  Nefrolitiasis sinistra dengan hidronefrosis ringan
 Ren Dextra ukuran normal, echo cortex normal, batas
medulla-cortex jelas batu (-), tanda bendungan (-)
 Ren Sinistra Batu (+)ukuran normal, echo cortex
normal, batas medulla-cortex jelas batu ukuran 0,44
cm, tanda bendungan (-)
 USG organ-organ abdomen lain dalam batas normal
WORKING DIAGNOSIS
• Nefrolitiasis sinistra
dengan hidronefrosis
ringan
• Status gizi buruk
• Status imunisasi lengkap
menurut IDAI
• Status tumbuh kembang
baik
 SUGGESTED LABORATORY
EXAMINATION
● Urine 24 hours
● Serum Elektrolit
● USG Abdomen
● CT Scan Abdomen
 MANAGEMENT
DPJP: Coass:
• Rawat inap dalam bangsal Non Medikamentosa:
• IVFD RL 20 tpm • Drink water 2-3 L/day
• Ranitidine 2 X 50 mg IV • Do not hold urinary
• Lactulac 3 X 5 ml PO
• Antasida 3x5 ml PO
• Keep hygiene urinary track
• Ketorolac 2 x 15 mg IV
• Paracetamol 3 x 500 mg PO Medikamentosa
• Konsul Urologi • Rawat inap dalam bangsal
• IVFD RL 2000 cc/24 jam
• Ranitidine 2 X 50 mg IV
• Paracetamol 3 x 500 mg PO
• Konsul Urologi
 PROGNOSIS
Quo ad vitam: bonam
Quo ad functionam : bonam
Quo ad sanationam: dubia ad bonam
 7 JANUARI 2019

FOLLOW UP S
Nyeri perut kiri bawah
0
HR : 96x/menit
A
Susp Nefrolitiasis
P
IVFD RL 14 tpm
menjalar ke pinggang RR: 21x/ menit sinistra Ketorolak 2 X ½ amp
belakang . Mual (+) Suhu: 36,5C Paracetamol 3 X II cth
Mata : Konjungtiva tdk USG Abdomen
pucat
Mukosa oral : basah, tdk
pucat
Paru; vesikuler +/+ , wh-
/-, rh -/-
Cor : BJ 1 dan II normal
Abd: Supel , BU (+)
normal, nyeri tekan (+)
iliaca sinistra
Rovsing sign (-)
Obtuartor sign (-)
Psoas sign (-)
Nyeri ketok CVA (-)
Ektremitas : Akral
hangat, crt < 2 detik
Lab:
Hb : 12,7 g/dl
Leukosit : 6.700/ul
Hematokrit: 37%
Trombosit:288.000/ul
Hasil Urine Lengkap :
normal
 8 JANUARI 2019
S 0 A P
Nyeri perut kiri bawah HR : 98x/menit Susp Nefrolitiasis IVFD RL 14 tpm
menjalar ke pinggang RR: 21x/ menit sinistra Ketorolak 3 X 15 mg IV
belakang . Mual (+) Suhu: 36C Ranitidine 2 X 50 mg IV
Mata : Konjungtiva tdk Antaside 3 X ml PO
pucat Paracetamol 3 X 500 mg
Mukosa oral : basah, tdk PO
pucat Lactulac 3 X 5 ml PO
Paru; vesikuler +/+ , wh-/- Tunggu hasil USG
, rh -/- Abdomen
Cor : BJ 1 dan II normal
Abd: Supel , BU (+)
normal, nyeri tekan (+)
iliaca sinistra
Rovsing sign (-)
Obtuartor sign (-)
Psoas sign (-)
Nyeri ketok CVA (-)
Ektremitas : Akral hangat,
crt < 2 detik
Lab:
Hb : 12,7 g/dl
Leukosit : 6.700/ul
Hematokrit: 37%
Trombosit:288.000/ul
Hasil Urine Lengkap:
normal
S 0 A P
Nyeri perut kiri bawah HR : 100x/menit Susp Nefrolitiasis sinistra IVFD RL 14 tpm
menjalar ke pinggang RR: 21x/ menit Ketorolak 3 X 15 mg IV
belakang . Mual (+) Suhu: 37 C Ranitidine 2 X 50 mg IV
Mata : Konjungtiva tdk Antaside 3 X ml PO
pucat Paracetamol 3 X 500 mg
Mukosa oral : basah, tdk PO
pucat Lactulac 3 X 5 ml PO
Paru; vesikuler +/+ , wh-/-,
rh -/- Pulang
Cor : BJ 1 dan II normal Ketorolak 2 X 1 tab
Abd: Supel , BU (+) Kontrol poli
normal, nyeri tekan (+)
iliaca sinistra
Rovsing sign (-)
Obtuartor sign (-)
Psoas sign (-)
Nyeri ketok CVA (-)
Ektremitas : Akral hangat,
crt < 2 detik
Lab:
Hb : 12,7 g/dl
Leukosit : 6.700/ul
Hematokrit: 37%
Trombosit:288.000/ul
Hasil Urine Lengkap:
Normal
Hasil USG :
 02
Discussion
 DEFINITION

Nephrolithiasis or stones in the kidney is a condition in

which stones occur in the renal pelvis or renal calix.
Nephrolithiasis is relatively rare in the pediatric
population.
 W orld • higher in Western countries than in the
Eastern hemisphere

• Children represent 2-3% of the total

Child population of stone-formers.

• 1-5% in Asia, 5-9% in Europe, 12% in

Canada, , Saudi Arabia 20,1%, 7% in
Prevalence Venezuela and 13% in Eutophia
• 13-15% USA, urolithiasis is said to be
responsible for 1 in 7,600 to 1 in 1,000
pediatric hospital admissions In economically, developed countries:
calcium oxalate (60–90%) or calcium
Age • 0-19 years phosphate
(10–20%), in low-income countries: acid
or ammonium
 ETIOLOGY
Diet
Renal stones occur as a result of the
following 3 factors: Drug
• Supersaturation of stone-forming
compounds in urine
• Presence of chemical or physical Fluid intake is important
stimuli in urine that promote stone quantitatively and
formation
qualitatively
• Inadequate amount of compounds in
urine that inhibit stone formation (eg,
magnesium, citrate) abnormalities of the urinary
tract, urinary obstruction,
urinary stasis, and infection
with urea-splitting
microorganisms
 PATOGENESIS

The theory of The theory of

supersaturation nucleation /
01 / crystallization 02 presence of
nidus

The theory of Combination

03 the absence
of inhibitors
04 Epitaxic theory
05 theory
 Classification of Stones

Struvite Stone • Stone infections are often

diagnosed in boys under 5 years

• More than 90% of them have had

a urine infection

• Stone fragments are soft and

easily come out through urine

• Stones are often located in the

upper urinary tract, usually the
renal pelvis, and are called
'staghorn’.
Calcium Stone
• Calcium-containing stones are
often associated with
underlying metabolic
disorders, especially if
accompanied by
nephrocalcinosis

• In childhood, the three most

common causes of
nephrocalcinosis are
hypercalciuric conditions,
distal tubular acidosis, and
hyperoxalurias.
Cystine Stone
• Cystiuria is a defect in the
transport of cystine, lysine,
ornitin, and arginine to the
intestinal and inherited tubular
renal cell membranes

• Cystine stones occur in children

of all age groups

• All cystine stones are radio-

opaque, and are sometimes not
seen on plain abdominal films
Uric Acid Stone
Uric acid comes from
•
endogenous sources, as well as
from consumption of foods
containing purines

• Decreased urine volume

accompanied by dehydration,
hyperuricemia and a persistent
urine pH of less than 6 are
important factors influencing
the formation of uric acid
stones
STONE LOCATION
 Clinical Presentation
Lower back or abdominal
Kidney stones in children
pain, called colic or severe
sometimes asymptomatic
attacks that arise, occurs
briefly and then disappears
and reappears
In adolescents, 40% to 75% of
young children suffering from
urolithiasis present with non- The pulse is fast, pale, cold
specific pain that to the sweat and blood pressure
abdomen, waist or pelvis drops

vomiting or nausea, flatulence

The classic symptoms are pain,
and symptoms of paralytic
hematuria, also urinary tract
ileus, nocturnal or diurnal
infection
enuresis, urgency or urinary
incontinence, suprapubic pain
 DIAGNOSIS
ANAMNESIS
• genetic disease
• environmental factors
• dietary habits
• consider chronic kidney disease (CKD) or
• other family diseases

PHSYCAL EXAMINATION

In children with urinary tract stones more often the results of

normal physical examination. Exceptions to normal findings
on physical examination include the following:
• Hypertension (can accompany urinary obstruction or pain)
• Tachycardia in children with pain
• Rickets, stones as part of Dent's disease
 Laboratory examination Imaging
1. Urinalysis 1. USG
2. Complete blood count 2. CT SCAN Abdomen
3. Electrolyte Serum
 TREATMENT
DIET AND FLUID INTAKE

• Adequate fluid intake is the key to treatment

regardless of the cause of the stone. High fluid
intake increases urine volume and dissolves stone-
forming compounds.
• Limiting intake of low-oxalate foods in moderation
such as vegetables, nuts, chocolate, star fruit, and
black tea seems better.

• Excessive intake of animal protein can cause

increased excretion of calcium and gout and
decrease citric excretion and should be avoided.
MEDICAL TREATMENT

• Children where dietary therapy is not effective in

controlling stone formation, pharmacological
therapy is not guaranteed, which is best guided by
the results of 24-hour urine collection analysis.

• Thiazide diuretics are often needed for children who

have hypercalciuria and do not respond to a restricted
sodium diet (hidroklorotiazid 1-2 mg/kg/hari)
• Children who have low citrate excretion, potassium
citrate 2 to 3 mEq /kg/day for infants or 30 to 80 mEq/
day for older children and teenagers .

• Stones due to infection (struvite), their large size

(staghorn calculus) and the tendency to recur if the
removal is incomplete. The current recommendation is to
combine surgical and medical therapy. Medical therapy is
centered on appropriate antibiotic therapy.
 SURGICAL CARE

• Stones smaller than 5 mm pass spontaneously in

children and do not require any surgical intervention.

• Stones larger than 5 mm may require percutaneous

nephrolithotomy (use of endoscopy to enter the
kidney), extracorporal shock wave lithotripsy (ESWL),
or retrograde endoscopic lithotripsy using holmium:
aluminum perovskite yttrium laser to disrupt the
stone
 PREVENTION
1. Avoid dehydration by drinking
enough water and producing 2-3
liters of urine per day
2. Diet to reduce levels of substances
forming stone
3. Sufficient daily activity
4. Provision of medical
 PROGNOSIS
Generally, the prognosis for children with kidney
stones is good; most children do well. However,
mortality and significant morbidity sometimes occur.

Kidney stones are not usually fatal, although some

primary conditions that produce kidney stones (eg,
Lesch-Nyhan syndrome, oxalosis) can lead to death
from problems associated with the primary disease or
complications of renal failure. Infected stones may
lead to urosepsis and death. Complete untreated
renal outflow obstruction causes renal failure.
.
 03
CASE ANALYSIS
 CASE TEORY
Definition Pain at abdomen and found a stone Nephrolithiasis or stones in the kidney is a condition in which
in urinary tract stones occur in the renal pelvis or renal calix

Epidemiology Patient’s Age 15 years old In adolescents present similar to adult patients, 40% to 75% of
young children suffering from urolithiasis present
Children represent 2-3% of the total population of stone-
formers.
Etiology Bad Diet and Hydration Diet, drugs, fluid intake is important quantitatively and
qualitatively, abnormalities of the urinary tract, urinary
obstruction, urinary stasis, and infection with urea-splitting
microorganisms
Clinical Left lower abdominal pain, pain felt In adolescents, 40% to 75% of young children suffering from
manifestation spread from the lower left to the urolithiasis present with non-specific pain that to the
abdomen lower right until the back abdomen, waist or pelvis
of the waist, the pain is felt to
Lower back or abdominal pain, called colic or severe attacks
disappear, feels irritating if sitting for
that arise, occurs briefly and then disappears and reappears
a long time, improved when lying
down. The patient also complained of Vomiting or nausea, flatulence and symptoms of paralytic
nausea ileus, nocturnal or diurnal enuresis, urgency or urinary
incontinence, suprapubic pain
 CASE THEORY
Diagnosis Patient’s symptom (abdominal • Urinalysis
• Complete blood count
pain) and USG
• Electrolyte Serum
• USG
• CT SCAN Abdomen

Treatment Non Medikamentosa: • Diet and fluid intake

• Drink water 2-3 L/day • Medical treatment (hidroklorotiazid 1-2 mg/kg/hari,

potassium citrate 2 to 3 mEq /kg/day for infants or 30 to 80
• Do not hold urinary
mEq/ day) for older children and teenagers, antibiotic
• Keep hygiene urinary track therapy)

Medikamentosa:Symptomatic • Surgical care

Medications

Prognosis Quo ad vitam: bonam Generally, the prognosis for children with kidney stones is good;
most children do well
Quo ad functionam : bonam
Quo ad sanationam: dubia ad
bonam
 References
● Kumar V., Abbas A. K., Fausto N., Mitchell R.N. The Kidney and Its Collecting System. In: Robbins
Basic Pathology. 8th ed. Philadephia: Saunders, an imprint of Elsevier Inc; 2007. p. 571-3.
● Rusepno Hassan, Husein Atlatas. Batu Saluran Kemih. In: Buku Kuliah Ilmu Kesehatan Anak. Jilid 2.
Jakarta: Bagian Ilmu Kesehatan Anak, Fakultas Kedokteran Universitas Indonesia; 2007. p. 807-13,
840-843.
● Marra Giuseppina, Francesca Taroni, Alfredo Berrettini et. al. 2017. Pediatric nephrolithiasis: a
systematic approach from diagnosis to treatment. Journal of Nephrology.
● Sharma A dan Guido Filler. 2010. Epidemiology of pediatric urolithiasis. Indian of Journal Urology.
● Fathallah Sahar. 2018. Pediatric Urolithiasis. Medscape.
https://emedicine.medscape.com/article/983884-overview#a5
● Trihono P dan Sudung O. 2002. Buku Ajar Nefrologi Anak Edisi 2. Ikatan Dokter Anak Indonesia
(IDAI): Jakarta.
● Hesse, A., Siener. R., Tiselius. H., Hoppe. B., 2009. Urinary Stones, Diagnosis, Treatment, and
Prevention of Recurrence. 3th ed. S. Karger AG, Basel, 11-44.
● Hulton, SA., 2001. Evaluation of urinary tract calculi in children. National Institute for Health
Research, 84(4): 1-6.
● Penido Moreira dan Marcelo. 2015. Pediatric primary urolithiasis: Symptoms, medical
management and prevention strategies. World Journal Nephrology.
● Cameron M, Khashayar S dan Moe C. 2005. Nephrolithiasis in children. Pediatric Nephrology.
● Marra G, Francesca T, Alfredo B et.al. 2017. Pediatric nephrolithiasis: a systematic approach from
diagnosis to treatment. Itali: Journal of Nephrology.
● Colella, J., Kochis E., Galli B., Munver R., 2005. Urolithiasis/Nephrolithiasis: What’s It All About.
Medscape reference, 25(6): 1-23.
● McKay Charles. 2010. Renal Stone Disease. Pediatrics in Review Vol.31 No.5.
 Thanks
CREDITS: This presentation template was created by
Slidesgo, including icons by Flaticon, and infographics
& images by Freepik.

Please keep this slide for attribution.