Pleno C Blok 8 2013

Urolithiasis. &
Glomerulo nephritis
Oleh
Dr.Liniyanti D.Oswari.MNS.MSc
 Urolithiasis & Glomerulonephritis
Be-jo 2 th laki-laki BB 17 kg ; Tinggi Badan:90 cm tinggal
didaerah penggunungan Gunung Dempo, sejak setahun lalu
tidak minum ASI dan telah diganti susu formula 6-7
botol(250cc) dan makannya bubur formula 3 kali
semangkuk/hari serta sering diberi multi vitamin drop. Bejo
Kelihatan gemuk menyenangkan tetapi kurang lincah
geraknya. Sejak 3 hari yang lalu badannya panas dan
kadang kadang meniggigil, pipis di Diapersnya berwarna
kecoklatan dan bila dipegang perut bagian bawahnya
menangis dan juga kalau kencing selalu nangis. Dibawa ke
dokter ahli anak dan di diagnosa glomerular nephritis,&
urolitiasis kemudian diresepkan antibiotika satu keur
(Cure=dosis)
 Pemeriksaan Fisik:
Suhu tubuh 38,5oC; Lidah normal, feces normal,
palpasi lower abdomen ada rasa nyeri

BNO X-ray : abdomen ada masa padat di vesica

urinaria.
Pemeriksaan Laboratorium::
Analisa urin : warna urine : kuning kecoklatan pH 5
; glukosa 0 ; kristalin dan presipitasi Calsium
oksalat, eritrosit : 10-20/lpb
pH urine =5 melarutkan 1/10 total asam urat atau
15mg/dl
pH urine = 7 melarutkan garam urat 150-200 mg/dl
 Urolithiasis
Introduction
Urolithiasis is increasingly recognized in pediatric patients and is
encountered in a variety of clinical settings. The wide geographic variation in
the incidence of urolithiasis in childhood is related to climatic, dietary, and
socioeconomic factors. Approximately 7% of urinary calculi occur in children
younger than 16 years of age. Many children with stone disease have a
metabolic abnormality. Revolutionary advances in the minimally invasive and
noninvasive management of stone disease over the past 2 decades have
greatly facilitated the ease with which stones are removed. Given the frequency
with which stones recur, the development of a medical prophylactic program to
prevent stone recurrences is desirable. The lifetime prevalence of kidney stone
disease is estimated at 1% to 15%, with the probability of having a stone
varying according to age, gender, race, and geographic location. Stone disease
typically affects boys more commonly as much as two to three times more
frequently than females. Upper urinary tract stones occur more commonly in
boys than girls by a ratio of 1.4:1 to 2.1:1.
 Classification of stones

Stone size:
<5 mm,
5-10 mm,
> 10-20 mm,
> 20 mm.
 Classification of stones

Stone location:
upper calyx,
middle calyx or lower calyx,
renal pelvis,
upper ureter,
middle ureter or distal ureter,
urinary bladder.
Location of Renal stones
 Classification of stones
X-ray characteristics

Radiopaque Poor radiopaque Radiolucent

Calcium oxalate Magnesium ammonium
Uric acid
dehydrate phosphate
Calcium oxalate
Apatite Ammonium urate
monohydrate
Calcium
Cystine Xanthine
phosphates
2,8-
dihydroxyadenine

'Drug-stones'
Stones classified according to their
aetiology
Non-infection stones
Calcium oxalates
Calcium phosphates
Uric acid
Infection stones
Magnesium-ammonium-phosphate
Apatite
Ammonium urate
Genetic causes
Cystine
Xanthine
2,8-dihydroxyadenine
'Drug stones'
Calcium oxalate monohydrates

Calcium oxalate dihydrates

Uric acid
Struvite
Cystine
 High risk stone formers
General factors
Early onset of urolithiasis in life (especially
children and teenagers)
Familial stone formation
Brushite containing stones (calcium hydrogen
phosphate; CaHP04. 2H20)
Uric acid and urate containing stones
Infection stones
Solitary kidney (The solitary kidney itself does
not have a particular increased risk of stone
formation, but the
prevention of a potential stone recurrence is of
more importance)
 High risk stone formers

Diseases associated with stone formation

Hyperparathyroidism

Nephrocalcinosis

Gastrointestinal diseases or disorders (i.e. jejuno-ileal bypass, intestinal

resection, Crohn's disease,malabsorptive conditions)

Sarcoidosis
 High risk stone formers
Genetically determined stone formation

Cystinuria (type A, B, AB)

Primary hyperoxaluria (PH)

Renal tubular acidosis (RTA) type 1

2,8-dihydroxyadenine

Xanthinuria

Lesh-Nyhan-Syndrome

Cystic fibrosis
 High risk stone formers

Anatomical and urodynamic abnormalities associated with stone formation

Medullary sponge kidney (tubular ectasia)

Ureteropelvic junction (UPJ) obstruction
Calyceal diverticulum, calyceal cyst
Ureteral stricture
Vesico-uretero-renal reflux
Horseshoe kidney
Ureterocele
Urinary diversion (via enteric hyperoxaluria)
Neurogenic bladder dysfunction
Compounds that cause drug stones
Active compounds crystallizing in urine
Allopurinol / oxypurinol
Amoxicillin / ampicillin
Ceftriaxone
Ciprofloxacin
Ephedrine
Indinavir
Magnesium trisilicate
Sulfonamide
Triamterene
Substances impairing urine composition
Acetazolamide
Allopurinol
Aluminium magnesium hydroxide
Ascorbic acid
Calcium
Furosemide
Laxatives
Methoxyflurane
Vitamin D
 Diagnostic steps in urolithiasis
(UTI urinary tract infection, CT computed tomography, MR1 magnetic resonance imaging, PTH
parathyroid hormone, pC02 partial pressure of carbon dioxide)
Fig. a,b. A 4-year-old boy with incomplete RTA and hyperoxaluria, a Sonogram
of right kidney showing medullary nephrocalcinosis grade III (Dick et al. 1999).
b Sonogram of bladder showing an ureteral stone on the right immediately
before the ureterovesical junction
An 8-year-old boy with primary hyperparathyroidism, hypercalciuria, and urinary
tract infection. Abdominal plain radiograph showing a huge ureteral stone on
the left immediately before the ureterovesical junction
Evaluation for a suspected stone.
(RBUS)-renal/bladder ultrasound
extracorporeal shockwave lithotripsy (ESWL)
percutaneous nephrolithotomy -(PCNL)
Recommendations for pain relief during renal colic:
-1st choice: treatment should be started with an NSAID(Diclophenac sodium,
Indomethacin, Ibuprofen)
-2nd choice: Hydromorphine(Pentazocine,Tramadol)
-Diclofenac sodium is recommended to counteract recurrent pain after an episode of
ureteral colic

For septic patients with obstructing stones, the collecting system should be
urgently decompressed, using either percutaneous drainage or ureteral stenting.
Definitive treatment of the stone should be delayed until sepsis is resolved.

Medical expulsive therapy

Alpha-blockers (Tamsulosin, 0.4 mg, doxazosin,terazosin, alfuzosin and naftopidil)
Calcium-channel blockers(nifedipine)
Corticosteroids

Chemolytic dissolution of stones:

-Percutaneous irrigation chemolysis
-Oral Chemolysis
 Methods of percutaneous irrigation chemolysis
Stone composition Refs. Irrigation solution Comments
Struvite 1-6 10% Hemiacidrin with pH 3.5-4 Combination with
Carbon apatite Suby's G Shockwave
lithotripsy for staghorn
stones
Risk of cardiac arrest due
to
hypermagnesaemia
Brushite 7 Hemiacidrin Can be considered for
Suby's G residual fragments
Cystine 8-13 Trihydroxymethyl- aminomethan Takes significantly longer
(THAM; 0.3 or 0.6 mol/L) with pH time than for uric acid
range stones
8.5-9.0 Used for elimination of
N-acetylcysteine (200 mg/L) residual fragments
Uric acid 10,14-18 Trihydroxymethyl- aminomethan Oral chemolysis is the
(THAM; 0.3 or 0.6 mol/L) with pH preferred option
range
8.5-9.0
The figure shows a 12 month-old child treated with the Modulith SLK
(Storz Medical AG, Kreuzlingen).
Operation: percutaneous nephrolithotomy
Rarely used in pediatric surgery
Utilize a nephroscope or ureteroscope
Extract with visualization
Break larger stones using ultrasonography
Operation: open stone removal
Rarely necessary, only when urinary calculi are not amenable to ESWL
or PL
Make an incision below the 12th rib
Expose the kidney and the ureter
Open the renal pelvis and extract the stone (or ureter in the case of a
ureteral stone)
Wash the entire calyx system
Suture the pyelon or the ureter
Postoperative care
Ureter drain for 25 days with an antegrade contrast X-ray before drain
removal
Antibiotic therapy as prophylaxis in cases of vesicoureteral reflux
Urine culture once a month
Ultrasonography
Prognosis
Stone recurrence is rare if urine is sterile and an obstruction does not
occur
Medical treatment of recurrent stones
Pathophysiology Glomerulonephritis

UTI generally begins in the bladder due to ascending

infection from perineal contaminants, usually bowel flora
such as Escherichia coli. In neonates, infection of the urinary
tract is assumed to be due to hematogenous rather than
ascending infection. This etiology may explain the
nonspecific symptoms associated with UTI in these patients.

After the neonatal period, bacteremia is not the usual cause

of UTI. The bladder is the initial primary locus of infection
with ascending disease to the kidneys. Bacteremia may then
appear as potential sequelae. Bacterial invasion of the
bladder with overt UTI is more likely to occur if urinary
stasis or low flow conditions exist. This is triggered by
infrequent or incomplete voiding, reflux, or other urinary
tract abnormalities.
Clinical Course

Generalized bacteremia or sepsis may follow

UTI. Approximately 30% of 1- to 3-month-old
infants with UTI are at risk of developing sepsis.
The risk drops to approximately 5% in patients
older than 3 months.
If left untreated, simple cystitis may progress to
pyelonephritis. More severe cases have the
potential for kidney damage, which may lead to
hypertension or renal insufficiency.
Approximately 5-10% of children with
symptomatic UTI and fever develop renal
scarring.
Frequency of UTI

UTI is more frequent in females than males at all

ages with the exception of the neonatal period,
during which UTI may be the cause of an
overwhelming septic syndrome in male infants
younger than 2 months.
Uncircumcised males have a higher incidence
than circumcised males. Uncircumcised male
infants have a higher incidence of UTI than
female infants.
Frequency of UTI

Excluding neonates, females younger than

11 years have a 3-5% risk; boys of the
same age have a 1% risk.
UTI is the source of infection in up to 6-8%
of febrile infants in the first 3 months of
life.
Investigations
Lab Studies:
Urinalysis: A urine specimen that is found to be positive
for nitrite, leukocyte esterase, or blood may indicate a
UTI.
Microscopic examination can evaluate presence of
WBCs (>5 per high-power field), RBCs, bacteria, casts,
and skin contamination (e.g., epithelial cells).
A midstream clean catch is appropriate if the patient is
old enough to cooperate. Clean skin around the urethral
meatus and allow first urine to go into the toilet; then,
collect the specimen in a sterile collection cup.
In neonates & infants sample obtained by bladder
puncture is the best, but a bag specimen may be used if
the urine bag is removed immediately after urine is
deposited. It is adequate for specific gravity and
chemical parameters but not for culture.
Physical Examination

Hypertension should raise suspicion of

hydronephrosis or renal parenchyma disease.
Costovertebral angle (CVA) tenderness
Abdominal tenderness or mass
Palpable bladder
Dribbling, poor stream, or straining to void
Examine external genitalia for signs of irritation,
pinworms, vaginitis, trauma, sexual abuse,
phimosis or meatal stenosis .
Etiology

Bacterial infections are the most common.

E coli is the most common causing 75-90% of
UTI episodes. Other bacteria include:
Klebsiella species
Proteus species
Enterococcus species
Staphylococcus saprophyticus
Adenovirus (rare)
Fungal in immune compromised patients
Differential Diagnoses
The symptoms of UTI may mimic other conditions
like:
Sepsis due to bacterimia or viremia
Falciparum malaria
Gastro-intestinal disorders
Renal Calculi with or without obstruction
Urethritis
Vaginitis & Vulvovaginitis
Imaging studies
Imaging typically is delayed 3-6 weeks after the infection
as part of outpatient follow-up, except in cases in which
urinary tract obstruction is suspected.
Renal ultrasound
This study adequately depicts kidney size and shape,
but it poorly depicts ureters and provides no information
on function.
A renal ultrasound can diagnose urolithiasis,
hydronephrosis, hydroureter, ureteroceles, and bladder
distention and has replaced the intravenous pyelogram
(IVP) in many cases.
A voiding cystourethrogram (VCUG) adequately depicts
urethral and bladder anatomy and detects vesicoureteral
reflux (VUR).
Procedure

Catheterization of the urinary bladder or

suprapubic bladder aspiration may be required
in patients who cannot provide a midstream
clean-catch urine sample.
A suprapubic tap is the most invasive diagnostic
procedure, but many practitioners view it as the
criterion standard despite the potential for gross
or microscopic hematuria.
Antibiotics
Start antibiotics after urinalysis and culture are obtained.
A 10-day course of antibiotics is recommended, even for
uncomplicated infection. Do not use short-course
therapy in children because it is more difficult to
differentiate cystitis from pyelonephritis. An exception is
the use of short-course therapy in adolescent females
with evidence of cystitis.
Empiric antibiotics for coverage of E coli, Enterococcus,
Proteus, and Klebsiella species should be started while
waiting the culture & sensitivity results. For cystitis, oral
antibiotic therapy is adequate, but if pyelonephritis is
suspected, a combination of parenteral antibiotics is
recommended. Recent evidence indicates that oral
antibiotics are adequate therapy for febrile UTI in young
infants and children; short-term (fever) and long-term
(renal scarring) outcomes are comparable to parenteral
therapy.
 Antibiotics/2
Amoxicillin
Provides bactericidal activity against susceptible organisms, mainly E.
Coli, but resistance is reported. Administered parenterally and used in
combination with gentamicin or cefotaxime. Pediatric Dose 100-200
mg/kg/d. IV/IM divided q6h.
Gentamicin
Aminoglycoside antibiotic for gram-negative coverage. Provides
synergistic activity with amoxicillin against gram-positive bacteria including
enterococcal species. Pediatric Dose <5 years: 2.5mg/kg/dose, IV/IM q8h.
>5 years: 1.5-2.5 mg/kg/dose IV/IM q8h.
Cefotaxime
Third-generation cephalosporin that covers most of the gram-negative
Bacteria, but weak activity against gram-positive organisms. Used as
initial parenteral therapy for pediatric patients with acute pyelonephritis.
May be used for neonates or jaundiced patients. Requires dosing at q6-8h
intervals. Pediatric Dose is 100-200 mg/kg/d IV/IM in divided doses.
 Antibiotics/3
Trimethoprim/sulfamethoxazole
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic
acid. Antibacterial activity of TMP-SMZ includes common
urinary tract pathogens, except Pseudomonas aeruginosa.
Pediatric Dose <2 months: Not recommended >2 months: 5-
10 mg/kg/d PO divided q12h, based on TMP component .
Cephalexin
First-generation cephalosporin that is useful in simple UTI.
Pediatric Dose 25-50 mg/kg PO q6h; not to exceed 3 g/d.
Cefixime
Third-generation oral cephalosporin with broad activity against
gram-negative bacteria. Pediatric Dose: 8 mg/kg PO qd; not to
exceed 400 mg/d.
Follow-up

Hospitalization is necessary for the following

individuals:
Patients who are toxemic or septic
Patients with signs of urinary obstruction or
significant underlying disease
Patients unable to tolerate adequate PO fluids or
medications
Infants younger than 3 months with febrile UTI
(presumed pyelonephritis)
All infants younger than 1 month with suspected
UTI even if not febrile
Complications

Dehydration is the most common complication of UTI in

the pediatric population. IV fluid replacement is
necessary in more severe cases. Treat febrile UTI as
pyelonephritis, and consider parenteral antibiotics and
admission for these patients.
Untreated UTI may progress to renal involvement with
systemic infection (e.g., urosepsis).
Long-term complications include renal parenchyma
scarring, hypertension, decreased renal function, and, in
severe cases, renal failure.
 Take home message

Most cases of UTI are simple, uncomplicated,

and respond readily to outpatient antibiotic
treatments without further sequelae.
Appropriate treatment, imaging, and follow-up
prevent long-term sequelae in patients with
more severe infections or chronic infections.
Mild VUR usually resolves without permanent
damage.
Any child with proven UTI should have imaging
studies performed to R/O VUR or renal
anomalies.
References
Ciftci, AO. Clinical Predictors for Diff. Diagnosis of Acute Scrotum,
European J. of Ped. Surgery. Oct 2004.
Blavis M., Emergency Evaluation of Patients Presenting with Acute
Scrotum, Academy of Emergency Medicine. Jan 2001
Doehn C., Value of Acute Phase Proteins in the Differential
Diagnosis of Acute Scrotum, Journal of Urology. Feb 2001.
Kaplan G., Scrotal Swelling in Children. Pediatrics in Review. Sep
2000.
Luzzi GA. Acute Epididymitis. BJU International. May 2001.
Fleisher G, Ludwig S, Henretig F. Textbook of Pediatric Emergency
Medicine. 2006.