Information pertaining to a family history of calculi, hematuria, and renal failure can be essential in identifying those patients at highest risk for inherited metabolic or genetic conditions (eg, cystinuria, primary hyperoxaluria, and Dent disease). A focused dietary history with special emphasis on fluid and salt intake, vitamin
(C, D) mineral supplementation, and special diets (eg, ketogenic diet) is indicated in every patient. Eliciting a detailed medication history with special emphasis on corticosteroids, diuretics (furosemide and acetazolamide), protease inhibitors (indinavir), and anticonvulsants (topiramate and zonisamide) can be instructive. Children with a history of prematurity, urinary tract abnormalities, UTIs, intestinal malabsorption (eg, Crohn’s disease, bowel Nutlin-3a in vivo resection, and cystic fibrosis), and prolonged immobility are all at special risk for calculi formation. Detailed physical examination of the child for dysmorphic features (William syndrome), rickets (Dent disease and HHRH), tetany (FHHNC and autosomal dominant hypocalcemic hypercalciuria), and gout (HPRT deficiency, PRPSS) can be helpful. The first step involved in the evaluation of urolithiasis is detection of the calculus. The sensitivity of plain abdominal radiography in the detection of calculi is approximately 45% to 58%; although many stones are radiopaque, radiography alone is insufficient
in the evaluation of a patient with suspected urolithiasis.36 In addition, calculi comprising uric acid, cystine, xanthine, or indinavir are usually radiolucent. Ultrasonography (US) has the ability to detect 90% of calculi confined to the kidney; however, the sensitivity for detecting ureteral calculi BIRB 796 ic50 and smaller calculi (<5 mm) is poor.5 Nonetheless, because radiation exposure is not without
risk, US remains the initial study of choice in the assessment of calculi in children. Noncontrast computed tomography remains the gold standard and is indicated in children with persistent symptoms of urolithiasis and a nondiagnostic US. In patients with hypercalciuria in whom medullary sponge kidney is suspected, an intravenous pyelogram can be considered. When urinary calculi develop during childhood, the risk of life-long stone formation is significant, with approximately 16% to 20% having recurrences Alectinib price within 3 to 13 years.10 and 37 Furthermore, children with an identifiable metabolic abnormality have an up to 5-fold increased risk of having a recurrence as compared with children with no identifiable metabolic disorder.10 As a result, all children should undergo a comprehensive initial evaluation. Whenever possible, analysis should begin with an infrared spectroscopy or radiograph diffraction analysis of a passed stone. If a cystine or struvite stone is found, the analysis will be diagnostic. Serum and urine studies should be obtained in patients in whom stone analysis could not be performed or for those with either calcium or uric acid-based stones.
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