Clinical presentation, etiological factors, and outcome in children diagnosed with urolithiasis in Ghaziabad, Uttar Pradesh

Sanjeev Vind; Veenu Agarwal; KC Agarwal

doi:10.4103/sujhs.sujhs_12_22

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ORIGINAL ARTICLE

Year : 2022 | Volume : 8 | Issue : 1 | Page : 57-61

Clinical presentation, etiological factors, and outcome in children diagnosed with urolithiasis in Ghaziabad, Uttar Pradesh

Sanjeev Vind, Veenu Agarwal, KC Agarwal
Department of Pediatrics, Santosh Deemed to be University, Ghaziabad, Uttar Pradesh, India

Date of Submission	12-Apr-2022
Date of Decision	18-Apr-2022
Date of Acceptance	25-Apr-2022
Date of Web Publication	21-Jul-2022

Correspondence Address:
Veenu Agarwal
Department of Pediatrics, Santosh Deemed to be University, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sujhs.sujhs_12_22

Abstract

Background: Children with urolithiasis (UL) are often encountered in general pediatric practice. Its rising incidence, high recurrence rate, serious long-term consequences, and paucity of data on pediatric UL led to the present research work. Recurrence usually remains unaltered unless dietary restrictions are followed stringently, so the emphasis in the present research was on the analysis of the diet consumed by participants.
Materials and Methods: Children with UL were enrolled from the general pediatrics outpatient department of an urban hospital over 22 months in a prospective study. Data were collected on clinical profile, 24 h dietary details, blood and urine investigations, and ultrasound (USG) abdomen. Attempts were made to get basic metabolic work-up in as many children as possible.
Results: Abdominal pain alone or with symptoms of urinary tract infection (UTI) was found in 40 (83.3%) and 22 (45.8%) participants. Important etiological associations found were UTI (30, 62.7%), positive family history of UL (22, 45.8%), and obesity (5, 10.4%). Idiopathic hypercalciuria, hyperuricosuria, and hyperoxaluria were found in 9 (18.7%), 2 (4.2%), and 12 (25%) participants. Daily intake of liquids and calcium was low in 38 (79%) and 35 (72.9%) children, respectively. Intake of both salt and proteins was high in 30 (62.5%) children. The persistence of symptoms was found in 28 (58.3%) participants. Recurrence was found in 7 (14.5%) participants.
Conclusion: Having a high index of suspicion of UL in all children presenting with recurrent unexplained UTI and/or recurrent abdominal pain and advocating USG abdomen early in such children can aid in the timely diagnosis of UL. Simple dietary manipulations such as adequate daily fluid and calcium intake along with avoiding high salt and animal protein diet may be beneficial by decreasing the recurrence rate of UL.

Keywords: Clinical features, diet, hypercalcinosis, pediatric, urinary tract infection, urolithiasis

How to cite this article:
Vind S, Agarwal V, Agarwal K C. Clinical presentation, etiological factors, and outcome in children diagnosed with urolithiasis in Ghaziabad, Uttar Pradesh. Santosh Univ J Health Sci 2022;8:57-61

How to cite this URL:
Vind S, Agarwal V, Agarwal K C. Clinical presentation, etiological factors, and outcome in children diagnosed with urolithiasis in Ghaziabad, Uttar Pradesh. Santosh Univ J Health Sci [serial online] 2022 [cited 2023 May 30];8:57-61. Available from: http://www.sujhs.org/text.asp?2022/8/1/57/351560

Background

Urolithiasis (UL) is often encountered in general pediatrics practice affecting children of all age groups. The prevalence quoted for Asian countries such as India, Pakistan, Thailand, and Myanmar which lie on Afro-Asian stone belts is 1%–5%.^[1] Universal rise of UL cases in the last two decades^[2] has been referred to as the stone wave. UL leads to high morbidity and accounts for 4%–8% of cases of end-stage renal disease during childhood.^{[3],[4],[5],[6]}

The etiology of pediatric UL still remains largely unknown in the developing world,^[7],[8] although western studies show anatomical abnormalities, infection, and metabolic causes in up to 90% of the cases.^[9] Various dietary factors, metabolic disorders,^{[10],[11],[12],[13],[14],[15],[16],[17],[18],[19]} obesity, diabetes, etc., contribute to the pathogenesis of the different types of stones.^[2],[3],[20] High prevalence, rising incidence, troublesome symptoms, and serious long-term consequences along with relative paucity of data in childhood UL were the reason to conduct the present research work.

Materials and Methods

Study design

This was a prospective observational study.

Place

General pediatric outpatient department (OPD) of a tertiary level care hospital situated in urban Ghaziabad.

Duration

The study duration was September 2016–June 2018 (22 months).

Sample size

All consecutive participants of UL attending pediatrics OPD of the hospital were enrolled prospectively.

Inclusion criteria

Children (till 18 years of age) diagnosed with UL were included in the study.

Exclusion criteria

Nephrocalcinosis.

Ethical clearance was obtained from the Institutional Ethics Committee.

Information on clinical presentation, positive family history of UL, 24-h diet recall was recorded and used to analyze daily average intake of liquids, protein, calcium, and salt. Dietary calcium was considered normal if it was between 800 and 1000 mg/dl per day. High salt intake was considered if it was more than 5 g/day. High protein was considered if it was more than 2.25 g/kg/day.

Definitions for diagnosing various metabolic anomalies^[19]

Idiopathic hypercalciuria – if the child's 24-h urine calcium was >4 mg/kg/day with serum calcium levels of 9–11 mg/dl.

OR if spot urinary calcium-to-creatinine ratio was >0.2.

Idiopathic hyperoxaluria – if the child's 24 h urine oxalate was >40 mg/1.73 m²/day.

Idiopathic hyperuricosuria – if the child's 24 h urine uric acid was >815/1.73 m²/day and his S. uric acid is between 2 and 6 mg/dl.

Urine routine microscopy, complete blood count, blood urea, and serum creatinine were done in all participants. Metabolic evaluation advised was serum calcium and magnesium, 24 h urinary calcium, oxalate and uric acid, and spot urinary calcium-to-creatinine ratio. Attempt was made to get these investigations done in all patients, but even if these investigations could not be done due to any reason, the patient was still included in the study. Ultrasound (USG) abdomen was done in all children. The dietary advice given to all participants consisted of increase daily fluid intake to 1–2 l, to ensure adequate daily intake of calcium providing age-specific Recommended Dietary Allowance (RDA), and to keep daily salt intake restricted to 3–5 g.

In follow-up, parents were contacted telephonically at 6 months and 1 year, and information related to the persistence of symptoms, recurrence of stones, and spontaneous passage of stones was recorded.

Results

Population characteristics

During the study period, 48 children were enrolled. The median age of participants was 8.5 years; the age range was 1.3–17 years. Majority (31, 64.5%) were male. The common presenting complaints were localized abdominal pain/renal colic, dysuria, and increased frequency of micturition reported by 40 (83.33%), 22 (45.83%), and 22 (45.83%) subjects, respectively [Table 1]. Two children (4.16%) presented with secondary enuresis, whereas vomiting associated with abdominal pain was reported by 16 (33.33%) children.

Table 1: Clinical symptoms in study participants

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Pyuria was found in 30 (62.7%) children, whereas hematuria and granular casts were present in 29 (60.41%) and 1 (2.08%) children, respectively. Urine culture was positive in 5 (10.41%) children. None of the participants had macroscopic hematuria. Majority (30, 62.5%) had unilateral stones. The kidney stones were more commonly found in 33 (68.75%) participants than stones elsewhere in the urinary tract. Bladder stones were found in 5 (10.41%) children only. Ureteric stones were found in 10 (20.83%) children, of which only 2 (4.16%) had hydronephrosis requiring surgical intervention. Stones were smaller than 5 mm in 26 (54.16%) children.

Metabolic risk factors

The metabolic abnormalities detected in study participants were idiopathic hypercalciuria, hyperoxaluria, and hyperuricosuria found in 9 (18.7%), 12 (25%), and 2 (4.2%) children, respectively.

Predisposing dietary factors found in study participants are shown in [Table 2].

Table 2: Predisposing dietary factors for urolithiasis in study participants

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Among studied etiological associations between genetic/familial predisposition and positive family, a history of UL was found in 22 (45.83%) children. The second most significant association was found was hot and dry weather conditions, and nearly half (45.83%, 22) of participants presented in the summer months (May and June). The next most important association was a history of recurrent diarrhea present in 10 (20.83) children. Anatomical genitourinary tract defects found were hydronephrosis. Only 2 participants were taking predisposing drug – magnesium trisilicate for few weeks due to gastritis out of the list of culprit drugs (such as loop diuretics, acetazolamide, topiramate, laxatives, ciprofloxacin, magnesium trisilicate, indinavir, and ephedrine). Nutritional status of nearly 90% (43) of children was normal, and only 5 (10.41%) children were overweight. None was immobilized for a long duration. Majority of the study participant at the of study period were being managed conservatively with medical treatment and 2 children underwent surgery for stone removal. History of recurrent renal calculi was found in 7 children (14.58%), whereas 18 (37.5%) children reported spontaneous passage of calculi and remained symptoms free till the last contact at the end of 1 year. Twenty-eight (58.3%) children continue to suffer from mild to moderate attacks of renal colicky pain requiring intermittent symptomatic treatment.

Discussion

The primary objective of the present research was to identify the clinical profile of pediatric UL, its associated etiological factors, and its outcome after 1-year follow-up. Since it was a hospital-based study, so the data collected gave a rough idea of disease (symptomatic cases) burden in the served locality. Forty-eight USG-confirmed cases of UL were enrolled.

The important feature of abdominal pain in most children was it being quite severe, nonlocalized, and without associated gastrointestinal symptoms such as constipation or diarrhea, unlike in adults, where presentation is typical colicky loin pain and its characteristic radiation of groin. The important clue for getting detailed investigations done in study subjects was either recurrent abdominal pain or urinary tract infection (UTI) and symptoms refractory to routine treatment.

Almost similar results have been reported from different parts of India by few researchers, and according to them, the top three presentations of pediatric UL were UTI, abdominal pain, and flank pain found in 29.3%, 24.1%, and 17.2% of children, respectively.^{[6],[16],[17],[18],[20]} While Rajma et al. reported that 90% of children with UL presented with abdominal pain, and symptomatic UTI was present in 33% of children.^[20] According to Bhatt et al., 54% of children presenting with UTI had UL.^[1]

None of the participants in the present study had gross hematuria, although microscopic hematuria was found in nearly two-thirds (60%) of participants. This symptom was found in 15.5% of cases by Bhatt et al.^[1] The plausible explanation for this difference in percentages of various presenting symptoms could be the difference in the site of affection or size, shape, type of stones, and duration of disease.

Another significant finding in the present study was confirmation of the preponderance of kidney stones over bladder stones. This shift from bladder stones to kidney stones is recent and has been documented by many researchers worldwide including India.^[1],[6] In the present research, the stones were located in the kidneys, upper urinary tract, and urinary bladder in 68.7%, 20.8%, and 10.4% of children, respectively. The observations of the present research are in concordance with Bhatt et al.^[1] who found kidney stones in 82.6% of children and bladder stones in 3.4% of children.

Second objective of the present study was to identify various etiological associations in enrolled study participants. Different etiological factors implicated in pediatric UL are metabolic,^{[15],[16],[17],[18]} genitourinary defects, genetic inheritance, ^[1],[2] infective, and dietary factors which may often co-exist.^[15] Important associations found in the present study were UTI, positive family history of UL, history of frequent diarrhea, and obesity found in 62.7% (30), 45.83% (22), 20.83% (10), and 10.4% (5) participants, respectively. Some researchers^[2] found UTI in 54% and metabolic abnormalities such as idiopathic hypercalciuria in 2 (6.6%) children.^[15] In a retrospective study, hyperoxaluria, hypercalciuria, hypocitraturia, and hyperuricosuria were found in 79.3%, 25.9%, 22.4%, and 24% of pediatric UL patients, respectively.^[9]

The major limitation of the present research work was that basic metabolic evaluation could be done in only 13 (27%) children and hypercalciuria, hypercalcemia, and hypocalcemia were present in 6.25%, 4.16%, and 8.33% of children, respectively. Various reasons for this inability to get basic metabolic workup done in the present study ranged were financial constraints, parental reluctance, and their firm faith in alternative treatment forms (other than allopathy).

Petrarulo et al.^[5] reported UTI in 25% of subjects, and according to them, the majority of such children had urogenital anomalies in contrast to our observations where hydronephrosis was found in 4.16% of participants only. In the present research, only 5 (10.4%) children were obese and none was malnourished, this may be because of small sample size and the enrolled patients belonged to middle or lower middle-class families.

The third objective of the present study was to identify the dietary factors associated with UL. Among dietary risk factors for UL in the present work, inadequate water intake topped the list and was found in staggering 79% of children, which directly explained the seasonal increase in UL cases observed during the summer months. This has been reported by Rajma et al.^[20] also. The explanation is dehydration coupled with decrease fluid intake leading to supersaturation of calcium and other metabolites followed by stone formation.

Low dietary calcium intake was found in 72.9% of children in the present study which is higher than 59% reported by Gajengi et al.^[6] Low calcium intake causes UL by two mechanisms; first, it increases intestinal oxalate availability and rising supersaturation of calcium oxalate. The second mechanism could be through stimulation of calcitriol production leading to hypercalcemia, inhibiting PTH production, and hypercalciuria. In their large cohort study, Curhan^[7] stressed on the need of high oral fluid intake and optimum (to meet RDA) calcium supplementation.

Another important observation related to the diet consumed in the present study participants was that their daily consumption of salt and protein was much higher than recommendations. The high dietary protein boosts urinary oxalates & can reduce urinary citrates which can predispose stone formation in urinary tract.^[3] High dietary salt intake expands intravascular volume, increases urinary calcium level most probably by decreasing renal tubular calcium reabsorption and is associated with increased urinary stones.^[15]

The last objective was to know the outcome at the end of study period in the participants. In the present research, recurrent calculi were reported by 7 (14.5%), the spontaneous passage of calculi was reported by 18 (37.5%), whereas 28 (58.3%) children continued to suffer from the persistence of symptoms of variable severity. Only 2 children in our study underwent surgery for stone removal, and the rest were being managed conservatively. Stone recurrence was found in 31% of children by Bhatt et al.^[1] Sternberg et al.^[3] reported that pediatric UL patients have 65% life-long recurrence of the stone. This recurrence could be prevented or at least it could be decreased by taking a sufficient amount of liquids, dietary calcium should be adequate to provide RDA along with reduced consumption of amounts of salt, animal protein, and oxalate-rich foods.

Conclusion

“At-risk children” like those with a positive family history of UL or those with urogenital malformations may also be benefitted by these dietary modifications. One of the major limitations of the present work was the inability to get stone for its chemical analysis so that specific dietary manipulations could be advocated to the children.

There is still a strong need of multicentric studies having a larger sample size, longer follow-up period with more detailed metabolic workup in the maximum number of participants to obtain answers to lots of poorly answered queries related to pediatric UL.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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