2. Urolithiasis Renal stone Nephrocalcinosis

3. Predisposig Factors 1. Age (20- 40 yr) 1. Age (20- 40 yr) 2. Sex (M>F) 2. Sex (M>F) 3. Enviromental Factors 3. Enviromental Factors 4. Genetic Factors 4. Genetic Factors 5. Dietary Habits (specially for bladder stone) 5. Dietary Habits (specially for bladder stone)

4. Renal stone - Ca-oxalate, ca-phosphate (the most common) - Struvite, uric acid, cystine, xanthin, etc. Bladder stone: - ca-oxalate, Amonium urate, Uric acid

5. Mechanism of stone formation - Supersaturation - Infection - Retension of crystals - Foreign body - Urine PH

6. Inhibitors Citrate, Mg, Pyrophosphate, Zn, glucosaminoglycan, nephrocalcin, THF protein THF protein

7. Major causes of nephrocalcinosis - RTA - Hyperoxaluria - Hypercalciuria Stone + Nephrocalcinosis: usually = DRTA

8. Hypocitraturia (15-63%) - Primary - Secondary (acidosis, ↑ protein intake, severe exercise, ↑ Na intake, ↓ urine Mg, UTI, chronic diarrhea, thiazides)

9. Clinical manifestations: Asymptomatic, unless with displacement, obstruction or UTI. Asymptomatic, unless with displacement, obstruction or UTI. Symptoms due to crystaluria Symptoms due to crystaluria Symptoms due to stone Symptoms due to stone - Stone passing, renal colic (15%), hematuria abdominal pain, FTT, lower urinary tract symptoms

10. Bladder stone symptoms - Lower UT symptoms - Erection - Urinary retension - Rectal prolapse - ↓ pain in supine position

11. Diagnosis KUBSono CT scan IVP

12. Secondary Signs on CT… Hydroureter Hydronephrosis Hydroureter Hydronephrosis (Catalano) Dilated renal pelvis (arrowhead) with minimal surrounding fat-tissue stranding (McDonald) Hydronephrosis in right kidney (long arrow) and tiny right renal calculus (short arrow). Left kidney is normal.

13. Plain Film Radiography… For evaluating initial episodes of suspected urolithiasis, the KUB’s sensitivity for detecting stones is low (58%- 62%) (ACR) KUB will miss: uric acid stones small stones stones obscured by bones KUB will detect: calcium stones struvite cystine stones Radiograph of left kidney shows a large stone (arrow) (Susah). a large stone (arrow) (Susah).

14. Metabolic evaluations - Indicated in all children - Serum (ca, P, alk. Phosphatase, uric acid, K, Na, AG, creatinine) - Fasting urine (U/A, U/C, Ca/Cr, Cystine, PH) - 24hr urine (Ca, P, Uric acid, Oxalate, Citrate, Mg)

15. Treatment - Pain control - Hydration - Control of UTI - Medical, surgical or ESWL - Prevention

16. Medical treatment - Non-pharmacological medical therapy in all children - Pharmacological therapy in children with multiple stones at presentation or recurrence of stone during one year.

17. Special indications for drug therapy - Hypercalciuria (the most common) - RTA - Cystinuria - Hyperuricosuria - Hypocitraturia

18. Non-pharmacological Non-surgical therapy - ↑ Water intake - Prevention of heavy exercise - ↓ Na intake - ↓ Protein intake ( ↓ urine Ca, ↑ Urine PH, ↓ Urine uric acid) - Ca-intake (regular or even ↑ ) - ↓ Lipid intake - ↓ Intake of tea, Coffee, bean, sea foods, …