4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

OfficialreprintfromUpToDate
www.uptodate.com2015UpToDate

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren
Authors
JodiSmith,MD,MPH
FBruderStapleton,MD

SectionEditor
LaurenceSBaskin,MD,FAAP

DeputyEditor
MelanieSKim,MD

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.
Literaturereviewcurrentthrough:Nov2015.|Thistopiclastupdated:Jun09,2015.
INTRODUCTIONNephrolithiasisisincreasinglyrecognizedinchildren.Itspresentationvaries,andoften
patients,especiallyyoungchildren,donotpresentwiththeclassicacuteonsetofflankpaincommonlyseenin
adults.Asaresult,childrenarefrequentlyevaluatedforotherconditionsbeforethediagnosisofnephrolithiasisis
made.Theclinicalfeaturesanddiagnosisofchildhoodnephrolithiasiswillbereviewedhere.Theepidemiology,
riskfactors,acutemanagement,andpreventionofrecurrentnephrolithiasisinchildrenarediscussedseparately.
(See"Epidemiologyofandriskfactorsfornephrolithiasisinchildren"and"Acutemanagementofnephrolithiasisin
children"and"Preventionofrecurrentnephrolithiasisinchildren".)
CLINICALPRESENTATIONMostchildrenwithnephrolithiasispresentsymptomatically,usuallywithflankor
abdominalpain.Approximately15to20percentareasymptomatic,primarilyyoungchildrenwhoarediagnosed
becauseofstonedetectionwhenabdominalimagingisperformedforotherpurposes[13].
Inthosewithsymptomaticpresentation,themostcommonsymptomispain[14].Otherpotentialmanifestations
includegrosshematuria,dysuriaandurgency,andnausea/vomiting.
PainPaincanbelocatedeitherasabdominalorflankpain(referredtoasrenalcolic).Inseveralcaseseries,
painwasthepresentingcomplaintin50to75percentofpatients[15].
Painfrequencyvarieswithage.Inonereport,forexample,painwaspresentin60,40,and20percentof
adolescents,schoolagedchildren,andchildrenbelowfiveyearsofage,respectively[2].Theagerelated
differenceinpainmayberelatedtostonelocationatpresentation.Youngerchildren(ie,lessthanfiveyearsof
age)aremuchlesslikelytohaveureteralstonesthanschoolagedchildrenandadolescents(32versus64and82
percent,respectively)[6].Ureteralstonesaregenerallypainful,sincetheycauseureteralobstruction,whereas
kidneystonesareoftenasymptomaticandmaybediagnosedasanincidentalfindingonabdominalimaging.
Similartoadultswithnephrolithiasis,theintensityofpaincanvaryfromamildachetoseveredebilitatingpain.In
childrenbelowfiveyearsofage,thepain,ifpresent,appearstobemilderandisnonspecific.Inaddition,young
childrenoftenareunabletoarticulatethelocationandseverityofthepain.Asaresult,youngchildrenare
frequentlyevaluatedforothercausesofabdominalpainbeforethediagnosisofnephrolithiasisismade.
Inaddition,nephrolithiasismaybethecauseofrecurrentabdominalpaininchildren,asillustratedbya
retrospectivestudythatincludedpatientsthatrequiredhospitalizationorunderwentappendectomyforabdominal
pain[7].
GrosshematuriaInpediatriccaseseries,grosshematuriaasapresentingsymptomfornephrolithiasisvaried
from30to55percent[14].Hematuriacanpresentasthesolesymptomorconcomitantlywithabdominalpain.
DysuriaandurgencyApproximately10percentofchildrenwithnephrolithiasispresentwithsymptomsof
dysuriaandurgencysuggestiveofaurinarytractinfection(UTI)[1,4,5].Insomecases,urinarytractinfectionis
presentandisacontributingfactortostoneformation,especiallyinyoungchildren[1,2,5].Inothercases,dysuria
andurgencycanbeseenwhenthestoneispresentinthebladderorurethrawithoutanassociatedUTI.(See
"Epidemiologyofandriskfactorsfornephrolithiasisinchildren",sectionon'Infection'.)
Inadditiontothesesymptoms,nauseaandvomitinghasbeendescribedasapresentingsymptomin10percentof
http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sear

1/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

patients[1].
YoungchildrenAsnotedabove,youngchildrenwithnephrolithiasisarelesslikelytodisplaytheclassical
presentationofabdominal/flankpaincommonlyseeninolderchildrenandadults[2,6,8].Youngerchildrenarealso
morelikelythanolderchildrentohavearenalratherthanaureteralstone[6,8].Inoneofthelargestcaseseries,
abdominalpainandgrosshematuriawerethepresentingsymptomsinaboutonehalfofthechildrenbelowsix
yearsofage[2].Theotherhalfofpatientspresentedwithaurinarytractinfectionand/orincidentalfindingof
stonesonabdominalimaging.
INITIALEVALUATIONBecauserenalstonescancauseurinaryobstruction,andareoftenassociatedwith
urinarytractinfection,childrenwhopresentwithsymptomssuggestiveofnephrolithiasisshouldbeevaluated
promptly.
HistoryTheevaluationbeginswithahistorythatidentifiesanyofthefollowingfactorsthatareassociatedwith
anincreasedlikelihoodfornephrolithiasis:
Historyofpreviousrenalstone.
Familyhistoryofnephrolithiasis.Inonecaseseries,16percentofchildrenhadafirstdegreerelativeand17
percenthadaseconddegreerelativewithrenalstones[3].(See"Epidemiologyofandriskfactorsfor
nephrolithiasisinchildren".)
Historyofunderlyingrenalandurinarytractstructuralabnormalities.(See"Epidemiologyofandriskfactors
fornephrolithiasisinchildren",sectionon'Congenital/structuralabnormalities'.)
Historyofunderlyingmetabolicconditionsassociatedwithnephrolithiasis,suchasmalabsorptionleadingto
enhancedentericabsorptionofoxalateandhyperoxaluria,ortheuseofaketogenicdiettotreatepilepsy.
(See"Epidemiologyofandriskfactorsfornephrolithiasisinchildren".)
Historyofmedicationsassociatedwithstoneformation,suchasindinavirorsulfadiazine[9].(See
"Epidemiologyofandriskfactorsfornephrolithiasisinchildren",sectionon'Othermetaboliccauses'.)
Historyofrecurrenturinarytractinfection,especiallywithaureaseproducingorganism,suchasProteusor
Klebsiella.(See"Epidemiologyofandriskfactorsfornephrolithiasisinchildren",sectionon'Infection'.)
PhysicalexaminationThephysicalexaminationinthechildwithsuspectednephrolithiasisshouldinclude:
Anabdominalexaminationfortendernessormass(eg,evidenceofurinaryobstructionoranothercauseof
abdominalpain,suchasappendicitis).
Growthmeasurements,aspoorweightgainand/orfailuretothrivemaybeanindicationofacongenitalor
chronicconditionthatmaybeassociatedwithnephrolithiasis,suchasrenaltubularacidosisorDent's
syndrome.(See"Epidemiologyofandriskfactorsfornephrolithiasisinchildren".)
Bloodpressuremeasurementandassessmentforedema.Thepresenceofhypertensionand/oredemaina
childwithhematuriasuggestsanalternativediagnosistonephrolithiasis,suchasglomerulardisease.(See
'Differentialdiagnosis'below.)
Documentationoftemperature.Thepresenceoffevermayrepresentaurinarytractinfection.
LaboratoryevaluationTheinitiallaboratoryevaluationforthechildwithsuspectednephrolithiasisincludes:
UrinalysisExaminationoftheurinesedimentmaybeusefulifcrystalsarepresent.Asanexample,cystine
crystals,whicharecolorless,flat,andhexagonal,arediagnosticofcystinuria(picture1).Othercrystalsthat
canbeseeninthesedimentincludecalciumoxalate(picture2AB),calciumphosphate,uricacid(picture3A
B),andphosphate(picture4).Drugs,suchassulfadiazineandindinavir,canalsocrystallizeintheurine
(picture5andpicture6).
http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sear

2/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

UrinecultureAurinecultureshouldbeobtainedbecauseurinarytractinfection(UTI)canbepresentina
childwithnephrolithiasis.AUTIisalsothemostcommonconditioninthedifferentialdiagnosisofpediatric
nephrolithiasis.(See'Differentialdiagnosis'below.)
SerumcreatinineMeasuringserumcreatininetodetermineinitialrenalfunction.
Furtherevaluationformetabolicriskfactors,suchashypercalciuriaorhyperuricosuria,isimportant,butshouldbe
performedoncetheacuteepisodeisover,whilethepatientisathome,fullyambulatory,consumingaregulardiet,
andfreeofinfection.(See"Preventionofrecurrentnephrolithiasisinchildren".)
DIAGNOSISThediagnosisofnephrolithiasisisinitiallysuspectedbythepresentationandinitialclinical
evaluation[10].Itisconfirmedbythedetectionofastoneonimagingstudiesorretrievalofapassedstone.As
previouslymentioned,thediagnosisismadeasanincidentalfindinginabout15to20percentofpediatriccases
whenabdominalimagingisperformedforotherpurposes[13].
ImagingThethreeimagingmodalitiescurrentlyusedtodiagnosisnephrolithiasisinchildrenarenoncontrast
helicalcomputedtomography(CT),ultrasonography,andplainabdominalradiography.CTisthemostsensitivefor
thedetectionofrenalstones,followedbyultrasonographyandplainradiography[11].Insmallchildren,thereare
concernsaboutradiationexposurefromCT[12].
UltrasonographyUltrasonographyisaneffectivemodalityfordiagnosisinmanycasesandavoidsthe
concernofradiation[13].Itisthemodalityofchoicewhenradiationshouldbeavoided,asinpregnantgirls,or
whentheradiationdosefromCTcannotbereducedtosafelevels.Ultrasonographycandetectradiolucentstones,
suchasuricacidstones,andurinaryobstruction[14].However,itislimitedinitsabilitytouncoversmallstones
(eg,lessthan5mm),papillaryorcalycealstones,orureteralstones[15].
Theexperienceandexpertiseoftheultrasonographerisanimportantfactorinthesensitivityofthestudy,
especiallyintheaccuratedetectionofsmallstonesorureteralstones.
Inonecaseseriesof50consecutivepatientswithsuspectednephrolithiasisfromatertiarycenter,
ultrasonographyfailedtodetectstonesseenonCTineightpatientsandmissedbilateralstonediseaseinsix
patients,resultingina76percentsensitivityand100percentspecificity[16].Themeansizeofmissedstones
was2.3mm.Infourcases,clinicalmanagementdecisionswouldhavechangedifCTwasnotperformed.These
resultssuggestthatultrasonographyisareasonablealternativetoCTtodetectnephrolithiasis,especiallywhen
thereareconcernsaboutradiationexposurefromCT.
NoncontrasthelicalCTSimilartoinadults,noncontrasthelicalCTisthemostsensitivemodalityto
detectrenalorureteralstonesinchildren(image1AB)[10,11,17].CTcandetectstonesinthefollowing
conditions,whichmaynotbedetectedbytheothermodalities:
Ureteralstones,whichmaynotbedetectedbyultrasonography
Radiolucentstones(eg,pureuricacidstones),whicharenotdetectedbyplainradiography
Small(ie,1mmindiameter)stones,whicharenotdetectedbyultrasonographyorplainradiography
CTalsoprovidesmoredetailedanatomicinformationincludingdetectionofobstructionorastructuralabnormality
[18].
CTisarapidprocedurerequiringlessthantwominutestobeperformed.PatientswhoundergoCTgenerallydo
notrequireanesthesia.Ifnecessary,contrastcanbegivenafternoncontrastimageshavebeenobtainedto
provideadditionalanatomicdetail,suchassubtlesignsofurinaryobstructionorincreaseddetailofananatomic
abnormality.
TheradiationexposureduringCTvarieswithdifferentequipmentandinstitutionalprotocols.Concernshavebeen
raisedthatsmallchildrencanbeexposedtoexcessiveradiation,ifconventionaladultradiationdosesareused
duringtheprocedure[12,19].However,radiationdosescanbesignificantlyreducedthroughadjustingscanning
parameterstothesizeandweightofthechildwhilestillmaintainingadequateimagingquality[20,21].In
http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sear

3/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

institutionsthatprovidecareforchildren,protocolstoensureeffectiveandsaferadiationdosesforCTshouldbe
implementedasoutlinedbyguidelinesfromtheNationalCancerInstitute[19,22].Ifthisisnotfeasible,another
imagingmodality,suchasultrasonography,shouldbeused[23].
AbdominalplainradiographyAplainabdominalradiographwilldetectradiopaquestones(eg,calcium,
struvite,andcystinestones)(image2),butwillmissradiolucentstones(eg,uricacidstones),maymisssmall
stonesorthosethatoverlaybonystructures,andwillnotdetecturinaryobstruction.Insettingswhererenal
ultrasonographyandCTarenotavailableinchildren,plainabdominalradiographyremainsareasonablealternative,
recognizingthatthereportedsensitivityofthisstudyisabout60percent[11].
OurapproachWerecommendnoncontrasthelicalCTinthediagnosticevaluationofpediatric
nephrolithiasis.Radiationdosesareadjustedtothesizeandweightofthechildtoreducetheradiationexposure.
AbdominalultrasonographyorplainfilmcanbeusedifappropriateCTimagingforchildrenisnotavailable.
Ultrasonographyispreferredtoplainfilmsinceitisamoresensitivetestandcanalsodetectradiolucentstones
andurinarytractobstruction.
DIFFERENTIALDIAGNOSISThedifferentialdiagnosisinachildwithsuspectednephrolithiasisdependsupon
thepresentingsymptoms.Nephrolithiasisisdifferentiatedfromtheotherconditionsbydemonstrationbyimaging
ofastonewithinthekidneyorurinarytract.
AbdominalorflankpainAbdominalpainisoneofthemostcommoncomplaintsinchildrenandthedifferential
isextensive.Infections,suchasgastroenteritis,urinarytractinfections(UTI),appendicitis,andpneumonia,are
themostcommoncauseofabdominalorflankpain.Othersignsandsymptoms,mostcommonlyfever,usually
distinguishthemfromnephrolithiasis.(See"Causesofacuteabdominalpaininchildrenandadolescents"and
"Emergentevaluationofthechildwithacuteabdominalpain".)
GrosshematuriaInchildren,themostcommonlyidentifiedcausesforgrosshematuriaincludeUTI,irritationof
themeatusorperineum,andtrauma.Thesearedifferentiatedfromnephrolithiasisbythehistoryandphysical
examination.Glomerulardisease,suchaspostinfectiousglomerulonephritis,isalesscommoncauseofgross
hematuriathatisdistinguishedfromnephrolithiasisbycolacoloredurineinsteadofredurine,examinationofthe
urinarysediment,andthepossiblepresenceofhypertensionand/oredema.(See"Evaluationofgrosshematuriain
children".)
UrinarytractinfectionManyofthesymptomsassociatedwithnephrolithiasis(eg,abdominal/flankpain,gross
hematuria,dysuria,andurgency)canalsobeseeninchildrenwithUTI.Inaddition,thetwoconditionscanpresent
concomitantlywiththeUTIcontributingtotheprocessofstoneformation.
ChildrenwithUTIdiagnosedbyurinecultureusuallybegintoshowclinicalimprovementwithin24to48hoursof
initiationofappropriateantibiotictherapy.Iftheclinicalconditionworsensorfailstoimproveasexpectedwithin24
to48hoursofthestartofantimicrobialtherapy,imagingshouldbeperformedtodetermineifthefailedorslow
responsetotherapyisduetothepresenceofrenalstone,renalabscess,orunderlyinganatomicabnormalitiesor
obstruction.(See"Urinarytractinfectionsininfantsolderthanonemonthandyoungchildren:Acutemanagement,
imaging,andprognosis",sectionon'Clinicalresponse'.)
INFORMATIONFORPATIENTSUpToDateofferstwotypesofpatienteducationmaterials,TheBasicsand
BeyondtheBasics.TheBasicspatienteducationpiecesarewritteninplainlanguage,atthe5thto6thgrade
readinglevel,andtheyanswerthefourorfivekeyquestionsapatientmighthaveaboutagivencondition.These
articlesarebestforpatientswhowantageneraloverviewandwhoprefershort,easytoreadmaterials.Beyond
theBasicspatienteducationpiecesarelonger,moresophisticated,andmoredetailed.Thesearticlesarewritten
atthe10thto12thgradereadinglevelandarebestforpatientswhowantindepthinformationandarecomfortable
withsomemedicaljargon.
Herearethepatienteducationarticlesthatarerelevanttothistopic.Weencourageyoutoprintoremailthese
topicstoyourpatients.(Youcanalsolocatepatienteducationarticlesonavarietyofsubjectsbysearchingon
http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sear

4/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

patientinfoandthekeyword(s)ofinterest.)
Basicstopics(see"Patientinformation:Kidneystonesinchildren(TheBasics)")
BeyondtheBasicstopics(see"Patientinformation:Kidneystonesinchildren(BeyondtheBasics)")
SUMMARYANDRECOMMENDATIONS
Childhoodnephrolithiasisusuallypresentswithsymptomsthatmostcommonlyincludeabdominalorflank
pain,and/orgrosshematuria.However,15to20percentofchildrenareasymptomaticandarediagnosed
becauseofstonedetectionwhenabdominalimagingisperformedforotherpurposes.(See'Clinical
presentation'above.)
Abdominalorflankpainasapresentingsymptomvariesinintensityfromamildachetoseveredebilitating
pain.Painisacommonfeatureinadolescentsandschoolagedchildrenwithnephrolithiasis,butisonly
presentinabouthalfofthechildrenbelowsixyearsofage.Urinarytractinfectionand/oranincidentalfinding
ofastoneonimagingarethepresentingfindingsinalmosthalfofthechildrenbelowsixyearsofage.(See
'Clinicalpresentation'above.)
Theinitialevaluationofachildwithsuspectednephrolithiasisincludesthefollowing:
Historyfocusingonunderlyingriskfactorsforstoneformation(eg,familyhistory,renalandurinarytract
structuralabnormalities,metabolicdisorders,orrecurrenturinarytractinfection).(See"Epidemiologyof
andriskfactorsfornephrolithiasisinchildren".)
Physicalexaminationthatincludesmeasurementofbloodpressureandgrowthparameters,and
abdominalexaminationforsignsofurinaryobstructionoranothercauseofabdominalpain.
Urinalysis,urineculture,andmeasurementofserumcreatinine.(See'Initialevaluation'above.)
Thediagnosisofnephrolithiasisismadebythedetectionofarenalstonebyimagingstudiesorretrievalofa
passedstone.
Werecommendabdominalimagingforanychildsuspectedtohavenephrolithiasis.Inmostpatients,we
recommendultrasoundornoncontrasthelicalcomputedtomography.
Computedtomographydoesprovidethegreatestsensitivityoftheavailableimagingmodalities,but
considerationofradiationexposureisimportant.Radiationdosescanbeadjustedtothesizeand
weightofthechildtoreduceradiationexposure.
Ultrasonographydetectsradiolucentstonesandurinaryobstruction,andremainstheoverallimaging
choicewhenradiationshouldbeavoided,suchasinpregnantadolescents.(See'Imaging'above.)
UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.
REFERENCES
1. GearhartJP,HerzbergGZ,JeffsRD.Childhoodurolithiasis:experiencesandadvances.Pediatrics1991
87:445.
2. MillinerDS,MurphyME.Urolithiasisinpediatricpatients.MayoClinProc199368:241.
3. CowardRJ,PetersCJ,DuffyPG,etal.EpidemiologyofpaediatricrenalstonediseaseintheUK.ArchDis
Child200388:962.
4. VanDervoortK,WiesenJ,FrankR,etal.Urolithiasisinpediatricpatients:asinglecenterstudyof
incidence,clinicalpresentationandoutcome.JUrol2007177:2300.
5. SternbergK,GreenfieldSP,WilliotP,WanJ.Pediatricstonedisease:anevolvingexperience.JUrol2005
174:1711.
http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sear

5/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

6. PietrowPK,PopeJC4th,AdamsMC,etal.Clinicaloutcomeofpediatricstonedisease.JUrol2002
167:670.
7. PolitoC,LaMannaA,SignorielloG,MarteA.Recurrentabdominalpaininchildhoodurolithiasis.Pediatrics
2009124:e1088.
8. KalorinCM,ZabinskiA,OkparekeI,etal.Pediatricurinarystonediseasedoesagematter?JUrol2009
181:2267.
9. CatalanoPonsC,BargyS,SchlechtD,etal.Sulfadiazineinducednephrolithiasisinchildren.Pediatr
Nephrol200419:928.
10. PersaudAC,StevensonMD,McMahonDR,ChristopherNC.Pediatricurolithiasis:clinicalpredictorsinthe
emergencydepartment.Pediatrics2009124:888.
11. NimkinK,LebowitzRL,ShareJC,TeeleRL.Urolithiasisinachildren'shospital:19851990.UrolRadiol
199214:139.
12. BrennerD,EllistonC,HallE,BerdonW.EstimatedrisksofradiationinducedfatalcancerfrompediatricCT.
AJRAmJRoentgenol2001176:289.
13. PenidoMG,SrivastavaT,AlonUS.Pediatricprimaryurolithiasis:12yearexperienceataMidwestern
Children'sHospital.JUrol2013189:1493.
14. SmithSL,SomersJM,BroderickN,HallidayK.Theroleoftheplainradiographandrenaltractultrasoundin
themanagementofchildrenwithrenaltractcalculi.ClinRadiol200055:708.
15. DiamentMJ,MalekzadehM.Ultrasoundandthediagnosisofrenalandureteralcalculi.JPediatr1986
109:980.
16. PasserottiC,ChowJS,SilvaA,etal.Ultrasoundversuscomputerizedtomographyforevaluating
urolithiasis.JUrol2009182:1829.
17. PalmerJS,DonaherER,O'RiordanMA,DellKM.Diagnosisofpediatricurolithiasis:roleofultrasoundand
computerizedtomography.JUrol2005174:1413.
18. SmergelE,GreenbergSB,CrisciKL,SalwenJK.CTurogramsinpediatricpatientswithureteralcalculi:do
adultcriteriawork?PediatrRadiol200131:720.
19. BrennerDJ,HallEJ.Computedtomographyanincreasingsourceofradiationexposure.NEnglJMed
2007357:2277.
20. DonnellyLF,EmeryKH,BrodyAS,etal.Minimizingradiationdoseforpediatricbodyapplicationsofsingle
detectorhelicalCT:strategiesatalargeChildren'sHospital.AJRAmJRoentgenol2001176:303.
21. KarmazynB,FrushDP,ApplegateKE,etal.CTwithacomputersimulateddosereductiontechniquefor
detectionofpediatricnephroureterolithiasis:comparisonofstandardandreducedradiationdoses.AJRAmJ
Roentgenol2009192:143.
22. Radiationrisksandpediatriccomputedtomography(CT):Aguideforhealthcareproviders.Availableat:
www.nci.nih.gov/cancertopics/causes/radiationriskspediatricCT(AccessedonApril29,2009).
23. NgC,TsungJW.AvoidingComputedTomographyScansByUsingPointOfCareUltrasoundWhen
EvaluatingSuspectedPediatricRenalColic.JEmergMed201549:165.
Topic6123Version14.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sear

6/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

GRAPHICS
Urinesedimentshowingcystinecrystals

Urinesedimentshowinghexagonalcystinecrystalsthatare
essentiallypathognomonicofcystinuria.
CourtesyofHarvardMedicalSchool.
Graphic56834Version2.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sear

7/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

Calciumoxalatecrystalsintheurine

Urinesedimentshowingbothdumbbellshapedcalciumoxalate
monohydrate(longarrow)andenvelopeshapedcalciumoxalate
dihydrate(shortarrows)crystals.Althoughnotshown,the
monohydratecrystalsmayalsohaveaneedleshapedappearance.
Theformationofcalciumoxalatecrystalsisindependentoftheurine
pH.
CourtesyofFrancesAndrus,BA,VictoriaHospital,London,Ontario.
Graphic65169Version2.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sear

8/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

Urinarycalciumoxalatemonohydratecrystals
underpolarizedlight

Urinesedimentviewedunderpolarizedlightshowingcoarse,needle
shapedcalciumoxalatemonohydratecrystals.Thesecrystalshavea
similarappearancetohippuratecrystals.
CourtesyofWMerrillHicks,MD.
Graphic67694Version2.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sear

9/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

Uricacidcrystalsintheurine

Urinesedimentloadedwithuricacidcrystals.Thesecrystalsare
pleomorphic,mostoftenappearingasrhombicplatesorrosettes.
Theyareyelloworreddishbrownandformonlyinanacidurine(pH
5.5orless).
CourtesyofHarvardMedicalSchool.
Graphic61827Version3.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sea

10/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

Uricacidcrystalsunderpolarizedlight

Urinesedimentshowinguricacidcrystalsviewedunderpolarized
light.
CourtesyofFrancesAndrus,BA,VictoriaHospital,London,Ontario.
Graphic73642Version2.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sea

11/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

Urinesedimentshowingstruvite(magnesium
ammoniumphosphate)crystals

Urinesedimentshowingmultiple"coffinlid"magnesiumammonium
phosphatecrystals(struvite)thatformonlyinanalkalineurine(pH
usuallyabove7.0)causedbyanupperurinarytractinfectionwitha
ureaseproducingbacteria.
CourtesyofHarvardMedicalSchool.
Graphic54594Version6.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sea

12/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

Photomicrographshowingurinesedimentofa
patientwithsulfonamidecrystalluria

Urinesedimentshowingsulfonamidecrystalswithaneedleshaped
appearance.Otherformsthatmaybeseenincluderosettesanda
shockofwheatappearance.
CourtesyofHarvardMedicalSchool.
Graphic56708Version3.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sea

13/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

Photomicrographsshowingurinesedimentofa
patientwithindinavirsulfatecrystalluria

Lightmicroscopicphotographsofafreshunstainedpreparationof
urinarysedimentshowingthreedifferentformsofindinavirsulfate
crystals.
(A)Rectangularplatesofvarioussizescontainingneedleshaped
crystals.Theplateshaveirregularborderswithoccasionaltapering,
andinternallayeringevidentinthelargestforms(arrows).Small,
triangularpieces(arrowheads)representbrokenendsofneedles.
(B)Asheafofdenselypackedindinavirsulfateneedles.
(C)Severalindinavircrystalgroupingsarearrangedinarosette.
Reprintedwithpermissionfrom:GagnonRF,TsoukasCM,WattersAK,Ann
InternMed1998128:321.
Graphic70939Version4.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sea

14/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

CTscanshowingureteralstone

CTscanshowsacalculusintheproximallefturetercausingdelayed
excretionofcontrastmaterialfromtheleftkidney(longarrow).All
thecontrasthasbeenexcretedfromthenormalfunctioningright
kidneyandisinthenondilatedrightureter(smallarrow).
CTscan:computedtomographicscan.
CourtesyofJonathanKruskal,MD.
Graphic69052Version4.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sea

15/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

CTscanshowinglargerenalpelvicstone

CTscanwithoutcontrastshowsalargecalculusintherightrenal
pelvis(arrow).
CTscan:computedtomographicscan.
CourtesyofMarkDAronson,MD.
Graphic72669Version6.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sea

16/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

KUBshowingstaghorncalculi

Theplainfilmoftheabdomenintheanteroposteriorprojectionrevealsastaghorncalculus.
Notecalcifications(arrows)intheoppositekidneyaswell.
Graphic62009Version4.0

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sea

17/18

4/12/2015

Clinicalfeaturesanddiagnosisofnephrolithiasisinchildren

Disclosures
Disclosures:JodiSmith,MD,MPHNothingtodisclose.FBruderStapleton,MDNothingtodisclose.LaurenceSBaskin,MD,FAAP
Nothingtodisclose.MelanieSKim,MDNothingtodisclose.
Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthrougha
multilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.Appropriatelyreferenced
contentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.
Conflictofinterestpolicy

http://www.uptodate.com/contents/clinicalfeaturesanddiagnosisofnephrolithiasisinchildren?topicKey=PEDS%2F6123&elapsedTimeMs=0&source=sea

18/18