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Evaluation and Medical Management of Kidney Stones in Children

Gregory E. Tasian* and Lawrence Copelovitch
From the Department of Surgery, Division of Urology (GET) and Department of Pediatrics, Division of Nephrology (LC), Childrens Hospital
of Philadelphia and Perelman School of Medicine at the University of Pennsylvania (GET, LC), Philadelphia, Pennsylvania

Purpose: We review the current literature on the diagnostic evaluation and

dietary and pharmacological management of children with nephrolithiasis.
Materials and Methods: We searched MEDLINE, EMBASE and the Cochrane
Library from their inceptions to March 2014 for published articles in English on
kidney stones and therapy in children 0 to 18 years old. Based on review of
the titles and abstracts, 110 of the 1,014 articles (11%) were potentially relevant
to the diagnostic evaluation and medical management of nephrolithiasis in
children. We summarized this literature and drew on studies performed in adult
populations to augment areas in which no studies of sufficient quality have been
performed in children, and to highlight areas in need of research.
Results: During the last 25 years the incidence of nephrolithiasis in children
has increased by approximately 6% to 10% annually and is now 50 per 100,000
adolescents. Kidney stones that form during childhood have a similar composition to those that form in adulthood. Approximately 75% to 80% of stones
are composed of predominantly calcium oxalate, 5% to 10% are predominantly
calcium phosphate, 10% to 20% are struvite and 5% are pure uric acid. The
recurrence rate of nephrolithiasis in patients with stones that form during
childhood is poorly defined. Ultrasound should be used as the initial imaging
study to evaluate children with suspected nephrolithiasis, with noncontrast
computerized tomography reserved for those in whom ultrasound is nondiagnostic and the suspicion of nephrolithiasis remains high. Current treatment
strategies for children with kidney stone disease are based largely on extrapolation of studies performed in adult stone formers and single institution cohort or
case series studies of children. Tamsulosin likely increases the spontaneous
passage of ureteral stones in children. Increased water intake and reduction of
salt consumption should be recommended for all children with a history of kidney
stones. Potassium citrate is a potentially effective medication for children with
calcium oxalate stones and concomitant hypocitraturia, as well as children with
uric acid stones. However, long-term compliance with therapy and the effect on
decreasing stone recurrence in children are unknown. Based largely on efficacy
in adult populations, thiazide diuretics should be considered in the treatment of
children with calcium based stones and persistent hypercalciuria refractory to
reductions in salt intake.
Conclusions: The incidence of kidney stone disease in children is increasing,
yet few randomized clinical trials or high quality observational studies have
assessed whether dietary or pharmacological interventions decrease the recurrence of kidney stones in children. Collaborative efforts and randomized clinical
trials are needed to determine the efficacy and effectiveness of alternative
treatments for children with nephrolithiasis, particularly those with calcium
oxalate stones and concomitant hypercalciuria and hypocitraturia. Additional

0022-5347/14/1925-0001/0
THE JOURNAL OF UROLOGY
2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.

Dochead: Review Article

http://dx.doi.org/10.1016/j.juro.2014.04.108
Vol. 192, 1-8, November 2014
Printed in U.S.A.

Abbreviations
and Acronyms
CT computerized tomography
MET medical expulsive therapy
RTA renal tubular acidosis
Accepted for publication April 16, 2014.
* Correspondence: Department of Surgery,
Division of Urology, Childrens Hospital of Philadelphia, 34th St. and Civic Center Blvd., 3rd
FlooreWood Center, Philadelphia, Pennsylvania
19104-4399 (telephone: 215-590-0317; FAX 215590-3985; e-mail: tasiang@chop.edu).

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areas in need of study are the optimal length of time for a trial of stone passage in children, the costeffectiveness of medical expulsive therapy vs analgesics alone, and the size and location of stones for which
medical expulsive therapy is most effective.
Key Words: child, diagnostic imaging, diet therapy, drug therapy, nephrolithiasis

NEPHROLITHIASIS is a major source of morbidity and

health care expenditures in the United States.
During the last 20 years the prevalence of nephrolithiasis has increased 70% in adults, and the
gender gap between men and women is narrowing.1
Furthermore, nephrolithiasis, once considered an
adult disease, has become increasingly prevalent
in children. In the last 25 years the incidence
of nephrolithiasis in children has increased by
approximately 6% to 10% annually and is now 50
per 100,000 adolescents.2 In 2000 nephrolithiasis
accounted for $2.1 billion in annual health care
expenditures in the United States.3 This increase in
the incidence of nephrolithiasis in children has
implications for future health care spending and
health services allocation, and will increase the
prevalence of what, for many, is a chronic condition
associated with substantial pain and morbidity.4
Most importantly the emergence of kidney stones
as a pediatric disease necessitates that specialists
who care for children with nephrolithiasis understand the optimal strategies to evaluate children
with kidney stones and the effectiveness of nonsurgical interventions to decrease the risk of recurrence.
We reviewed the current literature on the diagnostic and metabolic evaluation and dietary and
pharmacological management of children with
nephrolithiasis. A comprehensive review of the
large number of, but rare, genetic diseases that
cause kidney stones in childhood has been described
elsewhere and is beyond the scope of this review.
Similarly medical management for stones due to
infectious causes, primary hyperoxaluria and
cystinuria is not addressed. Finally, although this
review focuses on the management of pediatric
nephrolithiasis, it also draws on studies performed
in adult populations to augment areas in which no
studies of sufficient quality have been performed in
children, and to highlight areas in need of research.
Particular attention is given to the as yet unknown
effectiveness of alternative treatment strategies in
reducing the recurrence of kidney stone disease
in childhood.

METHODS
In consultation with a reference librarian we searched
MEDLINE, EMBASE and the Cochrane Library from
their inceptions to March 2014 for published articles on
Dochead: Review Article

kidney stones in children. Search terms and/or keywords

included kidney stone OR urolith* OR nephrolith*.
The explosion feature of each database was used and the
search was limited to studies on subjects 18 years or
younger, English language publications and human
studies. We excluded case reports, expert opinions and
editorials. Abstracts were reviewed to identify articles
on evaluation and medical treatment of pediatric nephrolithiasis. In addition, the bibliographies of all potentially relevant primary articles and review articles
identified in the search were read to identify other relevant articles not detected in the database search. Full
search terms are available on request.

SEARCH RESULTS
A total of 1,014 unique references were retrieved.
No additional studies were identified from review of
article references. A total of 18 previous systematic
reviews were identified through search of the
Cochrane Library, although these were based on
studies of adults. Based on review of the titles and
abstracts, 110 of 1,012 articles (11%) were potentially
relevant to and within the scope of this review.
Acute Management
imaging. Clinical practice guidelines
and evidence support using ultrasound for initial
diagnostic imaging in children with suspected
nephrolithiasis, and reserving CT for those with a
nondiagnostic ultrasound in whom the clinical suspicion for stones remains high. Although ultrasound
is less sensitive and specific than CT,5,6 ultrasound
accurately identifies clinically significant kidney
stones in children. In a study of 50 patients younger
than 18 years with suspected nephrolithiasis Passerotti et al determined the diagnostic performance
of ultrasound in accurately localizing kidney stones.6
Using CT as the gold standard, the sensitivity
and specificity of ultrasound were 70% and 100%,
respectively, when the radiologists interpreting the
ultrasounds were blinded to CT results. In this population the positive predictive value of ultrasound
was 96% and the negative predictive value was 62%.
Of the 13 stones that were not visualized on ultrasound only 1 was larger than 5 mm. Three stones
that were not visualized by ultrasound were in the
ureter, and the remainder were nonobstructive
stones in the kidney. The authors thus concluded
that stones missed by ultrasound were likely of little
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KIDNEY STONES IN CHILDREN

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clinical consequence. Similarly Johnson et al found

that ultrasound correctly identified 89% of stones
requiring surgical intervention.5
Noncontrast CT has nearly 100% sensitivity and
specificity to identify kidney stones. However, CT
delivers ionizing radiation, which is associated with
an increased risk of cancer.7 Although the attributable risk of cancer from a single CT performed for
kidney stones is small (0.2% to 0.3% above baseline),
the cumulative risk is higher for those undergoing
repeated studies.8 Highlighting the cumulative
risk of radiation exposure, Routh et al analyzed
7,921 children with kidney stones treated at hospitals within the Pediatric Health Information System and observed that more than 2,600 children
underwent a median of 2 CTs for a single kidney
stone episode.9 Additionally the risk may be greater
in children than in adults because of a longer life
expectancy and greater sensitivity of developing
tissues to the effects of radiation.
Given the good sensitivity of ultrasound in
detecting clinically significant stones and the radiation risk associated with CT, the American Urological
Association in 2012 and the European Association
of Urology in 2013 developed imaging guidelines
for children with suspected nephrolithiasis.10,11
Both groups recommend ultrasound as the first-line
imaging modality, with noncontrast CT reserved
for cases where ultrasound is nondiagnostic. Additionally Image Gently, founded by the Society
for Pediatric Radiology, American College of Radiology, American Society of Radiologic Technologists
and the American Association of Physicists in
Medicine, began its campaign in 2007 to decrease
radiation exposure in children who require diagnostic
imaging.12 Currently it is unknown whether
these guidelines will decrease unnecessary CT use.
Future studies are needed to identify barriers to selective use of CT in children with suspected
nephrolithiasis.
Medical expulsive therapy. There have been few

studies on patient and stone characteristics that

predict whether a ureteral stone will pass spontaneously in children. However, similar to stones in
adults, it stands to reason that smaller, distal ureteral stones are more likely to pass than larger, more
proximal stones.13 For those stones in which
spontaneous passage is deemed possible (usually
smaller than 10 mm) MET, the use of alphablockers or calcium channel blockers to increase
stone passage, may increase passage of ureteral
stones and thus obviate the need for surgical
intervention. The causal pathway underlying the
potential effect of MET on stone passage is that
alpha and calcium channel blockers dilate the
ureter due to high densities of a1a, a1d, and calcium
Dochead: Review Article

channel receptors in smooth muscle of the distal

third of the ureter and ureterovesical junction.
Two meta-analyses of randomized controlled trials have been performed in adults.14,15 Both studies
demonstrated that tamsulosin and nifedipine increased passage of ureteral stones. In adults alphablockers also decrease time to stone passage and
reduce analgesic requirements, and are cost effective relative to analgesics alone.16,17
Evidence regarding the efficacy of MET in children is relatively sparse. To date, only 3 studies
have tested whether MET increases the passage of
ureteral stones in children.18e20
Aydogdu et al conducted a retrospective cohort
study of 20 children who were prescribed ibuprofen
and 19 who were prescribed doxazosin for ureteral
stones.18 They did not observe any association between doxazosin and spontaneous stone passage.
However, their sample size would have had only
10% power to detect a 15% difference in passage
rates between the groups.
Mokhless et al performed a prospective cohort
study in which children with distal ureteral stones
received tamsulosin or ibuprofen and placebo.19
More stones passed in the tamsulosin cohort (88%)
vs the placebo group (64%, p <0.01), and the time to
passage was also shorter in those receiving tamsulosin (8 vs 14 days, p <0.001). However, the validity
of these observations is uncertain due to the potential for selection bias and confounding, as
different inclusion criteria were used to select children for the tamsulosin and placebo cohorts. Nearly
half of the children in the tamsulosin group had
retained ureteral stones following extracorporeal
shock wave lithotripsy or percutaneous nephrolithotomy, whereas all patients in the placebo
group had untreated stones. In addition, similar to
the study by Aydogdu et al,18 this series was not
adjusted for potentially confounding factors plausibly associated with stone passage, such as stone
size and location, and patient age.
Recently Tasian et al performed a multiinstitutional retrospective cohort study evaluating
the efficacy of tamsulosin for ureteral stones smaller
than 10 mm. After propensity score matching and
adjusting for stone size and location the stone
expulsion rate was higher in the tamsulosin cohort
(56%) than the analgesics alone cohort (44%, p
0.03). The adjusted odds of stone passage were 3.31
times higher in children prescribed tamsulosin (OR
3.31, 95% CI 1.49e7.34).20
The level of evidence supporting the use of MET
for ureteral stones in children remains moderate, as
no high quality randomized controlled trial evaluating the efficacy of MET has been performed in
children. The efficacy of doxazosin in children remains unclear. No study has evaluated whether

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KIDNEY STONES IN CHILDREN

concurrent nonsteroidal anti-inflammatory drugs or

steroids with tamsulosin increase passage vs tamsulosin alone. Additional areas in need of study are
the optimal length of time for a trial of stone passage in children, the cost-effectiveness of MET vs
analgesics alone, and the size and location of stones
for which MET is most effective.
Kidney Stone Recurrence in Children
Pietrow et al in 2002 observed that 19% of patients 1
to 18 years old had recurrent kidney stones during a
mean followup of 34 months.21 During the preceding
decade Diamond et al observed that 16% of patients
who formed stones in childhood had recurrent stones
during a mean followup of 27 years.22 These studies
suggest that the recurrence risk for kidney stones
is lower in children than in adults, in whom the risk
is approximately 50% within 5 years of the initial
occurrence.4 However, this conclusion should be interpreted with caution. The aforementioned studies
dealt with patients who were followed for different
lengths of time, which potentially decreased the
recurrence rate. A single institution study from
Turkey accounted for differential followup and
revealed that the rate of recurrent nephrolithiasis in
children was 0.32 recurrent stones per patientyear.23 It is noteworthy that all of these studies were
conducted 12 to 25 years ago, when the incidence of
stones in children was less. Contemporary studies of
stone recurrence rates are needed to effectively
counsel patients on the probability of recurrence and
to establish a baseline risk that can be used to
determine the efficacy of treatments.

interventions.26 Hypercalciuria and hypocitraturia,

both of which increase the risk of recurrent kidney
stones,27,28 are the most commonly identified metabolic abnormalities. Other risk factors include
hyperuricosuria and hyperoxaluria.
A complete evaluation includes serum sodium,
potassium, chloride, bicarbonate, creatinine and
calcium (basic metabolic panel), phosphorus and
uric acid. A 24-hour urine collection should be
analyzed for calcium, oxalate, citrate, uric acid, sodium, creatinine levels, volume, pH, cystine and
supersaturation profiles of calcium oxalate, calcium
phosphate and uric acid.29 Unlike in adults, these
values should be indexed to weight, body surface
area and creatinine level to be properly interpreted
in children. Additionally 24-hour creatinine excretion should be quantified to determine the adequacy
of the collection (normal 15 to 25 mg/kg/24 hours).
Hypercalciuria is defined by urinary calcium excretion greater than 4 mg/kg/24 hours. In children
before toilet training a spot urine sample, from
which the urinary calcium-to-creatine ratio is calculated, can be used to diagnose hypercalciuria.30
Urine calcium-to-creatinine ratios decrease with
age, and at approximately 6 years approach 0.21 mg/
mg, which is the upper limit of normal for adults.30
Despite the recommendation that children who
form kidney stones undergo a full metabolic evaluation, it is currently unknown how frequently
metabolic evaluations are obtained or, on a population level, how these evaluations mitigate the risk
of recurrent stones in children. Of adults at high
risk for stone recurrence fewer than 10% undergo
24-hour urine collection.31

Risk Reduction Strategies

Metabolic evaluation. The goal of performing a

Dietary modification. Diet is an important determi-

metabolic evaluation is to identify abnormalities for

which targeted therapies can be prescribed to
decrease the risk of recurrent stones. Stone analysis
should be performed for all patients to determine
the chemical composition of the stone. Knowing
the stone composition is critical for instituting
the proper, targeted therapy after urinalyses are
completed. In adults approximately 75% to 80% of
stones are composed of predominantly calcium oxalate, 5% are predominantly calcium phosphate,
10% to 20% are struvite and 5% are pure uric acid.24
Contemporary analyses of stones that formed during childhood demonstrate a similar distribution,
with calcium phosphate stones being slightly more
common, at 9%.25
The general consensus is that a complete metabolic evaluation should be performed in children with
a first stone occurrence, because up to 70% of children
with nephrolithiasis will have abnormalities in the
urine that increase the risk of stone formation and
may be targets for dietary and pharmacological

nant of urinary stone risk. Therefore, it is critical

for urologists treating children with kidney stones
to understand how dietary modification can decrease the risk of recurrent nephrolithiasis. In a
recently completed Cochrane Review of dietary
interventions for adults with recurrent nephrolithiasis and hypercalciuria adherence to diets
with normal levels of calcium, low protein and low
salt reduced the risk of stone recurrence and
decreased oxaluria and calcium oxalate supersaturation.32 High quality studies of whether dietary
interventions reduce stone recurrence have not
been performed in children.
One major risk factor for nephrolithiasis is inadequate fluid intake that results in low urine volume.33 Low urinary volume increases the relative
supersaturation of uric acid, which thereby promotes nucleation, growth and aggregation of calcium oxalate and uric acid in urine. In the United
States children older than 3 years, particularly
girls, consume less water than is recommended by

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the Institute of Medicine.34 The risk of stone formation may be further exacerbated by increased
sugary drink consumption. Consumption of fructose
containing drinks increases urinary excretion of
calcium and oxalate and thereby may increase stone
risk.35,36 Consumption of fructose is highest in those
younger than 30 years and one quarter of adolescents consume at least 15% of their calories from
fructose.37 Although the risk of nephrolithiasis
associated with fructose in children has not been
studied, it stands to reason that children with a
history of nephrolithiasis should be counseled to
increase water intake (to at least 2.5 L in adolescents) and reduce sugary drink intake.
Sodium intake increases calciuria due to competition between sodium and calcium for passive
reabsorption along the nephron. Low dietary salt
intake thus decreases urine calcium. Daily sodium
intake less than 2 to 3 mEq/kg for young children
and less than 2.4 gm in adolescents and adults is
recommended for patients with hypercalciuria or
calcium based stones.
The majority of hypercalciuria is not due to dietary intake, and cumbersome tests to determine
the etiology of hypercalciuria are no longer commonly performed. Therefore, decreasing or limiting
calcium intake is not recommended. Indeed, low
dietary calcium has been associated with an increased risk of nephrolithiasis and greater dietary
calcium intake has been associated with a decreased
risk of nephrolithiasis in adults.38 This seemingly
paradoxical relationship is likely due to oxalate
binding by calcium in the gut, thus decreasing the
bioavailable oxalate that can be absorbed.
Meals high in animal protein result in an acid
load that increases urine calcium and decreases
urine citrate. Additionally animal protein, through
the intake of purines, increases urinary uric acid.
However, although low protein diets have been
associated with a decreased risk of stone formation
in adults,32 these results should not be applied to
children who are still growing. Regardless of stone
risk, children should consume 100% of the recommended daily allowance of protein.
Although hyperoxaluria is a risk factor for calcium oxalate stone formation, less than 20% of urinary oxalate excretion is due to dietary sources.
Accordingly the strength of evidence that reducing
oxalate consumption decreases stone risk is low,39
although a randomized clinical trial in adults
showed that dietary oxalate restriction reduced
urinary oxalate excretion.40 However, given the
generally weak evidence that oxalate restriction
decreases the risk recurrent stone formation in
adults and the absence of any observation studies or
clinical trials in children, restriction of dietary oxalate is not generally recommended for children.
Dochead: Review Article

Targeted Pharmacological Therapy

Calcium based stones with hypocitraturia. Citrate in-

hibits calcium stone formation by complexing with

calcium, thus decreasing the supersaturation of calcium in urine, and also by directly inhibiting crystal
growth and aggregation. Hypocitraturia has been
observed in approximately 60% of children with
nephrolithiasis,26 making it an attractive modifiable
risk factor for patients who form calcium based stones.
The cornerstone of pharmacotherapy for patients
with hypocitraturia and calcium oxalate nephrolithiasis is alkali therapy, usually in the form of
potassium citrate. However, unlike in adults, in whom
3 randomized clinical trials of the effect of citrate on
recurrent calcium oxalate stone formation have been
reported, the evidence is less robust in children.
In a prospective cohort study Sarica et al
observed that potassium citrate administration was
associated with decreased new stone formation
and slowed growth of residual fragments after
extracorporeal shock wave lithotripsy in children
with calcium based stones and hypocitraturia.41 In
another prospective cohort study of the efficacy of
potassium citrate in reducing stone recurrence
Tekin et al observed that 1 mEq/kg potassium
citrate per day divided into 3 doses after meals
decreased stone recurrence and normalized urinary
citrate in children 1 to 15 years old with a history of
calcium based nephrolithiasis and hypocitraturia.23
It is noteworthy that during a mean followup of
nearly 2 years the stone recurrence rate in the
cohort was 0.17 recurrent stones per patient-year
after administration of potassium citrate, compared to 0.32 recurrent stones per patient-year in
the same patients before citrate therapy, which
represented a 53% decrease in the risk of recurrent
nephrolithiasis. Similar reductions in stone formation were observed in children treated with potassium citrate following percutaneous nephrolithotomy
for calcium oxalate nephrolithiasis.42
Although discontinuation of therapy during these
clinical studies has not been reported, long-term
compliance with potassium citrate therapy in children has not been assessed. Such studies are needed
to determine the effectiveness of citrate therapy in
actual clinical practice. Additionally the efficacy of
alternative sources of citrate supplementation has
not been examined in children. In adults lemonade
consumption increases urinary citrate and may
reduce stone formation.43,44 The effect of lemonade
on urine chemistries and stone recurrence in children has not been evaluated. Studies of the
comparative effectiveness of and adherence to potassium citrate and lemonade therapy would help
to determine the optimal therapy to decrease stone
recurrence in children with calcium stones and
hypocitraturia.

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KIDNEY STONES IN CHILDREN

Ketogenic diet. Potassium citrate therapy has been

associated with a decrease in the incidence of kidney

stones in children with epilepsy treated with a
ketogenic diet. Some authors suggest that potassium citrate should be administered empirically for
this population at high risk for nephrolithiasis.45
Renal tubular acidosis. Patients with distal RTA have

acidemia, which contributes to hypercalciuria and

hypocitraturia. These patients often form calcium
phosphate stones due to these risk factors and an
inability to acidify the urine. In a select group of
8 children with distal RTA, potassium citrate
(maximum dose 4 mEq/kg per day) resulted in
normalization of calcium-to-creatinine and citrateto-creatinine ratios.46 The goal of potassium
citrate therapy in patients with distal RTA is
to increase urine citrate concentration and decrease
acidemia by increasing plasma bicarbonate. However, urine pH should be monitored closely to avoid
increasing the already alkaline urine pH above 6.3,
which would increase the probability of calcium
phosphate crystal formation.
Hypercalciuria and calcium stones. Thiazide diuretics

(eg hydrochlorothiazide and chlorthalidone) are the

first-line drugs for children with calcium stones and
hypercalciuria. Thiazides are used after maximizing
urine calcium reduction by limiting dietary sodium
intake. Through volume contraction thiazides increase calcium absorption in the proximal tubule
and thereby decrease urine calcium. There have
been no randomized clinical trials to determine the
efficacy of thiazides in reducing stone recurrence in
children with hypercalciuria and a history of calcium stones. However, the evidence in adults is
robust. In 7 of 10 randomized controlled trials a 40%
to 80% decrease in the relative risk of recurrent
stone formation was observed. In a small uncontrolled cohort study children with stones of unknown composition and hypercalciuria were treated
with dietary modification, potassium citrate and
hydrochlorothiazide (1 to 2 mg/kg per day), and
normocalciuria was achieved in 50%.47 However,
stone recurrence was not assessed, and confounding
by diet and potassium citrate is likely. Based on the
consistent efficacy and safety of thiazides in adults
and the suggestions that similar effects may be
observed in children, thiazides can be recommended
in children. The optimal dosing still needs to be
established, as doses of 0.5 to 2 mg/kg per day have
been reported to decrease urine calcium in children.48 No study to date has analyzed stone
recurrence, which is the most important outcome
for any intervention.
Additionally the safety and efficacy of combined
therapy with potassium citrate and thiazides
in children is unknown. Although hypokalemia and
Dochead: Review Article

hypochloremic metabolic acidosis were not observed

in adults treated with combined therapy with thiazides and potassium citrate,49 studies are needed to
determine if similar effects are found in children.
Furthermore, it will be important to determine if
doses observed to be most effective in clinical trials
are used in clinical practice. A recent study revealed
that only 35% of adult stone formers were prescribed doses of hydrochlorothiazide that have been
demonstrated to decrease stone recurrence in randomized clinical trials.50
Hyperuricosuria and calcium stones. Uric acid de-

creases the solubility of calcium oxalate, and

hyperuricosuria is an independent risk factor for
calcium nephrolithiasis. Consequently treating
hyperuricouria is recommended to decrease the risk
of recurrent calcium stones. Purine restriction is the
first-line treatment for adults, with allopurinol,
an inhibitor of xanthine oxidase, indicated for
nonresponders with associated hyperuricemia.
Currently the optimal treatment for children with
hyperuricosuria and a history of calcium oxalate
stones is uncertain, as protein intake should not be
restricted during childhood and there have not been
any randomized controlled trials or high quality
observational studies of alternative treatment
strategies.
Uric acid stones. Pure uric acid stones are rare in

children but should be treated when found. The

major risk factors for uric acid stones are low urine
volume, hyperuricosuria and low urine pH. Hydration and urinary alkalinization are highly effective
to prevent uric acid stone recurrence. Although
there is a lack of robust literature to guide dosing
for children with uric acid nephrolithiasis, we
recommend 1 to 2 mEq/kg potassium citrate per day
divided twice daily and monitoring of urine pH
during therapy.

CONCLUSIONS
The incidence of kidney stone disease is increasing
in children, yet few randomized clinical trials or
high quality observational studies have assessed
whether dietary or pharmacological interventions
decrease the risk of stone recurrence. Current
treatment strategies are based largely on extrapolation of studies performed in adult stone formers
and single institution cohort or case series studies.
Increasing water intake and reducing salt consumption should be recommended for all children
with a history of kidney stones. Potassium citrate
is a potentially effective medication for hypocitraturia and calcium oxalate stones. However, longterm compliance with therapy and the effect on
decreasing stone recurrence in children remain

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unknown. Collaborative efforts and randomized

clinical trials are needed to determine the efficacy
and effectiveness of alternative treatments for

children with nephrolithiasis, particularly those

with calcium oxalate stones and concomitant
hypercalciuria and hypocitraturia.

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