Treating Kidney Stones in Children at CHOP's Pediatric Stone Center

Kidney Stones in Children: An Epidemic

Gregory Tasian, MD: Historically when we were thinking of kidney stones we thought of it as an adult disease with a very few rare children that were affected by stones.

Susan Furth, MD: It seems that more and more children are developing kidney stones.

Arun K. Srinivasan, MD: In the last 15 years, the incidence of kidney stones in children has doubled, quadrupled in some communities.  Various reasons have been attributed; diet, the way we drink, what we drink.

Kerry Ashcroft, BSN: It usually comes as a great surprise to parents that their child has a kidney stone.

Douglas A. Canning, MD: They're almost always stunned for us to tell them that yes, what I'm showing you on this ultrasound is a kidney stone, and it's nothing to be afraid of, but it's there and it's something that we're going to need to deal with.

Susan Furth, MD: The best care for many children with kidney stones would include involvement of a number of doctors and other specialists.

Gregory Tasian, MD: The kidneys are two organs that exist in what we call the retroperitoneum.  That's the space behind the belly cavity.  They filter the blood and by removing all the byproducts, of metabolism, they ultimately form what we know as urine.  Within that urine are all the waste products or many of the waste products that our body produces.

Lawrence Copelovitch, MD: Some of those substances can crystalize and turn into kidney stones, which can get stuck in the kidney.

Kerry Ashcroft, BSN: These minerals in the urine are like little snowflakes, so when there's too much of a mineral or maybe something as simple as not enough water in the system that concentrates the urine, now, there's more potential for these snowflakes to get together and form snowballs.

Gregory Tasian, MD: As they form in the kidney sometimes they just can sit there, but oftentimes they can move around and then sometimes get stuck in the ureter, which is the tube that drains the kidney down into the bladder.

Arun K. Srinivasan, MD: They are pretty narrow tubes and when the stone comes down, it's very much like a blocked sink.  So the water behind it builds up into the kidney while the kidney is trying to push it down.  This tug-of-war is what causes the pain and the symptoms associated with it.

Lawrence Copelovitch, MD: This is a chronic condition, which is likely to potentially recur over the rest of the patient's life.

Susan Furth, MD: By diagnosing and treating the causes of the stones you can really make them better and make a major impact for the rest of their lives that they'll be symptom free and pain free. 

Douglas A. Canning, MD: We're now seeing as many as 400 new stones a year between our Nephrology Team, our Urology Team, and all of the outpatient centers that we're working with. 

Gregory Tasian, MD: This is really what would define an epidemic.  That's a disease that at some point was much less common that for many reasons is now becoming increasingly common in our population.  So, it's really that increasing incidence of kidney stones that drove us to develop this kidney stone center.

Kerry Ashcroft, BSN: The center that could be the expertise in this to zone in on what's causing this disease in our pediatric population and to better manage their care.

Symptoms and Diagnosis

Carol Snyder, Mother: When Amanda was 6, she had been at a friend's birthday party and we were at a gym, so before we left the party I knew we had to run some errands, so I brought both Amanda and her little sister into the bathroom stall together, and she went to the bathroom and clearly, there must have been blood in the urine because it was all in the toilet bowl.

Gregory Tasian, MD, MSc., MSCE: When a child presents either to the office or to the Emergency Room and we think they might have a kidney stone the first thing we do is just get a general sense of their past medical history, do a physical exam, and then we would also get an ultrasound to see if there is a stone present. 

Lawrence Copelovitch, MD: A very detailed intake of all of their risk factors, prior medications, whether they take any mineral supplements, whether they have any odd dietary habits.

Susan Furth, MD, PhD: Whether there's a family history of kidney stones, whether other people — parents, uncles, aunts, grandparents — have also had kidney stones.

Carol Snyder, Mother: The family history, that definitely came into play, that I had passed two and my father had passed them, as well.

Amanda Snyder: It hurts really bad.  It's a lot of pain in your back and in your stomach, and you can't… if you're laying down you can't stay still.  You always feel like you're uncomfortable when it's moving. 

Gregory Tasian, MD, MSc, MSCE: It's often associated with nausea and vomiting.  Sometimes, you may see blood in the urine, but the most common presentation is the child will develop pain.

Arun K. Srinivasan, MD: When the kidney stones are moving down the path where there is some narrowing on the urinary tract where the urine gets trapped and the kidney's trying to push the urine beyond the stone, and that's when the pain starts.

Gregory Tasian, MD, MSc., MSCE: We've developed what we call an ultrasound first pathway, which is using ultrasound as that initial screening modality to see if a stone is indeed present in a kid.

Kerry Ashcroft, BSN: What's good about ultrasound is that it doesn't have any radiation, so it's very safe and it's not invasive. 

Douglas A. Canning, MD: It's reduced the exposure to CT scanning, which is a big dose of radiation, by as much as 70% in some cases.

Susan Furth, MD, PhD: We do a comprehensive assessment of all the possible causes of the kidney stones so that we can then find the best treatment.

Lawrence Copelovitch, MD: Individualized care is critical to the proper management of pediatric stone disease. 

Gregory Tasian, MD, MSc, MSCE: It really involves the expertise of multiple different medical specialties. 

Susan Furth, MD, PhD: We've organized so that at one single visit a child could see a nephrologist who's a medical kidney doctor, a urologist who's a surgical kidney doctor. 

Gregory Tasian, MD, MSc, MSCE: We create this seamless interplay between these different disciplines.

Arun K. Srinivasan, MD: Between radiologist, between ER physicians, dieticians.

Douglas A. Canning, MD: Social workers, psychologists, the anesthesiologists, the endocrinologists, the rheumatologists that are going to be critical parts of your child's care.

Carol Snyder, Mother: I was thankful that they knew exactly what the problem was and exactly how to treat it. 

Lawrence Copelovitch, MD: We pride ourselves on being able to diagnose and treat very rare forms of kidney stones, particularly in young children and in older children, but we also stress the importance and understand that the vast majority of our patients have much more of the adult-type stone disease and we've really specialized in and learned how to treat them appropriately to prevent the number of recurrences. 

Treatment and Surgery Options

Kerry Ashcroft, BSN: Once we understand what the diagnosis is and where the patient is after their workup process, now we can better manage them to whether or not they need simple medical management or whether or not we need to have surgical intervention.

Susan Furth, MD: When kids present with pain from a kidney stone, the first question is the size of the stone, the location of the stone, and is it causing an obstruction.

Lawrence Copelovitch, MD: It is rare for a child to present with kidney stone pain and have to go right to the operating room. 

Gregory Tasian, MD: When you do have a stone they're often very small stones that the child would be able to pass on their own.

Lawrence Copelovitch, MD: We try and use medications, which can both make the ureter or tube which connects the kidney and the bladder more relaxed and more able to dilate and pass the kidney stone. The majority of children are able to avoid a surgical intervention, but a significant minority of patients will require surgery if it's a large stone and depending on the location of the stone.

Gregory Tasian, MD: If a stone has lodged in the ureter and is blocking the flow of urine from the kidney down into the bladder, we would simply need to place a stent to allow the urine to bypass that obstructing stone and then that allows us to plan the definitive surgery at a later time. 

We go into the bladder with a very small scope and we're able to see where the ureter enters into the bladder.  We'll then put in a very soft wire that goes all the way up to the kidney, and then over that wire we'll thread that stent, and a stent is a hollow soft plastic tube that allows the urine to drain both through the stent and then also around it.  There are two curls on the stent, one is up in the kidney and then one is in the bladder, and that allows the stent, once we place it, to remain in place. 

So the surgical options that are available for kidney stones that occur in children are really the same options that you'd have in adults, but we've been able to refine the process here to be able to make it particularly effective for children.  Probably the most commonly-utilized method of taking care of a kidney stone is called ureteroscopy.  What a ureteroscope is, is really a long sort of telescope that we use to simply go into the bladder and then up the ureter and into the kidney where the stone is without making an incision to visualize the stone and then use usually lasers to break up the stone and then extract those fragments of the kidney stone should they exist.  When we extract those fragments, we then send them off for analysis to know what type of stone it is.

Arun K. Srinivasan, MD: Not leaving fragments after surgery in stone surgery is the most important factor that prevents the next stone from forming.  So if you leave a stone fragment behind, that's a crystal.  You've laid the seed for the next stone to form.

Gregory Tasian, MD: The other option that we sometimes use in the appropriate situations is called percutaneous nephrolithotomy.

Arun K. Srinivasan, MD: Percutaneous means through the skin.  Nephro means kidney.  Lithotomy means kidney stone removal. 

Douglas A. Canning, MD: We'll use various types of specialized endourologic scopes in that case to go directly through the flank of the child into the kidney and break the stone up, and bypass the ureter and get that stone out directly.  We reserve that approach to children that have huge stone burden that's located in the kidney.

Gregory Tasian, MD: Robotic surgery is another option that we have for treating children with kidney stones.  I particularly like the robotic approach if there's another operation that we have to do on the kidney.  When you're dealing with small spaces and those spaces tend to be smaller in children, the robotic surgery platform allows us to use very small incisions with instruments that we control, but through this robotic interface. 

Another modality that can be used to treat children with kidney stones is called ESWL, which allows us to focus sound waves on the kidney stone thus breaking it up and then the child would pass those fragments on their own.  But, at that point, they're small enough that they can fit down the ureter. 

So within the Kidney Stone Center at CHOP, we have every possible modality that could be used to treat children with kidney stones from the surgical interventions to the medical interventions to the way that we image children.  Every possible technology is at our disposal and that allows us to tailor the therapy to that child because no two children are alike.

Douglas A. Canning, MD: They're not just little adults, they're individuals with very different metabolic systems, very different anesthesia requirements, very different endoscopic requirements.

Gregory Tasian, MD: You really cannot find a more committed, more professional, more well-trained staff than there is in the operating rooms at CHOP.

Follow-up Care and Prevention

Kerry Ashcroft, BSN: Once a patient either passes a stone on their own or the stone was removed surgically, then our team really goes into the management mode.

Lawrence Copelovitch, MD: The best way to unravel the mystery of what's causing the stone is to actually isolate or identify what the kidney stone is composed of.  In reality, that's actually very difficult unless it's removed surgically.  Almost always, if a child passes a kidney stone it's not able to be captured and analyzed. 

Susan Furth, MD: So even if you don't have the stone, you can collect a full days' worth of urine and send it to the lab, and they'll measure all the various factors that can promote stones or inhibit stones, and then that can also often give us sort of a mirror of what that stone would look like if we caught it.

Lawrence Copelovitch, MD: If the stone can be captured and analyzed chemically, it can basically tell us whether it is a calcium-based stone, which up to two-thirds of kidney stones are in childhood, or a rarer type stone in which case a rare metabolic cause is usually much more likely.

Douglas A. Canning, MD: Once we fingerprint the reason why stones are forming in any individual patient, we can immediately work toward medical management of the stone disease for this particular child.

Lawrence Copelovitch, MD: There are several medications, which can be used to decrease the risk of stone recurrences.  The most common medications we use are ones which have the ability to decrease the amount of calcium which is excreted in the urine and also increase the amount of urine that the patient makes.  Another class of medications we use contain something called citric acid, which is found in fruits and vegetables, but they come in the medication form in very high doses, higher than can often be consumed in nature, and can prevent kidney stone formation that way. 

Kerry Ashcroft, BSN: You're always going to have genetic or metabolic reasons that you can inherit, but we're finding a lot of the kids that come into our stone center, it's really the environment that's around us now and the life they lead.  They're busy.  They're not drinking a lot of water.  They're eating and drinking a lot of different things than we had 100 years ago, a lot of things with increased sodium.

Arun K. Srinivasan, MD: Prevention of recurrence is all about habits and changing those habits is key.

Gregory Tasian, MD: It often involves making dietary recommendations.

Elisha Rampolla, RD: Today, I'm going to talk to you a little bit about how what you can eat will help with your kidney stones.

Kerry Ashcroft, BSN: The average child these days does not get enough water intake, and the stone former needs to drink double that.  So what they need to do is drink enough water that their urine is clear throughout the day.

Elisha Rampolla, RD: Water is definitely the best choice.  Cranberry juice and lemonade are okay too, but water would definitely be the best thing to drink.

Carol Snyder, Mother: When the doctors told us how much water she should be drinking, that was a shock because we know that she hadn't been.  So that was something easy for us to change, but for a 6-year-old girl, 7-year-old girl, and being told that she has to drink over 50 ounces of water a day, that was hard.

Kerry Ashcroft, BSN: Another important thing is avoiding salt.

Lawrence Copelovitch, MD: People are often unaware about the high sodium content that exists in most foods, particularly in a child's diet or an adolescent's diet.

Kelly Ashcroft, BSN: The stone former may have to avoid certain types of foods that may be healthy in someone else's diet, foods that are high in oxalate such as dark leafy green vegetables.  Some things that kids really love like chocolate, I may have to educate them that you can have these foods still, but you really have to eat them in moderation.  Along with dietary modification we also encourage the child to be… to have an active lifestyle.

Douglas A. Canning, MD: Part of what we're doing is getting people into the mindset.  It's not just the patient.  You've got to retool the way the family thinks about their entire environment. 

Elisha Rampolla, RD: Any kind of lifestyle change, especially a nutrition lifestyle change can be very challenging.  We do the best that we can to help support you in the lifestyle change and many of our families have been able to do this, and their children are doing well.

Amanda Snyder, Patient: I'm more responsible with my medicine.  My mom doesn't need to remind me to take it. 

Carol Snyder, Mother:  As far as the everyday dealing with knowledge that she has a kidney stone, it doesn't affect her.  I'm so proud of her with that.  My husband and I both are. 

Susan Furth, MD: We really work together and talk about, you know, this is what we think needs to be done, how can that fit into your lifestyle, do you understand our rationale for wanting to do this, so it really is a partnership. 

Lawrence Copelovitch, MD: Equally important, we communicate directly with the referring physician through both letters and conversations. 

Susan Furth, MD: So we're very conscious of trying to make sure we keep communication wide open between the nephrologist and the urologist, and the providers here at CHOP with the child's primary care pediatrician who often knows that child and that family even better than we do.

Gregory Tasian, MD: Although the incidence of stones is increasing in children, it's still relatively rare compared to the adult population and when you're dealing with a rare disease the most important thing is that you have experts treating your child.

Lawrence Copelovitch, MD: The volume of patients – of pediatric patients – with stones that we see really puts us in an enviable position to collect data, both clinical data and laboratory data, on pediatric stone disease and try and understand it in a way that hasn't been done before.

Douglas A. Canning, MD: So that the family and the child knows as much as we can possibly provide to them about why they got their stone, how we're going to deal with the stone, and how we're going to prevent them from ever having to deal with a stone again.

Amanda's Success Story

Carol Snyder, Mother: When Amanda was 6 she had been at a friend's birthday party and before we left the party I knew we had to run some errands, so I brought both Amanda and her little sister into the bathroom stall together, and she went to the bathroom.  Clearly there must have been blood in the urine because it was all in the toilet bowl. 

When we came through the ER at CHOP, Amanda was in a lot of pain, and we were very nervous. 

Amanda Snyder, Patient: It's a lot of pain in your back and in your stomach, and you can't… if you're laying down you can't stay still.  You always feel like you're uncomfortable when it's moving.

Carol Snyder, Mother: As soon as you see your little girl being in that kind of pain, you're just at a loss.  You just want someone, please, just take that pain away.  They admitted her right away and brought her into her room, and made us all comfortable and made us feel better, and assured us that everything would be okay.

Lawrence Copelovitch, MD: When I first saw Amanda I did a basic set of blood work and urine chemistries to try and pinpoint why she was forming stones at a very high rate at such a young age. 

Carol Snyder, Mother: We didn't believe it.  We couldn't believe it.  I mean, that's something that I passed as an adult and my father had kidney stones as an adult. So, to hear that a 6-year-old girl has kidney stones, I didn't even know that was possible.  But I think it was an unusual occurrence that she has two times the normal amount of calcium in her urine.  Her body produces that. 

Lawrence Copelovitch, MD: Usually when stones are greater than five millimeters or half a centimeter, they're unable to pass through the ureter on their own and require some form of surgical intervention.  Amanda's stone was twice that size. 

Carol Snyder, Mother: So we knew that she needed surgery. 

Lawrence Copelovitch, MD: Initially, Amanda had a procedure called lithotripsy where an attempt was made to break up the stone, but the stone was very large and subsequently, a second procedure was required where a stent had to be placed in the ureter.

Carol Snyder, Mother: That had to stay in for a week and then the week later we went in for the surgery and her doctor removed the stone.  We always felt like we were part of the CHOP team from the minute we would arrive.  They just treated us so special.  You feel like you're royalty and I was thankful that they knew exactly what the problem was and exactly how to treat it. 

Lawrence Copelovitch, MD: Our primary goal always is to keep her asymptomatic and we've been successful in doing that, but we continue to escalate her medications slowly to try and accommodate for her age and her changing diet as she becomes more of a teenager. 

Carol Snyder, Mother: We have follow up with Amanda's kidney stones every six months.  We come to CHOP and we usually spend a day.  Amanda's happy because she gets to be taken out of school.

Lawrence Copelovitch, MD: Amanda will always have predisposition to form kidney stones and it's important for her to continue to take her medications, and follow her fluid and sodium prescription. 

Carol Snyder, Mother: It's a tough thing for a kid, definitely, to have that kind of discipline with her diet and the foods that she should and shouldn't eat.

Amanda Snyder, Patient: I'm more responsible with my medicine, like my mom doesn’t need to remind me to take it, and I just know to take it.

Carol Snyder, Mother: I'm so proud of her with that, my husband and I both are. 

Lawrence Copelovitch, MD: We couldn't be happier with her progress in terms of the fact that she hasn't missed any school, had any emergency room visits, or had any symptoms for the last five years since we've gotten her medications and lifestyle changes under control.

Amanda Snyder, Patient: I know that I'm taking the medicine and that I'm drinking a lot of water.  I haven't had a surgery in a long time, so I feel like everything is getting better than it was before.

Carol Snyder, Mother: She's just the light of our life.  She's a happy girl.  We're proud of her every day and we're happy that we have the doctors and the team that are able to have her lead a normal life.