Pediatric Urolithiasis Medication
- Author: Sahar Fathallah-Shaykh, MD; Chief Editor: Craig B Langman, MD more...
Medical therapy depends on the type of stone produced. Children with idiopathic hypercalciuria caused by renal tubular calcium leak may benefit from treatment with a thiazide. If idiopathic hypercalcinuria is gastrointestinal (GI) absorptive and a low-calcium diet does not return urinary calcium levels to the reference range, neutral sodium phosphate may be beneficial in reducing dietary calcium absorption. Chelating agents such as cellulose sodium phosphate (Calcibind) are no longer available on the US market.
Hypocitraturia is treated with oral potassium citrate. Supplemental citrate leads to correction of hypocitraturia.
Struvite stones require treatment with an appropriate antibiotic. Surgical intervention or ESWL may be necessary if the stone produces high-grade obstruction, if antibiotic therapy is not adequately eliminating infection, or after infection is cleared to remove stone fragments.
Uric acid stones require alkalinization of urine with sodium bicarbonate or potassium citrate in 4 divided doses. Urine pH levels should be maintained at 7.5 or greater. Uric acid is much more soluble in alkaline than acid urine. Allopurinol is indicated in children with uric acid lithiasis whose daily uric acid excretion exceeds the reference range.
The medical management of cystinuria is mainly based on hyperhydration and urine alkalinization. Sulfhydryl agents such as tiopronin should be added.
Alkalinizing agents are used to increase urinary pH and/or provide increased citrate in the urine in persons with hypocitruria. Both have a tendency to increase solubility of some minerals.
Sodium citrate and citric acid mixture is indicated for systemic metabolic acidosis (ie, renal tubular acidosis), urinary alkalinization, or hypocitraturia. It contains disodium citrate. It is administered orally and is metabolized to bicarbonate by the liver. The preparation contains 500 mg sodium citrate and 334 mg citric acid per 5 mL (ie, 1 mEq potassium and 1 mEq sodium per 1 mL).
Sodium citrate and potassium citrate mixture (Citra-3, Tricitrates)
Sodium citrate and potassium citrate mixture is indicated for treatment of systemic metabolic acidosis, urinary alkalinization, or hypocitraturia. It is administered orally and metabolized to bicarbonate in the liver. Each 5 mL of the preparation contains sodium citrate 500 mg, citric acid 334 mg, and potassium citrate 550 mg (each mL contains 1 mEq potassium, 1 mEq sodium, and 2 mEq bicarbonate).
These agents are used to decrease urinary calcium excretion.
Hydrochlorothiazide, by an unknown mechanism, decreases urinary calcium excretion. By lowering urinary calcium concentration, the risk of calcium forming complexes with anions (eg, oxalate, phosphate) is reduced.
Xanthine oxidase inhibitors
A xanthine oxidase inhibitor is used to lower urinary uric acid. The doses provided in the table are for children with uric acid or calcium-urate renal calculi. Physicians treating gout, hyperuricemia, or uric acid nephropathy should consult other articles.
Allopurinol decreases uric acid production. Administer before meals and with extra fluid orally. Maintain urine output at approximately 1.5 mL/kg/h with oral fluid unless this is contraindicated.
Borghi L, Schianchi T, Meschi T, et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med. 2002 Jan 10. 346(2):77-84. [Medline].
Taylor EN, Curhan GC. Fructose consumption and the risk of kidney stones. Kidney Int. 2008 Jan. 73(2):207-12. [Medline].
Avci Z, Koktener A, Uras N, et al. Nephrolithiasis associated with ceftriaxone therapy: a prospective study in 51 children. Arch Dis ChildNov. 2004. 89(11):1069-72. [Medline].
Khositseth S, Gillingham KJ, Cook ME, Chavers BM. Urolithiasis after kidney transplantation in pediatric recipients: a single center report. Transplantation. 2004. 78(9):1319-23. [Medline].
Bergsland KJ, Coe FL, White MD, Erhard MJ, Defoor WR, Mahan JD, et al. Urine risk factors in children with calcium kidney stones and their siblings. Kidney Int. 2012 Feb 22. [Medline].
Routh JC, Graham DA, Nelson CP. Epidemiological trends in pediatric urolithiasis at United States freestanding pediatric hospitals. J Urol. 2010 Sep. 184(3):1100-4. [Medline].
Bush NC, Xu L, Brown BJ, Holzer MS, et al. Hospitalizations for pediatric stone disease in United States, 2002-2007. J Urol. 2010 Mar. 183(3):1151-6. [Medline].
Tasian GE, Ross ME, Song L, Sas DJ, Keren R, Denburg MR, et al. Annual Incidence of Nephrolithiasis among Children and Adults in South Carolina from 1997 to 2012. Clin J Am Soc Nephrol. 2016 Jan 14. [Medline].
Pong YH, Huang WY, Lu YC, Tsai VF, Chen YF, Chang HC, et al. Temporal trend of newly diagnosed incidence, medical utilization, and costs for pediatric urolithiasis, 1998-2007: a nationwide population-based study in Taiwan. Urology. 2015 Jan. 85 (1):216-20. [Medline].
Bove P, Kaplan D, Dalrymple N, et al. Reexamining the value of hematuria testing in patients with acute flank pain. J Urol. 1999 Sep. 162(3 Pt 1):685-7. [Medline].
Dangle PP, Bandari J, Lyon TD, Lee A, Ayyash O, Cannon GM Jr, et al. Outcomes of Ureteroscopic Management of Pediatric Urolithiasis: A Comparative Analysis of Prepubertal and Adolescent Patients. Urology. 2015 Dec 30. [Medline].
Erturhan S, Bayrak O, Sarica K, Seckiner I, Baturu M, Sen H. Efficacy of medical expulsive treatment with doxazosin in pediatric patients. Urology. 2013 Mar. 81(3):640-3. [Medline].
Velázquez N, Zapata D, Wang HH, Wiener JS, Lipkin ME, Routh JC. Medical expulsive therapy for pediatric urolithiasis: Systematic review and meta-analysis. J Pediatr Urol. 2015 Dec. 11 (6):321-7. [Medline].
Schwaderer AL, Cronin R, Mahan JD, Bates CM. Low bone density in children with hypercalciuria and/or nephrolithiasis. Pediatr Nephrol. 2008 Dec. 23(12):2209-14. [Medline].
|Mechanism of Stone Formation||Drug||Primary Stone Composition|
|Crystallization of highly excreted, poorly soluble drug or metabolite causes stone formation.||Phenytoin, triamterene, sulfonamides, felbamate, ceftriaxone, indinavir, ciprofloxacin, guaifenesin/ephedrine||Drug or its metabolites|
|Drug may increase the concentration of stone-forming minerals.||1. Anti-cancer drugs
3. Allopurinol (if used in tumor lysis)
4. Loop diuretics
5. Calcium and vitamin D
|1. Uric acid
4. Calcium oxalate
|Drug inhibits activity of carbonic anhydrase enzymes in the kidney, causing metabolic acidosis, hypocitraturia, and elevated urine pH.||Topiramate, zonisamide, acetazolamide||Calcium phosphate|