International Journal of Clinical Anesthesiology

Cite this article: Gupta A, Ravi PR, Yama (2020) Paediatric Urolithiasis in Northern Afghanistan: Analysis of Risk Factors. Int J Clin Anesthesiol 8(2): 1106.

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*Corresponding authorParli Ravi, Department of Anesthesiology, Command Hospital Air Force, Old Airport Road, Bangalore-560007, India, Tel: 810-5425-508; E-mail: parliravi@gmail.com

Submitted: 06 July 2020

Accepted: 28 July 2020

Published: 29 July 2020

ISSN: 2333-6641

Copyright© 2020 Gupta A, et al.

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Short Communication

Paediatric Urolithiasis in Northern Afghanistan: Analysis of Risk FactorsAnurakshat Gupta, Parli Raghavan Ravi* and YamaDepartment of Anesthesiology, Command Hospital Air Force, India

Keywords•Pediatric•Urolithiasis•Metabolic

Abstract

Background: Lithiatic disease in the pediatric age group in Afghanistan is a major problem facing the country. It’s a tremendous drain on its resources and aid. The lack of basic primary health care and hygiene coupled with problems of drinking water and dietary habits have led to an increase in incidence, whereas, all over the world incidences are going down.

Methods: 96 children who reported to IMM Mazer-E- Sharif were taken into a prospective study over a period of a year. The clinical and laboratory evaluation of these children was done in an attempt to find a possible etiology and draft out the risk factors.

Results: A high incidence of UTI, increased consumption of water, proteins and dietary fibers, increased oxalates and starchy food with Hyperoxalouria and Hypocitraturia were the most important biochemical findings. An increased incidence of bladder stones was also detected.

Conclusion: In addition to stone removal, treatment of pediatric urolithiasis involves a thorough metabolic and environmental evaluation of all patients on an individual basis. Children with a positive family history should be monitored carefully with respect to kidney stones. They should be encouraged to increase the intake of drugs and dietary agents that increase urine citrate level.

INTRODUCTIONAfghanistan is a country with a population of approximately

30 million people and has an extremely poor medical facility. It is placed at 170 out of 189 countries in the UNDP index (United Nations Development Index). It is estimated that the infant mortality in Afghanistan is almost 52 per 1000 life births while the mortality rate for the under-five is as high as 63 per 1000 births [1]. In addition to adverse mortality statistics, there is a high rate of morbidity in the pediatric age group due to various types of diseases. One of the conditions that show an unusually high prevalence is that of urolithiasis. Unfortunately, no definitive worldwide data accurately reflects the frequency of urolithiasis. This is because of the poor maintenance of hospital record in the developing regions of the world. Despite the presence of several studies in countries with high incidence of the disease, no uniformity in the reporting data exists. Although epidemiological data from some parts of the word is inadequate, it is estimated that the incidence of the disease may range from about 1:7000 to 1:10000 paediatric admissions. 32-33 % of all stone disease is thought to occur in the paediatric age group. Regarding the localization of the stones, a shift from lower the to the upper

urinary tract has been reported in the recent times in developed regions. Although the incidence observed in children is less than that of in adults, the pathology associated is accompanied by considerable morbidity with high recurrence rates.

Urolithiasis in childhood is a destructive pathology that causes progressive decline in renal function along with high rates of recurrence. The varied etiology requires carefully planned and individualized diagnostic and management protocols. In developed countries most of the children with stone disease have an underlying metabolic abnormality, and it is essential that these children be carefully evaluated so that the etiology can be ascertained. In this way, future stone formation and / or regrowth may be controlled, thus limiting the morbidity of the disease. There is unfortunately no concrete analytical study available for the prevalence of urolithiasis in Afghanistan, although local intelligence suggest high incidence of diarrhoeal diseases and infectious diseases in the paediatric population as a possible etiology for urolithiasis. The surgical team at the Indian Medical mission in Mazar-E-Sharief did a prospective study on the cases reported to it for a period of one year and did a follow up for a period of 12 years, to resolve some of the issues concerning urolithiasis in this remote part of the world.

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MATERIALS AND METHODSBetween January 2005 and November 2005, 96 children

reporting to our surgical department suffering from idiopathic urinary calculi were evaluated. Approval of the hospital ethical committee and the consent of parents of the diseased children was obtained before performing any examination and /or treatment. Children with documented urinary tract abnormality, renal failure, metabolic/intestinal and/or endocrinological disorders, and those who were immobilized or had congenital abnormalities were excluded. A detailed history of dietary habits and family history was obtained from the parents. 24 hour urine analysis was conducted (urinary pH and volume, urinary calcium, creatnine, uric acid, magnesium, oxalate and citrate excretions) along with a culture sensitive test, and various biochemical parameter indicative of renal functions (serum calcium, phosphorus, alkaline phospharus, creatinine, uric acid and electrolyte levels, together with pH and Pco2 values), were evaluated. All the urine samples were collected from the children without any dietary restriction. All standard laboratory procedures were followed for the analysis of urine as well as blood. All the children underwent radiological investigations in the form of ultrasonography, plain X-Ray of the abdomen and wherever necessary intravenous pyelography. There was no facility available for renal scintigraphy or cystourethrography in Mazar-e-Sharief. Stone analysis was done in 08 patients by infrared spectrometer, as it was available only in Kabul till date and it was economically not feasible for the parents of the children. Children who did not become stone free by means of conservative management, were treated with open surgery as there was no facility available for ESWL or endoscopic removal of stones in 2005. These children were followed up for a period of 12 years into their adolescence (10-19 years of age).

Statistical Analysis

Student t test, Mann-Whitney U test was performed for comparison of groups. A Pearson correlation test was also used, using the software package SPSS version 13 (SPSS, Chicago IL.CA, USA). A p<0.05 was accepted as significant.

RESULTS A total of 96 children were evaluated (71 males, 18 females;

mean age 6.8 yrs; age range 06 months -12 years). Six children having urinary tract abnormality were excluded from the study, leaving a total of 90. A detailed history provided by the parents of children revealed a history of previous stone passage in 25 of them (27.7%). A positive family history was noted in 56 of 90 children (62.2%) and detailed findings are present in Table 1. The dietary habits of the children were thoroughly investigated (Table 2) and comparative evaluation of the content of the foods consumed, by menu, was done. This demonstrated decreased intake of water which is almost one third of the normal recommended amount, decreased total protein (especially of animal origin), and decreased intake of high fiber foods. Additionally, increased intake of starchy food with high oxalate content was detected in our study population.

The mean age of the children during the first onset of symptoms was 4.1 yrs (range 06 months to 12 years). 18 (20%) children had a history of recurrent stones, with 17 of these

(18.8%) having undergone open surgical intervention earlier. As far as predisposing factors were concerned, 49 patients (54.5%) presented with urinary tract infections, which was treated with appropriate medicines. A positive history of recurrent urinary tract infections was found in 72 (78.8%) children. Associated genitourinary abnormalities were detected in 6 children who were excluded from the study.

As far as the localization of stones was concerned, 48 children had vesical calculas which amounted to 53.3% of the study population. In 27 (30%) patients stones were localized in the kidney, while 12 (13.3%0 children had stones in the ureters. Multiples localizations of stones were seen in 3 (3.3%) of the patients. Evaluations of metabolic risks factor in urine samples revealed 15 (16.6%) children testing positive for single, double, or triple factors, as shown in Table 3. Among these factors Hyperoxaluria and Hypocitraturia seemed to be significant.

The comparative mean values of various risk factors in patients, with stone disease and normal control subjects, demonstrated a statistically significant difference for almost all the parameter (Table 4). Evaluation of growth percentiles, using standard growth curves found a failure to thrive in a considerable proportion of patients. 85% of the children were below the 50 percentile range for the given, height and weight.

Among the 08 children for whom stone analysis was done, two had calcium oxalate and three had calcium oxalate with uric acid. Calcium oxalate with ammonium urate, calcium phosphate, calcium phosphate with uric acid was found in one each.

All patients underwent open surgery as the facilities for ESWL or Cystoscopic surgery were not available in this region. Cystolithotomy was the most common surgical procedure performed amounting to 48 of the total 90 children (53.3%). No major treatment related complications were observed. All

Table 1: Patients with History of Renal Stone Disease in Family.

History No of patients PercentageRecurrent UTI

Previous SurgicalIntervention

Positive Family HistoryFatherMother

Father and MotherSiblings

7217

5618141710

78.818.8

62.222.215.518.811.1

Table 2: Dietary Status of the Children.

Daily Intake Results Normal RangeWater (ml)Calcium (mmol)Phosphate (mmol)Oxalate (mmol)Sodium (mmol)Potassium (mmol)Magnesium (mmol)Vegetable (g)Animal (g)Fiber (g)Refined carbohydrates

400.1220.6242.2110.456.512.523.717.83.934.1

>150020-25Variable<1.5<160Variable >1625-3035-50>20<130

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children were subjected to General/Dissociative Anaesthesia, with 54 children (60%) receiving regional analgesia for postoperative pain, and 36(40%) patients receiving intravenous/ intramuscular analgesia. The mean post-operative hospital admission time was 32.87 hours. All the children were put on conservative therapy, post-surgery with advise for increase water intake and dietary modifications as per the local resources. As per the risk factor analysis 08 children were put on citrate therapy, 04 on pyridoxine and 04 on thiazide therapy.

In our study 38 out of the 80 children remained asymptomatic in a 12 year follow up. In children with recurrence, 21 had persisting calculi (operated upon more than two times), 13 had only one recurrence (operated upon only once), and eight patients were symptomatic, but did not warrant any intervention.

DISCUSSIONThe epidemiology of paediatric urolithiasis appears to have

changed in the past 30 years. The incidence of calculi in children has decreased significantly in the past 100 years in the developed world and also in the developing world. However, this study found the incidence of stone disease in children of Northern Afghanistan to be 5.2%, which is quite high in comparison to even other countries in the endemic lithiatic zone. Generally the incidence of stone disease in children in the endemic zone has been reported to be around 2-3%. Although Turkey lies in the endemic zone of urolithiasis, a Turkish study reports an incidence of 0.8% in the school age children which is better than more developed regions like Scandinavia and United States, where 1% of all renal stones occur in children aged less than 19 years [2,3].

Regarding predisposing factors for stone formation, 78.8% of the patients in our study had UTI, 16.6% had metabolic

abnormalities, while 4.65% were idiopathic. Concerning UTI in children with stone disease, while the incidence of UTI has been reported to be 47% in the available literature, the majority of our patients (78.8%) revealed the presence of UTI either in the past or during the first evaluation. Our findings show that stone can predispose towards UTI; conversely, UTI’s itself may be important in the formation of stones.

The proportion of metabolic abnormalities reported in literature from developed nations varies from 36%-50%. Studies in endemic zones have however reported the proportion of predisposing factors as 70% UTI, 25% metabolic abnormalities, and 5% with anatomic abnormalities [4-7]. As shown in Table 4, the commonest metabolic abnormalities were Hyperoxalouria and Hypocitraturia. These two factors were found to be coexisting in 3.3% of all the patients. Given the high risk of subsequent calculus formation and the shift of etiology to the underlying metabolic cause even in endemic regions [2,8,9] it could well be argued that all patients should undergo some form of metabolic workup to determine the cause of their renal stone in order to develop good preventive strategies. A metabolic evaluation of the most common predisposing abnormality is recommended in all children with urolithiasis, bearing in mind that structural, infectious, and metabolic factor often coexist.

Evaluation of dietary factors revealed that water intake in the study population was less than one-third of the recommended amount for that age. Diarrheal diseases are prevalent among children, especially during summer months. These are aggravated by severe water shortages, notably in rural areas. Approximately 65 percent of the population in urban areas and 81 percent in rural areas do not have access to safe water, with considerable regional disparities [1,10]. A decrease in daily water intake coupled with the prevalence of diarrhoeal disease in this country, is reason enough to educate the population at large about the aspects of water intake. Against a popular myth that etiology of stones lies in the quality of drinking water there has been an extensive water, study done in the lithiatic zone in the nearby countries of Uzbekistan, Kyrgyzstan and Tajikistan, which comprehensively rules out a possibility of increased salinity as the etiology for calculus formation [11].

Another factor which was found to be significant was the reduced amount of fiber content in the diet of children. Additionally, an increased amount of starchy food with high oxalate content was detected in our study. High consumption of black tea and soft drinks with relatively higher oxalate content was also observed in the study population. This has been found to have a statistically significant correlation with the prevalence of stones in some studies [10,11].

The evaluation of localizations of urinary stones in our study group demonstrated that the majority of the stones were (53.3%) in the bladder. There was a decreasing trend in the incidence of bladder stones in the western and developing countries, with the shift of localization of stones towards the upper urinary tract. A survey of bladder stones among children in Punjab in Pakistan, has found that the age of onset was as low as one year. It was also observed that in northern Punjab, upper tract stones were higher in incidence; whereas in southern Punjab, which is economically poor in comparison to its northern counterpart, bladder stone

Table 3: Evaluation of Urinary Excretion (24 Hours urine analysis) Risk Factor.Single Risk Factor No of Patients PercentageHyperoxaluriaHypocitraturiaHypercalciuriaHyperuricosuria

2312

2.23.31.12.2

Double Risk FactorHyperoxaluria + HypocitraturiaHyperoxaluria +HypercalciuriaHypocitraturia +Hypercalciuria

321

3.32.21.1

Triple Risk FactorHyperoxaluria + Hypocitraturia + Hypercalciuria 1 1.1

Table 4: Comparative Urinary Levels of risk factors in the Patient And Control Group.Risk factor Patient Group Control group P ValueCreatinine(Mg/Kg)Urea/Nitrogen (Mg/Kg)Calcium (Mg/Kg)Uric Acid(Mg/Kg)Magnesium(Mg/Kg)Phosphate(Mg/Kg)Oxalate (mmol/Kg)Citrate (mmol/Kg)

28.1 + 1.4159.3 + 1.44.7 + 0.422.6 + 1.24.1 + 0.128.2 + 1.40.423 + 0.760.435 + 0.056

14.7 + 0.87.47 + 1.22.2 + 0.114.4 + 0.652.76 + 0.1218.1 + 0.20.165 + 0.0250.323 + 0.040

<0.01<0.01<0.01<0.01<0.01<0.01<0.01<0.01

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Figure 1: Consort Flow Diagram

Assessed for eligibility (n=96)

Final Study population (n=90)

Excluded (n=06)

• Not meeting inclusion criteria (n=06)

• Declined to participate (n=0)

• Other reason (n=0)

Enrolment

Analysis

80 patients were followed up for a period of 12 years

Lost to follow up (n=10)

Study Group (n=90)

All biochemical parameters were recorded/dietary intake analysed/localisation of stones /symptoms of disease recorded

Analysed all the three groups.

No patient was excluded in study

Follow-Up

Control group (n=40)

Used for control for analysis of biochemical parameters.

ALLOCATION

Figure 1 Consort Flow Diagram.

were more common. It has been statistically found that there is a significant correlation between poverty and bladder stones [8,12]. Late reporting amongst patients in underdeveloped regions, gives time for the stones to migrate from the upper urinary tract to the bladder, thus explaining the high prevalence of same in this region.

All the patients in our study were treated with open surgery for removal of stones, since other invasive or non-invasive modalities of treatment were not available in Northern Afghanistan. The mean post-operative hospital stay for the patients in our study was 32.87 hours, which is quite high in comparison to patients treated with noninvasive treatments [13]. This adds to the economic burden of the hospital along loss of school days and working hours.

In our study 80 of the patients, who were followed up 34 patients, had evidence of calculi requiring surgical interventions, which was higher in comparison to other follow up studies [2,13]. Only 18 of the 80 patients were able to adhere to the advice

which was given at the time of discharge. 26 of the symptomatic patients in the follow up were not able to adhere to the discharge advice the second time too, this may be to the poor economic conditions, which would have forced parents of the children to abandon the post-operative advice.

CONCLUSIONAfghanistan lies in the endemic lithiatic zone. The major

predisposing factor for the formation of stones in this country remains a high rate of urinary tract infection. In comparison, in other countries of the lithiatic zone, and developed western countries the common etiology is shifting slowly towards that of metabolic origin. There exists a lack of clean drinking water leading to higher prevalence of diarrheal disease which results in chronically dehydrated state, causing urinary tract infections. This in turn predisposes one to stones. Further, poor medical facilities and a lack of awareness mean delay in reporting in health centers resulting in the migration of the stones to the bladder. Therefore in these areas incidence of bladder stone are high, whereas there

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Gupta A, Ravi PR, Yama (2020) Paediatric Urolithiasis in Northern Afghanistan: Analysis of Risk Factors. Int J Clin Anesthesiol 8(2): 1106.

Cite this article

is a shift in the localization of stones to the upper urinary tract in developed countries, where patients report early. There is no doubt that “Bladder stones in children are closely linked with poverty and diarrheal disease”. This reiterates the importance of effective primary health care and safe drinking water.

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