Paediatric implications for some adult disorders : Scientific proceedings of the 4th Unigate Workshop, held at the Royal Academy of Physicians, St. Andrews Place, London, N.W. 1, May 1976 / edited by Donald Barltrop.
- Unigate Paediatric Workshop 1976 : Royal College of Physicians)
- Date:
- 1977
Licence: Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0)
Credit: Paediatric implications for some adult disorders : Scientific proceedings of the 4th Unigate Workshop, held at the Royal Academy of Physicians, St. Andrews Place, London, N.W. 1, May 1976 / edited by Donald Barltrop. Source: Wellcome Collection.
51/168 page 39
![Discussion Asscher: There is an apparent paradox. When you screen for asymptomatic infection of the urinary tract as has been done in many centres in the United States and in this country, there is no radiological evidence of stones. Having heard you present these symptomatic patients, I suspect that this is because we have tended to avoid screen¬ ing boys and have concentrated on girls in view of their greater prevalence of infection. I suspect that asympto¬ matic infection in 99% of cases is due to E. coli. The bacterial screen, as you are doing it now, is not likely to be of great value in the prevention of stone forma¬ tion. Can you tell me whether these were urease-producing organisms associated with stones and to what extent are you certain that you are right in saying that the infective cause is the most important in children? Barratt: Urease activity is most important. Increasing urine pH will favour the precipitation of calcium phos¬ phate, and also by increasing the ammonium concentra¬ tion in the urine this will increase the ion product of magnesium ammonium phosphate. Where we have looked at it, all the Proteus organisms have been urease-producing organisms. The most compelling point is the specific association with Proteus. If the infection were secondary to the stone, then you would not on the whole expect to find this one organism so strongly associated with stone formation. One can isolate Proteus from inside the stone when it is not present in the urine. Asscher: Why is it that anti-bacterial agents are in¬ effective? You say that you cannot succeed until you have removed the stone, and I entirely agree with that. In fact, we have put infective stones into a medium con¬ taining anti-bacterial agents and found that eventually the medium and the surface of the stone become sterile, but if the same stone is transferred to a nutrient broth, the organism reappears. Barratt: There are several situations in which there is Proteus infection but in which stone formation is rather uncommon. The most important one that I see is neuro¬ genic bladder in the spina bifida population. These child¬ ren usually carry large amounts of Proteus but, although they form a stone occasionally, it is not very common. One aspect may be the localization of the infection since these stones occur in the upper urinary tract and on the whole most of the spina bifida infections are in the bladder. Peters: Does the association with Proteus still hold when you exclude the patients who have a known urological abnormality? I think you said that two-thirds of the struvite stone formers had no urological abnor¬ mality? Does this not weight the data in favour of Proteus'] Barratt; If you take out those with urological abnor¬ malities, it does weight it more heavily in favour of Proteus. Arneil: Do your incidence figures refer to patients who came to hospital? Our experience would be that toddlers perhaps up to the age of about three would be referred to a paediatrician or a paediatric urologist, but after that age more and more of them would be diffused to various urologists round the city who might never bring them to our attention. Do you have a similar situation in London? Barratt: We see quite a lot of the paediatric urology, though I think it is probably biased by the specific referral of small children to our hospital. However, we have surveyed paediatric surgeons and paediatric urologists throughout the country to get a figure of between one and two cases per million total population per annum. The age incidence appears to be about the same for referrals to both urological surgeons and paediatric surgeons. Watts : Dr Barratt's final conclusion was that there is no implication for the childhood infective stone former in adult life or for adult medicine. Looking at it from the other end of the time spectrum, would Dr Asscher agree with that rather important overall conclusion? Asscher: I am trying to recollect the data from the European Dialysis and Transplant Association on uro¬ lithiasis as a cause of end-stage kidney failure. That would be one way—not a very good way—of getting at mortality. I think you will find it is a very small cause of end-stage kidney failure and urolithiasis, but it is certainly present and is of the order of 7%. Peters: It would be a small identifiable cause, but I think that the implication of Dr Watt's question is how often do these children who have had stones treated, who do not appear to have recurrent stones, then go on to get pyelonephritis? Asscher : In terms of morbidity, I would not necessarily agree with Dr Barratt. It is surprising to hear that these children do not get recurrences. It is so unlike what happens in adults. Once you have had a stone infection, it is impossible to get rid of the infection even if you remove the stone. Barratt: I agree that the situation is quite different from that with adults. There is also the question of the sex incidence. Most of your infective stone formers are female. This immediately makes it a different situation from our population of children. Peters: It suggests that these stone formers are not responsible for adult pyelonephritic disease because they again are female and your patients are predominantly male. Asscher : I have not answered your question. I do not see boys with stones coming to a renal failure unit and I do not see boys with stones with hypertension later on. However, we see women with small kidneys and high blood pressure problems and recurrent infection. I do not think they are drawn from this particular population because they usually do not have stones. 39](https://iiif.wellcomecollection.org/image/b18031298_0052.JP2/full/800%2C/0/default.jpg)
