Background <p>Pediatric urolithiasis is increasingly recognized not merely as a localized urinary disorder but as part of a systemic metabolic–inflammatory process that may predispose to chronic kidney and cardiovascular disease. However, population-based data in Asian pediatric populations with urolithiasis remain limited. This nationwide study investigated the epidemiologic trends, metabolic risk factors, and systemic outcomes associated with pediatric urolithiasis in Taiwan.</p> Methods <p>Using the National Health Insurance Research Database, children newly diagnosed with urolithiasis between January 2009 and December 2019 were identified and matched with controls according to age, sex, and index year. Comorbidities and medication exposures were evaluated, and outcomes including renal, cardiovascular, and metabolic complications were analyzed using Cox proportional hazards models.</p> Results <p>Among 10,113 affected children and 101,130 matched controls, the annual incidence of pediatric urolithiasis declined from 23.85 to 16.22 per 100,000 persons. A male predominance and peak incidence during adolescence were noted. Major associated factors included hypercalciuria (adjusted hazard ratio [aHR] 31.54, with wide confidence intervals), congenital urinary anomalies (aHR 22.58), urinary tract infection (aHR 8.28), and exposure to diuretics or antibiotics. Compared with controls, children with urolithiasis had significantly higher risks of chronic kidney disease (aHR 5.92), hypertension (aHR 1.92), ischemic heart disease (aHR 1.93), and dyslipidemia (aHR 1.83).</p> Conclusions <p>Despite a modest decline in incidence, pediatric urolithiasis remains a clinically important condition that is associated with an increased risk of long-term renal and cardiovascular morbidity. These findings highlight the importance of early metabolic evaluation, careful medication stewardship, and continued nephrology follow-up to mitigate chronic sequelae.</p> Graphical abstract <p></p>