From the Guidelines
Management of kidney stones should prioritize increased fluid intake to achieve at least 2 L of urine per day, as recommended by the American College of Physicians (ACP) 1. This approach is based on low-quality evidence but is considered a weak recommendation to prevent recurrent nephrolithiasis.
- Key aspects of management include:
- Pain control with NSAIDs like ibuprofen or ketorolac for acute pain
- Hydration to promote stone passage
- Specific treatments based on stone size and composition, such as medical expulsive therapy with alpha-blockers for stones smaller than 10mm
- Urological intervention for larger stones or those causing severe symptoms
- Prevention strategies are crucial and include:
- Dietary modifications based on stone composition, such as reduced oxalate intake for calcium oxalate stones
- Pharmacologic approaches, including thiazide diuretics like hydrochlorothiazide to prevent calcium stones by reducing urinary calcium excretion
- Regular follow-up with urinalysis and imaging to monitor for recurrence According to the ACP guideline, pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol is recommended to prevent recurrent nephrolithiasis in patients with active disease in which increased fluid intake fails to reduce the formation of stones 1.
- The guideline emphasizes the importance of considering the effectiveness and safety of preventive dietary and pharmacologic management for recurrent nephrolithiasis.
- It also highlights the need for further research to determine the effect of dietary or pharmacologic therapy based on stone composition or blood and urine chemistries.
From the FDA Drug Label
The effect of oral Potassium Citrate therapy in a non-randomized, non-placebo controlled clinical study of five men and four women with calcium oxalate/calcium phosphate nephrolithiasis and documented incomplete distal renal tubular acidosis was examined Potassium Citrate therapy was associated with inhibition of new stone formation in patients with distal tubular acidosis. A three-year retrospective pre-study history for stone passage or removal was obtained and corroborated by medical records. The stone formation rate was reduced in all groups as shown in Table 1.
The management of kidney stones with Potassium Citrate involves:
- Inhibition of new stone formation in patients with distal tubular acidosis
- Reduction of stone formation rate
- Increase in urinary citrate excretion and urinary pH
- Dosing: 30-100 mEq per day, usually 20 mEq administered orally 3 times daily
- Key benefits:
- Reduced stone formation rate
- Increased urinary citrate excretion
- Increased urinary pH
- Stone-passage remission rate of 67% 2
From the Research
Management of Kidney Stones
- The management of kidney stones involves a combination of pain control, medical expulsive therapy, and surgical intervention when necessary 3, 4, 5, 6.
- Alpha-blockers have been shown to be effective in increasing stone clearance rates and reducing the need for auxiliary treatments after shock wave lithotripsy 3, 4.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for pain management in patients with kidney stones, as they have been shown to be effective in reducing pain scores and decreasing the need for rescue medications 7.
- Lifestyle modifications, such as increased fluid intake, are recommended for all patients with kidney stones to reduce the risk of recurrence 6.
- Thiazide diuretics, allopurinol, or citrates may be prescribed for patients with recurrent calcium stones to prevent future stone formation 6.
Medical Expulsive Therapy
- Alpha-blockers, such as tamsulosin, silodosin, and alfuzosin, are commonly used for medical expulsive therapy in patients with ureteral stones 3, 4, 5.
- The use of alpha-blockers has been shown to increase stone clearance rates and reduce the need for auxiliary treatments after shock wave lithotripsy 3, 4.
- The effectiveness of alpha-blockers may vary depending on stone size, with larger stones (>5 mm) being more responsive to treatment than smaller stones 5.
Pain Management
- NSAIDs are recommended for pain management in patients with kidney stones, as they have been shown to be effective in reducing pain scores and decreasing the need for rescue medications 7.
- Opioid-sparing pathways have been developed for patients undergoing ureteroscopy and percutaneous nephrolithotomy, with NSAIDs forming the core of most described pathways 7.
- Medications aimed specifically at targeting stent-related discomfort may be used in addition to NSAIDs to manage postoperative pain 7.
Prevention of Recurrence
- Lifestyle modifications, such as increased fluid intake, are recommended for all patients with kidney stones to reduce the risk of recurrence 6.
- Thiazide diuretics, allopurinol, or citrates may be prescribed for patients with recurrent calcium stones to prevent future stone formation 6.
- Patients at high risk of stone recurrence should be referred for additional metabolic assessment, which can serve as a basis for tailored preventive measures 6.