From the Guidelines
The management of nephrolithiasis should prioritize increased fluid intake to achieve at least 2 L of urine per day, as well as pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol for patients with active disease, as recommended by the American College of Physicians 1.
Management Options
The goal of managing nephrolithiasis is to prevent recurrent stone formation, reduce morbidity, and improve quality of life. Key management options include:
- Increased fluid intake spread throughout the day to achieve at least 2 L of urine per day, which helps to dilute the concentration of crystal-forming substances in the urine 1.
- Pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol for patients with active disease in which increased fluid intake fails to reduce the formation of stones 1.
Dietary Modifications
Dietary changes play a crucial role in preventing the recurrence of nephrolithiasis. These include:
- Reducing dietary oxalate
- Reducing dietary animal protein and other purines
- Maintaining normal dietary calcium
- Increasing water intake to maintain dilute urine
Pharmacologic Approaches
Pharmacologic approaches aim to decrease concentrations of lithogenic factors and increase concentrations of inhibitors of stone formation. These include:
- Thiazide diuretics for calcium stones
- Potassium citrate for uric acid or calcium stones
- Allopurinol for uric acid stones
Stone Analysis and Prevention
Stone analysis and 24-hour urine collection help guide specific preventive measures by identifying metabolic abnormalities that contribute to stone formation. This information can be used to tailor dietary and pharmacologic interventions to the individual patient's needs.
From the Research
Management Options for Nephrolithiasis
The management of nephrolithiasis, also known as kidney stones, involves various treatment strategies depending on the clinical scenario. Some of the management options include:
- Observation for small, asymptomatic renal stones, which is a reasonable strategy in children 2
- Medical expulsive therapy with an alpha blocker, such as tamsulosin, which may have a beneficial effect for passage of ureteral stones in children 2, 3
- Extracorporeal shock wave lithotripsy (ESWL), which remains an important treatment for nephrolithiasis in children 2
- Ureteroscopy, which has become more attractive with advances in digital imaging and single-use ureteroscopes 2
- Percutaneous nephrolithotomy, a more invasive treatment modality that remains a good choice for children with large-stone burdens 2
- Open or laparoscopic stone surgery, which should be reserved for unique cases 2
Non-Opioid Treatment Options
In light of the current opioid epidemic, non-opioid treatment options are being emphasized as initial treatment for nephrolithiasis 4. Medical expulsive therapy with alpha blockers or calcium channel blockers is a viable option for increasing the likelihood of spontaneous passage of ureteral stones 3, 5.
Shared Decision-Making
A shared decision-making process with discussion of risks and benefits should be used to help patients and families choose a treatment option 2. This approach takes into account the individual patient's needs and preferences, as well as the clinical scenario, to determine the most appropriate management strategy.