What is the treatment for an 88-year-old female with a kidney stone and Chronic Kidney Disease (CKD) stage 3, characterized by Impaired renal function?

From the Guidelines

For an 88-year-old female with kidney stones and stage 3 chronic kidney disease (CKD), the most effective treatment approach is to prioritize stone removal while protecting remaining kidney function, with a focus on increasing fluid intake to achieve at least 2 L of urine per day to prevent recurrent nephrolithiasis, as recommended by the American College of Physicians 1.

Initial Management

Initial management includes:

• Adequate hydration with 2-3 liters of fluid daily to dilute urine and prevent stone growth
• Pain management with acetaminophen, which is preferred over NSAIDs due to the potential of NSAIDs to worsen kidney function
• For small stones (<5mm), watchful waiting with medical expulsive therapy using tamsulosin 0.4mg daily may help passage, as this approach can reduce the need for more invasive procedures

Urological Intervention

Larger stones or those causing obstruction require urological intervention, with:

• Shock wave lithotripsy (SWL) or ureteroscopy being preferred over percutaneous nephrolithotomy due to lower invasiveness, which can help minimize the risk of complications and preserve kidney function
• The choice of procedure should be individualized based on the patient's specific condition, including the size and location of the stone, as well as their overall health status

Dietary Modifications

Dietary modifications are crucial and include:

• Limiting sodium to 2,000mg daily to reduce blood pressure and decrease the risk of kidney disease progression
• Moderating protein intake to 0.8g/kg/day to reduce the strain on the kidneys
• Avoiding excessive oxalate-rich foods like spinach and nuts, which can increase the risk of stone formation

Pharmacologic Management

Thiazide diuretics like hydrochlorothiazide 12.5-25mg daily may be prescribed for calcium stones to reduce urinary calcium excretion, but require careful monitoring of electrolytes and kidney function, as these medications can have potential side effects and interactions 1.

Follow-up Care

Regular follow-up with both nephrology and urology is essential to:

• Monitor kidney function and adjust medications as needed
• Prevent recurrence through 24-hour urine collections to identify specific metabolic abnormalities contributing to stone formation, which can help guide targeted interventions to reduce the risk of future stone formation.

From the Research

Treatment Options for Kidney Stones with CKD Stage 3

The treatment for an 88-year-old female with a kidney stone and Chronic Kidney Disease (CKD) stage 3, characterized by impaired renal function, may involve several options, including:

• Extracorporeal shockwave lithotripsy (ESWL) 2
• Ureteroscopy 2, 3, 4
• Percutaneous nephrolithotomy (PCNL) 2, 3, 4

Considerations for CKD Stage 3

Patients with CKD stage 3 may require special consideration due to their impaired renal function. Studies have shown that:

• Stone disease can affect renal function, and different stone compositions may have varying effects on renal impairment 5
• Higher CKD stage is associated with changes in urinary analytes that both promote and inhibit stone formation, with the net effect of decreasing calcium oxalate and phosphate supersaturation 6
• Patients with CKD may benefit from medical therapy that targets improving urinary citrate instead of lowering calcium or uric acid 6

Flexible Ureteroscopy as a Treatment Option

Flexible ureteroscopy has been shown to be an effective treatment option for kidney stones, with:

• Higher rates of treatment effectiveness and significance compared to PCNL 3
• Lower complication rates and less impact on renal function and coagulation function compared to PCNL 3
• The potential need for multiple procedures to achieve a stone-free rate 4