What is the treatment for kidney stones?

Treatment of Kidney Stones

The treatment of kidney stones should focus on increasing fluid intake to achieve a urine volume of at least 2.5 liters daily as the cornerstone of both acute management and prevention, combined with appropriate pain management, dietary modifications, and targeted pharmacotherapy based on stone composition. 1, 2

Initial Assessment and Management

• Perform a detailed medical and dietary history, serum chemistries (electrolytes, calcium, creatinine, uric acid), and urinalysis to identify underlying conditions and risk factors 3, 1
• Obtain imaging studies to quantify stone burden and guide treatment decisions 1
• When available, collect stone material for analysis at least once to determine composition and guide therapy 3, 1
• For patients with suspected infection, obtain urine culture and provide appropriate antibiotic therapy 3

Acute Pain Management

• NSAIDs are recommended as first-line treatment for acute kidney stone pain due to superior efficacy and fewer side effects 1
• Opioids should be reserved as second-choice analgesics when NSAIDs are contraindicated or ineffective 1

Conservative Management vs. Intervention

• Conservative management is appropriate for uncomplicated ureteral stones up to 10 mm 1
• Medical expulsive therapy with alpha-blockers (tamsulosin) is recommended for stones >5 mm in the distal ureter 1
• The maximum duration for conservative treatment should be 4-6 weeks from initial presentation 1
• Intervention is required for stones that fail to pass spontaneously within this timeframe 1

Medical Management Based on Stone Type

For All Stone Types:

• Increase fluid intake to achieve urine volume of at least 2.5 liters daily 3, 4
• Certain beverages like coffee, tea, wine, and orange juice may lower stone risk, while sugar-sweetened beverages should be avoided 3, 5

For Calcium Stones:

• Thiazide diuretics should be prescribed for patients with high urinary calcium and recurrent calcium stones 1, 4
• Potassium citrate therapy is indicated for patients with recurrent calcium stones and low urinary citrate 1, 4
• Maintain normal dietary calcium intake (1,000-1,200 mg/day) rather than restricting it 5, 6
• Limit sodium intake to 2,300 mg daily 5
• For calcium oxalate stones with hyperoxaluria, limit intake of oxalate-rich foods while maintaining normal calcium consumption 5, 4
• Avoid calcium supplements, which may increase stone risk unlike dietary calcium 5
• Allopurinol is indicated for calcium oxalate stone formers with hyperuricosuria 4

For Uric Acid Stones:

• Potassium citrate is first-line therapy to raise urinary pH to approximately 6.0 1, 4

For Cystine Stones:

• First-line therapy includes increased fluid intake, restriction of sodium and protein intake, and urinary alkalinization 1
• Tiopronin can be used if urinary alkalinization and adequate fluid intake are insufficient 4

For Struvite Stones:

• Complete surgical removal coupled with appropriate antibiotic therapy is necessary 4

Metabolic Evaluation and Follow-up

• Perform additional metabolic testing in high-risk or interested first-time stone formers and recurrent stone formers 3
• Metabolic testing should consist of one or two 24-hour urine collections analyzed for total volume, pH, calcium, oxalate, uric acid, citrate, sodium, potassium, and creatinine 3
• Obtain a follow-up 24-hour urine specimen within six months of initiating treatment to assess response to therapy 1
• After initial follow-up, obtain a single 24-hour urine specimen annually or with greater frequency, depending on stone activity 1

Common Pitfalls to Avoid

• Neglecting to address underlying metabolic abnormalities that contribute to stone formation 1
• Not considering the type of stone when determining appropriate medical therapy 1
• Prescribing allopurinol as first-line therapy for uric acid stones instead of urinary alkalinization with potassium citrate 1
• Restricting dietary calcium, which may actually increase stone risk by increasing intestinal oxalate absorption 5, 7
• Using supplemental calcium rather than dietary calcium, as supplements may increase stone risk 1, 5