What are the treatment options for Nephrolithiasis (Kidney Stones)?

From the Guidelines

Increased fluid intake to achieve at least 2 L of urine per day is the primary recommendation for preventing recurrent nephrolithiasis. This approach is based on the guideline from the American College of Physicians, which suggests that management with increased fluid intake spread throughout the day can help prevent recurrent kidney stones 1. The guideline grades this recommendation as weak with low-quality evidence, but it remains a fundamental aspect of kidney stone prevention.

Key Considerations for Kidney Stone Treatment

• The type and size of the stone play a crucial role in determining the treatment approach.
• For patients with active disease where increased fluid intake fails to reduce stone formation, pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol may be recommended, as suggested by the American College of Physicians guideline 1.
• Dietary changes, including reducing dietary oxalate, animal protein, and maintaining normal dietary calcium, are also crucial in preventing the recurrence of nephrolithiasis.

Prevention Strategies

• Staying well-hydrated is essential for both active stone episodes and long-term prevention.
• Medications such as thiazide diuretics, potassium citrate, or allopurinol may be prescribed based on stone composition to prevent recurrence, as indicated by the guideline 1.
• Reducing sodium and animal protein intake, and avoiding oxalate-rich foods if you have calcium oxalate stones, are also part of preventive dietary changes.

Medical Procedures for Larger Stones

• Extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, or percutaneous nephrolithotomy may be necessary for larger stones or those causing severe symptoms.
• These procedures are typically considered when the stone size exceeds 5mm or when there are severe symptoms, highlighting the importance of early intervention and prevention strategies.

From the Research

Kidney Stone Treatment Options

• Medical expulsive therapy (MET) is a treatment modality for kidney stones, which can be used alone or in combination with other modalities such as ureteroscopy, shock wave lithotripsy (SWL), and percutaneous nephrostolithotomy 2.
• The choice of intervention depends on patient factors, anatomical considerations, surgeon preference, and stone location and characteristics 2.

Medical Expulsive Therapy (MET)

• MET is an excellent treatment modality in the appropriately selected patient, and the AUA/EAU guidelines suggest MET as a reasonable treatment choice in select patients 2.
• Alpha antagonists and calcium channel blockers can improve stone expulsion rates, with alpha antagonists being superior to calcium channel blockers 2.
• Alpha antagonists can decrease colic events, narcotic use, and hospital visits, and may also reduce medical costs and prevent unnecessary surgeries and associated risks 2.

Alpha-Blockers for Kidney Stones

• Alpha-blockers are beneficial without lithotripsy for ureteral stones 5 to 10 mm, and are beneficial post-lithotripsy for renal or ureteral stones >10 mm 3.
• Alpha-blockers can increase clearance of stone fragments after SWL, reduce the need for auxiliary treatments, and reduce major adverse events 4.
• The use of alpha-blockers in patients with ureteral stones results in a higher stone-free rate and a shorter time to stone expulsion 5, 6.

Efficacy and Safety of Alpha-Blockers

• Alpha-blockers may improve stone clearance, reduce stone expulsion time, and decrease the need for analgesic medication and hospitalization 5, 6.
• However, alpha-blockers may also increase the risk of major adverse events, although the certainty of evidence is low 6.
• The efficacy and safety of alpha-blockers may vary depending on stone size, with alpha-blockers being more effective for larger stones 6.