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EAU Guidelines

European Urology

Eur Urol 2001;40:362–371

Guidelines on Urolithiasis 1
H.G. Tiselius, D. Ackermann, P Alken, C. Buck, P Conort, M. Gallucci . .
Working Party on Lithiasis, Health Care Office, European Association of Urology 2

Key Words Acute stone colic · Ureteral stones · Kidney stones · Risk factors · Reccurrence prevention

Abstract Objectives: A project was initiated by the Health Care Office of the European Association of Urology in order to formulate common recommendations and guidelines for the treatment of patients with urolithiasis. The basic task for the working group therefore was to extract and evaluate evidence from the literature in order to reach a consensus on how these patients could best be managed. Methods: Extensive reviews of the literature together with a thorough and detailed discussion of the various topics, by a working group including of experts from several European countries, provided the basis for a consensus overview of urolithiasis and its management. Results and Conclusions: Recommendations are given for the management of patients with acute stone colic and for active removal of stones from the ureter and kidney. Moreover, the principles for risk evaluation of patients with recurrent stone formation and appropriate recurrence preventive treatment are given.
Copyright © 2001 S. Karger AG, Basel

Urinary stone disease continues to occupy an important place in everyday urological practice. These guidelines and recommendations for the diagnosis, medical and interventional treatment of stone disease as well as for recurrence prevention have been formulated following a comprehensive and detailed evaluation of the current knowledge of various aspects of urolithiasis.
1 For more extensive information consult the EAU Guidelines presented at the 16th EAU Annual Congress, Geneva, Switzerland (ISBN 90–806179–3–9). 2

Classification

Based on the chemical composition of the stone and the severity of the disease different categories of stone formers can be identified (table 1). This classification enables useful sub-grouping of patients for decisions on the metabolic evaluation and medical treatment of the disease [1]. Irrespective of the previous course of the disease some patients need particular attention because of specific risk factors, summarized in table 2.

For the section on stone-preventive measures contributions also were made by the following members of the Advisory Board of European Urolithiasis Research: W. Achilles, J.M. Baumann, B. Dussol, K.-H. Bichler, R. Caudarella, M. Daudon, B. Hess, A. Hesse, P. Jaeger, D.J. Kok, B.D. Leusmann, P.N. Rao, K. Sarica, P.-O. Schwille, and W.L. Strohmaier.

2001 S.Karger AG, Basel 0302–2838/01/0404–0362 $17.50/0 Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/journals/eur

Prof. Hans-Göran Tiselius Department of Urology Huddinge University Hospital SE-141 86 Stockholm (Sweden) Tel. +46 8 58 58 77 62, Fax +46 8 58 58 77 60, E-Mail hans-goran.tiselius@urol.hs.sll.se

Categories of stone formers Description Non-calcium stones Infection stone Uric acid/sodium urate/ammonium urate Cystine stone First time stone former without residual stone or stone fragments First time stone former with residual stone or stone fragments Recurrent stone former with mild disease without residual stone(s) or stone fragments Recurrent stone former with mild disease with residual stone(s) or stone fragments Recurrent stone former with severe disease with or without residual stone(s) or fragments Stone forming patient with specific risk factor irrespective of otherwise defined category Abbreviation INF UR CY So Sres Rm-o Rm-res Rs Risk Calcium stones Table 2. Other special examinations that can be useful in diagnosis are spiral (helical) unenhanced computed tomography (CT). nitrate and pH. Imaging is imperative for patients with fever (c38 °C). 6]: Option 1: Two 24-hour urine collections • sample 1 collected in a bottle containing 15–30 ml of 6 mol/l hydrochloric acid (HCl) a Diagnosis Diagnostic Imaging Patients with an episode of renal stone colic usually present with typical pain.Table 1. ureters and bladder plus an ultrasound examination or an excretory pyelography (urography). In order to further identify abnormalities that might be of importance for stone-formation the following alternative urinanalyses are recommended [5.40:362–371 363 . 4]. which might be considered in case iodine containing contrast medium cannot be administered. it is important to measure the serum calcium and serum urate. the anti-diabetic drug metformine should be stopped 2–3 days prior to administration of iodine containing contrast medium [2]. Specific risk factors for stone formation Start of disease early in life: d25 years Stones containing brushite Only one functioning kidney Disease associated with stone formation Hyperparathyroidism Renal tubular acidosis (complete/partial) Jejunoileal bypass Crohn’s disease Intestinal resection Malabsorptive conditions Sarcoidosis Hyperthyroidism Medication associated with stone formation Calcium supplements Vitamin D supplements Ascorbic acid in megadoses (c4 g/day) Sulfonamides a Triamterene a Indinavir a Anatomical abnormalities associated with stone formation Tubular ectasia (MSK) PUJ-obstruction Calix diverticulum/calcix cyst Ureteral stricture Vesicoureteral reflux Horseshoe kidney Ureterocele PUJ = Pelvoureteral junction. Extended Urinalysis. solitary kidney and when the stone diagnosis is in doubt. The latter examination must not be carried out in patients with: an allergy to contrast media. Spiral (helical) CT is a new noninvasive technique [3. To exclude metabolic risk factors. In patients with fever. The clinical diagnosis should be supported by an appropriate imaging Guidelines on Urolithiasis Eur Urol 2001. Laboratory Investigations Routine Analyses. Routine examination involves a plain film of kidneys. serum creatinine c200 µmol/l. and a measurement of serum creatinine. The routine laboratory investigation should include examination of the urinary sediment and/or a dip stick test for red cells. Noncalcium stones procedure. Because of the risk of impaired renal function due to lactic acidosis. analysis of C-reactive protein. vomiting and mild fever. In cases of vomiting serum sodium and serum potassium should be measured. blood white cell count and a urine culture should be carried out. retrograde and antegrade pyelography and scintigraphy. white cells. treatment with metformine and myelomatosis. This makes it possible to decide if a conservative approach is justified or if another form of treatment has to be considered.

Also. The preferred analytical procedures are x-ray crystallography and infrared spectroscopy. Where stone material has not been analyzed conclusions on stone composition might be based on other observations. or specific risk factors (categories Rs and Risk). should have at least one stone analyzed. i. octacalcium phosphate and brushite.00 in a bottle containing 10 ml of 0. The recommended principles for metabolic evaluation and further medical management are given in table 5. hydroxyapatite. high in pa- tients with infection stones). Stones or stone fragments should be subjected to stone analysis to establish their composition [10]. Urine culture in case of bacteriuria. test for bacteriuria or urine culture. 364 Eur Urol 2001. serum urate (when a uric acid or urate stone is suspected). Every patient. Optional analysis. uric acid/urate stones. xanthine and various drug metabolites (sulfonamide. Analysis of urate can be carried out in collections with sodium azide but in samples with HCl only following alkalinization with sodium hydroxide. Based on the main chemical constituents the stones can be grouped as follows: Radio-opaque calcium containing stones. Analytical workup in patients with uncomplicated stone disease Stone analysis In every patient one stone should be analysed Blood analysis Calcium Albumin a Creatinine Urate b Urinalysis Fasting morning spot urine sample Dip-stick test: pH Leucocytes / Bacteria c Cystine test d a b c d Either calcium + albumin or free calcium ion concentration. Calcium stones.Table 3.8-dihydroxyadenine. For these patients the limited set of analyses in table 3 is recommended. when not associated with infection. triamterene and indinavir). • sample 2 collected in a bottle containing 20–30 ml of 0.3 mol/l sodium azide Option 4: Spot urine sample • the excretion of each urine variable is related to creatinine [8] Hydrochloric acid is used to prevent precipitation of calcium oxalate and calcium phosphate. Infection stones (INF) include magnesium ammonium phosphate and carbonate apatite. Stone Composition. carbonate apatite (in the absence of infection). include calcium oxalate monohydrate. Analytical Workup of Patients with Calcium Stones. sodium urate and ammonium urate. whenever possible.00 and 06. Analysis of urine should be postponed until at least 4 weeks have elapsed following an episode of obstruction and/or after stone removal and never in the presence of infection or hematuria. and radiographic appearance of the stone or conclusions from the ultrasound examination. In selected patients some additional special analyses such as acid [11.40:362–371 Tiselius/Ackermann/Alken/Buck/Conort/ Gallucci .00 in an bottle containing 10–20 ml of 6 mol/l HCl • sample 2 collected between 22. a qualitative cystine test with sodium nitroprussideBrands test. urine pH (low in patients with uric acid stones. The analytical program recommended for these patients is shown in table 4. Uric acid/urate stones (UR) include uric acid. demonstration of crystals of struvite or cystine in the urinary sediment.e.3 mol/l sodium azide Option 2: One 24-hour urine collection • sample collected in a bottle containing 15–30 ml of 6 mol/l HCl Option 3: One 16-hour urine and one 8-hour urine collection [7] • sample 1 collected between 06. calcium oxalate dihydrate. 12] and calcium loading [13] might be useful. Cystine stones (CY) are composed of cystine. There are also less commonly encountered stone constituents such as 2. Cystine test if cystinuria cannot be excluded by other means.00 and 22. first time stone formers and those with a mild disease who have residual fragments (categories Sres and Rm-res) might be included in this group. Patients with uncomplicated disease are stone-free either after the first stone episode or have a mild recurrent disease (categories So and Rm-o). and cystine stones associated with infection are referred to as ‘stones with infection’. and to counteract oxidation of ascorbate to oxalate [9]. Patients with a complicated disease have a history of frequent recurrences with or without residual fragments or stones in the kidney.

creatinine. Dip-stick tests are sufficient in the uncomplicated cases. calcium. urate d. magnesium b. e Magnesium and phosphate are necessary for calculations of estimates of the ion activity products of CaOx and CaP.40:362–371 365 . phosphate and pH are known [18]. respectively. When the test is positive for bacteriuria. Analyses in patients with complicated stone disease Table 5. pentazocin and tramadol. or the urine Guidelines on Urolithiasis Eur Urol 2001. f. c 24-hour urine can be replaced by collections during other periods of the day. When spontaneous stone passage is anticipated 50-mg suppositories or tablets of diclophenac sodium administered twice daily during 3–10 days might be useful in reducing ureteral edema and the risk of recurrent pain. hyperparathyroidism should be excluded by assessing the parathyroid hormone level [14]. urea b. hydromorphone hydrochloride + atropin sulfate (Dilaudid-Atropin®). d In samples that have not been acidified. Diclophenac sodium affects glomerular filtration rate in patients with reduced renal function. Treatment In patients with a high serum calcium (c2. When pain relief cannot be achieved by medical means. chloride b. Incomplete or complete renal tubular acidosis should be suspected in patients with a pH above 5. phosphate. but not in patients with normal renal function [19]. f. sodium and potassium reflect dietary habits.60 mmol/l). magnesium. Stone Removal General Recommendations for Stone Removal.Table 4. Treatment should be started with an NSAID and changed to an alternative drug if the pain persists. citrate. methamizol. magnesium. The net alkali absorption in mEq/24 h is derived from information on the excretion of sodium. Pain Relief Pain relief can be achieved with the administration by various routes of the following agents: diclophenac sodium (Voltaren®). Optional analysis. Estimates of the ion-activity products of calcium oxalate [AP(CaOx) index] and calcium phosphate [AP(CaP) index] can be calculated if the urine volume and the excretion of calcium. In these expressions the AP(CaOx) index approximately corresponds to the 108 E APCaOx. indomethacin. e. e. Analytical program for metabolic evaluation of patients with stone disease related to category Stones analysis In every patient on stone should be analyzed Blood analysis Calcium Albumin a Creatinine Urate b Potassium Urinalysis Fasting morning spot urine sample Dip-stick test pH Leukocytes/bacteria Cystine test 24-hour urine collection c Calcium. The AP(CaP) index approximately corresponds to 1015 E APCaP. volume. oxalate. potassium b. liters) the protein intake can be calculated [16]. oxalate. Passage of stone and evaluation of renal function should be confirmed with appropriate methods. In others a urine culture is necessary. Retrieved stone(s) should be analyzed. where APCaOx is the ion-activity product of calcium oxalate. f. Hydromorphone and other opiates without simultaneous administration of atropine should be avoided. potassium. drainage by stenting or percutaneous nephrostomy. Based on the urine urea concentration (mmol/l) and the urine volume (V. citrate. For all patients in whom stone removal is planned screening for bacteriuria must be carried out. From the analysis of urine composition as shown in table 4 valuable information can be derived. phosphate b. chloride and phosphate [17]. f Urea. b a Category Blood analysis Urinalysis Prevention follow-up Yes Yes Yes No Yes No Yes Yes Yes INF UR CY So Sres Rm-o Rm-res Rs Risk S creatinine S urate S creatinine S creatinine Yes (see table 3) Yes (see table 4) Yes (see table 3) Yes (see table 4) Yes (see table 4) Yes (see table 4) Culture pH Urate pH Cystine pH Limited urinalysis (see table 3) Yes (see table 4) Limited urinalysis (see table 3) Yes (see table 4) Yes (see table 4) Yes (see table 4) S = Serum. f. f Either calcium + albumin or free calcium ion concentration.8 in fasting morning urine [15]. sodium b. or by stone removal should be carried out. where APCaP is the ion-activity product of calcium phosphate.

Extracorporeal shock wave lithotripsy (ESWL). Principles for active removal of stones in the ureter Proximal ureter Radioopaque stones (1) ESWL in situ (2) ESWL after ‘push-up’ (3) Perc. treatment with antibiotics should be started before the stone-removing procedure. antegrade URS (1) AB + ESWL in situ. For stones in different parts of the ureter and with different composition the most appropriate methods for stone removal are given in table 6. and 70% for distal ureteral stones. contrast + ESWL (2) ‘Push-up’ + ESWL (3) Perc. or when there is suspicion of an infection. Principles for Active Removal of Ureteral Stones.v. = percutaneous. site and shape of the stone influence the decision on how to deal with it. antegrade URS (4) URS + disintegration (1) AB + ESWL in situ (2) AB + ESWL after ‘push-up’ (3) AB + Perc. therefore is drainage either with a double-J stent or a percutaneous nephrostomy catheter [20]. contrast + ESWL (2) ‘Push-up’ + ESWL (2) Stent + oral chemolysis (3) Perc. UC = ureteral catheter. The overall passage rate is 25% for proximal. prone position (1) AB + URS + disintegration (2) AB + UC /i. persistent obstruction with impaired renal function. PN = percutaneous nephrostomy catheter. URS has been performed successfully to remove ureteral stones during pregnancy. antegrade URS (1) ESWL in situ. i. The preferred treatment during pregnancy. The size. and is strongly recommended in patients with the following: persistent pain despite adequate medication. risk of pyonephrosis or urosepsis. 2. 45% for mid. contrast + ESWL (2) AB + ‘push-up’ + ESWL (3) AB + Perc. In expert hands. 22]. antegrade URS (4) URS + disintegration (1) ESWL in situ (2) URS + disintegration (2) UC + ESWL ESWL = Includes piezolithotripsy. antegrade URS Distal ureter (1) ESWL in situ (1) URS + disintegration (2) UC + ESWL Infection stones. AB = antibiotics. Spontaneous stone passage can be expected in up to 80% of patients with stones not larger than 4 mm. These patients should be referred to an internist for appropriate therapeutic measures in association with the stone removal. For stones with a diameter exceeding 7 mm the chance of spontaneous passage is low [21. The preferred alternative is always given the number 1. 366 Eur Urol 2001. percutaneous nephrolithotomy (PNL). Perc.v.Table 6. ESWL. Numbers 1. 3 and 4 are designated to the procedures according to the consensus reached. antegrade URS (4) AB + URS + disintegration (1) Stent + oral chemolysis (2) ESWL in situ + oral chemolysis (3) Perc. antegrade URS (1) ESWL in situ.40:362–371 Tiselius/Ackermann/Alken/Buck/Conort/ Gallucci .v contrast (1) URS + disintegration (2) UC + contrast + ESWL (3) PN + contrast + ESWL Uric acid stones Cystine stones (1) ESWL in situ (2) ESWL after ‘push-up’ (3) Perc. but it needs to be emphasized that complications following such a procedure might be difficult to manage. contrast + ESWL (2) ‘Push-up’ + ESWL (3) Perc. Indications for Active Stone Removal. ureteroscopy (URS) and open surgery are all contraindicated in patients with coagulation disorders. bilateral obstruction and obstructing calculus in a solitary functioning kidney. prone position (1) URS + disintegration (2) UC /i. prone position (1) URS + disintegration (2) UC /i. PNL and URS are contraindicated in pregnant women. Stone removal usually is indicated for stones with a diameter exceeding 6–7 mm. and when two procedures are considered equally useful they have been given the same number. Bleeding disorders and anticoagulation treatment should be considered. prone position (1) URS + disintegration (2) UC /i. culture shows bacterial growth.v. stones with infection (1) AB + ESWL in situ (1) AB + URS + disintegration (2) AB + PN + ESWL in situ (2) AB + UC + ESWL (1) ESWL in situ.v. For patients with a pacemaker it is wise to consult a cardiologist before an ESWL treatment. Treatment with salicylic acid preparations should be stopped 10 days before the stone-removing procedure. urinary tract infection. antegrade URS (4) URS + disintegration Mid ureter (1) ESWL in situ.

Stones composed of brushite and calcium oxalate monohydrate are characterized by particular hardness [36]. UR stones can be localized with ultrasound. cystine and brushite. those responding well to ESWL and those responding poorly [33]. Repeated sessions are frequently necessary for in situ ESWL treatment. can be dissolved by oral chemolytic treatment. an open surgical procedure might be required. UC = ureteral catheter. particularly for those situated in the lower ureter [26]. The recommended treatments according to stone size and composition are summarized in table 7. There is controversy as to whether ESWL or URS is the best method for removal of ureteral stones. stones with infection (1) AB + ESWL (2) AB + PNL (1) AB + PNL (2) AB + ESWL with or without stent (3) AB + PNL + ESWL Uric acid stones (1) Oral chemolysis (2) Stent + ESWL + oral chemolysis (1) Oral chemolysis (2) Stent + ESWL + oral chemolysis Cystine stones (1) ESWL (2) PNL (3) Open or videoendoscopic surgery (1) PNL (2) PNL + ESWL (3) PNL + flexible nephroscopy ESWL = Includes piezolithotripsy. It should be observed that also small stones residing in a cal- Guidelines on Urolithiasis Eur Urol 2001. Residual fragments. Principles for Active Removal of Stones in the Kidney. intravenous and retrograde contrast medium. The success rate in difficult cases can be improved by bypassing the stone with a catheter or by pushing it up into the kidney. are common after ESWL treatment of stones in the kidney. Stones composed of uric acid. Large and impacted stones have the highest retreatment rate. 28]. Lower calix fragments are more commonly seen when there is an acute (d90 °) infundibulopelvic angle [29]. Blind basketing without endoscopic or fluoroscopic control is not recommended. uric acid. so-called clinically insignificant fragments. In case of failure with minimally invasive techniques. This might militate in favor of percutaneous removal if the stones are large. Percutaneous chemolysis is an alternative treatment for stone fragments composed of magnesium ammonium phosphate. A lower pole resection is an alternative that should be considered in case of residual fragments and no functioning parenchyma [30]. For large ESWL-resistant stones. For stones with a diameter exceeding 20 mm double-J stenting before ESWL is recommended to avoid an accumulation of stones obstructing the ureter (steinstrasse) [31. Videoendoscopic retroperitoneal surgery is a minimally invasive alternative to open surgery. PNL with or without lithotripsy will be the best alternative for efficient removal. Larger stones need more treatment sessions [27.Table 7. but not of sodium urate or ammonium urate. There are two types of cystine stones. In case of chemolysis it is important to give appropriate antibiotics and to avoid a high intrarenal pressure and leakage by using two percutaneous nephrostomy catheters.40:362–371 367 . Percutaneous chemolytic treatment can be useful in selected cases of infection. carbonate apatite. The success rate of ESWL is related to the concrement volume. 32]. cystine and pure calcium phosphate stones [23–25]. Fragments in the upper and middle calices can be removed with URS and contact disintegration. uric acid. AB = antibiotics. Principles for active removal of stones in the kidney Kidney stones b20 mm Radioopaque stones (1) ESWL (2) PNL Kidney stones a20 mm (1) PNL (2) ESWL (3) PNL + ESWL Complete or partial staghorn stones (1) PNL (2) PNL + ESWL (3) ESWL + PNL (4) Open surgery (1) PNL (2) PNL + ESWL (3) PN:/ESWL + oral chemolysis (4) ESWL + PNL (5) AB + ESWL + chemolysis (1) PNL (2) PNL + ESWL (2) PNL/ESWL + oral chemolysis (3) ESWL + PNL (4) Open surgery (1) PNL (2) PNL + ESWL (3) ESWL + PNL (4) Open surgery Infection stones. but there is an ongoing debate as to whether large renal stones are best treated with ESWL or PNL.

Recommendations for the removal of stones in transplanted kidneys are ESWL or PNL. it is necessary to give antibiotics and to provide adequate drainage as soon as possible. In symptomatic patients. PN = percutaneous nephrostomy catheter. Recommendations for treatment are given in table 8. uric acid and calcium phosphate stones. Residual Fragments The importance of so-called clinically insignificant fragments is a matter of debate [41–43]. treatment should be applied according to the corresponding stone situation. the stones can be removed at the same time as the outflow abnormality is corrected either by percutaneous endopyelotomy [38. An optional method for removal of diverticular stones is videoendoscopic retroperitoneal surgery [36]. this is not the case for all. Managing Special Problems A stone in a caliceal diverticulum can be treated with ESWL. ESWL.40:362–371 Tiselius/Ackermann/Alken/Buck/Conort/ Gallucci . cystine. Transureteral endopyelotomy (Acucise) is another alternative that might be considered provided the stones are prevented from falling down in the pelvoureteral incision [40]. ESWL or videoendoscopic laparoscopic surgery are recommended. URS might be useful to remove the leading stone fragment by contact disintegration. Steinstrasse A steinstrasse or a fragment column in the ureter is an accumulation of gravel that does not pass within a reasonable period of time and that interferes with urine passage [44]. it is important to rule out obstruction and deal with this problem if present. In certain cases a narrow caliceal neck might require dilatation. 39] or by open reconstructive surgery. PNL or open surgery are the options for treating obese patients. For the pelvic kidney. Horseshoe kidneys may be treated according to the principles for stone treatment presented above. that according to the anterior position of the kidney.ix might cause considerable pain or discomfort [34. however. In asymptomatic patients where the stone is unlikely to pass. In all patients with signs of infection. It needs to be emphasized. it is often necessary to deliver shock waves from the abdominal aspect. Patients should be encouraged to have a high fluid intake [46]. an appropriate stone prevention might be particularly indicated for patients with residual fragments or stones. In other cases appropriate therapeutic steps need to be taken to eliminate symptoms. These patients might become asymptomatic as a result of the stone disintegration alone. Each stone problem has to be considered and treated on its individual merits. In selected cases of infection. In patients with pelvoureteral junction obstruction. The stones formed in a continent reservoir constitute a varied and often difficult problem [37]. Identification of biochemical risk factors and Table 8. In case of a narrow communication between the diverticulum and the renal collecting system. Although some residual fragments will represent a nidus for new stone formation. The frequency of this complication has decreased with the liberal insertion of double-J stents before ESWL of large renal stones. General directives for the management of this problem cannot be given. Preventive Treatment in Calcium Stone Disease The preventive treatment of patients with calcium stone disease should be started with conservative measures. Insertion of a percutaneous nephrostomy catheter usually results in the passage of the fragments [45]. well-disintegrated stone material will remain in the original position. Patients with residual fragments or stones should be regularly followed to monitor the course of the disease. PNL (if possible) or retrograde ureteroscopy. For a normal adult the 24-hour 368 Eur Urol 2001. Pharmacological treatment should be instituted only when the conservative regimen fails. 35]. the combined use of ESWL and chemolysis might be useful. Nephrectomy should be considered in case of a nonfunctioning kidney. Recommendations for treatment of steinstrasse Unobstructed Proximal ureter (1) ESWL Obstructed (1) PNL (2) Stent (3) ESWL (1) PN (2) Stent (3) ESWL (1) PN (2) Stent (3) URS Mid ureter (1) ESWL Distal ureter (1) ESWL (2) URS ESWL = Includes piezolithotripsy. repeated ESWL sessions with a stent can be a reasonable treatment alternative. This advice is valid irrespective of the stone composition. Complete or Partial Staghorn Stones For patients with small staghorn stones and a nondilated system. For distally located accumulations of fragments.

herring with skin. should exceed 2. anchovies and sprats. The use of magnesium salts as monotherapy is discouraged. Here are some examples of food rich in urate: calf thymus. Animal protein should not be ingested in excessive amounts [49. in which additional calcium should be ingested with meals. sardines. to avoid fruits and vegetables rich in oxalate. The fluid intake should be evenly distributed over the 24-hour period and particular attention should be paid to situations with an unusual loss of fluid. This is of particular importance in those patients in whom a high excretion of oxalate has been demonstrated.Table 9. Recommended pharmacological treatment of patients with calcium stone disease Indication Recommended Sometimes useful Note Hypercalciuria Thiazide Orthophosphate Thiazide + magnesium Alkaline citrate Alkaline citrate Alkaline citrate Calcium supplement Pyridoxine Alkaline citrate Alkaline citrate Alkaline citrate Thiazide + magnesium Alkaline citrate Allopurinol Alkaline citrate Alkaline citrate Orthophosphate Potassium supplements should be given with thiazides Hyperoxaluria (moderate) Hyperoxaluria (enteric) Hyperoxaluria (primary) These patients should be referred to someone with experience of this disease Hyperoxaluria RTA Brushite stone Potassium supplements should be given with thiazides Hyperuricosuric CaOx stone Low inhibitory activity No abnormality RTA = Renal tubular acidosis.000 ml. kidneys. Supplements of calcium are not recommended except in enteric hyperoxaluria. cocoa. however. the excessive intake of products rich in oxalate should be limited or avoided. The minimum daily requirement of calcium is 800 mg and the general recommendation is 1. Vitamin C in doses up to 4 g per day can be taken without increasing the risk of stone formation [48]. 53]. poultry skin. Pharmacological Treatment of Calcium Stone Disease The recommended forms of pharmacological treatment are summarized in table 9. urine volume. but avoiding any excesses [47]. but the supersaturation level should be used as a guide to the necessary degree of urine dilution. Care must be taken. The intake of urate should not be more than 500 mg/day. tea leaves and nuts. thereby. Wheat bran is rich in oxalate and should be avoided. spinach. Calcium intake should not be restricted unless there are very strong reasons for such advice [51]. In order to avoid an oxalate load. a mixed balanced diet with contributions from all nutrient groups. The intake of food stuffs particularly rich in urate should be restricted in patients with hyperuricosuric calcium oxalate stone disease [52. The intake of fruits and vegetables should be encouraged because of the beneficial effects of fibers. 50]. Diet should be dictated by common sense.40:362–371 369 . It is recommended that the animal protein intake is limited to approximately 150 g/day.000 mg/day. Neither cellulose phosphate nor sodium cellulose phosphate has a place in the preven- Guidelines on Urolithiasis Eur Urol 2001. liver. The following products have a high content of oxalate: rhubarb. as well as in patients with uric acid stone disease.

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