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Purpose: The purpose of this guideline is to provide a clinical framework for the
diagnosis, prevention and follow-up of adult patients with kidney stones based on
the best available published literature.
Methods: The primary source of evidence for this guideline was the systematic
review and data extraction conducted as part of the Agency for Healthcare
Research and Quality (AHRQ) Comparative Effectiveness Review titled Recurrent
Nephrolithiasis in Adults: Comparative Effectiveness of Preventative Medical
Strategies (2012). That report included rigorous searches of MEDLINE, the
Cochrane Database of Systematic Reviews, Google Scholar and ClinicalTrials.gov
for English-language studies published from 1948 through November 2011
relevant to recurrent nephrolithiasis in adults. To augment and broaden the body
of evidence provided in the original AHRQ report, the American Urological
Association (AUA) conducted additional supplementary searches of PubMed and
EMBASE for relevant articles published between January 2007 and November
2012 that were systematically reviewed using a methodology developed a priori.
In total, these sources yielded 46 studies that were used to inform the statements
presented in the guideline as Standards, Recommendations or Options. When
sufficient evidence existed, the body of evidence for a particular clinical action was
assigned a strength rating of A (high), B (moderate) or C (low). In the absence of
sufficient evidence, additional information is provided as Clinical Principles and
Expert Opinions. While some of the statements in this guideline may be applicable
to the pediatric population, this patient group was not the focus of our systematic
review due to the limited number of relevant studies available.
GUIDELINE STATEMENTS
Evaluation
1. A clinician should perform a screening evaluation consisting of a detailed
medical and dietary history, serum chemistries and urinalysis on a patient
newly diagnosed with kidney or ureteral stones. (Clinical Principle)
2. Clinicians should obtain serum intact parathyroid hormone (PTH) level as part
of the screening evaluation if primary hyperparathyroidism is suspected.
(Clinical Principle)
7. Clinicians should not routinely perform “fast and calcium load” testing to distinguish among types of
hypercalciuria. (Recommendation; Evidence Strength: Grade C)
Diet Therapies
8. Clinicians should recommend to all stone formers a fluid intake that will achieve a urine volume of at least 2.5
liters daily. (Standard; Evidence Strength: Grade B)
9. Clinicians should counsel patients with calcium stones and relatively high urinary calcium to limit sodium intake
and consume 1,000-1,200 mg per day of dietary calcium. (Standard; Evidence Strength Grade: B)
10. Clinicians should counsel patients with calcium oxalate stones and relatively high urinary oxalate to limit intake
of oxalate-rich foods and maintain normal calcium consumption. (Expert Opinion)
11. Clinicians should encourage patients with calcium stones and relatively low urinary citrate to increase their intake
of fruits and vegetables and limit non-dairy animal protein. (Expert Opinion)
12. Clinicians should counsel patients with uric acid stones or calcium stones and relatively high urinary uric acid to
limit intake of non-dairy animal protein. (Expert Opinion)
13. Clinicians should counsel patients with cystine stones to limit sodium and protein intake. (Expert Opinion)
Pharmacologic Therapies
14. Clinicians should offer thiazide diuretics to patients with high or relatively high urine calcium and recurrent
calcium stones. (Standard; Evidence Strength Grade B)
15. Clinicians should offer potassium citrate therapy to patients with recurrent calcium stones and low or relatively
low urinary citrate. (Standard; Evidence Strength Grade B)
16. Clinicians should offer allopurinol to patients with recurrent calcium oxalate stones who have hyperuricosuria and
normal urinary calcium. (Standard; Evidence Strength Grade B)
17. Clinicians should offer thiazide diuretics and/or potassium citrate to patients with recurrent calcium stones in
whom other metabolic abnormalities are absent or have been appropriately addressed and stone formation
persists. (Standard; Evidence Strength Grade B)
18. Clinicians should offer potassium citrate to patients with uric acid and cystine stones to raise urinary pH to an
optimal level. (Expert Opinion)
19. Clinicians should not routinely offer allopurinol as first-line therapy to patients with uric acid stones. (Expert
Opinion)
20. Clinicians should offer cystine-binding thiol drugs, such as alpha-mercaptopropionylglycine (tiopronin), to
patients with cystine stones who are unresponsive to dietary modifications and urinary alkalinization, or have
large recurrent stone burdens. (Expert Opinion)
21. Clinicians may offer acetohydroxamic acid (AHA) to patients with residual or recurrent struvite stones only after
surgical options have been exhausted. (Option; Evidence Strength Grade B)
Follow-up
22. Clinicians should obtain a single 24-hour urine specimen for stone risk factors within six months of the initiation
of treatment to assess response to dietary and/or medical therapy. (Expert Opinion)
23. After the initial follow-up, clinicians should obtain a single 24-hour urine specimen annually or with greater
frequency, depending on stone activity, to assess patient adherence and metabolic response. (Expert Opinion)
25. Clinicians should obtain a repeat stone analysis, when available, especially in patients not responding to
treatment. (Expert Opinion)
26. Clinicians should monitor patients with struvite stones for reinfection with urease-producing organisms and utilize
strategies to prevent such occurrences. (Expert Opinion)
27. Clinicians should periodically obtain follow-up imaging studies to assess for stone growth or new stone formation
based on stone activity (plain abdominal imaging, renal ultrasonography or low dose computed tomography
[CT]). (Expert Opinion)
Eligible studies included RCTs and large prospective The categorization of evidence strength is conceptually
observational trials of patient populations limited to distinct from the quality of individual studies. Evidence
adults aged 18 years or older with a history of one or strength refers to the body of evidence available for a
more past kidney stone episodes. Studies addressing particular question and includes consideration of study
acute pain management and treatment to promote design, individual study quality, consistency of findings
expulsion of stones were excluded. Full details of the across studies, adequacy of sample sizes, and
AHRQ search strategies and inclusion/exclusion criteria generalizability of samples, settings and treatments for
can be found in the original report. the purposes of the guideline. The AUA categorizes
body of evidence strength as Grade A (well-conducted
To augment and broaden the body of evidence provided
Other dietary measures have been evaluated in small Diet therapy has never been compared head-to-head
metabolic trials, which in some cases validate the with pharmacologic therapy. As such, recommendations
findings of large epidemiologic studies and RCTs, but by the Panel incorporate drugs and/or diet therapy in
sometimes do not. The endpoint of these studies is the select circumstances, until the superiority of one over
effect of therapy on urinary stone risk factors, rather the other can be demonstrated and to allow
than actual stone formation, despite a clear lack of individualization for particular patients.
validation of these parameters as proxies for stone
formation. Consequently, this Guideline focused
primarily on RCTs using actual stone formation rate as
the primary outcome, although the benefit of some
therapies was inferred from the effect on urinary stone
risk factors; the later treatment recommendations were
made with a lower strength of evidence.
Other than stone passage, imaging is the most Second, stones have consistently been shown to be
sensitive way to detect stone activity, defined as either associated with more morbidity than previously
existing stone growth or new stone formation. Plain expected. Associations with coronary artery disease151,
abdominal imaging has the advantages of being readily hypertension13 and diabetes14 have led to questions
available and associated with limited radiation exposure about which of these factors are simply associations,
and lower cost compared to other modalities. While the and which, if any, are actually in the causal pathways.
sensitivity and specificity of plain abdominal If stones precede these co-morbidities, we need to
radiographs and tomograms do not approach those of understand that relationship; if stones are another
CT, plain radiography provides an acceptable method of indicator of a metabolic alteration resulting from weight
assessment of stone activity in most patients with gain, we need to advance our efforts to intervene in our
radiopaque stones. Recent reports on the use of digital patients’ diet and exercise regimens. The impression
tomograms suggest that it may provide enhanced that stones may have more lasting effects or arise from
detection of radiopaque stones.144 factors that themselves are cardiovascular risk factors
Other studies may be utilized if plain imaging does not may help patients understand that renal colic is
adequately delineate stones. Renal ultrasonography is perhaps a sentinel event.
the preferred imaging modality for most patients with
radiolucent stones, as there is no exposure to ionizing With those newsworthy trends in mind, perhaps the
radiation, and it typically is less costly than CT. effort to prevent stones needs to be broadened to other
However, specificity and sensitivity of ultrasound are populations of practitioners. Many patients never see a
inferior to CT. Ultimately, unenhanced CT imaging urologist, most never see a nephrologist, and few are
remains the most sensitive imaging modality, and if evaluated and personally counseled regarding
needed, can be performed effectively using a low dose individualized regimens to address stone prevention.
protocol in many patients. A one-year imaging interval Primary care practitioners and physician extenders are
experts at counseling weight loss, exercise and smoking
CT Computed tomography
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DISCLAIMER For this reason, the AUA does not regard technologies
or management which are too new to be addressed by
This document was written by the Medical Management this guideline as necessarily experimental or
of Kidney Stones Guidelines Panel of the American investigational.
Urological Association Education and Research, Inc.,
which was created in 2013. The Practice Guidelines
Committee (PGC) of the AUA selected the committee
chair. Panel members were selected by the chair.
Membership of the committee included urologists and