Medical Management of Kidney Stones
Publication Date: July 31, 2014
Last Updated: March 14, 2022
Guideline Statements
Evaluation
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)
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Clinicians should obtain serum intact parathyroid hormone level as part of the screening evaluation if primary hyperparathyroidism is suspected. (Clinical Principle)
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When a stone is available, clinicians should obtain a stone analysis at least once. (Clinical Principle)
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Clinicians should obtain or review available imaging studies to quantify stone burden.
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Clinicians should perform additional metabolic testing in high-risk or interested first-time stone formers and recurrent stone formers. (Strong, B)
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Metabolic testing should consist of one or two 24-hour urine collections obtained on a random diet and analyzed at minimum for total volume, pH, calcium, oxalate, uric acid, citrate, sodium, potassium and creatinine. (Expert Opinion)
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Clinicians should not routinely perform “fast and calcium load” testing to distinguish among types of hypercalciuria. (Moderate, C)
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Diet Therapies
Clinicians should recommend to all stone formers a fluid intake that will achieve a urine volume of at least 2.5 liters daily. (Strong, B)
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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. (Strong, B)
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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)
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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)
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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.
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Clinicians should counsel patients with cystine stones to limit sodium and protein intake.
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Pharmacologic Therapies
Clinicians should offer thiazide diuretics to patients with high or relatively high urine calcium and recurrent calcium stones. (Strong, B)
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Clinicians should offer potassium citrate therapy to patients with recurrent calcium stones and low or relatively low urinary citrate. (Strong, B)
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Clinicians should offer allopurinol to patients with recurrent calcium oxalate stones who have hyperuricosuria and normal urinary calcium. (Strong, B)
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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. (Strong, B)
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Clinicians should offer potassium citrate to patients with uric acid and cystine stones to raise urinary pH to an optimal level. (Expert Opinion)
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Clinicians should not routinely offer allopurinol as first-line therapy to patients with uric acid stones. (Expert Opinion)
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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)
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Clinicians may offer acetohydroxamic acid to patients with residual or recurrent struvite stones only after surgical options have been exhausted. (Conditional, B)
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Follow-up
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)
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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)
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Clinicians should obtain periodic blood testing to assess for adverse effects in patients on pharmacological therapy. (Strong, A)
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Clinicians should obtain a repeat stone analysis, when available, especially in patients not responding to treatment. (Expert Opinion)
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Clinicians should monitor patients with struvite stones for reinfection with urease-producing organisms and utilize strategies to prevent such occurrences. (Expert Opinion)
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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 computerized tomography). (Expert Opinion)
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Recommendation Grading
Overview
Title
Medical Management of Kidney Stones
Authoring Organization
American Urological Association
Publication Month/Year
July 31, 2014
Last Updated Month/Year
January 9, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
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.
Inclusion Criteria
Female, Male, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient
Intended Users
Radiology technologist, nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D053040 - Nephrolithiasis, D052878 - Urolithiasis
Keywords
Nephrolithiasis, kidney stones, urolithiasis, hypercalciuria
Supplemental Methodology Resources
Methodology
Number of Source Documents
156
Literature Search Start Date
December 31, 2006
Literature Search End Date
October 31, 2012