Evaluation and Management of Nephrolithiasis in the Aging Population With Chronic Kidney Disease

Anna L Zisman; Fredric L Coe; Elaine M Worcester

Disclosures

Aging Health. 2011;7(3):423-433. 

In This Article

Conclusion & Future Perspective

Nephrolithiasis is an increasingly prevalent disorder in the elderly that is associated with multiple comorbid conditions such as hypertension, coronary artery disease, diabetes and CKD. Care of patients with stone disease and CKD is complicated by the need for closer monitoring with medical therapy, as well as by decreased stone-free rates with a greater frequency of complications with ESWL than in younger patients, for example. Bone disease in hypercalciuria and its interplay with the bone complications of aging-related osteoporosis and of CKD add an additional wrinkle in the proper management of these complicated patients.

As previously noted, much remains unknown regarding the optimal care of the geriatric stone former. With regard to medical therapy, for instance, randomized controlled studies are needed to determine the most successful treatment strategy for uric acid nephrolithiasis specifically in the elderly population. Febuxostat is a promising inhibitor of xanthine oxidase that has yet to be studied as a secondary preventative measure for either uric acid nephrolithiasis or for hyperuricosuric calcium stone disease. Also, randomized controlled studies are needed to delineate whether alkali supplementation with or without thiazide should become standard of care in the elderly calcium stone former to promote bone health, as early returns indicate improved BMD in this population as previously described. Furthermore, the impact on fracture, not BMD alone, needs to be established in controlled studies as this complication of stone disease is often overlooked. In fact, perhaps the most intriguing questions to be answered in the next decade deal with the stone-related bone disease and its relationship to the frequently coexistent bone diseases of aging such as osteoporosis and CKD. A female with decreased BMD secondary to hypercalciuria in her 30s, for example, enters menopause at a great disadvantage with already decreased bone mass. Perhaps there is also a history of poorly controlled diabetes and stage 3 CKD, each with inherent negative influences on bone health. Physiological studies with the pathological correlations via bone biopsy specimens need to be undertaken to determine not only the predominant physiology in such a patient, but also the impact of various commonly used therapies. With decreased bone formation being a key mechanism in hypercalciuric bone disease, does suppression of bone turnover with bisphosphonates once menopausal provide any benefit in fracture prevention, even if improved BMD is confirmed? These unanswered questions, along with many others, underscore the great need for future research not only in nephrolithiasis as a whole, but with specific emphasis on the rapidly expanding and unique population of stone-forming elderly.

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