Investigation and Management of Renal Stone Disease

Holly R. Mabillard; Charles R. V. Tomson

Disclosures

Nephrol Dial Transplant. 2017;32(12):1984-1986. 

In This Article

Treatment

Treatments to reduce kidney stone recurrence have common and stone-specific aspects. All stone formers should be advised to maintain a high fluid intake, night and day, sufficient to result in straw-coloured urine.

Calcium Oxalate and Phosphate Stones (not Primary or Enteric Hyperoxaluria)

  • Restrict animal protein.

  • Restrict sodium chloride intake (notably sodium chloride increases calciuria, whereas sodium bicarbonate does not).

  • Thiazide-type diuretics halve recurrence rate,[6] with or without amiloride (adds a weak anti-calciuretic action and may reduce adverse effects of potassium depletion).

  • Citrate supplementation [either dietary (e.g. citrus juices)[6] or potassium citrate] should be considered, particularly in hypocitraturia.[7]

  • Allopurinol reduces stone recurrence among patients with calcium oxalate stones and high 24-h urine uric acid excretion; Febuxostat has similar effects but has not been tested in outcome trials. Higher urine uric acid concentrations reduce calcium oxalate solubility.[8]

Enteric Hyperoxaluria

No RCT evidence exists, but the following are logical:[9]

  • Restriction of dietary oxalate.

  • Use of oxalate binders with meals (most phosphate binders also bind oxalate).

  • Bile acid sequestrants (reduce colonic permeability to oxalate; colestyramine and colestipol may also bind oxalate).

  • Pancreatic enzyme replacement, if indicated.

  • Restoration of normal bowel anatomy after malabsorptive bariatric surgery.

Primary Hyperoxaluria

  • Correct hypercalciuria, hyperuricosuria and hypocitraturia.

  • No proven role for dietary oxalate restriction.

  • High-dose pyridoxine supplementation is effective in some Type 1 patients, depending on the causative mutation;[10] watch for neuropathy.

  • Consider liver transplant in patients with severe phenotypes (typically Type 1, some Type 2), particularly if stone formation has caused kidney failure and the patient also needs a kidney transplant.

Cystinuria

  • Restrict animal protein (reduces acid load and methionine intake).

  • Restrict sodium intake.

  • Use potassium citrate to achieve urine pH ≥ 7; if not tolerated, use sodium bicarbonate (effects on urine pH outweigh effects of sodium load on cystine excretion).

  • Cystine-chelating drugs—penicillamine and tiopronin. Both require careful counselling about potential adverse effects.[7] Titrate to keep urine cystine concentration <1000 μmol/L.

Uric Acid Stones

  • Treat diarrhoea/high ileostomy output.

  • Restrict animal protein intake (reduces acid load).

  • Weight loss (probably restores urine buffering capacity).

  • Sodium bicarbonate, adjust dose to achieve pre-meal urine dipstick pH >7.

  • Allopurinol/Febuxostat contribute very little if urine remains acid.[4]

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