Kidney Stones: Treatment and Prevention

 

Am Fam Physician. 2019 Apr 15;99(8):490-496.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/kidney-stones.

Author disclosure: No relevant financial affiliations.

Kidney stones are a common disorder, with an annual incidence of eight cases per 1,000 adults. During an episode of renal colic, the first priority is to rule out conditions requiring immediate referral to an emergency department, then to alleviate pain, preferably with a nonsteroidal anti-inflammatory drug. The diagnostic workup consists of urinalysis, urine culture, and imaging to confirm the diagnosis and assess for conditions requiring active stone removal, such as urinary infection or a stone larger than 10 mm. Conservative management consists of pain control, medical expulsive therapy with an alpha blocker, and follow-up imaging within 14 days to monitor stone position and assess for hydronephrosis. Asymptomatic kidney stones should be followed with serial imaging, and should be removed in case of growth, symptoms, urinary obstruction, recurrent infections, or lack of access to health care. All patients with kidney stones should be screened for risk of stone recurrence with medical history, basic laboratory evaluation, and imaging. Lifestyle modifications such as increased fluid intake should be recommended for all patients, and thiazide diuretics, allopurinol, or citrates should be prescribed for patients with recurrent calcium stones. Patients at high risk of stone recurrence should be referred for additional metabolic assessment, which can serve as a basis for tailored preventive measures.

The prevalence of nephrolithiasis (kidney stones) is increasing in the United States, from one in 20 adults in 1994 to one in 11 adults in 2010.1,2 Worldwide, it is also increasing in Europe and is even higher in the hot-climate “stone belt” extending from the southeastern United States to northern Australia.3,4  Table 1 lists the incidence of different types of kidney stones among children and adults in developed countries.38 Most are of noninfectious etiology and are associated with low fluid intake, hot climate, and certain comorbidities and risk factors (e.g., hypertension; gout; obesity; nonalcoholic fatty liver disease; excessive intake of protein, carbohydrates, and sodium).1,4,911 Increasing exposure to these risk factors may explain the rising incidence of kidney stones and their prevalence in men, non-Hispanic whites, and persons with low socioeconomic status.1,3,4,9 The annual incidence of kidney stones is about eight cases per 1,000 adults and peaks around midlife in developed countries.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Nonsteroidal anti-inflammatory drugs are the first choice for pain relief in patients with kidney stones.

A

5, 13, 16, 17

Recommendation from consensus guideline based on meta-analysis of randomized controlled trials

Alpha blockers are the first choice for medical expulsive therapy in patients with kidney stones.

A

5, 27

Recommendation from consensus guideline based on meta-analysis of randomized controlled trials

Increasing fluid intake does not relieve pain or accelerate passage of kidney stones.

B

19

One randomized controlled trial for each outcome

Patients at low risk of stone recurrence should not routinely undergo extensive metabolic evaluation.

C

15, 31, 38

Recommendation from consensus guidelines

Patients should increase daily fluid intake to 2.5 to 3 L per day to prevent recurrence of kidney stones.

A

15, 31, 3840

Recommendation from consensus guideline based on meta-analysis of randomized controlled trials

Thiazide diuretics, potassium citrate, or allopurinol should be prescribed after recurrence of calcium stones, even in the absence of metabolic abnormalities.

A

15, 31, 38, 39, 41

Recommendation from consensus guideline based on meta-analysis of randomized controlled trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferencesComments

Nonsteroidal anti-inflammatory drugs are the first choice for pain relief in patients with kidney stones.

A

5, 13, 16, 17

Recommendation from consensus guideline based on meta-analysis of randomized controlled trials

Alpha blockers are the first choice for medical expulsive therapy in patients with kidney stones.

A

5, 27

Recommendation from consensus guideline based on meta-analysis of randomized controlled trials

Increasing fluid intake does not relieve pain or accelerate passage of kidney stones.

B

19

One randomized controlled trial for each outcome

Patients at low risk of stone recurrence should not routinely undergo extensive metabolic evaluation.

C

15, 31, 38

Recommendation from consensus guidelines

Patients should increase daily fluid intake to 2.5 to 3 L per day to prevent

The Authors

show all author info

LEONARDO FERREIRA FONTENELLE, MD, MPH, PhD, is a professor at Universidade Vila Velha Medical School, Vila Velha, Espírito Santo, Brazil....

THIAGO DIAS SARTI, MD, MPH, PhD, is a professor in the Department of Social Medicine at the Health Sciences Center of Universidade Federal do Espírito Santo, Vitória.

Address correspondence to Leonardo Ferreira Fontenelle, MD, MPH, PhD, Universidade Vila Velha, Rua Sao Joao, No. 48, Vila Velha, Espírito Santo, Brazil 29101-420 (e-mail: leonardof@leonardof.med.br). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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