brand logo

Am Fam Physician. 2013;88(9):609-610

Clinical Question

What is the best approach to prevent recurrent kidney stones?

Bottom Line

Increased fluid intake or decreased soft drink intake may prevent further kidney stones in patients with a single episode of a calcium stone, but other dietary interventions are not effective. Thiazides and citrates with increased fluid intake decrease recurrence in patients with multiple past stones, as does allopurinol (Zyloprim) in patients with high uric acid levels. Combinations—allopurinol and citrates with a thiazide—are no more effective than thiazides alone. (Level of Evidence = 1a)


The researchers conducting this systematic review searched several databases, including the Cochrane library, and identified 28 English-language randomized trials that compared approaches to prevent recurrent kidney stones. The studies primarily evaluated patients with calcium stones, and included patients with a single incidence or with multiple recurrences. One reviewer abstracted the data and a second author checked for accuracy. Two reviewers independently rated the quality of the identified research. For patients with a single recurrence, low-quality evidence showed that increased fluid intake (greater than 2 to 2.5 L per day) or reduced soft drink consumption halved the recurrence of stones compared with no treatment. Decreased-protein diets or high-fiber diets and multicomponent diet changes (high fiber, low purine, and low protein) were all ineffective. In patients with recurrent calcium stones, six moderate-quality studies showed that thiazide treatment, combined with high fluid and decreased oxalate intake, decreased stone recurrence by one-half (relative risk = 0.52; 95% confidence interval, 0.39 to 0.69) and decreased rates of lithotripsy. Treatment with citrates (potassium citrate, potassium-magnesium citrate, or potassium-sodium citrate) and increased fluid intake also decreased composite stone recurrence (relative risk = 0.25; 95% confidence interval, 0.14 to 0.44). Allopurinol decreases composite stone recurrence in patients with baseline hyperuricemia or hyperuricosuria. Combinations with thiazides were no more effective than a thiazide alone.

Study Information

Study design: Systematic review

Setting: Outpatient (any)

Funding source: Government

Reference:FinkHAWiltTJEidmanKEet alMedical management to prevent recurrent nephrolithiasis in adults: a systematic review for an American College of Physicians clinical guideline [published correction appears in Ann Intern Med. 2013;159(3):230–232]. Ann Intern Med. 2013; 158( 7): 535– 543.

POEMs (patient-oriented evidence that matters) are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, see Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to

This series is coordinated by Natasha J. Pyzocha, DO, contributing editor.

A collection of POEMs published in AFP is available at

Continue Reading

More in AFP

More in PubMed

Copyright © 2013 by the American Academy of Family Physicians.

This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.  See permissions for copyright questions and/or permission requests.