Management of kidney stone

Management of kidney stones other than surgery

1. MANAGEMENT OF KIDNEY STONES

2. Introduction A kidney stone is a solid piece of material that forms in a kidney when substances that are normally found in the urine become highly concentrated Kidney stones are one of the most common disorders of the urinary tract One in every 20 people develop kidney stones at some point in their life

3. Symptoms Intermittent colicky flank pain – radiation to lower abdomen or groin Nausea and vomiting Dysuria Urinary urgency Restlessness Hematuria

4. Risk factors Family history Hypercalciuria Cystic kidney disease Hyperparathyroidism Renal tubular acidosis Dehydration from low fluid intake High dietary intake of animal protein Crohn’s disease

5. Diagnosis Detailed medical and dietary history Medical conditions Nutritional factors in diet Medications ( probenecid, some protease inhibitors, lipase inhibitors, triamterene, chemotherapy, vitamin C, vitamin D) Serum chemistries electrolytes (sodium, potassium, chloride, bicarbonate), calcium, creatinine and uric acid Urinanalysis Dipstick and microscopic evaluation Review of imaging studies Plain radiography Ultrasonogrphy CT 24 hour urine profile Stone analysis

6. Management Pain relief – IV NSAIDs, opioids Diet therapy Pharmacologic therapy

7. Diet therapy Fluid intake that will achieve a urine volume of at least 2.5 liters daily Calcium stones and relatively high urinary calcium – limit sodium intake and consume 1,000-1,200 mg per day of dietary calcium Calcium oxalate stones and relatively high urinary oxalate - limit intake of oxalate-rich foods and maintain normal calcium consumption Calcium  stones and relatively low urinary citrate - increase intake of fruits and vegetables and limit non-dairy animal protein Uric acid stones / calcium stones and relatively high urinary uric acid - limit intake of non-dairy animal protein Cystine   stones - limit sodium and protein intake

8. Pharmacologic therapy Thiazide diuretics - high or relatively high urine calcium and recurrent calcium  stones Potassium citrate - recurrent calcium stones and low or relatively low urinary citrate Allopurinol - recurrent calcium oxalate stones who have hyperuricosuria and normal urinary calcium Thiazide diuretics and/or potassium citrate - recurrent calcium stones in whom other metabolic abnormalities are absent or have been appropriately addressed and stone formation persists Potassium citrate - uric acid and cystine  stones to raise urinary pH to an optimal level Cystine -binding thiol drugs ( tiopronin ) - cystine  stones who are unresponsive to dietary modifications and urinary alkalinization , or have large recurrent  stone burdens Acetohydroxamic acid (AHA ) -  residual or recurrent struvite stones only after surgical options have been exhausted Should not routinely offer allopurinol as first-line therapy to patients with uric acid stones

9. Other procedures Lithotripsy Percutaneous nephrolithotomy Ureteroscopic surgery

10. Follow up 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 After the initial follow-up, should obtain a single 24-hour urine specimen annually or with greater frequency, depending on stone activity, to assess patient adherence and metabolic response Obtain periodic blood testing to assess for adverse effects in patients on pharmacological therapy Obtain a repeat stone analysis, when available, especially in patients not responding to treatment

11. Monitor patients with struvite stones for reinfection with urease-producing organisms and utilize strategies to prevent such occurrences Periodically obtain follow-up imaging studies to assess for stone growth or new stone formation based on stone  activity

12. Reference http://www.guideline.gov/content.aspx?id=48229&search=kidney+stone http://www.niddk.nih.gov/health-information/health-topics/urologic-disease/kidney-stones-in-adults/Pages/facts.aspx