Does medical therapy work

for kidney stones?

Dr Palaniappan Sundaram
Consultant Urologist
SKGH
Kidney stones
• Very common condition
• Lifetime risk of kidney stones 10 –
15%
• High recurrence rate 50% over the
next 10 yrs
In renal colic, who needs referral?
• Diagnostic uncertainty esp if >60yrs
• Significant fever
• Solitary kidney
• Worsening renal impairment
• Worsening pain
 Who can be managed in primary care?
• Younger patient
• Clear diagnosis within 1 week with CT KUB
• 95% of ureteric stones < 4mm pass within 40 days
• Adequate pain relief
• Recurrent stone former

Miller OF, Kane CJ. Time to stone passage for observed ureteral calculi: a guide for patient education. J Urol. 1999
Sep;162(3 Pt 1):688-90
Metabolic evaluation
• Calcium and PTH if Ca high
• Uric acid
• Urine pH
• Stone analysis
• 24hr urine testing only in recurrent/ complex stone formers
Medications
• Use NSAIDs for analgesia
• Anti spasmodics (buscopan) no benefit
Medical expulsion therapy with alpha
blockers?
• Meta analysis continue to show benefit
• Use in patients with distal ureteric stones or those >5mm
• Alpha blockers are cheap and well tolerated
• tamuslosin 400mcg ON/ alfuzosin 10mg ON given for 1 month
• SE postural hypotension
General advise
• Increase fluids to 2.5 – 3L/ day
• Reduce sodium/ salt intake
<3g/day
• Moderate protein intake
• Limit oxalate foods
• Reduce refined sugars
• Increase fruits and veg
• Limit Vit C/ calcium supplements
• Weight loss to achieve normal BMI
 Fluid advise
• Drink adequately to produce
2L urine/ day, til urine is clear
• Hence 2.5 – 3L/day of fluid
needed
• 10 – 12 glasses of water
• RCT shown reduction in
recurrences (27% vs 12%)

Borghi L, Meschi T, Amato F, Briganti A, Novarini A, Giannini A. Urinary volume, water and recurrences in idiopathic
calcium nephrolithiasis: a 5-year randomized prospective study. J Urol. 1996 Mar;155(3):839-43.
Good fluids
• Mineral water rich in
bicarbonate
• Urine pH increases
• Urine citrate
increases
• Citrus juices –
Orange, Lemonade
• Alkalinisation
 Bad fluids
• Sweetened soft drinks (6.4%
more recurrences)
• Higher amounts of fructose
• Those with phosphoric acid rather
than citric acid
• Beer
• Increase urine uric acid

Shuster J et al. Soft drink consumption and urinary stone recurrence - a randomized prevention trial. J Clin
Epidemiol 1992;45:911-6.
 Moderate calcium intake 1 – 1.2g/day
• RCT shows reduction in calcium intake
increases risk of stones (38% vs 20%)
• Hence normal intake of calcium in diet
is important
• Binds with dietary oxalate, limiting its
absorption
• Not with supplements (increases stone
risk)
• Calcium containing foods
• Dairy products like cheese, milk, yoghurt
• Broccoli
Borghi L et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med.
2002 Jan 10;346(2):77-84.
Nouvenne A et al. Effects of a low-salt diet on idiopathic hypercalciuria in calcium-oxalate stone formers: a 3-mo
randomized controlled trial. Am J Clin Nutr 2010;91:565-70.
Salt intake
• Reduce salt <3g/day
• Fast food
• Processed meats
• Canned foods
• Reduces calcium excretion in urine
Animal protein
• Restrict animal protein to 0.8 –
1g/kg/day
• Containing high acid content
• Reduces uric acid and calcium in
urine and increases urine pH and
urine citrate
Increase fruits and vegetables
• High alkali content
• Increase urine citrate
• Examples
• Orange juices high in
potassium citrate
• DASH (dietary approaches to
stop hypertension) diet rich in
fruits and veg
Types of Stones
• Calcium 80%

• Uric acid 10%

• Infection 10%
Ca oxalate
• Important causes
• Low fluid intake
• Hyperoxaluria due to high oxalate intake
• Dark chocolate
• Beetroot
• Spinach
• Tea
• Nuts
• Soy
• Hypercalciuria
• Absorptive is most common
• Reduce salt and protein intake as reducing
calcium is detrimental too
• Bone demineralisation and oxalate absorption
increased
• Hypocitraturia
Ca Phosphate
• Frequently seen in women
• Past or latent UTI
• Important causes
• Renal tubular acidosis
• Primary hyperparathyroidism
• Medullary sponge kidney
Uric acid stones
• Important causes
• Low pH
• Metabolic syndrome, Type 2
diabetes
• Hyperuricosuria due to gout, cancer
chemotherapy, diet

• High purine foods

• Shellfish
• Sardines
• Anchovies
• Organ meats
Infection/ Struvite stones
• Triple phosphate stones (Magnesium,
ammonium and calcium)
• Seen more in women than in men
• Commonly result in staghorn stones
• Important causes
• Recurrent UTI with Proteus, Klebsiella,
Pseudomonas
 Medical therapy for calcium stones
• Thiazides reduce 47% stone recurrence
in a meta analysis of 6 RCT
• For use in hypercalciuria calcium stone
formers
• Hydrochlorthiazide 25mg BD
• SE hypokalaemia, hypocitraturia

Fink HA et al. Medical management to prevent recurrent nephrolithiasis in adults: a systematic review for an American
 Medical therapy for calcium and uric acid
stones
• Potassium citrate reduces stone
recurrence in calcium stone formers
with hypocitraturia
• Uric acid stones dissolve at pH about 6
– 6.5 so it dissolves and prevents uric
acid stones
• No RCT had assessed this effect
• Potassium citrate 15 - 30mEq BD
• SE diarrhoea and GI upset

Barcelo P et al. Randomized double-blind study of potassium citrate in idiopathic hypocitraturic calcium
nephrolithiasis. J Urol 1993;150:1761-4
 Medical therapy for calcium and uric acid
stones
• Xanthine oxidase inhibitor reduces urine
uric acid when dietary changes are
ineffective
• Allopurinol 300mg OM
• SE skin rash and altered LFTs
(transaminases)
• Alternative Febuxostat 80mg OM

Goldfarb D et al. Randomized controlled trial of febuxostat versus allopurinol or placebo in individuals with higher urinary
uric acid excretion and calcium stones. Clin J Am Soc Nephrol 2013;8:1960-7.
Medical therapy for infection/ struvite stones
• Urease producing bacteria that cause UTI need to be treated
aggressively after complete removal of stone
Take home message
• Stones, in general, do not respond to dissolution therapy unless uric
acid stones
• Medical expulsion remains controversial but often used in ureteric
stones as they causes minimal side effects
• Lifestyle and dietary intervention is however most important in
recurrent stone formers for prevention
• Thiazides and potassium citrate are used in recurrent calcium stone
formers