MARCH 13, 2021

TREATMENT/
MANAGEMENT:
NEPHROLITHIASIS
OTARRA, JEANA CARLA A.
BUCM- YR. II
 DIETARY MANAGEMENT : FLUID
INTAKE

• The AUA Medical Management of Kidney Stones Guideline

recommends a fluid intake that will yield a urine output of at
least 2.5 L/day for stone formers, and even more (3 L/day) for
higher risk groups such as patients with cystinuria
 DIETARY MANAGEMENT :
CALCIUM
• 1000-1200 mg/day but severe calcium restriction should be avoided
o accelerate bone loss
o lead to hyperoxaluria- interaction between calcium and oxalate in
the intestinal lumen

• Calcium in the form of food is preferred over calcium supplements

 DIETARY MANAGEMENT : OXALATE
• Increased oxalate urine
1. excessive dietary intake
2. endogenous oxalate overproduction
3. intestinal oxalate overabsorption

• normal calcium diet in association with oxalate restriction is recommended in hyperoxaluric

patients, individuals with forms of primary hyperoxaluria, or patients with malabsorptive
disorders from intestinal resection, roux-en-Y gastric bypass surgery, Crohn’s disease, celiac
sprue, pancreatitis or use of fat-malabsorbing medications
 DIETARY MANAGEMENT : CITRATE

• directly inhibit nucleation, agglomeration and growth of calcium

oxalate and/or calcium phosphate crystals and by complexing with
calcium to reduce urinary saturation of calcium salt
o Acid: increase citrate reabsorption
o Alkalosis: enhances citrate production and excretion in the renal
proximal tubule
 DIETARY MANAGEMENT : SODIUM
• Sodium increases the risk of stone formation
1. Increasing urinary calcium excretion
2. Decreasing urinary citrate

• AUA guideline recommends limiting sodium intake to no more than 2 300

mg/day
 DIETARY MANAGEMENT : PROTEIN

• Animal proteins increases the risk of stone formation

1. increasing urinary calcium and oxalate
2. reducing pH and citrate

• The recommended dietary allowance of protein is 0.8 g/kg/day, and animal

protein restriction should include all forms of meat, including beef, poultry,
and fish.
 DIETARY MANAGEMENT
• Higher calcium intake
o ↓ absorption of oxalate

• R e d u c e i n t a k e o f a n i m a l p ro te in
o ↓ excretion of calcium & uric acid
o ↑ urinary excretion of citrate

• I n c re a se i n t a k e o f p o t a ss iu m -ric h fo o d
o ↓ excretion of calcium
o ↑ urinary excretion of citrate

• R e d u c e i n t a k e o f s o d i u m a n d su c ro se
o ↓ excretion of calcium
 PHARMACOLOGICAL
MANAGEMENT
CALCIUM STONES: THIAZIDES
H y d ro c h o l o ro t h i a z i d e , M e t o l a z o n e , C h o l o ro t h i a z i d e , C h l o r t h a l i d o n e

Mechanism of Action Effects Clinical Toxicities/ Interactions

Applications
• Modest increase in
NaCl excretion • Hypertension • Hypokalemic metabolic
Inhibition of the NaCl • Some K+ wasting • Mild heart failure alkalosis
transporter in the distal • Nephrolithiasis • Hyperuricemia
• Hypokalemic • Nephrogenic • Hyperglycemia
convoluted tubule metabolic alkalosis diabetes insipidus • Hyponatremia
• Decreased urine
calcium
 PHARMACOLOGICAL
MANAGEMENT
CALCIUM STONE: THIAZIDES
Hydrocholorothiazide, Metolazone, Cholorothiazide, Chlorthalidone

• Chlorthalidone- reduce calcium oxalate stone recurrence by 50%

• Dietary sodium restriction is essential to obtain desired reduction in
urinary calcium excretion and minimize urinary potassium losses.
• potassium supplementation is recommended to prevent hypokalemia, to
avoid increased cardiovascular risk and to minimize glucose intolerance
 PHARMACOLOGICAL
MANAGEMENT
CALCIUM STONE: POTASSIUM CITRATE
H y d ro c h o l o ro t h i a z i d e , M e t o l a z o n e , C h o l o ro t h i a z i d e , C h l o r t h a l i d o n e

• used to correct hypocitraturia as the alkali load corrects the metabolic

acidosis, increases urinary citrate excretion and reduces stone recurrence
rates
• may also reduce urinary calcium excretion by decrease in bone turnover
due to systemic alkalinization, by binding of calcium by citrate in the
intestine and reducing calcium absorption or as a result of a direct effect on
the distal renal tubule
• most common side effects of potassium citrate are gastrointestinal upset,
abdominal pain, and diarrhea
 PHARMACOLOGICAL
MANAGEMENT
URIC ACID STONE

• Mainstay of prevention is increasing the urine pH by administrating alkali

o Target is a pH of 6-6.5
• Potassium citrate first-line therapy for uric acid stone formers, with sodium
alkali (sodium bicarbonate) reserved for those unable to tolerate potassium citrate
or for whom renal dysfunction or hyperkalemia precludes its use

• Allopurinol
o xanthine oxidase inhibitor that lowers serum and urinary uric acid
 PHARMACOLOGICAL
MANAGEMENT
CYSTINE STONES

• therapeutic goal in treating patients with cystinuria is to reduce cystine concentration

or raise cystine solubility

• TIOPRONIN
o 2 nd generation cystine-binding thiol drugs (CBTD), considered as the first-line of
drug
o Adverse effects include fever, gastrointestinal upset, asthenia, rash, joint aches,
loss of taste, thrombocytopenia, aplastic anemia, proteinuria, and changes in
mental status
 PHARMACOLOGICAL
MANAGEMENT
STRUVITE STONE

• Acetohydroxamic acid (AHA)

o potent urease inhibitor, decreases the risk of struvite stone formation by
preventing bacterial-induced urease from altering the urinary
o milieu.
The only thiazide available for parenteral
administration.

A. CHLORTHALIDONE B. HYDROCHLOROTHIAZIDE

C. METOLAZONE D. CHLOROTHIAZIDE
The only thiazide available for parenteral
administration.

D.
CHLOROTHIAZIDE

Katzung 14 t h ed, page 264 & 273

All of the following are major indications
for thiazide diuretics EXCEPT

A. HEART FAILURE B. NEPHROGENIC DIABETES

MELLITUS

C. HYPERTENSION D. NONE OF THE

ABOVE
All of the following are major indications
for thiazide diuretics EXCEPT

Katzung 14 t h ed, page 265

B. NEPHROGENIC DIABETES
MELLITUS
 Oxalate is a metabolic end product and the only known strategy
that reduces its endogenous production is avoiding high-dose vit C
supplements

TRUE FALSE
 Oxalate is a metabolic end product and the only known strategy
that reduces its endogenous production is avoiding high-dose vit C
supplements

Harrison’s 20 t h ed, page 2172

TRUE
One of the main risk factors for uric acid stone formation is a low
urine pH. Thus, the recommended pH goal is to prevent
its formation.
One of the main risk factors for uric acid stone formation is a low
urine pH. Thus, the recommended pH goal is 6.5 to
prevent its formation.

Harrison’s 20 t h ed, page 2172