November 18, 2014Preventing Recurrent Nephrolithiasis in Adults.Allan S. Brett, MD reviewing Qaseem A et al. Ann Intern Med 2014 Nov 4.
Advise patients to drink at least 2 L daily; consider drug therapy for patients with “active” stone formation.Sponsoring Organization: American College of Physicians (ACP)
Target Audience: Primary care clinicians
Background and Objective
Clinicians are expected to advise patients with symptomatic nephrolithiasis on strategies to prevent recurrent episodes. The ACP developed this guideline based on a review of evidence supporting dietary and pharmacologic interventions.
Key Recommendations
For preventing recurrent nephrolithiasis, the ACP recommends:
Increased fluid intake to achieve 2 L of urine output daily (weak recommendation; low-quality evidence).
Drug therapy with a
thiazide diuretic,
citrate, or
allopurinol for patients with active disease despite increased fluid intake (weak recommendation; moderate-quality evidence). “Active disease” was not defined, but it presumably means multiple recurrences over relatively short periods.
The authors also found low-quality evidence to support
abstaining from soft drinks acidified by phosphoric acid (e.g., colas). None of the reviewed studies addressed low-oxalate diets.
Comment
The absence of high-quality evidence to inform physicians about treating patients with this very common affliction is striking. The guideline authors note that
80% of stones in adults are calcium stones, but oddly, the authors don't distinguish clearly between calcium and uric acid stones in their discussion. The above-noted drug therapies are all directed toward calcium stones: Thiazides reduce urinary calcium excretion, citrate helps to inhibit stone formation, and allopurinol prevents calcium stone formation by unclear mechanisms.Citation(s):
Qaseem A et al.
Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2014 Nov 4; 161:659. (Δεν είναι ορατοί οι σύνδεσμοι (links).
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