Preventing Recurrent Nephrolithiasis in Adults.

[Argirios Argiriou]

November 18, 2014
Preventing 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). Εγγραφή ή Είσοδος)

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