Kidney stone medical therapy: Difference between revisions
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{{Kidney stone}} | {{Kidney stone}} | ||
{{CMG}}; {{AE}} | {{CMG}}; {{AE}}{{ADS}} | ||
==Overview== | ==Overview== | ||
The treatment of nephrolithiasis involves different measures e.g non pharmacological measures consisting of increased fluid intake, straining an dietary restrictions. Pharmacological measures include pain relief using NSAIDs and opioids., helping passage of stone spontaneously with drugs like [[tamsulosin]] and [[nifedipine]]. The treatment of underlying cause and being specific to type of stones is very important.It involves treating [[Hyperparathyroidism medical therapy|primary hyperparathyroidism]] and [[Renal tubular acidosis]]. For those having high urinary calcium, [[Hydrochlorothiazide]] or [[Chlorthalidone]] are used. For recurrent stones and high urine [[uric acid]], [[Allopurinol]] is used. For recurrent stones and [[hypocitraturia]], [[Potassium citrate]] is sued to alkalinize the urine. For uric acid stones, alkalinizing urine with [[potassium citrate]]/[[potassium bicarbonate]] is done and if needed [[Allopurinol]] is also used. For struvite stones, medical therapy is not of much help, although urease inhibitors such as [[Acetohydroxamic Acid|acetohydroxamic acid]] can be given in urease +ve etiology. For cysteine stones, again alkalinizing urine helps along with [[Tiopronin]]. The Urological consult is needed when stone >10 mm in diameter, uncontrolled pain, [[Anuria]], or there is [[Acute kidney injury]]. | |||
The | |||
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==Medical Therapy== | ==Medical Therapy== | ||
===Nephroliithiasis=== | ===Nephroliithiasis=== | ||
| Line 40: | Line 12: | ||
* Straining | * Straining | ||
** Stone ≤5 mm can pass spontaneously. | ** Stone ≤5 mm can pass spontaneously. | ||
** Passage of stone also depends on the site of stone | ** Passage of stone also depends on the site of stone<ref name="pmid10458343">{{cite journal |vauthors=Miller OF, Kane CJ |title=Time to stone passage for observed ureteral calculi: a guide for patient education |journal=J. Urol. |volume=162 |issue=3 Pt 1 |pages=688–90; discussion 690–1 |date=September 1999 |pmid=10458343 |doi= |url=}}</ref> | ||
* Evaluating diet as per the composition of stones | * Evaluating diet as per the composition of stones, for example: | ||
** | ** Diet containing excess proteins can precipitate uric acid stones | ||
* | ** Diet containing excess [[phosphorus]] can cause struvite stone | ||
==== '''Pharmacological measures''' ==== | ==== '''Pharmacological measures''' ==== | ||
| Line 77: | Line 49: | ||
===== Type specific treatment ===== | ===== Type specific treatment ===== | ||
Treating the underlying cause is very important. | Treating the underlying cause is very important. | ||
* Calcium stones | * '''Calcium stones''' | ||
**Treating [[Hyperparathyroidism medical therapy|primary hyperparathyroidism]] | **Treating [[Hyperparathyroidism medical therapy|primary hyperparathyroidism]] | ||
**Treating [[Renal tubular acidosis]] | **Treating [[Renal tubular acidosis]] | ||
**For those having high urinary calcium | **For those having high urinary calcium: | ||
***Preferred regimen (1): [[Hydrochlorothiazide]] 50 mg PO q24h<ref name="pmid24857648">{{cite journal |vauthors=Pearle MS, Goldfarb DS, Assimos DG, Curhan G, Denu-Ciocca CJ, Matlaga BR, Monga M, Penniston KL, Preminger GM, Turk TM, White JR |title=Medical management of kidney stones: AUA guideline |journal=J. Urol. |volume=192 |issue=2 |pages=316–24 |date=August 2014 |pmid=24857648 |doi=10.1016/j.juro.2014.05.006 |url=}}</ref> | ***Preferred regimen (1): [[Hydrochlorothiazide]] 50 mg PO q24h<ref name="pmid24857648">{{cite journal |vauthors=Pearle MS, Goldfarb DS, Assimos DG, Curhan G, Denu-Ciocca CJ, Matlaga BR, Monga M, Penniston KL, Preminger GM, Turk TM, White JR |title=Medical management of kidney stones: AUA guideline |journal=J. Urol. |volume=192 |issue=2 |pages=316–24 |date=August 2014 |pmid=24857648 |doi=10.1016/j.juro.2014.05.006 |url=}}</ref> | ||
***Alternative regimen (1): [[Chlorthalidone]] 25 mg PO q24h<ref name="pmid24857648" /> | ***Alternative regimen (1): [[Chlorthalidone]] 25 mg PO q24h<ref name="pmid24857648" /> | ||
*Uric acid stones | **For recurrent stones and high urine [[uric acid]]: | ||
** | ***Preferred regimen (1): [[Allopurinol]] 200-300 mg PO in single or divided doses | ||
*Struvite stones | **For recurrent stones and [[hypocitraturia]]:<ref name="pmid37842842">{{cite journal |vauthors=Pak CY, Sakhaee K, Fuller C |title=Successful management of uric acid nephrolithiasis with potassium citrate |journal=Kidney Int. |volume=30 |issue=3 |pages=422–8 |date=September 1986 |pmid=3784284 |doi= |url=}}</ref> | ||
** | ***Preferred regimen (1): [[Potassium citrate]] 15 mEq extended release q12h in mild-to-moderate hypocitraturia (>150 mg urinary citrate); maximum dose: 100 mEq/day | ||
*Cysteine stones | ***Alternative regimen (1): [[Potassium citrate]] 10 mEq extended release q8h | ||
** | ***Preferred regimen (2): [[Potassium citrate]] 30 mEq extended release q12h in severe hypocitraturia (<150 mg/day urinary citrate); maximum dose: 100 mEq/day | ||
***Alternative regimen (2): [[Potassium citrate]] 20 mEq extended release q8h | |||
*'''Uric acid stones''' | |||
**Alkalinizing urine with [[potassium citrate]]<ref name="pmid37842842" />/[[potassium bicarbonate]]<ref name="pmid19911683">{{cite journal |vauthors=Trinchieri A, Esposito N, Castelnuovo C |title=Dissolution of radiolucent renal stones by oral alkalinization with potassium citrate/potassium bicarbonate |journal=Arch Ital Urol Androl |volume=81 |issue=3 |pages=188–91 |date=September 2009 |pmid=19911683 |doi= |url=}}</ref> as above<ref name="pmid20425021">{{cite journal |vauthors=Kenny JE, Goldfarb DS |title=Update on the pathophysiology and management of uric acid renal stones |journal=Curr Rheumatol Rep |volume=12 |issue=2 |pages=125–9 |date=April 2010 |pmid=20425021 |doi=10.1007/s11926-010-0089-y |url=}}</ref> | |||
**Preferred regimen (1): [[Allopurinol]] 200-300 mg PO in single or divided doses<ref name="pmid20425021" /> | |||
*'''Struvite stones''' | |||
**Medical therapy is not of much help, although urease inhibitors can be given in urease +ve etiology | |||
***Preferred regimen (1): [[Acetohydroxamic Acid]] 250 mg PO q6-8h for a total daily dose of 10 to 15 mg/kg/day; maximum dose: 1500 mg daily<ref>Wong H, Riehl RL, Griffith DP. Medical management and prevention of struvite stones. In: Kidney stones: Medical and surgical management, Coe FL, Favis MJ, Pak CC, et al (Eds), Lippincott-Raven, Philadelphia 1996.</ref> | |||
*'''Cysteine stones''' | |||
**Alkalinizing urine | |||
**Preferred regimen (1):[[Tiopronin]] 800 mg/day PO in 3 divided doses; average dose: 1000 mg q24h<ref name="pmid24857648" /> | |||
===== Urologic consult ===== | ===== Urologic consult ===== | ||
Latest revision as of 01:47, 18 June 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]
Overview
The treatment of nephrolithiasis involves different measures e.g non pharmacological measures consisting of increased fluid intake, straining an dietary restrictions. Pharmacological measures include pain relief using NSAIDs and opioids., helping passage of stone spontaneously with drugs like tamsulosin and nifedipine. The treatment of underlying cause and being specific to type of stones is very important.It involves treating primary hyperparathyroidism and Renal tubular acidosis. For those having high urinary calcium, Hydrochlorothiazide or Chlorthalidone are used. For recurrent stones and high urine uric acid, Allopurinol is used. For recurrent stones and hypocitraturia, Potassium citrate is sued to alkalinize the urine. For uric acid stones, alkalinizing urine with potassium citrate/potassium bicarbonate is done and if needed Allopurinol is also used. For struvite stones, medical therapy is not of much help, although urease inhibitors such as acetohydroxamic acid can be given in urease +ve etiology. For cysteine stones, again alkalinizing urine helps along with Tiopronin. The Urological consult is needed when stone >10 mm in diameter, uncontrolled pain, Anuria, or there is Acute kidney injury.
Medical Therapy
Nephroliithiasis
Non pharmacological measures
- Increased fluid intake
- Straining
- Stone ≤5 mm can pass spontaneously.
- Passage of stone also depends on the site of stone[1]
- Evaluating diet as per the composition of stones, for example:
- Diet containing excess proteins can precipitate uric acid stones
- Diet containing excess phosphorus can cause struvite stone
Pharmacological measures
- Both NSAIDS and opiods are seen efficacious for the pain relief related to nephrolithiasis.[2]
- The combination works in effective pain relief.[3]
- NSAIDS should be stopped before undergoing Extracorporeal shockwave lithotripsy to reduce the risk of bleeding.
Pain relief
Non steroidal anti inflammatory drugs (NSAIDS)
- Parenteral regimen
- Oral regimen
- Preferred regimen (1): Ketorolac 20 mg, followed by 10 mg q4-6 h as needed; maximum: 40 mg/day; follows the parenteral dose (contraindicated in patients with renal failure)
- Alternative regimen (1):Indomethacin 20 mg PO q8h
- Alternative regimen (2):Indomethacin 40 mg PO q8-12h
Opioids
- Parenteral regimen
- Preferred regimen (1): Morphine 5 mg IV q4h as needed
Passage of stone
- The passage of stones depend on the size and location of the stone.[4][5][6]
- Stones ≤5 mm in diameter pass spontaneously.
- It decrease as the size grows and not likely for sizes ≥10 mm in diameter.
- Stones which are proximal are less likely to pass spontaneously.
- Oral regimen
- Preferred regimen (1):Tamsulosin 0.4 mg PO q24h until stone passage occurs or for up to 30 days[7]
- Preferred regimen (2):Used as adjuvant in Extracorporeal shockwave lithotripsy; Tamsulosin 0.4 mg PO q24h for 14 days to 3 months[8]
- Preferred regimen (3): Nifedipine 10-30 mg PO q8h for up to 4 weeks or until expulsion of lower stones[9]
Type specific treatment
Treating the underlying cause is very important.
- Calcium stones
- Treating primary hyperparathyroidism
- Treating Renal tubular acidosis
- For those having high urinary calcium:
- Preferred regimen (1): Hydrochlorothiazide 50 mg PO q24h[10]
- Alternative regimen (1): Chlorthalidone 25 mg PO q24h[10]
- For recurrent stones and high urine uric acid:
- Preferred regimen (1): Allopurinol 200-300 mg PO in single or divided doses
- For recurrent stones and hypocitraturia:[11]
- Preferred regimen (1): Potassium citrate 15 mEq extended release q12h in mild-to-moderate hypocitraturia (>150 mg urinary citrate); maximum dose: 100 mEq/day
- Alternative regimen (1): Potassium citrate 10 mEq extended release q8h
- Preferred regimen (2): Potassium citrate 30 mEq extended release q12h in severe hypocitraturia (<150 mg/day urinary citrate); maximum dose: 100 mEq/day
- Alternative regimen (2): Potassium citrate 20 mEq extended release q8h
- Uric acid stones
- Alkalinizing urine with potassium citrate[11]/potassium bicarbonate[12] as above[13]
- Preferred regimen (1): Allopurinol 200-300 mg PO in single or divided doses[13]
- Struvite stones
- Medical therapy is not of much help, although urease inhibitors can be given in urease +ve etiology
- Preferred regimen (1): Acetohydroxamic Acid 250 mg PO q6-8h for a total daily dose of 10 to 15 mg/kg/day; maximum dose: 1500 mg daily[14]
- Medical therapy is not of much help, although urease inhibitors can be given in urease +ve etiology
- Cysteine stones
Urologic consult
- The Urological consult is needed in the following:[15][16]
- Stone >10 mm in diameter
- Uncontrolled pain
- Anuria
- Acute kidney injury
- Acute abdomen features like nausea and vomiting
- Signs of sepsis
References
- ↑ Miller OF, Kane CJ (September 1999). "Time to stone passage for observed ureteral calculi: a guide for patient education". J. Urol. 162 (3 Pt 1): 688–90, discussion 690–1. PMID 10458343.
- ↑ Holdgate A, Pollock T (June 2004). "Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic". BMJ. 328 (7453): 1401. doi:10.1136/bmj.38119.581991.55. PMC 421776. PMID 15178585.
- ↑ Cordell WH, Wright SW, Wolfson AB, Timerding BL, Maneatis TJ, Lewis RH, Bynum L, Nelson DR (August 1996). "Comparison of intravenous ketorolac, meperidine, and both (balanced analgesia) for renal colic". Ann Emerg Med. 28 (2): 151–8. PMID 8759578.
- ↑ Miller OF, Kane CJ (September 1999). "Time to stone passage for observed ureteral calculi: a guide for patient education". J. Urol. 162 (3 Pt 1): 688–90, discussion 690–1. PMID 10458343.
- ↑ Parekattil SJ, Kumar U, Hegarty NJ, Williams C, Allen T, Teloken P, Leitão VA, Netto NR, Haber GP, Ballereau C, Villers A, Streem SB, White MD, Moran ME (February 2006). "External validation of outcome prediction model for ureteral/renal calculi". J. Urol. 175 (2): 575–9. doi:10.1016/S0022-5347(05)00244-2. PMID 16406999.
- ↑ Coll DM, Varanelli MJ, Smith RC (January 2002). "Relationship of spontaneous passage of ureteral calculi to stone size and location as revealed by unenhanced helical CT". AJR Am J Roentgenol. 178 (1): 101–3. doi:10.2214/ajr.178.1.1780101. PMID 11756098.
- ↑ Ahmed AF, Al-Sayed AY (March 2010). "Tamsulosin versus Alfuzosin in the Treatment of Patients with Distal Ureteral Stones: Prospective, Randomized, Comparative Study". Korean J Urol. 51 (3): 193–7. doi:10.4111/kju.2010.51.3.193. PMC 2855456. PMID 20414396.
- ↑ Vicentini FC, Mazzucchi E, Brito AH, Chedid Neto EA, Danilovic A, Srougi M (November 2011). "Adjuvant tamsulosin or nifedipine after extracorporeal shock wave lithotripsy for renal stones: a double blind, randomized, placebo-controlled trial". Urology. 78 (5): 1016–21. doi:10.1016/j.urology.2011.04.062. PMID 21802124.
- ↑ Ye Z, Yang H, Li H, Zhang X, Deng Y, Zeng G, Chen L, Cheng Y, Yang J, Mi Q, Zhang Y, Chen Z, Guo H, He W, Chen Z (July 2011). "A multicentre, prospective, randomized trial: comparative efficacy of tamsulosin and nifedipine in medical expulsive therapy for distal ureteric stones with renal colic". BJU Int. 108 (2): 276–9. doi:10.1111/j.1464-410X.2010.09801.x. PMID 21083640.
- ↑ 10.0 10.1 10.2 Pearle MS, Goldfarb DS, Assimos DG, Curhan G, Denu-Ciocca CJ, Matlaga BR, Monga M, Penniston KL, Preminger GM, Turk TM, White JR (August 2014). "Medical management of kidney stones: AUA guideline". J. Urol. 192 (2): 316–24. doi:10.1016/j.juro.2014.05.006. PMID 24857648.
- ↑ 11.0 11.1 Pak CY, Sakhaee K, Fuller C (September 1986). "Successful management of uric acid nephrolithiasis with potassium citrate". Kidney Int. 30 (3): 422–8. PMID 3784284.
- ↑ Trinchieri A, Esposito N, Castelnuovo C (September 2009). "Dissolution of radiolucent renal stones by oral alkalinization with potassium citrate/potassium bicarbonate". Arch Ital Urol Androl. 81 (3): 188–91. PMID 19911683.
- ↑ 13.0 13.1 Kenny JE, Goldfarb DS (April 2010). "Update on the pathophysiology and management of uric acid renal stones". Curr Rheumatol Rep. 12 (2): 125–9. doi:10.1007/s11926-010-0089-y. PMID 20425021.
- ↑ Wong H, Riehl RL, Griffith DP. Medical management and prevention of struvite stones. In: Kidney stones: Medical and surgical management, Coe FL, Favis MJ, Pak CC, et al (Eds), Lippincott-Raven, Philadelphia 1996.
- ↑ Portis AJ, Sundaram CP (April 2001). "Diagnosis and initial management of kidney stones". Am Fam Physician. 63 (7): 1329–38. PMID 11310648.
- ↑ Teichman JM (February 2004). "Clinical practice. Acute renal colic from ureteral calculus". N. Engl. J. Med. 350 (7): 684–93. doi:10.1056/NEJMcp030813. PMID 14960744.