Medical Management of Kidney Stones

General Principles

  • Fluid intake that will achieve a urine volume of at least 2.5 liters daily
  • Pain control:
    • NSAIDS:
      • Any, but toradol has been given special interest. In one emergency department study, the narcotic-like analgesic effects of this agent were superior to the effects of meperidine
      • Contraindication to the use of extracorporeal shock wave lithotripsy, because of the increased risk of perinephric bleeding
      • Must balance with the presence of acute kidney injury
    • Narcotics: Codeine, morphine, hydromorphone, and meperidine are effective in suppressing pain
    • Medical Expulsive Therapy
      • Alpha blockers: tamsulosin: faster stone passage, fewer hospitalizations, fewer procedures
      • CCB: nifedipine – not as good as alpha-blockers

Stone-Specific Management

  • Calcium stones and low urinary citrate:
    • Potassium citrate to raise urine pH
    • Increase intake of fruits and vegetables and limit non-dairy animal protein
    • Thiazide diuretics to patients with high or relatively high urine calcium and recurrent calcium stones
  • Cystine stones:
    • Limit sodium and protein intake.
    • Potassium citrate to raise urine pH
  • Struvite stones: acetohydroxamic acid (AHA) to patients with residual or recurrent struvite stones only after surgical options have been exhausted
  • Calcium oxalate stones:
    • Limit intake of oxalate-rich foods and maintain normal calcium consumption
    • Give allopurinol to patients with recurrent calcium oxalate stones who have hyperuricosuria and normal urinary calcium
    • Oral calcium carbonate in doses up to 4 g/d is used for patients with enteric hyperoxaluria to bind oxalate within the gastrointestinal tract
  • Uric acid stones or calcium stones and relatively high urinary uric acid:
    • Limit intake of non-dairy animal protein
    • Potassium citrate to raise urine pH
    • Allopurinol is not first line therapy