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Asian Journal of Urology, 2018, 5(4): 243-255    doi: 10.1016/j.ajur.2018.08.005
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Medical therapy for nephrolithiasis: State of the art
Igor Sorokina,Margaret S. Pearlebc*()
a. Department of Urology, University of Massachusetts, Worcester, MA, USA
b. Department of Urology, UT Southwestern Medical Center, Dallas, TX, USA
c. Charles and Jane Pak Center for Mineral Metabolism and Bone Research, UT Southwestern Medical Center, Dallas, TX, USA
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Abstract: 

The prevalence of nephrolithiasis is increasing worldwide. Understanding and implementing medical therapies for kidney stone prevention are critical to prevent recurrences and decrease the economic burden of this condition. Dietary and pharmacologic therapies require understanding on the part of the patient and the prescribing practitioner in order to promote compliance. Insights into occupational exposures and antibiotic use may help uncover individual risk factors. Follow-up is essential to assess response to treatment and to modify treatment plans to maximize therapeutic benefit.

Key words:  Medical management    Kidney stones    Medical therapy    Pharmacology    Nephrolithiasis
收稿日期:  2018-01-14      修回日期:  2018-04-08           出版日期:  2018-10-20      发布日期:  2018-11-19      整期出版日期:  2018-10-20
引用本文:    
. [J]. Asian Journal of Urology, 2018, 5(4): 243-255.
Igor Sorokin,Margaret S. Pearle. Medical therapy for nephrolithiasis: State of the art. Asian Journal of Urology, 2018, 5(4): 243-255.
链接本文:  
http://www.ajurology.com/CN/10.1016/j.ajur.2018.08.005  或          http://www.ajurology.com/CN/Y2018/V5/I4/243
Dietary component Recommendation
Fluid Maintain fluid intake that achieves urine volume ≥2.5 L daily
Limit sugar-sweetened soft drinks
Consider intake of orange juice with no added sugar to prevent calcium nephrolithiasis
Calcium Avoid severe dietary calcium restriction
Maintain calcium intake of 1000-1200 mg/day
Oxalate Avoid oxalate rich foods (nuts, chocolate, brewed tea, spinach, rhubarb, beets, potatoes, peanut butter, wheat bran, beans)
Avoid juices with cranberry, grapefruit, starfruit
Maintain normal calcium intake
Protein Modestly restrict animal protein (red meat, fish, poultry, pork, shellfish) to no more than 6-8 ounces daily
Carbohydrate Restrict refined carbohydrates to <20 g/day
Sodium Limit sodium intake to ≤100 mEq/day (2300 mg/day)
Citrate Increase intake of fruits and vegetables, orange juice is beneficial
Calcium supplement Consider for enteric hyperoxaluria (take with the two largest meals) but avoid for idiopathic calcium stone disease if dietary calcium intake is sufficient
Vitamin B6 supplement Consider for primary hyperoxaluria type 1, but not proven for idiopathic causes
Vitamin C supplement Limit intake of vitamin C to <2 g/day
Vitamin D supplement Should not be withheld solely on the basis of stone disease. If deficient and repletion is indicated, monitor with 24 h urine analysis.
Low carbohydrate/high protein diet (Atkins) Avoid (increase in net acid; hypocitraturia; hypercalciuria, hyperuricosuria)
DASH diet Likely protective against stone disease
Mediterranean diet Likely protective against stone disease (inferred from similarities to DASH diet)
Table 1  Dietary recommendations to prevent kidney stone recurrence.
Medication Rationale Dose Specifics/side effects Monitoring
Calcium oxalate stones
Thiazide Hypercalciuria Hydrochlorothiazide 25-50 mg BID, chlorthalidone 25-50 mg/day, indapamide 1.25-5 mg/day Hypokalemia, hyperlipidemia, hyperuricemia, hyperglycemia, hypocitraturia, hyperuricosuria, fatigue, erectile dysfunction BMP, uric acid, lipid profile
Potassium citrate (oral) Hypocitraturia, low urine pH 10-30 mEq BID GI side effects Serum creatinine & potassium
Potassium citrate (liquid) Enteric hyperoxaluria, chronic diarrhea 15-30 mEq TID-QID (titrate to reduce oxalate) GI side effects, take with two largest meals Serum creatinine & potassium
Allopurinol Hyperuricosuria 100-300 mg/day Hypertransaminasemia, Stevens-Johnson syndrome Liver enzymes
Uric acid stones
Potassium citrate (oral)a Alkalinization 10-30 mEq BID (titrate dose to pH 6-6.5) GI side effects Serum creatinine & potassium
Sodium bicarbonate Alkalinization 650 mg BID-QID Increased sodium load may increase risk of calcium stones BMP
Allopurinol Hyperuricosuria 2nd line therapy when alkalinization not successful 100-300 mg/day Hypertransaminasemia, Stevens-Johnson syndrome Liver enzymes
Cystine stones
Tiopronin (α-MPG) Increase cystine solubility Initial 400 mg/day titrate to effect Hematologic effects, tachyphylaxis, proteinuria, nausea, diarrhea, vitamin B6 deficiency (long-term use) CBC, BMP, urine protein
Potassium citrate (oral) Alkalinization 10-30 mEq BID (titrate dose to pH 7-7.5) GI side effects Serum creatinine & potassium
Struvite stones
Acetohydroxamic acid Urease-inhibitor 250 mg BID-TID Headache, anemia, thrombophlebitis, rash, tremulousness CBC
Table 2  Pharmacologic treatments by stone type.
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