Nephrolithiasis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

acute renal colic nonpregnant

1st line – hydration, analgesia, and antiemetic

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1st line –

hydration, analgesia, and antiemetic

Acute medical treatment for suspected renal or ureteric colic includes conservative therapies such as hydration, analgesia (a nonsteroidal anti-inflammatory drug [NSAID] such as diclofenac, indomethacin, or ketorolac, and/or an opioid such as morphine), and an antiemetic (e.g., ondansetron).[78] [ ]

NSAIDs should be offered first-line unless contraindicated (e.g., patients at risk of renal impairment, cardiac failure, and gastric ulceration).[79][80][Evidence C] Parenteral NSAIDs provide the most sustained pain relief, with fewer adverse effects, when compared with opioids.[77][81] However, NSAIDs can be offered by any route.[79][Evidence C]

Acetaminophen and intravenous lidocaine are alternative opioid-sparing options, although NSAIDs should remain first-line therapy unless contraindicated.[48][82][83][84] Intravenous lidocaine requires continuous cardiac monitoring, and its use is contraindicated in various cardiac conditions. Consult your local drug information source for a full list of contraindications and cautions before using lidocaine.

Primary options

indomethacin: 25-50 mg orally (immediate-release) three times daily when required

diclofenac sodium: 50 mg orally (immediate-release) three times daily when required; 37.5 mg intravenously every 6 hours when required

ketorolac: consult specialist for guidance on dose

-- AND / OR --

morphine sulfate: 2.5 to 10 mg intravenously/intramuscularly/subcutaneously every 2-6 hours when required; 10-30 mg orally (immediate-release) every 4 hours when required initially, adjust dose according to response

-- AND --

ondansetron: 4 mg intravenously every 8-12 hours when required

Secondary options

acetaminophen: <50 kg body weight: 15 mg/kg intravenously every 6 hours when required, or 12.5 mg/kg intravenously every 4 hours when required, maximum 75 mg/kg/day; ≥50 kg body weight: 1000 mg intravenously every 6 hours when required, or 650 mg intravenously every 4 hours when required, maximum 4000 mg/day

lidocaine: consult specialist for guidance on dose

ACUTE

confirmed stone: no evidence of obstruction nonpregnant

1st line – hydration, analgesia, and antiemetic

Back

1st line –

hydration, analgesia, and antiemetic

Conservative treatment for confirmed stones with renal or ureteric colic includes hydration, analgesia (NSAIDs such as diclofenac, indomethacin, or ketorolac, and/or an opioid such as morphine), and an antiemetic (e.g., ondansetron).[78] [ ]

Primary options

indomethacin: 25-50 mg orally (immediate-release) three times daily when required

diclofenac sodium: 50 mg orally (immediate-release) three times daily when required; 37.5 mg intravenously every 6 hours when required

ketorolac: consult specialist for guidance on dose

-- AND / OR --

-- AND --

ondansetron: 4 mg intravenously every 8-12 hours when required

Secondary options

lidocaine: consult specialist for guidance on dose

Consider – antibiotic therapy

stones <10 mm

Consider – medical expulsive therapy (MET)

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Consider –

medical expulsive therapy (MET)

Treatment recommended for SOME patients in selected patient group

Patients with newly diagnosed ureteric stones <10 mm without complicating factors (urosepsis, intractable pain and/or vomiting, impending acute renal failure, obstruction of a solitary or transplanted kidney, or bilateral obstruction) can be managed expectantly.[74][85]

Many ureteric stones <10 mm pass spontaneously, with exact passage rate related to both stone size and location.[86] There is evidence to support that MET can increase ureteral stone passage rate and decrease the time to stone passage in stones <10 mm in size.[87] However, if a 4-6 weeks trial of MET has been attempted without successful stone passage, the patient should undergo definitive surgical management.

Using an alpha-blocker, such as tamsulosin, alfuzosin, or silodosin may be of benefit in promoting larger (but still <10 mm) distal ureteral stone passage; however, efficacy rates have been questioned.[88][89][90][91][92][144][145][146] [ ]

Patients should be made aware that prescribing alpha-blockers for this indication is considered an off-label use of these drugs. Alpha-blockers may cause orthostatic hypotension and syncope; additionally, tamsulosin has been associated with intraoperative floppy iris syndrome, therefore it should not be prescribed if a patient has planned cataract surgery.[97]

These agents should be given for 4-6 weeks or until the stone is passed. If the stone has still not passed by that time, surgical intervention is recommended. In general, such patients are followed-up with periodic imaging, either with ultrasound (KUB and renal) or noncontrast CT (abdomen and pelvis), to monitor stone position and degree of hydronephrosis.

Primary options

tamsulosin: 0.4 mg orally once daily

alfuzosin: 10 mg orally once daily

silodosin: 8 mg orally once daily

stones ≥10 mm or failed medical therapy

Consider – surgical removal

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Consider –

surgical removal

Treatment recommended for SOME patients in selected patient group

For larger stones (≥10 mm), and for smaller stones that fail conservative therapies (e.g., uncontrolled symptoms, failure of stone to progress, or persistent obstruction), where immediate decompression is not indicated, additional surgical treatment is necessary. Options include extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrostolithotomy ureteroscopy (PCNL), ureteroscopy (URS) and laparoscopic stone removal. Each of the surgical options has their own specific indications and considerations, but in general they are all relatively comparable in terms of safety and efficacy.[99]

ESWL and URS are considered first-line treatments for calculi size <10-20 mm. However, URS and PCNL are in general is associated with better stone-free rates than ESWL.[100][101][102]

ESWL is the least invasive method of definitive stone treatment and is suitable for most patients with uncomplicated stone disease. Limitations to ESWL include stone size and location, though ESWL has the potential benefit of being done under intravenous sedation/analgesia, without need for general anesthesia. Contraindications to ESWL treatment include pregnancy, severe skeletal malformations, severe obesity, aortic and/or renal artery aneurysms, uncontrolled hypertension, disorders of blood coagulation, and uncontrolled urinary tract infections.[113]

URS involves placing a small semi-rigid or flexible scope per urethra and into the ureter and/or kidney, and visualizing and fragmenting the stone. The procedure is more invasive than ESWL, but is generally thought to have a higher stone-free rate. General anesthesia is routinely used, and a ureteric stent may be placed at the end of the procedure. [ ] The procedure can be safely performed in coagulopathic patients using a holmium laser.

Percutaneous antegrade ureteroscopy involves percutaneous antegrade removal of ureteric stones, and can be considered in select cases with very large (>15 mm) stones impacted in the upper ureter or when retrograde access is not possible.

PCNL is minimally invasive and usually reserved for renal and proximal ureteric stones (i.e., in the lower pole) and those that are large (>20 mm), have failed therapy with ESWL and URS, or are associated with complex renal anatomy.[74]

Mini-PCNL, which uses a smaller scope and sheath than standard PCNL, results in higher stone-free rate for stones 10-20 mm than URS, but incurs greater blood loss and longer length of hospital stay because it is more invasive than URS.[128][129] Mini-PCNL may be an option for stones <20 mm, as some evidence suggests equivalent stone-free rate with fewer bleeding complications (due to smaller tract size).[130][131][132] However, for an equivalent stone-free rate, mini-PCNL usually requires longer operating time, due to the smaller size of operating equipment.[132]

Laparoscopic or open surgical stone removal may be considered in rare cases where ESWL, ureteroscopy, and percutaneous ureteroscopy fail, or are unlikely to be successful.

confirmed stone: with evidence of obstruction nonpregnant

1st line – hydration, analgesia, and antiemetic

Back

1st line –

hydration, analgesia, and antiemetic

Patients with urinary calculi with obstruction (in the absence of infection) can be counseled regarding hydration and analgesia; urologic consult is needed, but the timing of this depends on the size of the stone, likelihood of passing it spontaneously, and local availability of urology specialists.

Conservative treatment includes hydration, analgesia (NSAIDs such as diclofenac, indomethacin, or ketorolac, and/or an opioid such as morphine), and an antiemetic (e.g., ondansetron). NSAIDs should be offered first-line unless contraindicated (e.g., patients at risk of renal impairment, cardiac failure, and gastric ulceration).[79][80][Evidence C] Parenteral NSAIDs provide the most sustained pain relief, with fewer adverse effects, when compared with opioids.[77][81] However, NSAIDs can be offered by any route.[79][Evidence C]

Primary options

indomethacin: 25-50 mg orally (immediate-release) three times daily when required

diclofenac sodium: 50 mg orally (immediate-release) three times daily when required; 37.5 mg intravenously every 6 hours when required

ketorolac: consult specialist for guidance on dose

-- AND / OR --

-- AND --

ondansetron: 4 mg intravenously every 8-12 hours when required

Secondary options

lidocaine: consult specialist for guidance on dose

Consider – antibiotic therapy

Consider – surgical decompression

Consider – surgical removal

Back

Consider –

surgical removal

Treatment recommended for SOME patients in selected patient group

For larger stones (≥10 mm), and for smaller stones that fail conservative therapies (e.g., uncontrolled symptoms, failure of stone to progress, or persistent obstruction), additional surgical treatment is necessary. Options include ESWL, PCNL, URS, and laparoscopic stone removal. Each of the surgical options has their own specific indications and considerations, but in general they are all relatively comparable in terms of safety and efficacy.[99]

ESWL and URS are considered first-line treatments for calculi size <10-20 mm. However, URS and PCNL are in general are associated with better stone-free rates than ESWL.[100][101][102]

ESWL is the least invasive method of definitive stone treatment and is suitable for most patients with uncomplicated stone disease. Limitations to ESWL include stone size and location though ESWL has the potential benefit of being done under intravenous sedation/analgesia, without need for general anesthesia. Contraindications to ESWL treatment include pregnancy, severe skeletal malformations, severe obesity, aortic and/or renal artery aneurysms, uncontrolled hypertension, disorders of blood coagulation, and uncontrolled urinary tract infections.[113]

PCNL is minimally invasive and usually reserved for renal and proximal ureteric stones (i.e., in the lower pole) and those that are large (>20 mm), have failed therapy with ESWL and ureteroscopy, or are associated with complex renal or ureteral anatomy.[74]

Mini-PCNL, which uses a smaller scope and sheath than standard PCNL, results in higher stone-free rate for stones 10-20 mm than URS, but incurs greater blood loss and longer length of hospital stay because it is more invasive.[128][129] Mini-PCNL may be an option for stones <20 mm, as some evidence suggests equivalent stone-free rate with fewer bleeding complications (due to smaller tract size).[130][131][132] However, for an equivalent stone-free rate, mini-PCNL usually requires longer operating time, due to the smaller size of operating equipment, because the scopes/sheaths are smaller.[132]

Laparoscopic or open surgical stone removal may be considered in rare cases where ESWL, URS, and percutaneous ureteroscopy fail, or are unlikely to be successful.

pregnant

1st line – specialist referral

ONGOING

following an acute episode nonpregnant

1st line – hydration and dietary modification

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1st line –

hydration and dietary modification

Long-term dietary modification is essential for preventing future calculi.[46] This modification is centered on increasing fluid intake. In patients that are known stone formers, a target urine output of 2.0 to 2.5 L per day is recommended; intake volume may need to be up to 4 L per day to achieve this.[17][18][19]

Decreased dietary sodium, animal protein intake, and oxalate should be recommended for stone prevention.[47] Increased citrus fruit intake is recommended to prevent stone recurrence.

Normal calcium intake is recommended. Dietary calcium restriction can lead to less binding of calcium to oxalate in the GI tract, promoting hyperoxaluria and increased stone formation.[147]

hyperuricosuria

Consider – xanthine oxidase inhibitor

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Consider –

xanthine oxidase inhibitor

Treatment recommended for SOME patients in selected patient group

Hyperuricosuria is treated with allopurinol. Elevated urinary uric acid levels (>800 mg/day) promote calcium oxalate and uric acid stones. Allopurinol is effective; it may work especially well in patients with gout. Febuxostat is an alternative agent which, at high dose, lowers urinary uric acid to a greater extent than allopurinol.[148] Febuxostat should only be prescribed for patients who can not tolerate allopurinol or when treatment with allopurinol has failed, and who have been counseled regarding cardiovascular risk.[138] Febuxostat should be avoided in patients with preexisting major cardiovascular disease (e.g., myocardial infarction, unstable angina, stroke), unless no other therapy options are appropriate.[140] The double-blind Cardiovascular Safety of Febuxostat or Allopurinol in Patients with Gout (CARES) safety trial found that cardiovascular death and all cause mortality were significantly more common among patients taking febuxostat than allopurinol (4.3% vs. 3.2%, HR 1.34 [95% CI 1.03 to 1.73]; 7.8% vs. 6.4%, HR 1.22 [95% CI 1.01 to 1.47], respectively).[139] Treatment group did not differ with respect to a primary composite outcome of cardiovascular events.

Primary options

allopurinol: 100-300 mg orally once daily

Secondary options

febuxostat: 40-80 mg orally once daily

An increased risk of death has been reported with febuxostat compared with allopurinol. The FDA recommends that febuxostat should only be prescribed in patients who cannot tolerate, or have failed treatment with, allopurinol.[138]

Back

Consider –

alkalinization/thiol binding agent/cystine chelator

Treatment recommended for SOME patients in selected patient group

The goal for treatment of cystinuria is to decrease urine levels to <250 mg/L.[2]

Conservative therapy involves increased hydration to keep urine output at ≥3 L/day in order to reduce the saturation of cystine and decreased sodium intake.[2]

Alkalinization of urine with potassium citrate leads to an increase in the solubility of cystine, although a substantial increment in solubility does not occur unless the pH is >7.5.[2]

If conservative therapy and alkalinization fail, chelating agents such as tiopronin or penicillamine should be used.[2] Tiopronin has a better adverse-effect profile than penicillamine and is therefore the preferred therapy.[2][150]

Primary options

potassium citrate: 30-60 mEq/day orally given in 2-3 divided doses, adjust dose according to response, maximum 100 mEq/day

Secondary options

tiopronin: 800 mg/day orally in 3 divided doses, adjust dose according to response, usual dose is 1000 mg/day

penicillamine: 250 mg orally four times daily

struvite stones

Consider – urease inhibitor

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Nephrolithiasis

Treatment algorithm

acute renal colic nonpregnant

hydration, analgesia, and antiemetic

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

confirmed stone: no evidence of obstruction nonpregnant

hydration, analgesia, and antiemetic

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

antibiotic therapy

medical expulsive therapy (MET)

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

surgical removal

confirmed stone: with evidence of obstruction nonpregnant

hydration, analgesia, and antiemetic

Primary options

Secondary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

antibiotic therapy

surgical decompression

surgical removal

pregnant

specialist referral

following an acute episode nonpregnant

hydration and dietary modification

xanthine oxidase inhibitor

Primary options

Secondary options

alkalinization

Primary options

Secondary options

thiazide diuretic/alkalinization

Primary options

alkalinization

Primary options

Secondary options

oxalate chelator/alkalinization/pyridoxine

Primary options

alkalinization/thiol binding agent/cystine chelator

Primary options

Secondary options

urease inhibitor

Primary options