Acute Kidney Stone Management

Initial Pain Management

The European Association of Urology recommends nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatment for acute kidney stone pain management due to superior efficacy, fewer side effects, and lower risk of dependence 1
NSAIDs should be used at the lowest effective dose due to potential cardiovascular and gastrointestinal risks, particularly in patients with reduced glomerular filtration rate 1
Opioids should be reserved as second-choice analgesics when NSAIDs are contraindicated or ineffective 1
If opioids are required, agents other than pethidine (such as hydromorphone, pentazocine, or tramadol) are recommended due to pethidine's association with higher rates of vomiting and need for additional analgesia 1

Alpha-blockers (tamsulosin) are recommended for medical expulsive therapy, particularly for stones >5 mm in the distal ureter 1

The American Urological Association recommends thiazide diuretics for patients with high or relatively high urine calcium and recurrent calcium stones 2, 3
Potassium citrate therapy should be offered to patients with recurrent calcium stones and low or relatively low urinary citrate 4
Allopurinol should be offered to patients with recurrent calcium oxalate stones who have hyperuricosuria and normal urinary calcium 3, 4

Potassium citrate is first-line therapy for uric acid stones to raise urinary pH to approximately 6.0 3, 5
Allopurinol should not be routinely offered as first-line therapy to patients with uric acid stones, as most have low urinary pH rather than hyperuricosuria as the predominant risk factor 3, 5

First-line therapy includes increased fluid intake, restriction of sodium and protein intake, and urinary alkalinization 5
Potassium citrate should be used to raise urinary pH to approximately 7.0 3
Cystine-binding thiol drugs (tiopronin) should be offered to patients unresponsive to dietary modifications and urinary alkalinization, or those with large recurrent stone burdens 5

In cases of sepsis and/or anuria in an obstructed kidney, urgent decompression of the system via either percutaneous nephrostomy or ureteral stenting is strongly recommended 1
Definitive treatment of the stone should be delayed until sepsis is resolved 1
Avoid nephrotoxic medications in patients with acute kidney injury or at risk for kidney injury 6

A single 24-hour urine specimen for stone risk factors should be obtained within six months of initiating treatment to assess response to dietary and/or medical therapy 5
After initial follow-up, a single 24-hour urine specimen should be obtained annually or with greater frequency, depending on stone activity 5
Periodic blood testing should be performed to assess for adverse effects in patients on pharmacological therapy 5
Repeat stone analysis should be obtained, when available, especially in patients not responding to treatment 5

Neglecting to address underlying metabolic abnormalities that contribute to stone formation 2, 3
Not considering the type of stone when determining appropriate medical therapy 3, 5
Prescribing allopurinol as first-line therapy for uric acid stones instead of urinary alkalinization with potassium citrate 3