Kidney Stone Management Guidelines

Initial Assessment and Management

The American Urological Association recommends obtaining a detailed medical and dietary history to identify conditions, habits, or medications that may predispose to stone disease 1
Serum chemistries including electrolytes, calcium, creatinine, and uric acid should be ordered to identify underlying medical conditions 1
Urinalysis including dipstick and microscopic evaluation should be performed to assess urine pH, indicators of infection, and identify crystals pathognomonic of stone type 1
Urine culture should be obtained if urinalysis suggests urinary tract infection or if patient has history of recurrent UTIs 1
Imaging studies should be obtained to quantify stone burden and guide treatment decisions, with renal ultrasonography as the recommended first-line imaging modality 1

NSAIDs are recommended as first-line treatment for acute kidney stone pain management due to superior efficacy, fewer side effects, and lower risk of dependence 2
Opioids should be reserved as second-choice analgesics when NSAIDs are contraindicated or ineffective 2

Conservative management is appropriate for uncomplicated ureteral stones up to 10 mm according to AUA guidelines and up to 6 mm according to EAU guidelines 3
Medical expulsive therapy (MET) with alpha-blockers (tamsulosin) is recommended, particularly for stones >5 mm in the distal ureter 2
The maximum duration of conservative treatment should be 4-6 weeks from initial clinical presentation 3
For stones that fail to pass spontaneously, intervention is required based on stone size and location 3

For patients with calcium stones, thiazide diuretics should be offered to patients with high or relatively high urine calcium and recurrent calcium stones 4, 2
Potassium citrate therapy should be offered to patients with recurrent calcium stones and low or relatively low urinary citrate 4, 2
For patients with uric acid stones, potassium citrate is first-line therapy to raise urinary pH to approximately 6.0 5, 2
For patients with cystine stones, first-line therapy includes increased fluid intake, restriction of sodium and protein intake, and urinary alkalinization 5, 2

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
Not considering the type of stone when determining appropriate medical therapy 2
Prescribing allopurinol as first-line therapy for uric acid stones instead of urinary alkalinization with potassium citrate 2
Using supplemental calcium rather than dietary calcium, as supplemental calcium may be associated with an increased risk of stone formation 4

The American Urological Association recommends first-line pharmacological therapy for brushite stone formers with hypocitraturia or elevated urine pH, using potassium citrate 6, 7
Potassium citrate is a potent inhibitor of calcium phosphate crystallization, and is preferred over sodium citrate as the sodium load in the latter may increase urine calcium excretion 6, 7, 8
Thiazide diuretics should be offered to brushite stone formers with hypercalciuria, as they lower urinary calcium excretion and may increase the safety and efficacy of citrate therapy 6, 8
The combination of potassium citrate and thiazide diuretics can be used for patients with persistent stone formation 6, 7

The American Urological Association recommends obtaining a 24-hour urine specimen within six months of initiating treatment to assess response to therapy, and annually or more frequently depending on stone activity 6, 7