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Recurrent Nephrolithiasis in Adults
Comparative Effectiveness Reviews, No. 61
Investigators: Howard A Fink, MD, MPH, Timothy J Wilt, MD, MPH, Keith E Eidman, DO, Pranav S Garimella, MD, MPH, Roderick MacDonald, MS, Indulis R Rutks, BS, Michelle Brasure, PhD, MSPH, MLIS, Robert L Kane, MD, and Manoj Monga, MD.
Author Information and AffiliationsStructured Abstract
Objective:
To determine the efficacy and harms of diet and pharmacological interventions for preventing recurrent kidney stones, and whether stone composition and pre- and post-treatment biochemistries predict treatment efficacy.
Data Sources:
MEDLINE®, Cochrane Database of Systematic Reviews, Google Scholar, ClinicalTrials.gov, and Web of Science electronic databases; hand searches of references from relevant systematic reviews and eligible trials; and references from expert consultants.
Review Methods:
We screened abstracts and full text articles of identified references for eligibility and reviewed randomized controlled trials (RCTs) for evidence on treatment prevention of recurrent kidney stones, and reviewed RCTs and prospective observational studies for evidence on treatment harms. We extracted data, rated quality, and graded strength of evidence. Our primary efficacy outcomes were symptomatic stone recurrence, composite recurrence (either symptomatic or radiographic), or radiographic recurrence. Evidence on treatment benefits and harms was quantitatively synthesized when possible.
Results:
We found 28 eligible RCTs (8 diet, 20 pharmacological), all but one of fair quality. In patients with a single past calcium stone, increased fluid intake reduced risk of composite stone recurrence (RR, 0.45 [95 percent CI, 0.24 to 0.84]), n=1 trial), and low animal protein and high fiber diets as isolated interventions did not reduce stone recurrence. In men with high soft drink intake, decreased soft drink consumption reduced symptomatic stone recurrence (RR, 0.83 [CI, 0.71 to 0.98], n=1 trial). Multi-component diet interventions were heterogeneous in composition and had mixed results. In one trial, a low animal protein, normal to high calcium, and low sodium diet reduced risk of composite stone recurrence compared with a low calcium diet (RR, 0.52 [CI, 0.29 to 0.95]), whereas in a second trial a low animal protein, high fruit and fiber, and low purine diet increased risk of composite stone recurrence compared with a control diet (RR, 5.88 [CI, 1.39 to 24.92]). In another trial, extensive biochemical evaluation and tailored diet reduced the risk of composite stone recurrence versus a limited evaluation and empiric diet (RR, 0.32 [CI, 0.14 to 0.74]). Strength of evidence for all these interventions was low. In patients with multiple past calcium stones, we found moderate strength of evidence that treatment reduces risk of composite recurrent stones versus control for thiazide diuretics (RR, 0.53 [CI, 0.41 to 0.68], n=6 trials), citrate (RR, 0.25 [CI, 0.14 to 0.44], n=4 trials), and allopurinol (RR, 0.59 [CI, 0.42 to 0.84], n=2 trials), but not for magnesium. We found that acetohydroxamic acid does not reduce risk of recurrent struvite stones (RR, 0.81 [0.18 to 3.66], n=2 trials) (low strength of evidence), and that neither addition of citrate (RR, 0.94 [CI, 0.52 to 1.68], n=1 trial) (low strength of evidence) nor allopurinol (RR, 0.79 [CI, 0.18 to 3.49], n=1 trial) to thiazide (insufficient strength of evidence) reduces risk of recurrent calcium stones compared with thiazides alone. Adverse event reporting was poor. Allopurinol effectiveness may be limited to participants with hyperuricosuria or hyperuricemia. Based on limited data, baseline urine calcium, oxalate, and citrate do not appear to affect stone recurrence outcomes of empiric diet or pharmacological treatments. We identified no RCT data regarding whether followup biochemistries predict treatment efficacy in preventing stone recurrence. Scant data suggest that reduction in urine supersaturation may correlate with reduced stone recurrence.
Conclusions:
Increased fluid intake, reduced soft drink consumption, thiazide diuretics, citrate pharmacotherapy, and allopurinol reduce risk of recurrent calcium stones. Effects of other dietary interventions appear mixed. We identified no RCTs for uric acid or cystine stones. Data regarding whether baseline or followup biochemistries predict treatment efficacy is extremely limited.
Contents
- Errata
- Preface
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Topic Refinement
- Comparative Effectiveness Review
- Criteria for Inclusion/Exclusion of Studies in the Review
- Population(s)
- Interventions
- Searching for the Evidence: Strategies for Identifying Relevant Studies
- Data Abstraction and Data Management
- Assessment of Methodological Quality of Individual Studies
- Data Synthesis
- Strength of Evidence for Key Questions
- Assessing Applicability
- Results
- Key Question 1 In adults with a history of nephrolithiasis, do results of baseline stone composition and blood and urine chemistries predict the effectiveness of diet and/or pharmacological treatment on final health outcomes and intermediate stone outcomes, and reduce treatment adverse effects?
- Key Question 2 In adults with a history of nephrolithiasis, what is the effectiveness and comparative effectiveness of different dietary therapies on final health outcomes and intermediate stone outcomes?
- Key Question 3 In adults with a history of nephrolithiasis, what is the evidence that dietary therapies to reduce risk of recurrent stone episodes are associated with adverse effects?
- Key Question 4 In adults with a history of nephrolithiasis, what is the effectiveness and comparative effectiveness of different pharmacological therapies on final health outcomes and intermediate stone outcomes?
- Key Question 5 In adults with a history of nephrolithiasis, what is the evidence that pharmacological therapies to reduce risk of recurrent stone episodes are associated with adverse effects?
- Key Question 6 In adults with a history of nephrolithiasis being treated to prevent stone recurrence, do results of followup blood and urine biochemistry measures predict final health outcomes and intermediate stone outcomes?
- Discussion
- What Is the Evidence That Treatments Reduce Risk of Kidney Stone Recurrence?
- What Is the Evidence That Stone Characteristics and Baseline Biochemistry Results Predict Effectiveness of Treatment To Reduce Risk of Recurrent Stones?
- What Is the Evidence That Biochemistry Results Measured After Beginning Treatment Predict Treatment Effectiveness in Reducing Subsequent Risk of Recurrent Stones?
- Applicability
- Future Research Recommendations
- References
- Acronyms and Abbreviations
- Appendix A Search Strategy
- Appendix B Excluded Studies
- Appendix C Evidence Tables
- Appendix D Primary Stone Recurrence Outcomes Tables
- Appendix E Secondary Stone Recurrence Outcomes Tables
- Appendix F Baseline Characteristics Summary Tables
- Appendix G Withdrawals and Adverse Events Tables
- Appendix H Baseline and Followup Urine Biochemical Measures Tables
- Appendix I References
Revised March 2013 and May 2013
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-02-0009, Prepared by: Minnesota Evidence-based Practice Center, Minneapolis, MN
Suggested citation:
Fink HA, Wilt TJ, Eidman KE, Garimella PS, MacDonald R, Rutks IR, Brasure M, Kane RL, Monga M. Recurrent Nephrolithiasis in Adults: Comparative Effectiveness of Preventive Medical Strategies. Comparative Effectiveness Review No. 61. (Prepared by the University of Minnesota Evidence-based Practice Center under Contract No. 290-02-0009.) AHRQ Publication No. 12-EHC049-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2012. Revised March 2013 and May 2013. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the Minnesota Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-0009). The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products or actions may not be stated or implied.
None of the investigators has any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov
- Review Medical management to prevent recurrent nephrolithiasis in adults: a systematic review for an American College of Physicians Clinical Guideline.[Ann Intern Med. 2013]Review Medical management to prevent recurrent nephrolithiasis in adults: a systematic review for an American College of Physicians Clinical Guideline.Fink HA, Wilt TJ, Eidman KE, Garimella PS, MacDonald R, Rutks IR, Brasure M, Kane RL, Ouellette J, Monga M. Ann Intern Med. 2013 Apr 2; 158(7):535-43.
- Review Dietary treatment of urinary risk factors for renal stone formation. A review of CLU Working Group.[Arch Ital Urol Androl. 2015]Review Dietary treatment of urinary risk factors for renal stone formation. A review of CLU Working Group.Prezioso D, Strazzullo P, Lotti T, Bianchi G, Borghi L, Caione P, Carini M, Caudarella R, Ferraro M, Gambaro G, et al. Arch Ital Urol Androl. 2015 Jul 7; 87(2):105-20. Epub 2015 Jul 7.
- Review Chronic Kidney Disease Stages 1–3: Screening, Monitoring, and Treatment[ 2012]Review Chronic Kidney Disease Stages 1–3: Screening, Monitoring, and TreatmentFink HA, Ishani A, Taylor BC, Greer NL, MacDonald R, Rossini D, Sadiq S, Lankireddy S, Kane RL, Wilt TJ. 2012 Jan
- Review Diet, fluid, or supplements for secondary prevention of nephrolithiasis: a systematic review and meta-analysis of randomized trials.[Eur Urol. 2009]Review Diet, fluid, or supplements for secondary prevention of nephrolithiasis: a systematic review and meta-analysis of randomized trials.Fink HA, Akornor JW, Garimella PS, MacDonald R, Cutting A, Rutks IR, Monga M, Wilt TJ. Eur Urol. 2009 Jul; 56(1):72-80. Epub 2009 Mar 13.
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