Kidney Stones

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Treatment

Treatment depends on the size and type of stone, the underlying cause, the presence of any urinary infection, and whether the condition recurs. Stones 4 mm and smaller (less than 1/4 inch in diameter) pass without intervention in 90% of cases; those 5–7 mm do so in 50% of cases; and those larger than 7 mm rarely pass without a surgical procedure. Patients are advised to avoid becoming too sedentary, because physical activity, especially walking, can help move a stone.

Medications called alpha blockers have been shown to increase the spontaneous passage of kidney stones, especially smaller stones in the lower ureter near the bladder. These medications have the ability to relax the muscle tension inside the ureter. This relaxation serves to improve spontaneous stone passage rates by about 30%. Examples of alpha blocker medications include tamsulosin (Flomax®), alfuzosin (Uroxatral® ), terazosin (Hytrin® ), and doxazosin (Cardura® ). If you are trying to pass a stone, ask your physician about trying one of these medications.

If possible, the kidney stone is allowed to pass naturally and is collected for analysis. The patient is instructed to strain their urine to obtain the stone(s) for analysis. It is important to analyze the chemical composition of kidney stones to help determine how to prevent recurrent stone formation. The urine may be strained using an aquarium net or another device. Each voiding should be strained until the physician instructs the patient otherwise.

Dietary changes may be required and fluid intake should be increased. Patients with stones must increase their urinary output. Generally, 2000 cc of urine per day (slightly more than 1/2 gallon) is recommended and patients should drink enough water to produce this amount of urine daily. In some cases (e.g., some cystine stone formers), even higher levels of fluid intake are required.

Dietary calcium usually should not be severely restricted. Reducing calcium intake often causes problems with other minerals (e.g., oxalate) and may result in a higher risk for calcium stone disease.

Preventative Testing
The only way to definitively identify the underlying causes for kidney stones is to perform a 24-hour urine collection analysis. This test ideally should be done after the painful kidney stone attack is over and the patient has resumed his or her usual diet and routine activities.

Performing the test is not difficult, but interpretation of the results can be complicated and many physicians have little or no experience in this type of complex laboratory analysis. If possible, try to find a specialist in kidney stone prevention analysis to help or ask your physician about his or her experience in this particular area. If your urologist is not comfortable analyzing this type of test data, ask for a referral to an expert.

Another problem with 24-hour urine testing is the need for long-term compliance by the patient. Most patients start with the best of intentions, but after 6 months or so many patients have given up on their preventive treatments and go back to their old ways.

In order to prevent as many stones as possible, patients must do the 24-hour urine test so the underlying causes can be identified. Then, they must find a physician skilled in this area and follow his or her advice on a long-term basis, even if they don't think it’s helping. Patients with stones are kidney stone formers for life and if preventive treatment is not continued, more stones will begin to form.

Also, even the very best preventive treatment plan may eventually fail. This is not due to bad science, but is due to the fact that preventing kidney stones is fighting against nature. Successful treatment often means not giving up even if an occasional stone develops.

The five most common findings on 24-hour urine tests are hypercalciuria (high urinary calcium), hyperuricosuria (high urinary uric acid), hyperoxaluria (high urinary oxalate), hypocitraturia (low urinary citrate) and low urinary volume.

Hypercalciuria

Thiazides, water pills (diuretics), are sometimes prescribed to reduce high levels of urinary calcium (hypercalciuria) and to increase urinary volume. Salt (sodium) intake needs to be reduced for thiazides to be effective. Patients with hypercalciuria who do not respond to thiazide therapy may be prescribed orthophosphates to reduce calcium absorption and may be given moderate dietary calcium restrictions.

Patients should not reduce their calcium intake unless their physicians advise them to do so. Overly aggressive oral calcium restrictions have been shown to actually increase calcium stone disease. The reason for this is that calcium binds other minerals and chemicals like oxalate in the digestive tract. If the oral calcium intake is too low, then there is no intestinal oxalate binding and the oxalate absorption and urinary excretion increases dramatically. This results in a net increase in kidney stone production.

Hyperuricosuria

Patients with elevated uric acid levels (hyperuricosuria) are advised to reduce excessive dietary meat protein. Potassium citrate (medication that maintains the antacid level in urine) and/or allopurinol (medication that stops the production of uric acid) may also be prescribed. If the blood level of uric acid is high, then allopurinol is usually used. If the stones are pure uric acid stones, then potassium citrate supplementation is generally recommended.

Hyperoxaluria

Hyperoxaluria (high levels of urinary oxalate) may be mild, enteric, or primary. Mild hyperoxaluria is usually caused by an excess of dietary oxalate (found in tea, chocolate, cola, nuts, and green leafy vegetables). Prevention consists of daily doses of pyridoxine (vitamin B-6), which reduces oxalate excretion, increased fluids, phosphate therapy, and sometimes calcium citrate supplementation.

A low-oxalate, low-fat diet, increased fluid intake, and calcium supplementation is prescribed for enteric hyperoxaluria. This rare condition is often severe and is usually caused by an intestinal disorder (e.g., Crohn's disease, colitis). Calcium citrate, magnesium, iron, and cholestyramine may be given to reduce oxalate levels.

Primary hyperoxaluria is rare, severe, and caused by an inherited liver disorder. Primary hyperoxaluria requires aggressive treatment to prevent severe renal stone disease and kidney failure. High doses of vitamin B-6, orthophosphates, magnesium supplements, and increased fluid intake (to produce 2 liters of urine/day) are prescribed. Rarely, kidney and liver transplants are necessary.

Hypocitraturia

Hypocitraturia (low levels of urinary citrate) usually requires a prescribed supplement, such as potassium citrate. The dosage depends on the level of urinary citrate, which is determined initially by the 24-hour urine test but can also be monitored by measuring the urinary antacid level (ph) with special dipsticks. Patients with renal tubular acidosis usually respond particularly well to treatment with prescription potassium citrate supplements. Citrus fruits and lemon juice can also be used as additional sources of natural potassium citrate.

Low Urine Volume

Low urinary volume is both the easiest and the hardest problem to solve. It can be very difficult for many stone patients to significantly increase their fluid level on a daily basis for long periods of time. Increasing fluid intake is the only known remedy that helps all types of stones, regardless of the chemical makeup of the stones.

While increasing fluid intake often is difficult at first, there are some helpful techniques to make the transition easier. First, try drinking a small glass of water, roughly 4 ounces, with each meal. Then, slowly increase the frequency of that extra small glass from mealtimes to in-between and other convenient times.

Follow the 24-hour urine volume—if the volume is close to 2000 cc (roughly ½ gallon), then you are probably doing fine. Once the urinary volume up to where it should be, your system will adjust and you will become used to this increased fluid. At that point, you will become thirsty if you skip some your usual water intake.

Measuring 24-hour urine volume is a far better way to manage fluid intake than an arbitrary number of glasses of water to drink. If you just can't stand any more water, try lemonade made with real lemon juice to break up the monotony. Real lemon juice also is rich in natural citrates.

Cystinuria

Treatment for high cystine levels in the urine (cystinura) includes substantially increasing fluid intake and raising the pH of the urine (usually with sodium bicarbonate or potassium citrate). Penicillamine (Cuprimine® ) and tiopronine (Thiola® ) may also be prescribed.

Pain Medication

Over-the-counter pain relievers (e.g., aspirin, Tylenol® , Advil® ) usually are not effective by themselves for the more severe pain caused by kidney stones. However, you can try a combination of Aleve® , Advil®, or Motrin® plus Tylenol® for milder pain. Talk to your physician about what dosages of these medications is safe for you to take.

Oral opiod analgesics, such as acetaminophen/codeine (Tylenol with Codeine® ), propoxyphene HCL (Darvon® ), hydrocodone/acetaminophen (Vicodin® ) and oxycodone/acetaminophen (Percocet® ) may be prescribed to minimize moderate pain associated with stones.

Injectable medications such as morphine sulfate (Duramorph PF® ), hydromorphone (Dilaudid® ), and ketorolac HCL (Toradol® ) may be administered intravenously (IV) or intramuscularly (by injection) for severe pain. There is a risk for dependency with oral narcotic analgesics used for more than 3–4 weeks at a time and a small risk for accidental overdose if injectable medications are given directly into a vein.

Side effects of these medications include the following:

• Constipation
• Drowsiness
• Nausea
• Slowed breathing (respiration)
• Vomiting

Nausea and vomiting can be reduced using medications such as prochlorperazine edisylate (Compazine®), promethazine HCL (Phenergan®), and metoclopramide HCL (Reglan®).

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