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; Jeannine Ouellette; Manoj Monga, MD
Disclaimer: This report is based on research conducted by the Minnesota Evidence-based Practice Center under contract to AHRQ, Rockville, Maryland. The findings and conclusions in this document are those of the authors, 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, the U.S. Department of Health and Human Services, or the U.S. Department of Veterans Affairs.
Acknowledgment: The authors thank Marilyn Eells and Maureen Carlyle for technical editing support.
Grant Support: By contract HHSA 290 2007 10064 1 from AHRQ to the Minnesota Evidence-based Practice Center.
Potential Conflicts of Interest: Dr. Fink: Grant (money to institution): AHRQ; Payment for writing or reviewing the manuscript: American College of Physicians; Travel/accommodations/meeting expenses unrelated to activities listed: USPSTF. Dr. Wilt: Grant (money to author and institution): AHRQ. Dr. Eidman: Grant (money to institution): AHRQ. Dr. Brasure: Grant (money to institution): AHRQ. Dr. Monga: Grant (money to institution): AHRQ; Payment for lectures, including service on speakers bureaus: Mission Pharmacal. All other authors have no disclosures. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-0883.
Requests for Single Reprints: Howard A. Fink, MD, MPH, Minneapolis Veterans Affairs Medical Center (11-G), One Veterans Drive, Minneapolis, MN 55417; e-mail, email@example.com.
Current Author Addresses: Dr. Fink: VA Medical Center (11-G), One Veterans Drive, Minneapolis, MN 55417.
Dr. Wilt, Mr. MacDonald, and Mr. Rutks: VA Medical Center (111-O), One Veterans Drive, Minneapolis, MN 55417.
Dr. Eidman: Hennepin County Medical Center, Division of Nephrology, 701 Park Avenue, Minneapolis, MN 55415.
Dr. Garimella: Tufts Medical Center, 800 Washington Street, Box 391, Boston, MA 02111.
Drs. Brasure and Kane and Ms. Ouellette: Division of Health Policy and Management, University of Minnesota School of Public Health, D351 Mayo (MMC 197), 420 Delaware Street SE, Minneapolis, MN 55455.
Dr. Monga: Department of Urology, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195.
Author Contributions: Conception and design: H.A. Fink, T.J. Wilt, K.E. Eidman, M. Monga.
Analysis and interpretation of the data: H.A. Fink, T.J. Wilt, K.E. Eidman, R. MacDonald, M. Brasure, M. Monga.
Drafting of the article: H.A. Fink, K.E. Eidman, M. Brasure, R.L. Kane, J. Ouellette, M. Monga.
Critical revision of the article for important intellectual content: H.A. Fink, T.J. Wilt, K.E. Eidman, P.S. Garimella, R. MacDonald, R.L. Kane, J. Ouellette, M. Monga.
Final approval of the article: H.A. Fink, T.J. Wilt, K.E. Eidman, P.S. Garimella, R. MacDonald, I.R. Rutks, R.L. Kane, M. Monga.
Provision of study materials or patients: I.R. Rutks, M. Brasure.
Statistical expertise: T.J. Wilt, R. MacDonald.
Obtaining of funding: H.A. Fink, T.J. Wilt, R.L. Kane, M. Monga.
Administrative, technical, or logistic support: H.A. Fink, T.J. Wilt, I.R. Rutks, M. Brasure, R.L. Kane.
Collection and assembly of data: H.A. Fink, K.E. Eidman, P.S. Garimella, R. MacDonald, I.R. Rutks, M. Brasure, M. Monga.
Fink HA, Wilt TJ, Eidman KE, Garimella PS, MacDonald R, Rutks IR, et al. Medical Management to Prevent Recurrent Nephrolithiasis in Adults: A Systematic Review for an American College of Physicians Clinical Guideline. Ann Intern Med. 2013;158:535-543. doi: 10.7326/0003-4819-158-7-201304020-00005
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Published: Ann Intern Med. 2013;158(7):535-543.
This article has been corrected. The original version (PDF) is appended to this article as a supplement.
Optimum management to prevent recurrent kidney stones is uncertain.
To evaluate the benefits and harms of interventions to prevent recurrent kidney stones.
MEDLINE, Cochrane, and other databases through September 2012 and reference lists of systematic reviews and randomized, controlled trials (RCTs).
28 English-language RCTs that studied treatments to prevent recurrent kidney stones and reported stone outcomes.
One reviewer extracted data, a second checked accuracy, and 2 independently rated quality and graded strength of evidence.
In patients with 1 past calcium stone, low-strength evidence showed that increased fluid intake halved recurrent composite stone risk compared with no treatment (relative risk [RR], 0.45 [95% CI, 0.24 to 0.84]). Low-strength evidence showed that reducing soft-drink consumption decreased recurrent symptomatic stone risk (RR, 0.83 [CI, 0.71 to 0.98]). In patients with multiple past calcium stones, most of whom were receiving increased fluid intake, moderate-strength evidence showed that thiazides (RR, 0.52 [CI, 0.39 to 0.69]), citrates (RR, 0.25 [CI, 0.14 to 0.44]), and allopurinol (RR, 0.59 [CI, 0.42 to 0.84]) each further reduced composite stone recurrence risk compared with placebo or control, although the benefit from allopurinol seemed limited to patients with baseline hyperuricemia or hyperuricosuria. Other baseline biochemistry measures did not allow prediction of treatment efficacy. Low-strength evidence showed that neither citrate nor allopurinol combined with thiazide was superior to thiazide alone. There were few withdrawals among patients with increased fluid intake, many among those with other dietary interventions and more among those who received thiazide and citrate than among control patients. Reporting of adverse events was poor.
Most trial participants had idiopathic calcium stones. Nearly all studies reported a composite (including asymptomatic) stone recurrence outcome.
In patients with 1 past calcium stone, increased fluid intake reduced recurrence risk. In patients with multiple past calcium stones, addition of thiazide, citrate, or allopurinol further reduced risk.
Agency for Healthcare Research and Quality.
Analytic framework and key questions.
KQ = key question; OTC = over-the-counter.
Appendix Table 1. Literature Search Strategies
Appendix Table 2. Study Eligibility Criteria
Appendix Table 3. Individual Study Quality
Appendix Table 4. Strength of Evidence Grades and Definitions
Appendix Table 5. Strength of Evidence for Prevention of Stone Recurrence: Dietary Intervention Trials
Appendix Table 6. Strength of Evidence for Prevention of Stone Recurrence: Pharmacologic Intervention Trials
Summary of evidence search and selection.
RCT = randomized, controlled trial; SWL = shock wave lithotripsy.
Appendix Table 7. Summary of Evidence: Dietary Interventions to Prevent Stone Recurrence
Forest plots for risk for composite stone recurrence with pharmacologic treatment versus placebo or control.
MH = Mantel–Haenszel.
Appendix Table 8. Summary of Evidence: Pharmacologic Interventions to Prevent Stone Recurrence
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Guidelines, Nephrolithiasis, Nephrology, Prevention/Screening, Urological Disorders.
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