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Prevention of Repeated Episodes of Kidney Stones in Adults: A Clinical Practice Guideline From the American College of Physicians FREE

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The full report is titled “Dietary and Pharmacologic Management to Prevent Recurrent Nephrolithi-asis in Adults: A Clinical Practice Guideline From the American College of Physicians.” It is in the 4 November 2014 issue of Annals of Internal Medicine (volume 161, pages 659-667). The authors are A. Qaseem, P. Dallas, M.A. Forciea, M. Starkey, and T.D. Denberg, for the Clinical Guidelines Committee of the American College of Physicians.

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Ann Intern Med. 2014;161(9):I-24. doi:10.7326/P14-9038
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Who developed these recommendations?

The American College of Physicians (ACP) developed these recommendations. Members of the ACP are internists (specialists in the care of adults).

What is the problem and what is known about it so far?

Kidney stones are caused by the accumulation of certain solid materials in the kidney. Although kidney stones can sometimes occur without causing any symptoms, many patients experience severe pain and other problems when the stone is passed in the urine. The problems may include bleeding and damage to the kidney. People who have had a kidney stone are at risk for having another, so effective measures to prevent recurrent kidney stones would be useful. Although dietary or drug therapies are often recommended, whether these therapies can prevent repeated episodes of kidney stones is not clear. In addition, doctors often perform tests to figure out what material the stones are made of to try to better direct therapy and prevent future stones. Whether this is useful is also not clear.

How did the ACP develop these recommendations?

The ACP reviewed research on the benefits and harms of drug and dietary treatments to prevent recurrent episodes of kidney stones. They also assessed what evidence is available about the value of determining what a kidney stone is made of to direct treatment against repeated episodes.

What did the authors find?

Not enough evidence is available to know whether determining what a kidney stone is made of would be helpful in preventing additional episodes. Some evidence shows that drinking more liquids may help prevent additional episodes of kidney stones without causing harmful side effects. In addition, there is some evidence that reducing the amount of cola that one drinks may be helpful. Studies of dietary changes varied, and a consistent benefit was not found. Certain drugs (a thiazide diuretic, citrate, and allopurinol) that may help decrease the production of certain materials that commonly cause kidney stones or increase their elimination in urine may also help prevent kidney stones that are made of calcium deposits. Using drugs to prevent kidney stones may cause some side effects.

What does the ACP recommend that patients and doctors do?

Drinking at least 2 L of fluid during the day should be encouraged to prevent additional episodes of kidney stones. If this proves ineffective, doctors should consider prescribing a thiazide diuretic, citrate, or allopurinol. It is not clear whether doing tests to determine what a patient's kidney stones are made of is helpful in preventing future episodes.

What are the cautions related to these recommendations?

The quality of available research varies, and studies comparing 1 treatment with another are limited.





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Clinical Practice guidelines for the Prevention of Kidney Stones in Adults
Posted on November 13, 2014
Amy E. Krambeck, John C. Lieske
Mayo Clinic
Conflict of Interest: None Declared
We read with interest the recent Clinical Practice guidelines from the American College of Physicians (ACP) for the Prevention of Kidney Stones in Adults. The recommendations for drinking at least 2 L of fluid per day and the use of thiazide diuretics, citrate, or allopurinol when fluids alone are insufficient mirror recent guidelines released by the American urological Association (AUA). However, several features of the ACP recommendations are in disagreement with those of the AUA. For example, baseline stone composition is not recommended by ACP, nor is 24-hour urine analysis for stone risk factors. Kidney stone analysis by infrared spectroscopy is relatively inexpensive and very precise and, in our opinion, essential to properly diagnose the form of kidney stone disease. For example, a thiazide diuretic would not be helpful for patient with uric acid kidney stones or someone with cystinuria, both of which can be determined by stone analysis alone. Furthermore, a 24-hour urine analysis can help to guide logical therapeutic choices and specific dietary advice for an individual patient. For example, pharmacotherapy may not be helpful for individuals where a very low urine volume is the only major risk factor, and individuals with enteric hyperoxaluria need very specific therapy geared towards dietary measures to reduce oxalate loads. In these cases allopurinol or thiazide would probably not have any benefit. Although rare, certain genetic conditions associated with stone disease such as primary hyperoxaluria can be diagnosed by extreme abnormalities noted on 24 hour urine studies. Early intervention in such diseases can slow disease progression. These are just a few situations in which urine studies would be diagnostic and extremely helpful for management of patients, and demonstrate potential flaws in the minimalistic approach recommended by the ACP. Like many disorders, kidney stone disease is complicated with a variable phenotype. The ACP guidelines do little to acknowledge or highlight these issues. Current studies indicate that less than 10% of individuals with kidney stone disease undergo a full metabolic workup to prevent further stone formation (1). The approach implied by the ACP guidelines will do little to increase the rate of appropriate metabolic evaluations or help to abate the rising stone disease incidence in the United States (2). In contrast, the AUA guidelines appear to be more balanced and, in general, contain much more useful advice for a physician faced with a patient suffering from recurrent kidney stones.

Amy E. Krambeck, MD
Associate Professor of Urology

John C. Lieske, MD
Professor of Medicine
Fellow American College of Physicians

Mayo Clinic O’Brien Urology Research Center
Rochester, MN

1. Milose JC, Kaufman SR, Hollenbeck BK, Wolf JS, Jr., Hollingsworth JM. Prevalence of 24-hour urine collection in high risk stone formers. The Journal of urology. 2014;191(2):376-80.
2. Scales CD, Jr., Smith AC, Hanley JM, Saigal CS. Prevalence of kidney stones in the United States. European urology. 2012;62(1):160-5.
Writing guidelines when there is a paucity of medical evidence
Posted on December 3, 2014
Margaret S. Pearle, David S. Goldfarb
University of Texas Southwestern, Dallas, TX, NYU School of Medicine, New York, NY
Conflict of Interest: None Declared
To the Editor,

We were disappointed by the recent Clinical Practice guidelines from the American College of Physicians (ACP) about prevention of recurrent nephrolithiasis.(1) The guidelines were based exclusively on randomized controlled trial-generated evidence, which had been summarized in a recent review sponsored by the Agency for Healthcare Research and Quality.(2) That valuable review documented that there was a relative paucity of high quality evidence regarding kidney stone prevention. The members of the American Urological Association’s guideline panel on Medical Management of Kidney Stones therefore recognized that, if the trial data were limited, useful guidelines require access to a broader set of data than could be derived solely from randomized controlled trials.(3) The resulting AUA guidelines, in contrast to the ACP guidelines, relied not only on the AHRQ review but also in part on extensive studies of urine and crystal chemistry, renal physiology, pharmacology, and nutrition. They also rely, of course, on the extensive experience of a diverse group of experts, whose “expert opinion” we understand is considered a flawed body of lore. Nonetheless we believe the AUA guidelines provide a more practical basis for practitioners and patients to prevent recurrent kidney stones, a practice which needs to be advanced in an era of increasing stone prevalence.(4)

Margaret S. Pearle MD
Professor of Urology,
University of Texas Southwestern,
Dallas, TX
Chair, AUA Guidelines Panel, Medical Management of Kidney Stones

David S. Goldfarb MD, FACP
Professor of Medicine and Physiology
NYU School of Medicine,
New York, NY
Vice-Chair, AUA Guidelines Panel, Medical Management of Kidney Stones

1. Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD. Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: a clinical practice guideline from the american college of physicians. Ann Intern Med. 2014;161(9):659-67.
2. Fink HA, Wilt TJ, Eidman KE, Garimella PS, MacDonald R, Rutks IR, et al. Recurrent Nephrolithiasis in Adults: Comparative Effectiveness of Preventive Medical Strategies. Rockville MD; 2012.
3. Pearle MS, Goldfarb DS, Assimos DG, Curhan G, Denu-Ciocca CJ, Matlaga BR, et al. Medical management of kidney stones: AUA guideline. J Urol. 2014;192(2):316-24.
4. Scales CD, Smith AC, Hanley JM, Saigal CS. Prevalence of kidney stones in the United States. Eur Urol. 2012;62(1):160-5.

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