DescriptionAn in-depth report on the causes, diagnosis, treatment, and prevention of kidney stones.
Alternative NamesCalcium Stones; Extracoporeal Shock Wave Lithotripsy; Lithotripsy; Nephrolithiasis; Oxalates; Uric Acid
Diuretics. Diuretics are commonly used in the treatment of high blood pressure and other disorders to eliminate fluid and sodium from the body. Low doses of diuretics known as thiazides are sometimes used to reduce the amount of calcium released by the kidneys into the urine. In fact, a major analysis comparing a number of agents reported that only thiazides protected against kidney stones. Some thiazides include hydrochlorothiazide (Esidrix, HydroDiuril), chlorothiazide (Diuril), trichlormethiazide (Metahydrin, Naqua), and chlorthalidone (Hygroton). Thiazides, however, also cause potassium loss, which, in turn, reduces citrate levels and can increase the risk for stones. Potassium citrate should therefore be taken along with a thiazide to prevent citrate loss. Amiloride (Midamor) is a potassium-sparing diuretic, which may be used if a thiazide is not effective, and offers an extra benefit by reducing potassium loss.
Citrates. Citrate salts are often given to people with calcium oxalate or uric acid stones:
None of these products should be used by people with struvite stones, urinary tract infections, bleeding disorders, or kidney damage. Patients who take citrate supplements containing potassium should not take any other medications that either contain the mineral or prevent its loss (such as so-called potassium-sparing diuretics). People with peptic ulcers should avoid them or discuss using non-tablet forms with their physician.
Phosphates. Phosphates help reduce bone resorption (the breakdown of bone that releases calcium into the bloodstream) and are also involved in reabsorption of calcium from urine by the kidney. Certain phosphate compounds may be helpful.
Acidic forms of phosphate should not be used, since this increases the risks for both hypocitraturia and hypercalciuria.
Cholestyramine. Cholestyramine (Questran, Questran Light) is a drug normally used to reduce cholesterol levels; it also binds with oxalate in the intestine and so reduces elevated levels in urine (hyperoxaluria). The drug is usually taken in powder form, dissolved in water, milk, or fruit juice; it is also available as a chewable bar (Cholybar). Bloating and constipation are common side effects of this drug, so many people cannot tolerate it. The drug also interferes with other medications, including digoxin (Lanoxin) and warfarin, and may contribute to calcium loss and osteoporosis. In order to prevent such interactions, other drugs should be taken one hour before or four to six hours after taking cholestyramine. If the drug is taken for a long period of time, deficiencies of vitamins A, D, E, and K can result, and vitamin supplements may be necessary.
Investigative Therapies. The following are some investigative therapies for eliminating the causes of some kidney stones.
Medications for Uric Acid Stones
Sodium Bicarbonate. Patients whose uric acid stones are caused by persistently acidic urine may take sodium bicarbonate to reduce acidity. Patients taking this must test their urine regularly with pH paper, which turns different colors depending on whether the urine is acidic or alkaline. Too much sodium bicarbonate can cause the urine to become overly alkaline and increase the risk for calcium phosphate stones. This treatment should not be used by patients who need to restrict sodium for other medical conditions.
Potassium Citrate. Potassium citrate, which restores citrate to the urine, is useful for patients with high levels of uric acid in the urine.
Allopurinol. Allopurinol (Lupurin, Zyloprim) is very effective in reducing high levels of uric acid and may be helpful for patients with uric acid stones. It should be noted that allopurinol will not prevent calcium stones from forming. There is also a slight risk for xanthine stones with this drug.
The drugs side effects, experienced by 3% to 5% of patients, include diarrhea, headache, and fever. More severe complications include blood disorders that may produce fatigue, bleeding, or bruising. About 2% of patients experience an allergic reaction to allopurinol that causes a rash. In rare cases, the rash can become severe and widespread enough to be life threatening. Allergic individuals who had experienced only a mild rash may be able to build up their tolerance for the drug by undergoing a desensitization process. The drug may also increase the risk for cataracts.
Some patients experience an allergic reaction to allopurinol, which can be fatal. Because allopurinol reduces uric acid levels rapidly, it may trigger an attack of gout in susceptible people. To prevent this, patients should take a nonsteroidal anti-inflammatory (NSAID) for two or three months. One study recommended indomethacin, although many NSAIDs are available. (Aspirin, which is also an NSAID, should not be taken, since it increases uric acid levels.) Patients should discuss the appropriate drug with their physician.
Medications for Struvite Stones
Before any medical treatment is given for struvite stones, they must be completely removed with surgery. They do not respond well to standard stone-crushing procedures (lithotripsy) so major surgery may be necessary. (New procedures may be helpful.)
Antibiotics for Eliminating Infection. The first medical line of defense against struvite (magnesium ammonium phosphate) stones are on-going antibiotics to keep the urine free of bacteria that cause urinary tract infections. Careful follow-up afterward and testing urine for acidity is extremely important. (A high pH indicates low acidity and an increased risk of infection.)
Acetohydroxamic Acid (AHA). Acetohydroxamic acid or AHA (Lithostat) is beneficial when used with long-term antibiotics. AHA blocks the enzymes released by the bacteria and has been effective in preventing stones even when bacteria are present. Side effects, however, can be severe. The drug reduces iron stores in the body, so anemia is a common problem. Iron supplements may be needed. Other side effects include nausea and vomiting, depression, anxiety, rash, persistent headache, and, rarely, small blood clots in the legs. Experts recommend this drug only for patients with healthy kidneys who have chronic diseases caused by these specific struvite-causing organisms. Alcohol should be avoided. Pregnant women should not take it.
Organic Acids. Medical treatments to dissolve stones may be useful with in patients who do not respond or in combination with surgeries, although they have limited long-term use. Acidic urine dissolves struvite stones, so the physician may irrigate the urinary tract with a solution of organic acids (e.g., Renacidin). Candidates for irrigation must have sterile urine and healthy kidney function. In surgical patients, irrigation is performed four or five days after the operation. The urinary tract is irrigated with saline for one to two days, and if there are no problems, the organic acid solution is administered for another one or two days until all stones are dissolved. The patient's urine should be tested on a regular basis to be sure that bacteria do not return.
Aluminum Hydroxide Gel. An aluminum hydroxide gel anti-acid may reduce phosphate levels but it carries a long-term risk of aluminum toxicity. Prolonged depletion of phosphorus can also increase the risk for calcium oxalate stones. Experts recommend limiting phosphorus through a low-protein diet.
Medications for Cystine Stones
The first-line treatment for cystine stones is increasing the alkalization of urine so the stone can dissolve. If alkalization fails, drugs such as d-penicillamine, alpha-mercaptopropionylglycine (tiopronine), or captopril may be used to lower cystine concentration. Fluid intake for cystine stones must be even more voluminous than for regular stones. The patient should uniformly drink at least four quarts of water over a 24-hour period.