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Metabolic risk-evaluation and prevention of recurrence in stone disease: does it make sense?

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In this review, aspects on the importance of information on urine composition and selection of the most appropriate regimen for prevention of recurrence are discussed. For patients with urolithiasis the treatment is facilitated by urine analysis with estimates of supersaturation levels. Despite lack of strong scientific evidence for the benefit of selective versus non-selective prevention of recurrence in patients with calcium stone disease, there is currently both convincing and logical information in support of tailored/selective treatment regimens aiming at correction of abnormal target variables. Such an approach is also recommended in the EAU and AUA guidelines. It is important, however, that every preventive regimen is balanced between the effects on urine composition and patients' tolerance to the treatment in order to achieve satisfactory compliance. It is possible that future improved understanding of the causes of calcium stone formation might provide a different therapeutic approach.
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Urolithiasis (2016) 44:91–100
DOI 10.1007/s00240-015-0840-y
INVITED REVIEW
Metabolic risk‑evaluation and prevention of recurrence in stone
disease: does it make sense?
Hans‑Göran Tiselius1
Received: 8 June 2015 / Accepted: 5 November 2015 / Published online: 27 November 2015
© Springer-Verlag Berlin Heidelberg 2015
Introduction
For the medical and metabolic care of patients with uro-
lithiasis, there are two essential questions that immediately
seek an answer. Is prevention of recurrence at all possi-
ble and of value and if so, does prevention of recurrence
require metabolic risk-evaluation?
Before addressing this issue in detail, it is necessary to
know that the risk of recurrent stone formation varies con-
siderably between patients. It has accordingly been shown
that without preventive treatment the recurrence risk for
patients with cystinuria is around 85 % [1]. For infection
and uric acid stone forming patients, despite lack of spe-
cific information, it can be assumed that the recurrence risk
also is very high and probably at similar or even higher
levels.
A more variable response to preventive treatment has
been recorded and can be expected in patients who have
formed stones composed of calcium salts; calcium oxa-
late and calcium phosphate. In these patients the average
recurrence risk after 10 years is around 50 % [2, 3] (Fig. 1).
Patients forming brushite stones (calcium hydrogen phos-
phate) have a particularly high recurrence risk as high as
70 % [3, 4]. But for the other calcium stone patients it
stands to reason that while some will only form one stone
during their life-time others are afflicted by a more severe
disease with repeated stone formation and repeated need of
active stone removing interventions. When patients, who
had formed their first and only stone (S), were compared
with those who had formed at least two stones (R) at the
start of follow-up, two different courses were recorded
(Fig. 1). For S-patients less than 30 % have formed one
or several new stones after 10 years. This should be com-
pared with a 10-year recurrence risk of almost 70 % for
R-patients. It thus seems reasonable to assume that whereas
Abstract In this review, aspects on the importance of
information on urine composition and selection of the
most appropriate regimen for prevention of recurrence are
discussed. For patients with urolithiasis the treatment is
facilitated by urine analysis with estimates of supersatura-
tion levels. Despite lack of strong scientific evidence for
the benefit of selective versus non-selective prevention of
recurrence in patients with calcium stone disease, there is
currently both convincing and logical information in sup-
port of tailored/selective treatment regimens aiming at
correction of abnormal target variables. Such an approach
is also recommended in the EAU and AUA guidelines. It
is important, however, that every preventive regimen is
balanced between the effects on urine composition and
patients’ tolerance to the treatment in order to achieve sat-
isfactory compliance. It is possible that future improved
understanding of the causes of calcium stone formation
might provide a different therapeutic approach.
Keywords Calcium stones · Non-calcium stones · Stone
analysis · Serum analysis · Urine analysis · Risk factors ·
Supersaturation · Prevention of recurrence · Dietary
advice · Drinking advice · Pharmacological treatment ·
Selective treatment · Non-selective treatment
* Hans-Göran Tiselius
hans-goran.tiselius@telia.com; hans-goran.tiselius@ki.se
1 Division of Urology, Department of Clinical Science,
Intervention and Technology (CLINTEC), Karolinska
Institutet, Stockholm, Sweden
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An optimum metabolic evaluation strategy for urinary stone patients has not been clearly defined. To evaluate the optimum strategy for metabolic stone evaluation and management to prevent recurrent urinary stones. Several databases were searched to identify studies on the metabolic evaluation and prevention of stone recurrence in urolithiasis patients. Special interest was given to the level of evidence in the existing literature. Reliable stone analysis and basic metabolic evaluation are highly recommended in all patients after stone passage (grade A). Every patient should be assigned to a low- or high-risk group for stone formation. It is highly recommended that low-risk stone formers follow general fluid and nutritional intake guidelines, as well as lifestyle-related preventative measures to reduce stone recurrences (grade A). High-risk stone formers should undergo specific metabolic evaluation with 24-h urine collection (grade A). More specifically, there is strong evidence to recommend pharmacological treatment of calcium oxalate stones in patients with specific abnormalities in urine composition (grades A and B). Treatment of calcium phosphate stones using thiazides is only highly recommended when hypercalciuria is present (grade A). In the presence of renal tubular acidosis (RTA), potassium citrate and/or thiazide are highly recommended based on the relative urinary risk factor (grade A or B). Recommendations for therapeutic measures for the remaining stone types are based on low evidence (grade C or B following panel consensus). Diagnostic and therapeutic algorithms are presented for all stone types based on the best level of existing evidence. Metabolic stone evaluation is highly recommended to prevent stone recurrences. In this report, we looked at how patients with urolithiasis should be evaluated and treated in order to prevent new stone formation. Stone type determination and specific blood and urine analysis are needed to guide patient treatment. Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.