Treatment (Non Surgical)

Conservative Treatment

DIET
In men with recurrent calcium oxalate stones and hypercalciuria, restricted intake of animal protein and salt, combined with a normal calcium intake, provides greater protection than the traditional low-calcium diet. Milk should be encouraged especially with intake of high oxalate foods. (7)

BEVERAGES
23% higher risk of stones w/ sweetend cola, 33% higher risk if sugar sweetened non-cola. Marginally higher risk w/ artificially sweetened non-cola. Coffee and alcohol are protective against stone disease, based on study from NHANES 2007-2010 (6)

ALPHA BLOCKERS
Alpha blockers are routinely part of conservative trial of passage. Neither alpha blockers nor calcium-channel blockers showed any benefit in the large SUSPEND trial (3), but alpha blockers were shown to be beneficial in a large systematic review and meta-analysis (4). A second 2017 meta-analysis supported this, particularly for ureteral calculus >5mm (5) and a 3rd did in 2019. (10)

PROPHYLACTIC THERAPY

Low Salt diet
High fluid intake (12 - 8 oz cofee cups or 8 - 12 oz of water)
Lemon & juices w/ citrate (causing alkalanization, good for uric acid and cystine stones)
Continue thiazides
Moderate Ca++ intake (1000-1200mg/day)
Limited animal protein
Potassium citrate (bedtime K citrate to avoid nighttime fluid excess)
Glucocorticoids if from granuloma disease
Some patients benefit from bisphosphonates, calcitonin, denosumab

Restricting dietary salt and animal protein significantly reduces stone recurrence compare to Ca++ restricted diet. (1) Vitamin D with Ca++ associated with increased risk in kidney stones and a large meta-analysis of 11 RCT showed that supplementation did not reduce fractures for the general population and only reduced fractures in patients unless that were deficient in vitamin D, had osteoprosis or prior fracture. (9)

POTASSIUM CITRATE
Doesn't lower as much as thiazide. (2) Acts two ways: binding Ca++ and also alkali load reducing bone resoprtion which causes increased Ca++ resorption in kidneys.

THIAZIDES
Lowers Ca++ in urine more than potassium citrate. (2) Bind Na-Cl cotransporter, causing volume depletion which stimulates calcium reabsorption in the PCT. Must have a low sodium diet to maximize the hypocalciuric effect of this.

HORMONE REPLACEMENT
Meta-analysis suggests hormone replacement in women does not increase their risk of stones. (8)