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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)
  1. Borghi, Loris, et al. "Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria." New England Journal of Medicine 346.2 (2002): 77-84.​
  2. Pak, Charles YC, et al. "Long-term treatment of calcium nephrolithiasis with potassium citrate." The Journal of urology134.1 (1985): 11-19.
  3. Pickard, Robert, et al. "Use of drug therapy in the management of symptomatic ureteric stones in hospitalised adults: a multicentre, placebo-controlled, randomised controlled trial and cost-effectiveness analysis of a calcium channel blocker (nifedipine) and an alpha-blocker (tamsulosin)(the SUSPEND trial)." Health technology assessment (Winchester, England)19.63 (2015): vii.
  4. Hollingsworth, John M., et al. "Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis." bmj 355 (2016): i6112.
  5. Raison, Nicholas, et al. "Alpha blockers in the management of ureteric lithiasis: A meta‐analysis." International journal of clinical practice 71.1 (2017).
  6. Ferraro, Pietro Manuel, et al. "Soda and other beverages and the risk of kidney stones." Clinical Journal of the American Society of Nephrology 8.8 (2013): 1389-1395.
  7. Borghi, Loris, et al. "Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria." New England Journal of Medicine 346.2 (2002): 77-84.
  8. Yu, Juan, and Binyan Yin. "Postmenopausal hormone and the risk of nephrolithiasis: A meta-analysis." EXCLI journal 16 (2017): 986.
  9.  Kahwati, Leila C., et al. "Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling AdultsUS Preventive Services Task Force Recommendation  Statement."  JAMA. 2018;319(15):1592-1599.
  10. Cui, Y., Chen, J., Zeng, F., Liu, P., Hu, J., Li, H., … Li, Y. (2019). Tamsulosin as a Medical Expulsive Therapy for Ureteral Stones: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. The Journal of Urology, 201(5), 950–955.
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