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The Role of the 24-Hour Urine Collection in the Prevention of Kidney Stone Recurrence

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The Role of the 24-Hour Urine Collection in the Prevention of Kidney Stone Recurrence UCSF UC San Francisco Previously Published Works Title The Role of the 24-Hour Urine Collection in the Prevention of Kidney Stone Recurrence. Permalink https://escholarship.org/uc/item/8vc0s2g1 Journal The Journal of urology, 197(4) ISSN 0022-5347 Authors Hsi, Ryan S Sanford, Thomas Goldfarb, David S et al. Publication Date 2017-04-01 DOI 10.1016/j.juro.2016.10.052 Peer reviewed eScholarship.org Powered by the California Digital Library University of California 1 58 2 59 3 60 4 61 5 62 6 63 7 The Role of the 24-Hour Urine Collection in the Prevention 64 8 of Kidney Stone Recurrence 65 9 66 10 Ryan S. Hsi,* Thomas Sanford, David S. Goldfarb and Marshall L. Stoller 67 11 68 From the Department of Urologic Surgery, Vanderbilt University School of Medicine (RSH), Nashville, Tennessee, 12 Department of Urology, University of California-San Francisco (RSH, TS, MLS), San Francisco, California, and Nephrology 69 13 Section, New York Harbor Veterans Affairs Healthcare System and New York University Langone Medical Center, 70 14 New York University School of Medicine (DSG), New York, New York 71 15 Accepted for publication October 2, 2016. 72 16 Purpose: Kidney stone prevention relies on the 24-hour urine collection to No direct or indirect commercial incentive 73 17 diagnose metabolic abnormalities and direct dietary and pharmacological ther- associated with publishing this article. 74 apy. While its use is guideline supported for high risk and interested patients, The corresponding author certifies that, when 18 applicable, a statement(s) has been included in 75 19 evidence that the test can accurately predict recurrence or treatment response is the manuscript documenting institutional review 76 20 limited. We sought to critically reassess the role of the 24-hour urine collection in board, ethics committee or ethical review board 77 stone prevention. study approval; principles of Helsinki Declaration 21 were followed in lieu of formal ethics committee 78 22 Materials and Methods: In addition to a MEDLINEÒ search to identify approval; institutional animal care and use 79 23 controlled studies of dietary and pharmacological interventions, evidence sup- committee approval; all human subjects provided 80 written informed consent with guarantees of 24 porting the AUA (American Urological Association) and EAU (European Asso- confidentiality; IRB approved protocol number; 81 25 ciation of Urology) guidelines for metabolic stone prevention were evaluated. animal approved project number. 82 26 Additionally, the placebo arms of these studies were examined to assess the stone * Correspondence: Department of Urologic 83 Surgery, Vanderbilt University Medical Center, 27 clinic effect, that is the impact of regular office visits without specific treatment A-1302 Medical Center North, Nashville, 84 28 on stone recurrence. Tennessee 37232 (e-mail: [email protected]). 85 29 Results: The 24-hour urine test has several limitations, including the complexity Editor’s Note: This article is the 86 30 of interpretation, the need for repeat collections, the inability to predict stone of 5 published in this issue for 87 31 recurrence with individual parameters and supersaturation values, the unclear which category 1 CME credits 88 can be earned. Instructions for 32 rationale of laboratory cutoff values and the difficulty of determining collection obtaining credits are given with 89 33 adequacy. Only 1 prospective trial has compared selective dietary recommen- the questions on pages and 90 34 dations based on 24-hour urine collection results vs general dietary instructions. 91 35 While the trial supported the intervention arm, significant limitations to 92 36 the study were found. Placebo arms of intervention trials have noted a 0% to 93 37 61% decrease in stone recurrence rate and a remission rate during the study of 94 38 20% to 86%. 95 39 Conclusions: Whether all recurrent stone formers benefit from 24-hour urine 96 40 collection has not been established. Additional comparative effectiveness trials 97 41 are needed to determine which stone former benefits from selective therapy, as 98 42 guided by the 24-hour urine collection. 99 43 100 44 Key Words: kidney, urolithiasis, secondary prevention, 101 45 urine specimen collection, recurrence 102 46 103 47 104 48 105 49 THE goal of metabolic management recommended that a 24-hour urine 106 50 for kidney stones is to prevent recur- collection should represent the spe- 107 51 rent stone episodes, which occur in up cific metabolic evaluation to be per- 108 52 to 50% of individuals after 10 years.1 formed in high risk stone formers.2,3 109 53 National guideline panels have The rationale for testing is that 110 54 111 55 0022-5347/17/1974-0001/0 http://dx.doi.org/10.1016/j.juro.2016.10.052 112 THE JOURNAL OF UROLOGY® Vol. 197, 1-6, April 2017 56 www.jurology.com j 1 113 57 Ó 2017 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH,INC. Printed in U.S.A. 114 Dochead: Adult Urology FLA 5.4.0 DTD JURO14096_proof 4 January 2017 4:16 pm EO: JU-16-1644 2 24-HOUR URINE COLLECTION AND KIDNEY STONE RECURRENCE 115 identifying specific metabolic abnormalities in urine the dietary prevention of stone recurrence. In a 172 116 would enable the clinician to make individualized study by Kocvara et al, 242 idiopathic calcium 173 117 diet and pharmacological interventions to correct based, first-time stone formers were evenly assigned 174 118 these abnormalities and reduce the recurrence risk. to a group with a specific dietary regimen tailored 175 119 There is weighty reliance on this test to guide the by a 24-hour urine collection or to a second group in 176 120 metabolic stone management. According to AHRQ which general, nonselective dietary measures were 177 121 (Agency for Healthcare Research and Quality), begun.7 After 3 years, stone recurrence and/or 178 122 additional studies are needed “to estimate the growth occurred in 7% of the intervention group and 179 123 effectiveness, cost-effectiveness and harms of in 23% of the nonselective group (p <0.01). 180 124 different kidney stone evaluation, treatment and While these results would appear to favor the 181 125 followup strategies vs a control strategy to prevent 24-hour urine collection, several issues should be 182 126 stone recurrence.”4 Which stone formers should noted. The intervention group had regular follow- 183 127 undergo this test, when and how often is unclear. ups, including repeat collections and dietary 184 128 We examine the evidence supporting the role of the adjustment, while the nonselective group had no 185 129 24-hour urine collection for the prevention of future followup. Urine collections were performed only in 186 130 stone events. the intervention group and, except for an improve- 187 131 ment in uricosuria, there was no appreciable 188 132 improvement in any other urinary parameters. In 189 133 ROLE IN CONTEMPORARY PRACTICE fact, there were significantly higher mean levels of 190 134 Both AUA and EAU guidelines recommend 24-hour urinary calcium and oxalate at the end of the study 191 2,3 135 urine collections in the high risk individual. AUA compared to baseline in the selective therapy group. 192 136 also recommends testing in the motivated first-time The difference in stone recurrence rates in the 2 193 137 stone former. In the EAU guidelines, 2 consecutive groups may be explained more by the stone clinic 194 138 collections are recommended initially, again after effect, which has been documented to have a sig- 195 139 initiating dietary or pharmacological prevention for nificant effect on recurrence.8 196 3 140 8 to 12 weeks and every 12 months thereafter. AUA 197 141 recommends 1 or 2 collections performed initially, Drawbacks 198 142 an additional collection within 6 months of inter- No laboratory test is perfect but the interpretation 199 143 vention to assess adherence and response, and of the 24-hour urine collection has several issues 200 2 144 yearly collection thereafter. (see Appendix). Often more than 1 abnormality is 201 145 The utilization of the collection is increasingly present, placing the clinician in a quandary about 202 146 viewed as a quality metric in nephrolithiasis care. which abnormality to address. Borderline values 203 147 In current practice, however, this test is uncom- may have clinical importance. Stone composition 204 148 monly performed. Among privately insured Ameri- provides value in the role of medical management, 205 149 cans identified as high risk for stone recurrence, the especially if the composition is uric acid or cystine, 206 5 150 prevalence of testing is only 7%. Of those tested, for example. However, it is less helpful for the pre- 207 151 16% with an abnormality in the initial collection dominant calcium oxalate stone former in whom a 208 6 152 undergo repeat collections within 6 months. Why 24-hour urine collection is performed. 209 153 overall use is so low is unclear but before broad The 24-hour urine collection negates diurnal and 210 154 quality metrics tied to reimbursement are imple- nocturnal variations in the urinary constituents 211 155 mented, more study is needed to determine who related to diet and metabolism, so that often a single 212 156 benefits most from this test. test is difficult to interpret. While performing 1 or 2 213 157 consecutive collections as part of the initial workup 214 158 has been debated, variation is intrinsic to patient 215 24-HOUR URINE COLLECTION 159 diets and activities, so that it remains uncertain 216 160 Rationale whether doing more collections and making more 217 161 A systemic search was done in PubMedÒ for orig- diagnoses increases clinical value. Patients may 218 162 inal publications involving adult kidney stone dis- prefer to do collections at home, on the weekends, 219 163 ease formers up to 2016.
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