Metabolic Evaluation and Recurrence Prevention for Urinary Stone Patients: EAU Guidelines
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EUROPEAN UROLOGY 67 (2015) 750–763 available at www.sciencedirect.com journal homepage: www.europeanurology.com Guidelines Metabolic Evaluation and Recurrence Prevention for Urinary Stone Patients: EAU Guidelines Andreas Skolarikos a,*, Michael Straub b, Thomas Knoll c, Kemal Sarica d, Christian Seitz e, Ales Petrˇı´k f,g, Christian Tu¨rk h a Second Department of Urology, Sismanoglio Hospital, Athens Medical School, Athens, Greece; b Department of Urology, Technical University Munich, Munich, Germany; c Department of Urology, Sindelfingen-Boeblingen Medical Center, University of Tu¨bingen, Sindelfingen, Germany; d Department of Urology, Dr Lutfi Kırdar Research and Teaching Hospital, Istanbul, Turkey; e Department of Urology, Medical University Vienna, Austria; f Department of Urology, Region Hospital, Cˇeske´ Budeˇjovice, Czech Republic; g Department of Urology, Charles University, 1st Faculty of Medicine, Prague, Czech Republic; h Department of Urology, Rudolfstiftung Hospital, Vienna, Austria Article info Abstract Article history: Context: An optimum metabolic evaluation strategy for urinary stone patients has not Accepted October 16, 2014 been clearly defined. Objective: To evaluate the optimum strategy for metabolic stone evaluation and man- agement to prevent recurrent urinary stones. Keywords: Evidence acquisition: Several databases were searched to identify studies on the meta- Stone bolic evaluation and prevention of stone recurrence in urolithiasis patients. Special Lithiasis interest was given to the level of evidence in the existing literature. Evidence synthesis: Reliable stone analysis and basic metabolic evaluation are highly Urinary recommended in all patients after stone passage (grade A). Every patient should be Metabolic evaluation assigned to a low- or high-risk group for stone formation. It is highly recommended that Medical treatment low-risk stone formers follow general fluid and nutritional intake guidelines, as well as Recurrence and conservative lifestyle-related preventative measures to reduce stone recurrences (grade A). High-risk treatment stone formers should undergo specific metabolic evaluation with 24-h urine collection (grade A). More specifically, there is strong evidence to recommend pharmacological European Association of Urology treatment of calcium oxalate stones in patients with specific abnormalities in urine Guidelines 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. Please visit Conclusion: Metabolic stone evaluation is highly recommended to prevent stone recur- www.eu-acme.org/ rences. europeanurology to read and Patient summary: In this report, we looked at how patients with urolithiasis should be answer questions on-line. evaluated and treated in order to prevent new stone formation. Stone type determina- tion and specific blood and urine analysis are needed to guide patient treatment. The EU-ACME credits will # 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved. then be attributed automatically. * Corresponding author. Athens Medical School, Second Department of Urology, Sismanoglio Hospi- tal, Athens, Greece. Tel. +30 123 0080139; Fax: +30 124 0803074. E-mail address: [email protected] (A. Skolarikos). http://dx.doi.org/10.1016/j.eururo.2014.10.029 0302-2838/# 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved. EUROPEAN UROLOGY 67 (2015) 750–763 751 1. Introduction Table 1 – Investigating patients with stones of unknown composition The lifetime risk of stone formation in an individual is Investigation Rationale for investigation estimated at 5–10% [1,2]. The recurrence rate after Medical history Stone history (former stone events, family history) formation of an initial stone is reported to be as high Dietary habits as 50% at 5 yr and 80–90% at 10 yr [3]. People who form Medication chart stones are more likely to have urinary metabolic abnormal- Diagnostic Ultrasound ities compared to a healthy population (level of evidence imaging Unenhanced helical CT in cases of a suspected stone Blood analysis Creatinine [LE] III/C) [4,5], while patients who form recurrent stones Calcium (ionized calcium or total calcium + albumin) tend to have more significant metabolic abnormalities Uric acid than those with a single stone episode (LE III/C) Urinalysis Dipstick test: leukocytes, erythrocytes, nitrite, [5,6]. Because the removal of an existing calculus does protein, urine pH, specific weight Urine culture not prevent further stone formation, patients should be Urine pH profile (measurement after each voiding, thoroughly evaluated and educated on stone prevention. minimum four times daily) The aim of this review is to clarify the need and describe a Microscopy of urinary sediment (morning urine) method for evaluation of patients with first-time and Cyanide nitroprusside test (exclusion of cystinuria) recurrent stone formation. Diagnostic protocols for CT = computed tomography. different etiologies of nephrolithiasis are provided. Spe- cific therapeutic algorithms have been created to guide etiologic treatment of different stone types. specific workup of the patient should be performed (Table 1) [11]. 2. Evidence acquisition After stone passage, every patient should undergo basic evaluation and be assigned to a group with low or high risk A professional research librarian carried out literature of stone recurrence (Tables 2 and 3; Fig. 1) [11]. searches for all sections of the urolithiasis guideline, Only high-risk stone formers require specific metabolic covering the timeframe between 1976 until August evaluation [12], which should be individualized based 2013. Searches were carried out using the Cochrane Library on different stone types. Specific metabolic evaluation Database of Systematic Reviews, the Cochrane Library of requires collection of two consecutive 24-h urine samples Controlled Clinical Trials, and Medline and Embase on the [13,14]. Patients should remain on a self-selected diet Dialog-Datastar platform. The searches used the controlled [15]. The collection method should be chosen in close terminology of the respective databases. Both MesH and cooperation with the particular laboratory. EMTREE were analyzed for relevant terms. In many cases, Spot urine samples are an alternative sampling method, the use of free text ensured the sensitivity of the searches. particularly when 24-h urine collection is difficult, for The focus of the searches was identification of all level example, in younger children. Spot urine studies normally 1 scientific papers (systematic reviews and meta-analyses link the excretion rates to creatinine [16]. Because the results of randomized controlled trials). If sufficient data were may vary with collection time and patients’ sex, body weight, identified to answer the clinical question, the search was and age, the value of spot urine studies is limited. not expanded to include lower-level literature. LE and/or There is limited evidence to support the exact time to grade of recommendation (GR) values were given according perform the specific metabolic evaluation and follow-up of to the Oxford Centre for Evidence-based Medicine LEs [7].In stone patients (level III/grade C). For the initial specific some cases, the link between LE is and GR is not directly metabolic workup, the patient should be stone-free. A obvious and recommendations have been up- or down- minimum of 20 d is recommended between stone expulsion graded following expert panel discussion. These cases are or removal and 24-h urine collection [17,18]. Follow-up clearly identifiable and marked in the recommendation section with an asterisk (*). Table 2 – Basic evaluation of a stone former 3. Evidence synthesis Investigation Rationale for investigation 3.1. General metabolic considerations for patient workup Medical history and Stone history (prior stone events, family physical examination history) and recurrence prevention Dietary habits Medication chart 3.1.1. Evaluation of patient risk Diagnostic imaging Ultrasound All patients should undergo stone analysis using infrared Blood analysis Creatinine spectroscopy or X-ray diffraction prior to metabolic Calcium (ionized calcium or total calcium + albumin) evaluation [8]. Stone analysis should be performed in Uric acid recurrent stone formers during each stone episode, even if Urinalysis Dipstick test: leukocytes, erythrocytes, the initial stone composition is known, because changes in nitrite, stone content have been reported in recurrent stone protein, urine pH, specific weight Urine culture formers [9,10]. When stone analysis is not available, a 752 EUROPEAN UROLOGY 67 (2015) 750–763 Table 3 – High-risk stone formers Table 4 – General preventive measures General factors Fluid intake (drinking advice) Fluid amount: 2.5–3.0 l/d Early onset of urolithiasis (especially children and teenagers) Circadian drinking Familial stone formation Neutral pH beverages Brushite-containing stones (calcium hydrogen phosphate; CaHPO4Á2H2O) Diuresis: 2.0–2.5 l/d Uric acid and urate-containing