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Recurrent Stone Former: Approach

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Dr Jatin Kothari, Mumbai    29 December 2018

  • Spectrum of stone composition in India - Ca oxalate 93%; Ca apatite 2%; Struvite 1%; Uric acid 1%; Cystine 0%; Mixed 3%. Prevention is considered in recurrent stone formers because: stone removal does not alter the underlying pathophysiology of stone causation; stones can be recurrent; every stone leaves a scar on the kidney; procedures are not cheap.
  • Single stone formers should undergo the same evaluation as recurrent stone formers. Who should undergo a complete metabolic evaluation – Those who are at risk for recurrence: Family history of stones, chronic diarrhea, pathologic fractures, osteoporosis, UTI, gout, solitary kidney, anatomic abnormalities, renal insufficiency; Stones composed of: Cystine, uric acid, struvite; Kids with stones.
  • Tools used to infer stone composition - History of predisposing conditions, dietary excesses, inadequate fluid intake or excessive fluid loss; Medications (calcium, vitamin C/D, acetazolamide); Prior stone history; Urine pH; Urinary crystals; Urine culture for urea-splitting organisms; Radiography; Stone analysis; Metabolic work-up.
  • Treatment - Basic evaluation and stone analysis for everyone; Recurrent stone formers should undergo a thorough metabolic evaluation; Only baseline UA predicts outcome; universal acceptance of high water intake. Thiazides can yield 57% reduction in stone formation (meta-analysis of 8 RCTs). K Mag citrate is useful only in hypocitraturia. Allopurinol is useful in hyperuricosuric calcium oxalate stone formers (without any other metabolic abnormalities).
  • General preventive measures - Fluid intake; balanced diet; lifestyle advice to normalize general risk factors.

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