Diagnosis, treatment and prevention of urolithiasis from the standpoint of evidence-based medicine

According to statistics, the prevalence of urolithiasis in the general population is about 5-10%.
The National Institute for Health and Care Excellence − NICE provides guidelines for the diagnosis and treatment of patients with nephrolithiasis in 2019.

The goal of the protocol is to increase the effectiveness of diagnostic interventions, develop preventive measures and improve the quality of life of patients with urolithiasis.

Find out in the article on estet-portal.com the main approaches to the diagnosis of renal colic and the treatment of urolithiasis from the perspective of evidence-based medicine.

Urgent diagnosis of nephrolithiasis

Urgent (within 24 hours of onset of clinical symptoms of urolithiasis) low-dose, non-contrast computed tomography (CT) is indicated for adults with suspected renal colic. For pregnant women with nephrolithiasis, preference should be given to ultrasound examination (ultrasound).

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Urgent (within 24 hours after the onset of clinical symptoms of nephrolithiasis) ultrasound of the kidneys and urinary tract for children and adolescents (under 16 years of age) with suspected renal colic.
Low-dose non-contrast computed tomography is recommended for children and adolescents with suspected for renal colic provoked by nephrolithiasis, appoint only if diagnostic data are inaccurate according to the results of ultrasound.

Pharmacotherapy of chronic renal failure

Control of pain syndrome during exacerbation of urolithiasis

First line for pain syndrome caused by nephrolithiasis − These are non-steroidal anti-inflammatory drugs (NSAIDs) in any dosage form for adults, children and adolescents with suspected renal colic. Paracetamol may also be administered to adults, children, and adolescents with suspected renal colic if NSAIDs are contraindicated or have failed.

It is recommended that opioids be considered in adults, children, and adolescents with suspected renal colic due to urolithiasis, if there are contraindications to the use of NSAIDs and the administration of paracetamol, or if these measures do not reduce the severity of pain manifestations.

It is forbidden to use antispasmodics in adults, children and adolescents with suspected renal colic in urolithiasis, which can further increase pain due to spasm.

Medical expulsive therapy for nephrolithiasis

Recommended drug therapy includes alpha-adrenergic blockers in adults, children, and adolescents with stones smaller than 10 mm at the level of the distal ureter.

The use of stenting is age-specific: it is mandatory to perform stenting before performing shock wave lithotripsy to remove staghorn kidney stones in children and adolescents, but it is not recommended to perform stenting before performing shock wave lithotripsy for nephrolithiasis in adult patients.

Kidney pathology in heart failure

Surgical treatment of urolithiasis

Expectant management is possible in asymptomatic clinical course of urolithiasis in adults, children and adolescents if:

1)    calculus size less than 5 mm or;

2)    calculus size greater than 5 mm and the patient (or his family, caregivers) agrees to monitor the condition after a detailed discussion of the possible risks and benefits of such tactics.

The timing of surgical treatment of nephrolithiasis, including shock wave lithotripsy, for adults with ureteral calculi and renal colic depends on the intensity of pain in the position of the calculus.

Surgical treatment of nephrolithiasis, including shock wave lithotripsy, is recommended in adult patients with ureteral calculi and renal colic within 48 hours of diagnosis or at follow-up inpatient examination if: the pain continues and is unbearable, or physiological passage of the calculus is unlikely.

Medical expulsive therapy for nephrolithiasis as an adjunct to shock wave lithotripsy for adult patients with ureteral calculi smaller than 10 mm is possible in the form of alpha-adrenergic blockers.

Prevention of recurrence of urolithiasis

Dietary and lifestyle advice to further prevent recurrence of nephrolithiasis:

1.    Adult patients should take from 2.5 to 3 liters of clean drinking water per day, children and adolescents, depending on age - 1-2 liters;

2.    Recommended adding fresh lemon juice to drinking water;

3.    Sodas should be avoided;

4.    For adults, limit salt intake to 6 g / day, for children and adolescents, depending on age - up to 2-3 g

5.    It is important not to limit but maintain daily calcium intake at 700-1200 mg/day for adults and 350-1000 mg/day for children and adolescents, depending on age.

The Nephrologist's Approach to the Treatment of Chronic Renal Failure

It may also be necessary to prescribe thiazide diuretics to adult patients with recurrent urolithiasis with a predominance of calcium oxalates in the calculus (more than 50%) and hypercalciuria after limiting sodium intake to no more than 6 g / day.

The effect of nephritis on the development of renal failure