Prevention of recurrent nephrolithiasis in adults and children

Abstract

BACKGROUND: Recurrent kidney stones are unpleasant and may lead to kidney damage, sepsis, or invasive procedures.

PURPOSE: To assess benefits and harms of diet, pharmacologic therapy, and surveillance imaging to prevent recurrent nephrolithiasis.

DATA SOURCES: PubMed, Cochrane Library, and trial registries through December 2025.

STUDY SELECTION: Randomized controlled trials (RCTs) or nonrandomized studies of interventions (NRSIs) in nonpregnant adults or children.

DATA EXTRACTION: One reviewer extracted data, and a second reviewer checked for accuracy. Dual independent assessments of risk of bias and strength of evidence (SOE) were done.

DATA SYNTHESIS: Among 31 studies (26 RCTs and 5 NRSIs), none evaluated imaging strategies. All but 3 included adults only. For adults with calcium oxalate or phosphate stones, increased water intake; a diet with normal to high calcium, low protein, and low sodium; thiazides; alkali treatment; and allopurinol may reduce stone recurrence (low SOE). There may be no difference between selective and empirical pharmacotherapy (low SOE). Acetohydroxamic acid may reduce stone growth in adults with infection-related stones (low SOE) but had insufficient evidence on prevention of recurrent stones and probably increased adverse events (moderate SOE). There may be increased minor adverse events with lemon juice but no increased harm due to serious adverse events with thiazides and allopurinol (low SOE).

LIMITATION: Studies not published in English or with fewer than 30 participants per group were excluded.

CONCLUSION: Increased fluid intake; a diet with normal to high calcium, low protein, and low sodium; thiazides; alkali therapy; and allopurinol may prevent stone recurrence in adults with calcium oxalate or calcium phosphate stones. Evidence is limited on other interventions, including imaging strategies, in children and on harms and other outcomes.

PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute and Agency for Healthcare Research and Quality (contract no. 75Q80120D00007/75Q80124F32010). (PROSPERO: CRD42024617257).