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Nephrolithiasis

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Updated 2024 EAU and 2023 ACR guidelines for the diagnosis and management of nephrolithiasis.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of nephrolithiasis are prepared by our editorial team based on guidelines from the European Association of Urology (EAU 2024), the American College of Radiology (ACR 2023), the European Society of Anaesthesiology and Intensive Care (ESAIC 2023), the Canadian Urological Association (CUA 2022), the American Urological Association (AUA/ES 2016), and the American ...
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Diagnostic investigations

Clinical evaluation: as per EAU 2024 guidelines, elicit a medical history including stone history (former stone events, family history), dietary habits and medication history in patients with stones of unknown composition.
A
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  • Blood tests

  • Urine tests

  • Diagnostic imaging

  • Bone mineral density testing

Diagnostic procedures

Stone analysis
As per EAU 2024 guidelines:
Obtain stone analysis in first-time formers using a valid procedure (X-ray diffraction or infrared spectroscopy).
A
Repeat stone analysis in patients presenting with:
recurrent stones despite drug therapy
early recurrence after complete stone clearance
late recurrence after a long stone-free period because stone composition may change
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Medical management

Observation
As per EAU 2024 guidelines:
Offer initial periodic evaluation in patients with newly diagnosed small ureteral stones, if active removal is not indicated.
A
Offer active surveillance in patients at high risk of thrombotic complications in the presence of an asymptomatic calyceal stone.
B
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  • Medical expulsive therapy

  • Oral chemolysis

  • Management of struvite stones

  • Pain management

Nonpharmacologic interventions

Dietary modifications: as per EAU 2024 guidelines, advise maintaining a generous fluid intake, preferably water, allowing for a 24-hour urine volume > 2.5 L, for the prevention of recurrence.
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  • Dietary supplements

Therapeutic procedures

Indications for stone treatment: as per EAU 2024 guidelines, offer active treatment for renal stones in patients with stone growth, de novo obstruction, associated infection, and acute and/or chronic pain.
B
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  • Choice of procedure (general principles)

  • Choice of procedure (renal stones)

  • Choice of procedure (ureteral stones)

  • Choice of procedure (steinstrasse)

  • Technical considerations (shock wave lithotripsy)

  • Technical considerations (ureterorenoscopy)

  • Technical considerations (percutaneous nephrolithotomy)

  • Urgent decompression

Perioperative care

Preoperative evaluation, laboratory tests
As per EAU 2024 guidelines:
Obtain a urine culture or perform urinary microscopy before any treatment is planned.
A
Exclude or treat UTIs before stone removal.
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  • Preoperative evaluation (imaging)

  • Preoperative precautions

  • Preoperative antibiotic prophylaxis

  • Postoperative evaluation

Surgical interventions

Surgical stone removal: as per EAU 2024 guidelines, offer laparoscopic or open surgical stone removal in rare cases when shock wave lithotripsy, retrograde or antegrade ureteroscopy and percutaneous nephrolithotomy fail or are unlikely to be successful.
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  • Nephrectomy

Specific circumstances

Pregnant patients: as per EAU 2024 guidelines, obtain ultrasound as the preferred imaging in pregnant patients.
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  • Pediatric patients

  • Patients at high thrombotic risk

  • Patients with transplanted kidneys

Preventative measures

Prevention of stone recurrence: as per EAU 2024 guidelines, offer the following agents and dietary modifications for the prevention of stones, according to the composition abnormalities:
Situation
Guidance
Hypercalciuria
Thiazide
Alkaline citrates
A
Hyperoxaluria
Oxalate restriction
B
; a diet with a low fat and oxalate content in enteric hyperoxaluria
B
; calcium supplements with meals in enteric hyperoxaluria
A
; alkaline citrates in enteric hyperoxaluria
B
; pyridoxine in primary hyperoxaluria type 1; lumasiran in primary hyperoxaluria type 1 if not responsive to pyridoxine
A
Hyperuricosuria
Reduced dietary animal protein
Alkaline citrates
Allopurinol
Febuxostat as second-line therapy
A
Hypocitraturia
Alkaline citrates
Sodium bicarbonate
A
Cystinuria
Increased fluid intake allowing for a 24-hour urine volume > 3 L
Potassium citrate 3-10 mmol BID or TID, to achieve pH > 7.5
Tiopronin 250-2,000 mg/day in addition to other measures in patients with cystine excretion > 3 mmol/day or when other measures are insufficient
A
Renal tubular acidosis
Alkaline citrates
A
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Follow-up and surveillance

Laboratory follow-up: as per AUA 2014 guidelines, obtain 24-hour urine specimen for stone risk factors within 6 months to assess response to dietary and/or medical therapy.
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  • Imaging follow-up