Dietary changes and pharmacologic interventions may prevent recurrent nephrolithiasis

1.  In this systematic review, low-strength evidence suggests that increased fluid intake, dietary modification (normal-to-high calcium, low protein, low sodium), and pharmacologic therapies (thiazides, alkali therapy, allopurinol, and acetohydroxamic acid) may reduce kidney stone recurrence in adults.

2. The overall strength of evidence is limited, as most included studies had moderate-to-high risk of bias.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Nephrolithiasis, commonly known as kidney stones, is a prevalent condition affecting both pediatric and adult populations. While smaller stones may pass unnoticed through the urinary tract, larger stones often cause significant pain, hematuria, and distress. Moreover, serious complications, including sepsis and permanent kidney damage, can occur if urinary obstruction develops. Despite advances in management, recurrence rates remain high, reaching up to 75% in children and 25–50% in adults. This systematic review evaluated the benefits and harms of dietary, pharmacologic, and imaging surveillance strategies for preventing stone recurrence. In total, 31 studies were included, comprising 26 randomized controlled trials and 5 nonrandomized interventional studies; only three involved pediatric populations. Pharmacologic interventions were assessed in 23 studies, with low-strength evidence suggesting that thiazides, alkali therapy, allopurinol, and acetohydroxamic acid (AHA) may reduce recurrence in adults. Dietary interventions were examined in 7 studies, with low-strength evidence supporting increased fluid intake (targeting ≥2 L urine output per day) and a diet characterized by normal-to-high calcium, low protein, and low sodium intake. The generalizability of these findings is limited by the paucity of studies on surveillance imaging, heterogeneity among included studies, and concerns regarding risk of bias. Nevertheless, the evidence suggests that increased fluid intake, dietary modification, and select pharmacologic therapies may help reduce kidney stone recurrence, although further high-quality research is needed to clarify the effectiveness of these and other preventive strategies.

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Relevant Reading: Risk of recurrence of idiopathic calcium kidney stones: analysis of data from the literature

In-Depth [systematic review]: This systematic review evaluated the benefits and harms of dietary, pharmacologic, and imaging surveillance strategies for preventing recurrent nephrolithiasis, updating a 2012 review. Literature from MEDLINE, the Cochrane Library, and the World Health Organization International Clinical Trials Registry Platform was searched through December 2025. Eligible studies included randomized controlled trials (RCTs) and nonrandomized studies of interventions in non-pregnant adults or children with a history of kidney stones. A total of 31 studies (33 publications) were included: 26 RCTs (n = 4477) and 5 nonrandomized studies (n = 25,623). Only three studies involved pediatric populations. Most studies had moderate-to-high risk of bias. Dietary interventions were evaluated in 7 RCTs. Increased fluid intake to achieve ≥2 L urine output per day reduced recurrence (absolute risk difference [ARD] 148 fewer per 1000; low-strength evidence). A diet with normal-to-high calcium, low protein, and low sodium also reduced recurrence compared with a low-calcium diet (ARD 183 fewer per 1000; low-strength evidence). Pharmacologic interventions were assessed in 23 studies. In adults, thiazide diuretics demonstrated a small reduction in recurrence at 3 years (e.g., 40 fewer recurrences per 1000; low-strength evidence). Alkali therapy showed benefit, with citrate salts reducing recurrence by 333 fewer per 1000 (low-strength evidence). Allopurinol also reduced recurrence (265 fewer per 1000; low-strength evidence). Evidence in pediatric populations was insufficient. Limited evidence evaluated tailoring therapy based on 24-hour urine testing, showing no difference in recurrence (hazard ratio 0.97 [95% CI, 0.84–1.12]; low-strength evidence). Overall, despite heterogeneity and risk of bias, the review suggests that increased fluid intake, dietary modification, and select pharmacologic therapies may reduce kidney stone recurrence.

Image: PD

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