What diuretic to give with kidney stones?

[Induc(junc)tion]

Ive seen sources that say lopp diuretics, others say thiazides. I would guess thiazides, since they tend to decrease urinary calcium, whereas loop diuretics increase the urinary calcium. Anyone wanna chime in?

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[smgilles]

Ive seen sources that say lopp diuretics, others say thiazides. I would guess thiazides, since they tend to decrease urinary calcium, whereas loop diuretics increase the urinary calcium. Anyone wanna chime in?

You give thiazides. Loops will just compound the problem.

 

[poloace]

agreed- 'loops lose calcium' - that's how you would get calcium out of your system and into your urine. however, that's NOT what you want to do if you're trying to prevent kidney stones- if you increase the concentration of calcium in the tubules, the result is a greater propensity to form stones.

 

[lsu1000]

Boards and Wards is BLATANTLY wrong on this when they say use Loops for stones.

I can't believe the newest edition still has that in there.

 

[Idiopathic]

Boards and Wards is BLATANTLY wrong on this when they say use Loops for stones.

I can't believe the newest edition still has that in there.

I think their recommendation for loops comes from the fact that the best at home treatment for stones is to pee out a lot of fluid. The loops are not necessarily a metabolic treatment, but rather a way to clear liters of fluid at once.

Ive seen <3mm stones treated with "a six pack of beer and a urine strainer" before.

 

[Analyzethis]

idiopath-that is just untrue-there is a huge difference between a diuretic such as alcohol and increasin fluids etc-to make you pee and loops-loops sure make you pee but it works as you know by blocking a main channel that effects CA resporption-so there is no way to justify using a loop to help stones-any clearence of stones from the increased urine is way offset by the increase in urine calcium from the block of the NAK2CL channel so it is a blatent error in that book

thiazide is the board and real world pimp answer and the real life treatment-thiazide is your answer

 

[Richie Truxillo]

Ive seen <3mm stones treated with "a six pack of beer and a urine strainer" before.

I passed my 2mm stone this way. I am for once thankful for alcohol's effect on ADH!

For boards though, thiazides increase excretion of Ca ions into the lumen, thus playing along with the theory that less Ca leads to a decreased formation in Calcium Oxalate stones.

 

[Idiopathic]

idiopath-that is just untrue-there is a huge difference between a diuretic such as alcohol and increasin fluids etc-to make you pee and loops-loops sure make you pee but it works as you know by blocking a main channel that effects CA resporption-so there is no way to justify using a loop to help stones-any clearence of stones from the increased urine is way offset by the increase in urine calcium from the block of the NAK2CL channel so it is a blatent error in that book

thiazide is the board and real world pimp answer and the real life treatment-thiazide is your answer

Yeah so there isnt much difference between the two clinically. We all know that lasix makes you excrete calcium into the urine but it also dilutes the urine and IN AN ACUTE SETTING CAN BE HELPFUL TO TREAT A STONE

Ca stone formation happens over a period of time and the goal of immediate rx is to clear the stone. Aggressive hydration and diuresis (better achieved with a loop, NOT HCTZ) is the immediate goal, and perhaps a loop is an appropriate therapy in the acute setting.

We all know that HCTZ reduces the risk of stone formation, but it wont do much for a stone already formed, I hope you realize.

 

[mjl1717]

Yeah so there isnt much difference between the two clinically. We all know that lasix makes you excrete calcium into the urine but it also dilutes the urine and IN AN ACUTE SETTING CAN BE HELPFUL TO TREAT A STONE

Ca stone formation happens over a period of time and the goal of immediate rx is to clear the stone. Aggressive hydration and diuresis (better achieved with a loop, NOT HCTZ) is the immediate goal, and perhaps a loop is an appropriate therapy in the acute setting.

We all know that HCTZ reduces the risk of stone formation, but it wont do much for a stone already formed, I hope you realize.

In agreement with the resurrection of Idiopathic-"Im ready" I just want to add that with Lasix you would tend to loss more water and with HCTZ you would tend to loss more sodium. HCTZ is closer to a naturetic. But for the boards we all know what the answer is.

 

[Idiopathic]

In agreement with the resurrection of Idiopathic-"Im ready" I just want to add that with Lasix you would tend to loss more water and with HCTZ you would tend to loss more sodium. HCTZ is closer to a naturetic. But for the boards we all know what the answer is.

Im not sure if you are arguing with me or agreeing with me. Im NOT sure what the right answer would be. If someone asked the best diuretic in an acute setting, Id say lasix, if they asked me about a chronic stone former and what woudl be the best thing for prevention, HCTZ obviously.

 

[ljl1982]

I believe the answer would be thiazide diuretics (loop diuretics "lose calcium"). I did a pubmed search for treatment of nephrolithiasis, and all of the articles mentioned hydration and thiazide diuretics. I wasn't able to find any info regarding acute tx of nephrolithiasis or use of loop diuretics in treatment of nephrolithiasis.

1: Am Fam Physician. 2006 Jul 1;74(1):86-94. Links
Medical management of common urinary calculi.Pietrow PK, Karellas ME.
University of Kansas Medical Center, Kansas City, USA. [email protected]

Nephrolithiasis is a common condition affecting nearly 5 percent of U.S. men and women during their lifetimes. Recurrent calculi can be prevented in most patients by the use of a simplified evaluation, reasonable dietary and fluid recommendations, and directed pharmacologic intervention. Serum studies and 24-hour urine collections are the mainstays of metabolic investigation and usually are warranted in patients with recurrent calculi. Although some stones are the result of inherited conditions, most result from a complex interaction between diet, fluid habits, and genetic predisposition. Calcium-sparing diuretics such as thiazides often are used to treat hypercalciuria. Citrate medications increase levels of this naturally occurring stone inhibitor. Allopurinol can be helpful in patients with hyperuricosuria, and urease inhibitors can help break the cycle of infectious calculi. Aggressive fluid intake and moderated intake of salt, calcium, and meat are recommended for most patients.

PMID: 16848382 [PubMed - indexed for MEDLINE]

 

[mjl1717]

Im not sure if you are arguing with me or agreeing with me. Im NOT sure what the right answer would be. If someone asked the best diuretic in an acute setting, Id say lasix, if they asked me about a chronic stone former and what woudl be the best thing for prevention, HCTZ obviously.

I agree buddy. We all know that for the boards the answer is HCTZ. But one might think that for a stone less the 5mm one could literally FLUSH it out quicker with a high ceiling diuretic since it creates a greater water flow especially if its a non calcium stone. But I guess this is not written in stone.

 

[deleted9493]

For recurrent kidney stone issues, prophylaxis with hctz seems to be the way most tend.

Using Lasix to get a 'flushable' stone out seems a bit like overkill to me, when you could just throw back large volumes of alcohol/coffee/water, as people have been saying. Mechanistically I'm sure it's sound to give Lasix but probably not that practical given the aforementioned options.

 

[mjl1717]

For recurrent kidney stone issues, prophylaxis with hctz seems to be the way most tend.

Using Lasix to get a 'flushable' stone out seems a bit like overkill to me, when you could just throw back large volumes of alcohol/coffee/water, as people have been saying. Mechanistically I'm sure it's sound to give Lasix but probably not that practical given the aforementioned options.

Thank you everyone. I just found this to be quite an intriguing topic with plenty of variables!

 

[SquidDoc]

The question also depends on the etiology of the stone...Not all stone-formers have hypercalemia, nor do all stone-formers have calcium based stones (though the majority do).

 

[mjl1717]

The question also depends on the etiology of the stone...Not all stone-formers have hypercalemia, nor do all stone-formers have calcium based stones (though the majority do).

True, and at another angle just because someone has hyperuricemia doesnt mean they will have gout or urate lithiasis but if someone has gout they have hyperuricemia. I dont mind beating the stone topic into the ground!

 

[(nicedream)]

if someone has gout they have hyperuricemia.

Not at all actually. Various physicochemical parameters can cause urate crystals to precipitate in joints without an elevated serum uric acid level. A JAMA study, in fact, showed that 33% of the study's patients with gout had normal serum uric acid levels. For this reason, gout often gets misdiagnosed when clinicians use serum uric acid to rule it out. Arthrocentesis is the only reliable method of diagnosing or ruling out gout.

 

[mjl1717]

Not at all actually. Various physicochemical parameters can cause urate crystals to precipitate in joints without an elevated serum uric acid level. A JAMA study, in fact, showed that 33% of the study's patients with gout had normal serum uric acid levels. For this reason, gout often gets misdiagnosed when clinicians use serum uric acid to rule it out. Arthrocentesis is the only reliable method of diagnosing or ruling out gout.

Thanks -thats what Im saying this severly painful topic(stones) has a lot of variables and is a tortuous topic. I believe the most accurate diagnosis would be a synovial tissue biopsy.
Some trivia--If you see rectangular envelope shape crystals think calcium oxalate stones in ethylene glycol posoning.