Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: a clinical practice guideline from the American College of Physicians

Ann Intern Med. 2014 Nov 4;161(9):659-67. doi: 10.7326/M13-2908.


Description: The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on the comparative effectiveness and safety of preventive dietary and pharmacologic management of recurrent nephrolithiasis in adults.

Methods: This guideline is based on published literature on this topic that was identified using MEDLINE, the Cochrane Database of Systematic Reviews (through March 2014), Google Scholar,, and Web of Science. Searches were limited to English-language publications. The clinical outcomes evaluated for this guideline include symptomatic stone recurrence, pain, urinary tract obstruction with acute renal impairment, infection, procedure-related illness, emergency department visits, hospitalizations, quality of life, and end-stage renal disease. This guideline grades the quality of evidence and strength of recommendations using ACP's clinical practice guidelines grading system. The target audience for this guideline is all clinicians, and the target patient population is all adults with recurrent nephrolithiasis (≥1 prior kidney stone episode).

Recommendation 1: ACP recommends management with increased fluid intake spread throughout the day to achieve at least 2 L of urine per day to prevent recurrent nephrolithiasis. (Grade: weak recommendation, low-quality evidence).

Recommendation 2: ACP recommends pharmacologic monotherapy with a thiazide diuretic, citrate, or allopurinol to prevent recurrent nephrolithiasis in patients with active disease in which increased fluid intake fails to reduce the formation of stones. (Grade: weak recommendation, moderate-quality evidence).

Publication types

  • Practice Guideline
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Allopurinol / therapeutic use
  • Calcium Chelating Agents / therapeutic use
  • Citric Acid / therapeutic use
  • Fluid Therapy
  • Gout Suppressants / therapeutic use
  • Humans
  • Nephrolithiasis / diet therapy*
  • Nephrolithiasis / drug therapy
  • Nephrolithiasis / prevention & control*
  • Secondary Prevention / methods
  • Sodium Chloride Symporter Inhibitors / therapeutic use


  • Calcium Chelating Agents
  • Gout Suppressants
  • Sodium Chloride Symporter Inhibitors
  • Citric Acid
  • Allopurinol