Effect of Alkaline Citrate Therapy on Clearance of Residual Renal Stone Fragments after Extracorporeal Shock Wave Lithotripsy in Sterile Calcium and Infection Nephrolithiasis Patients

Abstract

The natural history of post-extracorporeal shock wave lithotripsy residual stone fragments (clearance, growth and aggregation) is incompletely known, even though they are believed to constitute a risk in terms of new stone formation and persistent infection of the urinary tract. We addressed this issue and the hypothesis that alkaline citrate therapy improves residual stone fragment clearance in a 12-month followup study. There were 40 sterile calcium and 30 struvite stone patients with residual fragments after extracorporeal shock wave lithotripsy (diameter less than 5 mm.) consecutively enrolled and randomly assigned to a citrate therapy (6 to 8 gm. per day) or control (hygienic measures only) group. Infection stone patients also received adequate antibiotic therapy throughout the study. Among the patients in the untreated sterile group 21% and 32% were stone-free at 6 and 12 months, respectively. In the infection group these figures were 27% and 40%, respectively. Among the untreated sterile calcium stone patients in whom clearance was not achieved a high percentage experienced residual fragment growth or reaggregation. Citrate therapy significantly improved the stone clearance rate in the sterile (at 6 and 12 months 65% and 74% were stone-free, respectively) and infection (71% and 86%, respectively) stone patients, and prevented residual fragment growth or reaggregation in subjects in whom clearance was not achieved. The data show that growth and persistence are common in the natural history of residual stone fragments. Citrate ameliorated the outcome of these residual fragments by reducing the growth or agglomeration, and by increasing the clearance rate in calcium oxalate and in infection stone patients.

Long-Term Treatment with Potassium Citrate and Renal Stones in Medullary Sponge Kidney

“…However, a significant decrease in calciuria was also observed. This is an unprecedented finding because, in our experience, it does not occur in idiopathic calcium SFs (14).…”

Treatment of Renal Stones by Extracorporeal Shockwave Lithotripsy

“…Thus, to improve stone clearance after ESWL, others have suggested various regimens, such as positioning the patient head down, ureteral stenting and flushing the lower pole with saline during ESWL or transcutaneous needle flushing of the lower calyx [72, 73, 74, 76, 78]. The outcome of these procedures has been favorable.…”

“…‘stir up ESWL’ [75]or ‘booster technique’ [15]. Conclusively, this strategy also increases the percentage of clinically insignificant fragments [76, 77, 78, 79, 80, 81]. Even before this era, the majority of the residual fragments could be classified as clinically insignificant (CIRF): 75–87% of the patients remained asymptomatic and only 4–25% required a secondary intervention which mostly consisted of a repeat ESWL [8, 13, 16, 52].…”

Inhibition of Nanobacteria by Antimicrobial Drugs as Measured by a Modified Microdilution Method

“…The stimuli for calcium salt deposition in patients with these conditions are unclear, but nidi for precipitation and crystallization are needed even under supersaturation conditions (9). In this regard, antibiotics (27,70,74), bisphosphonates (5,8,20,28,(38)(39)(40)60), citrate (12), and other chemotherapeutics (5, 37) have been used with some success for the treatment of pathological calcification-related diseases. The inhibitory effects of antibiotics on the calcifications of surgically implanted artificial materials have also been shown (11).…”