Ten tips on the work-up and management of CKD patients with nephrolithiasis

Historically, the management of patients with nephrolithiasis has been primarily delivered by urologists. In recent decades nephrologists have had an increasing role in caring for these patients not only in advanced stages of chronic kidney disease (CKD) but also in the diagnosis and management of underlying systemic disease, and metabolic and genetic risk factors. Globally the burden of kidney stone disease has been increasing, with metabolic disorders strongly associated with nephrolithiasis and stone-promoting urinary risk factors, including hypercalciuria, hyperoxaluria and hypocitraturia. At a healthcare level, kidney stones account for a relatively large number of emergency department visits, while individually the impact of kidney stones and the fear of recurrence often result in loss of work and high levels of psychological distress, in addition to an increased CKD risk. Kidney stones in the context of CKD of unknown cause can be the signature of an inherited disorder such as Dent disease, primary hyperoxaluria or adenine phosphoribosyltransferase deficiency (among others). Diagnosing these diseases is imperative in the current age of new treatments (e.g. small interfering RNA therapies), to avoid further deterioration of kidney function and disease recurrence post-transplantation. We outline 10 practical tips to guide clinicians in the diagnostic evaluation and management of nephrolithiasis in CKD.