Hyperuricosuria and Gouty Diathesis Treatment & Management
- Author: Bijan Shekarriz, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS more...
In the acute phase, the primary goals are symptomatic relief with hydration for the euvolemic state and adequate pain management. When the acute stone episode has resolved, the cornerstones of medical treatment are urinary alkalinization (ie, pH 6.5-7.0), hydration (ie, urinary output 1500-2000 mL/d), and allopurinol (ie, patients with hyperuricosuric calcium nephrolithiasis) to decrease serum and urinary uric acid levels. The authors have observed impressive dissolution of large uric acid stones (staghorn) with oral alkalinization (see the images below). These measures are effective for dissolving existing uric acid stones and for stone prophylaxis.
In the acute phase, surgical intervention may be indicated to relieve urinary obstruction associated with infection or to relieve pain in patients who are not responding to medical treatment. Furthermore, a complete or high-grade ureteral obstruction may require intervention irrespective of the clinical symptoms. In all these circumstances, the urinary obstruction should be relieved. This may be achieved by retrograde insertion of a ureteral stent or a percutaneous nephrostomy tube.
Once the acute stone event has subsided, urinary alkalinization is the treatment of choice for dissolution of uric acid stones. Percutaneous or retrograde irrigation with alkalinizing agents was a common practice in the past. It was mainly used for dissolution of residual stone fragments after percutaneous or retrograde manipulations or in patients who did not tolerate systemic alkalinization. The most commonly used solutions are sodium bicarbonate (pH 7.0-8.0), tromethamine (THAM, pH 8.6), and 0.3 M tromethamine E (THAM-E, pH 10.5). These procedures require prolonged hospitalization and are currently not cost-effective compared with modern endourological modalities.
Surgical intervention (eg, percutaneous nephrolithotomy) may be necessary for treating large uric acid stones that do not dissolve with medical management.
Hyperuricosuric calcium stones are not amenable to chemolysis; surgical intervention may be indicated based on stone size.
Extracorporeal shockwave lithotripsy (ESWL) is the primary mode of treatment for renal and proximal ureteral stones up to 2.5 cm in maximal diameter. Uric acid stones fragment easily with ESWL, and this modality may improve oral chemolysis by increasing the stone surface. Larger stones may require percutaneous nephrolithotripsy. Intravenous or retrograde contrast via ureteral catheters or double-J stents may be necessary for visualization of the uric acid calculi during ESWL.
Ureteroscopy and intracorporeal lithotripsy are the treatments of choice for most large or impacted distal ureteral stones. All intracorporeal lithotripsy modalities, such as electrohydraulic, ultrasonic, or laser, are effective for uric acid stone fragmentation.
See the list below:
Internal medicine specialist for gout
Oncologist for management of myeloproliferative disease
A diet with high fluid intake, low sodium intake, and moderate protein intake is recommended. Low sodium intake reduces sodium urinary excretion, which reduces monosodium urates that are catalysts for hyperuricosuric calcium nephrolithiasis. Additionally, decreased sodium intake reduces sodium urinary excretion, which reduces urinary calcium excretion.
Individuals with sedentary and white-collar occupations are at an increased risk for urinary stones; therefore, regular physical exercise may be beneficial in all persons who form stones. Physical activity may facilitate stone passage during acute renal colic.
Sakhaee K, Maalouf NM. Metabolic syndrome and uric acid nephrolithiasis. Semin Nephrol. 2008 Mar. 28(2):174-80. [Medline].
Ferraro PM, Robertson WG, Johri N, Nair A, Gambaro G, Shavit L, et al. A London experience 1995-2012: demographic, dietary and biochemical characteristics of a large adult cohort of patients with renal stone disease. QJM. 2014 Dec 17. [Medline].
Del Valle EE, Negri AL, Spivacow FR, Rosende G, Forrester M, Pinduli I. Metabolic diagnosis in stone formers in relation to body mass index. Urol Res. 2011 Jun 10. [Medline].
Mehta TH, Goldfarb DS. Uric acid stones and hyperuricosuria. Adv Chronic Kidney Dis. 2012 Nov. 19(6):413-8. [Medline].
Leng S, Shiung M, Ai S, Qu M, Vrtiska TJ, Grant KL, et al. Feasibility of discriminating uric acid from non-uric acid renal stones using consecutive spatially registered low- and high-energy scans obtained on a conventional CT scanner. AJR Am J Roentgenol. 2015 Jan. 204(1):92-7. [Medline]. [Full Text].
Asplin JR. Uric acid stones. Semin Nephrol. 1996 Sep. 16(5):412-24. [Medline].
Bernardo NO, Smith AD. Chemolysis of urinary calculi. Urol Clin North Am. 2000 May. 27(2):355-65. [Medline].
Cameron MA, Sakhaee K. Uric acid nephrolithiasis. Urol Clin North Am. 2007 Aug. 34(3):335-46. [Medline].
Coe FL, Kavalach AG. Hypercalciuria and hyperuricosuria in patients with calcium nephrolithiasis. N Engl J Med. 1974 Dec 19. 291(25):1344-50. [Medline].
Low RK, Stoller ML. Uric acid-related nephrolithiasis. Urol Clin North Am. 1997 Feb. 24(1):135-48. [Medline].
Moe OW, Abate N, Sakhaee K. Pathophysiology of uric acid nephrolithiasis. Endocrinol Metab Clin North Am. 2002 Dec. 31(4):895-914. [Medline].
Pak CY. Medical management of urinary stone disease. Nephron Clin Pract. 2004. 98(2):c49-53. [Medline].
Pak CY, Moe OW, Sakhaee K, Peterson RD, Poindexter JR. Physicochemical metabolic characteristics for calcium oxalate stone formation in patients with gouty diathesis. J Urol. 2005 May. 173(5):1606-9. [Medline].
Pak CY, Poindexter JR, Peterson RD, Koska J, Sakhaee K. Biochemical distinction between hyperuricosuric calcium urolithiasis and gouty diathesis. Urology. 2002 Nov. 60(5):789-94. [Medline].
Pak CY, Sakhaee K, Moe O, Preminger GM, Poindexter JR, Peterson RD, et al. Biochemical profile of stone-forming patients with diabetes mellitus. Urology. 2003 Mar. 61(3):523-7. [Medline].
Shekarriz B, Stoller ML. Uric acid nephrolithiasis: current concepts and controversies. J Urol. 2002 Oct. 168(4 Pt 1):1307-14. [Medline].
Steele TH. Hyperuricemic nephropathies. Nephron. 1999. 81 Suppl 1:45-9. [Medline].
Stoller ML. Gout and stones or stones and gout?. J Urol. 1995 Nov. 154(5):1670. [Medline].
Xu H, Zisman AL, Coe FL, Worcester EM. Kidney stones: an update on current pharmacological management and future directions. Expert Opin Pharmacother. 2013 Mar. 14(4):435-47. [Medline].