Nephrolithiasis Clinical Pathway — Outpatient Specialty Care

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Goals and Metrics

Refer to ED if patient has:

Suspected pyelonephritis
(fever & flank pain)
Vomiting
Pain refractory to adequate oral analgesics
ED Suspected Nephrolithiasis Pathway

HIGH RISK

FH of stone disease or renal failure

Known history of:

Bone Disease, Inflammatory Bowel Disease (IBD), Cystic Fibrosis, Gout, Deafness, Failure to Thrive (FTT), Seizure Disorder, Immobility, Cerebral Palsy, Spina Bifida, Nephrectomy, Single Kidney, Nephrocalcinosis

Urologic abnormality:

Ureteropelvic Junction Obstruction (UPJO), Posterior Urethral Valves (PUV), Duplex System, Bladder Exstrophy

Medication exposure

Lasix, Calcitriol, Topamax, steroids, antiretrovirals, vitamin use (C or D), ketogenic diet, Acetazolamide, Zonisamide

Non-emergent Referral for Stone Disease

Preparation for Office Visit

Office Visit

Detailed H & P
Review Laboratory Studies and Imaging Consult Nephrology for Abnormal Results

Obstructive Stone
Call Urology

Non-obstructive Stone

Indications for Surgery

Tamsulosin

Surgery

Follow-up Evaluation
Repeat RBUS 1 month
Sooner if pain, nausea or vomiting

Not Passed

Passed

Metabolic Evaluation

First Stone NOT High Risk

Normal Metabolic Evaluation

Abnormal Metabolic Evaluation

Recurrent Stone
First Stone AND High Risk
Cystine, Uric Acid or Rare Stones

Remain with Current Urology or Nephrology Provider

Nephrology Clinic

Consider
pharmacotherapy

Follow-up Evaluation
Every 6 months until
- 24-hour urine test is normal for 2 years
  RBUS without stone
Then every year until 24-hour urine is normal twice
If above met, discharge from Kidney Stone Center

Joint Urology/Nephrology Clinic

Medications: Potassium Citrate, Hydrochlorothiazide or Chlorthalidone; other medications as indicated
Follow-up/Evaluation:
Every 6 months until
- 24-hour urine is normal for 2 years RBUS without stone
Then every year until normal for three years

Posted: January 2013
Revised: June 2015, August 2017
Authors: G. Tasian, MD, MSc, MSCE; L. Copelovitch, MD; N. Plachter, CRNP; K. Ashcroft, CRNP; S. Schneider, PA-C

Evidence

Community Resources

Stonewall Kidney Stone Formation +

CHOP Program

Kidney Stone Center

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.