A multi-institutional study involving researchers from Children’s Hospital of Philadelphia (CHOP) found that a behavioral program designed to increase fluid intake and decrease risk of kidney stones — using tools such as a smart water bottle, hydration goals, incentives, and coaching — modestly increased urine output. However, this increased urine output was not enough to reduce recurrence rates of symptomatic kidney stones. The findings were recently published in the journal The Lancet.
Increasing fluid intake is universally recommended to reduce recurrence risk. The findings from the Prevention of Urinary Stones with Hydration (PUSH) trial highlight the challenge faced by many people with urinary stone disease – also known as kidney stones – when trying to drink the recommended amount of fluids, even with structured support, and emphasize the need for new strategies to prevent stone recurrence.
“Prior to PUSH, no large-scale clinical trials studied prevention approaches for kidney stones in adolescents. It was important to test the effectiveness of strategies to increase adherence to a cornerstone of prevention of symptomatic stone event for patients across the lifespan, including those whose disease began in childhood,” said Gregory E. Tasian, MD, Director of the PKIDS Care Improvement Network, an attending pediatric urologist in the Division of Urology and principal investigator and co-senior author of the PUSH trial at CHOP.
The PUSH trial enrolled 1,658 adolescents and adults across six U.S. academic centers – including CHOP – between 2017 and 2024, making it the largest health behavior intervention trial ever conducted for kidney stone prevention.
The trial tested a health behavior approach to maintain high fluid intake – or how consistently someone drinks adequate fluids, like water or lemonade – in people ages 12 years and up with urinary stone disease and low urine volume. This research was conducted by the Urinary Stone Disease Research Network, coordinated by the Duke Clinical Research Institute (DCRI), and funded by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.
The PUSH intervention was designed using behavior-change principles that aimed to help people overcome common barriers to consistently following health recommendations. Participants in the intervention group received a Bluetooth enabled smart water bottle that measured and recorded how much fluid a person drank; financial incentives to encourage meeting a “fluid prescription” (or personalized hydration goal); adaptive health coaching to help participants identify and overcome barriers to reaching fluid intake goals, and supportive measures such as text reminders. Participants in the control group received a smart water bottle to use if they wished (without a “fluid prescription”) and followed clinical guideline-directed usual care.
The “fluid prescription” for high fluid intake (or drinking more water than usual) was determined by comparing how much urine a participant typically makes with how much more water they needed to drink to reach the urine output goal of at least 2.5 liters (or about 10.5 cups) recommended in clinical guidelines or the equivalent amount for younger adolescents per day.
Importantly, the PUSH findings do not challenge existing guideline recommendations for increasing fluid intake. However, the evidence supporting this recommendation is surprisingly limited, underscoring the need for more contemporary, methodologically rigorous trials such as PUSH to strengthen the evidence base.
“Across adolescents and adults, PUSH moves the field toward more precise prevention,” Tasian said. “Rather than asking every patient to meet the same fluid goal, we should determine who benefits from which targets, understand why adherence breaks down, and build interventions—behavioral and medical—that reliably reduce stone recurrence.”
This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases grants DK110986, DK110961, DK110954, DK110994 DK110988.
Desai et al, “Prevention of Urinary Stones with Hydration: A Randomised Clinical Trial of an Adherence Intervention.” Lancet. Online March 19, 2026. DOI: 10.1016/S0140-6736(25)02637-6.
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A multi-institutional study involving researchers from Children’s Hospital of Philadelphia (CHOP) found that a behavioral program designed to increase fluid intake and decrease risk of kidney stones — using tools such as a smart water bottle, hydration goals, incentives, and coaching — modestly increased urine output. However, this increased urine output was not enough to reduce recurrence rates of symptomatic kidney stones. The findings were recently published in the journal The Lancet.
Increasing fluid intake is universally recommended to reduce recurrence risk. The findings from the Prevention of Urinary Stones with Hydration (PUSH) trial highlight the challenge faced by many people with urinary stone disease – also known as kidney stones – when trying to drink the recommended amount of fluids, even with structured support, and emphasize the need for new strategies to prevent stone recurrence.
“Prior to PUSH, no large-scale clinical trials studied prevention approaches for kidney stones in adolescents. It was important to test the effectiveness of strategies to increase adherence to a cornerstone of prevention of symptomatic stone event for patients across the lifespan, including those whose disease began in childhood,” said Gregory E. Tasian, MD, Director of the PKIDS Care Improvement Network, an attending pediatric urologist in the Division of Urology and principal investigator and co-senior author of the PUSH trial at CHOP.
The PUSH trial enrolled 1,658 adolescents and adults across six U.S. academic centers – including CHOP – between 2017 and 2024, making it the largest health behavior intervention trial ever conducted for kidney stone prevention.
The trial tested a health behavior approach to maintain high fluid intake – or how consistently someone drinks adequate fluids, like water or lemonade – in people ages 12 years and up with urinary stone disease and low urine volume. This research was conducted by the Urinary Stone Disease Research Network, coordinated by the Duke Clinical Research Institute (DCRI), and funded by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health.
The PUSH intervention was designed using behavior-change principles that aimed to help people overcome common barriers to consistently following health recommendations. Participants in the intervention group received a Bluetooth enabled smart water bottle that measured and recorded how much fluid a person drank; financial incentives to encourage meeting a “fluid prescription” (or personalized hydration goal); adaptive health coaching to help participants identify and overcome barriers to reaching fluid intake goals, and supportive measures such as text reminders. Participants in the control group received a smart water bottle to use if they wished (without a “fluid prescription”) and followed clinical guideline-directed usual care.
The “fluid prescription” for high fluid intake (or drinking more water than usual) was determined by comparing how much urine a participant typically makes with how much more water they needed to drink to reach the urine output goal of at least 2.5 liters (or about 10.5 cups) recommended in clinical guidelines or the equivalent amount for younger adolescents per day.
Importantly, the PUSH findings do not challenge existing guideline recommendations for increasing fluid intake. However, the evidence supporting this recommendation is surprisingly limited, underscoring the need for more contemporary, methodologically rigorous trials such as PUSH to strengthen the evidence base.
“Across adolescents and adults, PUSH moves the field toward more precise prevention,” Tasian said. “Rather than asking every patient to meet the same fluid goal, we should determine who benefits from which targets, understand why adherence breaks down, and build interventions—behavioral and medical—that reliably reduce stone recurrence.”
This study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases grants DK110986, DK110961, DK110954, DK110994 DK110988.
Desai et al, “Prevention of Urinary Stones with Hydration: A Randomised Clinical Trial of an Adherence Intervention.” Lancet. Online March 19, 2026. DOI: 10.1016/S0140-6736(25)02637-6.
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