Nephrolithiasis
Conditions
Keywords
kidney stones, hydrochlorothiazide
Brief summary
The investigators plan to assess the efficacy of standard and low dose HCTZ treatment in the recurrence prevention of calcium-containing kidney stones. More specifically, the investigators aim to assess the dose-response relationship for three different dosages of HCTZ. Study intervention: HCTZ 12.5 mg, 25 mg or 50 mg once daily per os for 24 or 36 months. In addition, all patients in HCTZ treatment arms will receive state-of-the-art non-pharmacologic recommendations for stone prevention according to current guidelines. Control intervention: Placebo once daily per os for 24 to 36 months. In addition, all patients in the placebo arm will receive state-of-the-art non-pharmacologic recommendations for stone prevention according to current guidelines.
Detailed description
Nephrolithiasis is a global healthcare problem with a current lifetime risk of 18.8% in men and 9.4% in women. Without specific treatment, 5- and 20-year recurrence rates are 40% and 75%, respectively. Given the high cost of medical treatments and surgical interventions as well as the morbidity related to symptomatic stone disease, medical prophylaxis for stone recurrence is an attractive approach. About 80-90% of stones are composed of calcium oxalate with various admixtures of calcium phosphate. Increased excretion of calcium in the urine, hypercalciuria, is the most common metabolic abnormality encountered in patients with recurrent nephrolithiasis. Thiazide diuretics have been the cornerstone of pharmacologic metaphylaxis for more than 40 years. The effect of thiazides to reduce the risk of stone recurrence has been attributed to their ability to decrease urinary calcium excretion. However, other factors, such as reduction of urinary pH and urinary oxalate excretion, probably contribute to this effect. Efficacy of thiazides on recurrence prevention of calcareous nephrolithiasis was tested in 11 randomized controlled trials (RCTs). With the exception of two trials, thiazides significantly reduced stone recurrence. Most of these trials are from the 1980's and 90's and the cumulative number of patients studied is remarkably low for such a prevalent disease. Our systematic review of these RCTs revealed major methodological deficiencies in all trials, including: lack of double-blinding and intention-to-treat analysis, unclear allocation concealment, lack of adverse event and drop out reporting and unknown baseline risk of disease severity. Furthermore, high doses of thiazides were employed in all trials, in the case of the best studied thiazide, hydrochlorothiazide (HCTZ), up to 100 mg daily. At such high doses, side effects occur frequently. Nowadays, thiazides are widely used in the treatment of recurrent nephrolithiasis and arterial hypertension, but at significantly lower doses. In the case of recurrent nephrolithiasis, however, this practice is not supported by randomized evidence and consequently, the investigators do not know whether the currently employed low dose thiazide regimens are effective in reducing the risk for stone recurrence. Thus, evidence for benefits and harms of thiazide diuretics in the prevention of calcium-containing kidney stones in general remains unclear. In addition, the efficacy of the currently employed low dose thiazide regimens to prevent stone recurrence is not known.
Interventions
DRUGPlacebo oral capsule
Once daily for 3 years
DRUG12.5 mg hydrochlorothiazide
Once daily for 3 years
DRUG25.0 mg hydrochlorothiazide
Once daily for 3 years
DRUG50.0 mg hydrochlorothiazide
Once daily for 3 years
Sponsors
Insel Gruppe AG, University Hospital Bern
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
DOUBLE (Subject, Caregiver)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Informed Consent as documented by signature 2. Age 18 years or older 3. Recurrent kidney stone disease (≥ 2 stone events within the last 10 years prior to randomization) 4. Any past kidney stone containing 50% or more of calcium oxalate, calcium phosphate or a mixture of both
Exclusion criteria
1. Pharmacologic prevention for stone recurrence less than 3 months prior to randomization 2. Patients with secondary causes of recurrent calcareous nephrolithiasis including: * Severe eating disorders (anorexia or bulimia) * Chronic inflammatory bowel disease, bariatric surgery, intestinal surgery with malabsorption or chronic diarrheal status * Sarcoidosis * Primary hyperparathyroidism * Complete distal tubular acidosis * Active malignancy 3. Patients with the following medications: * Thiazide or loop diuretics * Carbonic anhydrase inhibitors (including topiramate) * Xanthine oxidase inhibitors (febuxostat or allopurinol) * Alkali, including potassium citrate or sodium bicarbonate * Treatment with 1,25-OH Vitamin D (calcitriol) * Calcium supplementation * Bisphosphonates * Denosumab * Teriparatide * Glucocorticoids 4. Obstructive uropathy, if not treated successfully 5. Urinary tract infection, if not treated successfully 6. Chronic kidney disease (defined as CKD-EPI eGFR \< 30 mL/min per 1,73 m2 body surface area for more than 3 months) 7. Patients with a kidney transplant 8. \> 3 gout arthritis episodes within one year prior to randomisation or gout arthritis requiring uric acid lowering therapy 9. Cystinuria at screening 10. Hypokalemia (blood potassium level \< 3 mmol/L) at screening 11. Hyponatremia (blood sodium level \< 125 mmol/L) at screening 12. Pregnant and lactating women \[pregnancy test to be performed for women of child-bearing potential (defined as women who are not surgically sterilized/ hysterectomized, and/ or who are postmenopausal for less than 12 months)\] 13. Previous (within 3 months prior to randomization) or concomitant participation in another interventional clinical trial 14. Inability to understand and follow the protocol 15. Known allergy to the study drug
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Number of Participants With Stone Recurrences | After 3 years | Composite of symptomatic or radiological recurrences, defined as either a symptomatic kidney stone passage or radiological kidney stone recurrence on CT. Symptomatic recurrence was defined as the visible passage of a stone with or without accompanying typical symptoms (such as flank or loin pain and hematuria) or as the presence of a symptomatic or asymptomatic stone that was determined to require surgical removal. If a patient had symptoms during the trial that were suggestive of a possible stone passage but no visible stone had been observed, local investigators evaluated the symptoms of the patient and judged whether a stone passage had occurred. Radiological recurrence was defined as a new stone formed or enlargement of a preexisting stone. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Number of Symptomatic Stone Recurrences | After 3 years | Symptomatic recurrence was defined as the visible passage of a stone with or without accompanying typical symptoms (such as flank or loin pain and hematuria) or as the presence of a symptomatic or asymptomatic stone that was determined to require surgical removal. If a patient had symptoms during the trial that were suggestive of a possible stone passage but no visible stone had been observed, local investigators evaluated the symptoms of the patient and judged whether a stone passage had occurred. |
| Number of Radiologic Stone Recurrences. | After 3 years | Radiological stone recurrence was defined as a new stone formed or enlargement of a preexisting stone (assessed by low-dose CT of the kidney at the end of the study compared to the low-dose CT of the kidney at the baseline visit). |
Countries
Switzerland
Participant flow
Recruitment details
Specified in the protocol
Pre-assignment details
No significant events.
Participants by arm
| Arm | Count |
|---|---|
| Placebo Once daily for 3 years
Placebo oral capsule: Once daily for 3 years | 102 |
| 12.5 mg Hydrochlorothiazide Once daily for 3 years
12.5 mg hydrochlorothiazide: Once daily for 3 years | 105 |
| 25.0 mg Hydrochlorothiazide Once daily for 3 years
25.0 mg hydrochlorothiazide: Once daily for 3 years | 108 |
| 50.0 mg Hydrochlorothiazide Once daily for 3 years
50.0 mg hydrochlorothiazide: Once daily for 3 years | 101 |
| Total | 416 |
Baseline characteristics
| Characteristic | 50.0 mg Hydrochlorothiazide | Total | Placebo | 12.5 mg Hydrochlorothiazide | 25.0 mg Hydrochlorothiazide |
|---|---|---|---|---|---|
| Age, Continuous | 50 years | 49 years | 47 years | 49 years | 48 years |
| Ethnicity (NIH/OMB) Hispanic or Latino | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 101 Participants | 416 Participants | 102 Participants | 105 Participants | 108 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 0 Participants | 0 Participants | 0 Participants | 0 Participants |
| Region of Enrollment Switzerland | 101 Participants | 416 Participants | 102 Participants | 105 Participants | 108 Participants |
| Sex: Female, Male Female | 21 Participants | 85 Participants | 26 Participants | 16 Participants | 22 Participants |
| Sex: Female, Male Male | 80 Participants | 331 Participants | 76 Participants | 89 Participants | 86 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk | EG002 affected / at risk | EG003 affected / at risk |
|---|---|---|---|---|
| deaths Total, all-cause mortality | 0 / 102 | 0 / 105 | 0 / 108 | 0 / 101 |
| other Total, other adverse events | 1 / 102 | 2 / 105 | 7 / 108 | 2 / 101 |
| serious Total, serious adverse events | 2 / 102 | 0 / 105 | 2 / 108 | 1 / 101 |
Outcome results
Primary
Number of Participants With Stone Recurrences
Composite of symptomatic or radiological recurrences, defined as either a symptomatic kidney stone passage or radiological kidney stone recurrence on CT. Symptomatic recurrence was defined as the visible passage of a stone with or without accompanying typical symptoms (such as flank or loin pain and hematuria) or as the presence of a symptomatic or asymptomatic stone that was determined to require surgical removal. If a patient had symptoms during the trial that were suggestive of a possible stone passage but no visible stone had been observed, local investigators evaluated the symptoms of the patient and judged whether a stone passage had occurred. Radiological recurrence was defined as a new stone formed or enlargement of a preexisting stone.
Time frame: After 3 years
Population: Intention-to-treat
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Placebo | Number of Participants With Stone Recurrences | 60 Participants |
| 12.5 mg Hydrochlorothiazide | Number of Participants With Stone Recurrences | 62 Participants |
| 25.0 mg Hydrochlorothiazide | Number of Participants With Stone Recurrences | 61 Participants |
| 50.0 mg Hydrochlorothiazide | Number of Participants With Stone Recurrences | 49 Participants |
Secondary
Number of Radiologic Stone Recurrences.
Radiological stone recurrence was defined as a new stone formed or enlargement of a preexisting stone (assessed by low-dose CT of the kidney at the end of the study compared to the low-dose CT of the kidney at the baseline visit).
Time frame: After 3 years
Population: Intention-to-treat
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Placebo | Number of Radiologic Stone Recurrences. | 46 Participants |
| 12.5 mg Hydrochlorothiazide | Number of Radiologic Stone Recurrences. | 44 Participants |
| 25.0 mg Hydrochlorothiazide | Number of Radiologic Stone Recurrences. | 32 Participants |
| 50.0 mg Hydrochlorothiazide | Number of Radiologic Stone Recurrences. | 31 Participants |
Secondary
Number of Symptomatic Stone Recurrences
Symptomatic recurrence was defined as the visible passage of a stone with or without accompanying typical symptoms (such as flank or loin pain and hematuria) or as the presence of a symptomatic or asymptomatic stone that was determined to require surgical removal. If a patient had symptoms during the trial that were suggestive of a possible stone passage but no visible stone had been observed, local investigators evaluated the symptoms of the patient and judged whether a stone passage had occurred.
Time frame: After 3 years
Population: Intention-to-treat
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Placebo | Number of Symptomatic Stone Recurrences | 35 Participants |
| 12.5 mg Hydrochlorothiazide | Number of Symptomatic Stone Recurrences | 40 Participants |
| 25.0 mg Hydrochlorothiazide | Number of Symptomatic Stone Recurrences | 43 Participants |
| 50.0 mg Hydrochlorothiazide | Number of Symptomatic Stone Recurrences | 28 Participants |