UPDATE THIAZIDE DIURETIC EVIDENCE REVIEW FOR CARI GUIDELINES KIDNEY STONES RECOMMENDATIONS
Dr David Tunnicliffe1,2, Prof Andrew Mallett3,4,5, Brydee Cashmore1,2, Dr Adam Mullan6, Lyn Llyod7, Ieuan Wickham8, Dr Hicham Hassan9,10, Prof Matthew Jose11
1Sydney School of Public Health, The University Of Sydney, Sydney, Australia, 2Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Australia, 3Department of Renal Medicine, Townsville University Hospital, Douglas, Australia, 4College of Medicine and Dentistry, James Cook University, Douglas, Australia, 5Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia, 6Northland Renal Services, Te Tai Tokerau, Northland, New Zealand, 7Te Whatau Ora Health NZ Te Toka Tumai,, Auckland, New Zealand, 8Consumer partner, , , 9Graduate School of Medicine, University of Wollongong, Wollongong, Australia, 10School of Medicine, Lebanese American University , Beirut, Lebanon, 11School of Medicine, University of Tasmania, Hobart, Australia
Introduction: The NOSTONE study found that hydrochlorothiazide, compared to placebo, did not reduce the risk of recurrent kidney stones. No kidney stone guideline has been updated since NOSTONE was published. Our aim was to assess the role of thiazides in the prevention of kidney stone recurrence to update the CARI Kidney Stones guidelines.
Methods: We integrated the NOSTONE trial into a high-quality systematic review on thiazide role in reducing recurrent kidney stones. New studies underwent dual data extraction and critical appraisal. Data was pooled using random-effects meta-analysis, dichotomous effect estimates were expressed as risk ratios (RR) and absolute effects calculated. Heterogeneity was assessed using I2 statistic. Subgroup analyses were conducted, exploring differences between short-acting versus long-acting thiazides, placebo versus no treatment, and the impact of reported concomitant high fluid and low sodium diet intake. The certainty of the evidence was rated using GRADE.
Results: Thiazides may decrease symptomatic recurrence of kidney stones (9 studies, n=997, RR 0.55, 95% 0.37-0.84; I2%=68%; absolute effects – 202 fewer per 100,000 person years, 95%CI 285-72 fewer; low certainty evidence). Effect modification was evident when short-term versus long-term thiazides were compared (test for subgroup differences p=0.02; I2=82.8%). RCTs contrasting thiazides with standard of care without a placebo may have overstated efficacy compared to the six RCTs that compared to placebo. Moreover, RCTs with low risk of bias for allocation concealment displayed little difference in kidney stone recurrence compared to the seven RCTs that were high or unclear risk. Concomitant nutrition therapy did not modify effects.
Conclusions: Thiazides should remain in the armamentarium for preventing kidney stones, but physicians should carefully consider clinical, demographic, and practical aspects in collaboration with patients.
Presentation Slides PDF – Click here
Biography:
David is a Senior Research Fellow (Level C) at the Sydney School of Public Health, The University of Sydney and recipient of an Australian National Health and Medical Research Council Emerging Leadership 1 Investigator Grant (APP1197337). His research expertise is in the areas of evidence synthesis, living evidence and in eliciting patient priorities for healthcare and research and its application in chronic kidney disease. David is the Scientific Director of the Australian and New Zealand Guideline Developer for kidney disease (CARI Guidelines).