FAQs: The 2026 AUA Guideline on Medical Management of Kidney Stones

The American Urological Association’s (AUA’s) updated guideline on the medical management of kidney stones, published in 2026, replaces guidance that had not been revised since 2014.¹ The update reflects a modest but meaningful expansion of the evidence base since that time, extends recommendations to pediatric and adolescent patients for the first time, and offers guidance for genetic testing and additional metabolic evaluation in high-risk patients.

To help urologists apply the updated recommendations in daily practice, the following FAQs address key recommendations spanning the guideline, supplemented with perspective from Justin B. Ziemba, MD, MSEd, senior author of the guideline and an associate professor of surgery at the Hospital of the University of Pennsylvania in Philadelphia. Asked what he hoped urologists would take from the guideline, Ziemba pointed to its practical, individualized approach to counseling.

“The guidelines are a great wealth of information [and] have a lot of practical advice on how to counsel patients and think about this as a disease that can be potentially prevented in certain individuals or modified in others to lower their recurrence and improve their quality of life. From a urologist thinking about how we can help other urologists, hone in on that 24-hour urine collection. It's a little bit burdensome on the patient's side, but it does provide a lot of good information that you can use to try to target and individualize specific recommendations,” he said.

What initial workup does the guideline recommend for a newly diagnosed kidney stone?

For both adult and pediatric patients with a newly diagnosed stone, the guideline recommends a screening evaluation consisting of a medical, dietary, and family history; a pertinent physical examination; laboratory testing including serum chemistries; and a urinalysis with microscopic examination (Clinical Principle). Clinicians should obtain serum parathyroid hormone if primary hyperparathyroidism is suspected (Expert Opinion) and a stone analysis when one is not already available (Clinical Principle). Recent or new imaging should also be reviewed or obtained to assess stone burden (Clinical Principle).

How should urologists identify patients who need more extensive metabolic evaluation?

Based on the initial screening evaluation, the guideline calls on clinicians to identify patients at increased risk of recurrent stone formation for further metabolic testing (Expert Opinion). Ziemba described the clinical factors that inform that judgment, including younger age, a strong family history, and a large or bilateral stone burden at first presentation. He also pointed to the growing evidence linking stone disease to other metabolic conditions.

"Kidney stone disease is strongly associated with other metabolic disorders, such as obesity, hypertension, [and] hyperlipidemia,” he said. “So in individuals [who] have a significant number of those other clinical conditions, those are people who are potentially at risk as well."

What does 24-hour urine testing add, and who should be offered it?

The guideline recommends 1 or more 24-hour urine collections in adults at increased stone risk, in all pediatric patients with stones, and in motivated first-time stone formers to guide dietary and pharmacologic therapy (Expert Opinion). Collections should measure total volume, pH, calcium, oxalate, uric acid, citrate, sodium, potassium, creatinine, and either sulfate or urea nitrogen.

Ziemba characterized the test as the specialty's closest equivalent to personalized medicine.

"Twenty four–hour testing is our mainstay advanced diagnostic for patients with kidney stones,” he noted. “That's traditionally thought [of as] genetic screening in other clinical conditions, but for kidney stones, we have the benefit of the urine profile.”

Which patients should be considered for genetic testing?

The guideline states that clinicians may offer genetic testing to adult and pediatric patients with an extensive family history of stone disease, nephrocalcinosis, rare stone composition, or frequent recurrence (Expert Opinion). For patients with calcium oxalate stones and very high urinary oxalate not otherwise explained, or high clinical suspicion for primary hyperoxaluria, genetic testing may also be obtained (Expert Opinion). This is a newly expanded area of the guideline compared with 2014.

What dietary changes reduce recurrence risk in calcium-based stones?

For adults with a history of calcium-based stones, the guideline recommends sufficient water intake to produce a urinary volume of at least 2.5 L (85 oz) daily, with pediatric intake targeted to at least 30 mL/kg (Moderate Recommendation, Grade C, for adults; Expert Opinion for children). Depending on 24-hour urine findings, additional guidance may include adequate calcium intake, limited sodium, avoidance of excess nondairy animal protein, and a diet rich in fruits and vegetables (Expert Opinion).

What pharmacologic options are recommended for recurrent calcium-based stones?

For adults with recurrent calcium-based stones and high urinary calcium, the guideline recommends a thiazide or thiazide-like diuretic paired with limited sodium and normal calcium intake (Moderate Recommendation, Grade C, and Expert Opinion, respectively). For low urinary citrate, alkali therapy should be offered (Expert Opinion), and alkali therapy may also be considered more broadly for recurrent calcium oxalate stones (Conditional Recommendation, Grade C). Allopurinol may be offered for recurrent calcium oxalate stones with high urinary uric acid (Conditional Recommendation, Grade C). Patients with primary hyperoxaluria type 1 may be offered pyridoxine and/or RNA interference therapy (Expert Opinion).

When metabolic testing reveals no detectable abnormality, thiazides and/or alkali therapy may still be offered (Conditional Recommendation, Grade C).

How does management differ for uric acid stones?

Fluid recommendations mirror those for calcium-based stones: at least 2.5 L (85 oz) daily in adults and 30 mL/kg in pediatric patients (Expert Opinion). For patients with low urinary pH, the guideline recommends a diet high in fruits and vegetables with nondairy animal protein limited to standard dietary allowances (Expert Opinion).

Pharmacologically, alkali therapy to raise urinary pH is recommended for both adult and pediatric patients (Expert Opinion). Notably, the guideline specifies that xanthine oxidase inhibitors such as allopurinol or febuxostat should not be used as first-line therapy for uric acid stones (Expert Opinion).

What does the guideline recommend for cystine stone prevention?

Cystine stones require the highest fluid targets in the guideline: at least 3 L (100 oz) daily in adults and a urine output greater than 40 mL/kg daily in pediatric patients, along with limited salt intake and avoidance of excess animal protein (Expert Opinion). Alkali therapy to raise urinary pH should be offered to both adult and pediatric patients (Expert Opinion), and cystine-binding thiol drugs may be offered when stones recur despite dietary and alkali therapy (Expert Opinion).

How should struvite stones be managed?

For adults with a history of struvite stones, the guideline recommends fluid intake sufficient to produce a urinary volume of at least 2.5 L (85 oz) daily (Expert Opinion), and acetohydroxamic acid may be offered when stones are not amenable to surgical removal (Conditional Recommendation, Grade C).

Ziemba noted that surgery, not medical therapy, remains the primary approach for this stone type, explaining, "The mainstay of that is surgical therapy, thinking about how you can remove all the stone surgically and treat the underlying infection."

What are the recommendations for stones of unknown or mixed composition?

The guideline notes that adults with kidney stones may be counseled to limit soft drink consumption (Conditional Recommendation, Grade C). Over-the-counter alkali products may be offered to adult and pediatric patients with uric acid or calcium-based stones to raise urinary pH and/or citrate (Expert Opinion). For adults with recurrent stones of unknown composition, empiric preventive pharmacotherapy, such as thiazide diuretics, alkali therapy, or allopurinol, may be offered in the absence of urine chemistry data (Conditional Recommendation, Grade C).

What follow-up and monitoring protocols does the guideline recommend once therapy starts?

Patients on pharmacotherapy for kidney stones should be monitored for adverse effects (Expert Opinion). For those on dietary and/or pharmacologic therapy, the guideline recommends monitoring effectiveness with periodic surveillance imaging and metabolic testing, with the interval informed by metabolic findings and clinical stone activity (Expert Opinion).

How does the guideline's approach differ for pediatric patients?

Pediatric and adolescent patients are addressed throughout the 2026 guideline for the first time, reflecting a growing burden of disease in this population. Fluid, dietary, and pharmacologic recommendations for children generally parallel those for adults but are adjusted for body weight and growth needs rather than applied as fixed adult targets.

Ziemba pointed to protein intake as one area where the adult approach does not simply carry over, noting, "Animal protein limitation or getting your normal dietary allowance in an adult isn't recommended in children because they need the protein for growth."

REFERENCE

1. Pearle MS, Matlaga BR, Antonelli JA, et al. Medical management of kidney stones: AUA guideline (2026) part I: evaluation of patients with kidney stones and dietary management of patients with calcium stones. J Urol. Published online July 30, 2026. doi:10.1097/JU.0000000000005227