Prognosis Scenario

A 58 year old male had several weeks of intermiitent right loin to groin pain, but no microscopic hematuria, and negative X-ray, IVP and CT scan. Eventually he passed a 1mm calcium oxalate stone. Electrolytes, renal function, and urine microscopy and culture were all normal. We discussed prevention and he wanted to know the chances of recurrence. We formulate the clinical question, what is the risk of recurrence of ureteric calculus after a single episode in a middle aged male?

Searching terms and evidence source:
(renal OR ureteric) AND (calculus OR stone* OR colic) AND recurrence AND year* – search in PROGNOSIS section of PubMed Clinical Queries (emphasising “sensitivity”)

Read the article and decide:

Is the evidence from this trial valid?
If valid, is this evidence important?
If valid and important, can you apply this evidence in caring for your patient?

Completed Prognosis Worksheet for Evidence-Based General Practice

Citation

Kamihira O, et al Long-term stone recurrence rate after extracorporeal shock wave lithotripsy. J Urol 1996 Oct;156(4):1267-71

Are the results of this prognosis study valid?

Was a defined, representative sample of patients assembled at a common (usually early) point in the course of their disease?: 903 consecutive patients without residual fragments 3 months after lithotripsy were enrolled.
Was patient follow-up sufficiently long and complete?: Mean followup was 25 months; with maximum followup beyond 5 years.
Were objective outcome criteria applied in a “blind” fashion?: Plain abdominal films and/or excretory urograms were evaluated every 6 months.
If subgroups with different prognoses are identified, was there adjustment for important prognostic factors?: Recurrence rates were higher with multiple stones and pyuria.
Was there validation in an independent group (“test-set”) of patients?: No.

Are the valid results of this prognosis study important?

How likely are the outcomes over time?: At 25 months mean followup, 183 of 903 patients (20.3%) had had a recurrence. Kaplan-Meier curves show recurrence of:
6.7% (1 year), 28.0 (3 years) and 41.8% (5 years) respectively.
How precise are the prognostic estimates?: 20% recurrence at 25 months; 95% CI 17%-23%.

If you want to calculate a Confidence Interval around the measure of Prognosis

Clinical Measure	Standard Error (SE)	Typical calculation of CI
Proportion (as in the rate of some prognostic event, etc.) where: the number of patients = n the proportion of these patients who experience the event = p	$$sqrt{frac{ptimes(1-p)}{n}} \\ text{where $p$ is proportion and $\\n$ is number of patients} $$	$$text{If $p$ = 24/60 = 0.4 (or 40%) and $n$=60}$$ $$ mathit{SE} = sqrt{frac{0.4times(1-0.4)}{60}} \\ = 0.063 $$ $$ text{95% $CI$ is 40% +/- 1.96 x 6.3% or 27.6% to 52.4%} $$
$$ text{$n$ from your evidence: } underline{qquad qquad} \\ text{$p$ from your evidence: }underline{qquad qquad} $$	$$ sqrt{frac{ptimes(1-p)}{n}}\\ text{where $p$ is proportion and $\\n$ is number of patients} $$	Your calculation: $$mathit{SE}: underline{qquad qquad}\\ text{95% $CI$:}$$

Clinical Measure

Standard Error (SE)

Typical calculation of CI

Proportion (as in the rate of some prognostic event, etc.) where:

the number of patients = n

the proportion of these patients who experience the event = p

$$sqrt{frac{ptimes(1-p)}{n}} \\
text{where $p$ is proportion and $\\n$ is number of patients} $$

$$text{If $p$ = 24/60 = 0.4 (or 40%) and $n$=60}$$
$$ mathit{SE} = sqrt{frac{0.4times(1-0.4)}{60}} \\
= 0.063 $$
$$ text{95% $CI$ is 40% +/- 1.96 x 6.3% or 27.6% to 52.4%}
$$

$$
text{$n$ from your evidence: } underline{qquad qquad} \\
text{$p$ from your evidence: }underline{qquad qquad} $$

$$ sqrt{frac{ptimes(1-p)}{n}}\\
text{where $p$ is proportion and $\\n$ is number of patients} $$

Your calculation:
$$mathit{SE}: underline{qquad qquad}\\
text{95% $CI$:}$$

Can you apply this valid, important evidence about prognosis in caring for your patient?

Were the study patients similar to your own?: My patient is likely to be at lower risk (single small stone, no pyuria, first episode).
Will this evidence make a clinically important impact on your conclusions about what to offer or tell your patient?: Yes – the risk is lower than expected, hence we have not considered prophylaxis for this episode.

Additional Notes

Several other studies were found but none looked at a cohort of ALL first presentations of renal colic. The filters in these studies will generally tend to overestimate the recurrence rate.

Renal stones – The risk of recurrence is less than 10% per year

Clinical Bottom Line

In patients who have had lithotripsy for urerteric calculus, the risk of recurrence is modest – less than 10% per year. Patients with multiple stones or pyuria are at higher risk; those without at lower risk.

Citation

Kamihira O, et al Long-term stone recurrence rate after extracorporeal shock wave lithotripsy.J Urol 1996 Oct;156(4):1267-71

Clinical Question

What is the risk of recurrence of ureteric calculus after a single episode in a middle aged male?

Search Terms

(renal OR ureteric) AND (calculus OR stone* OR colic) AND recurrence AND year* – search in PROGNOSIS section of PubMed Clinical Queries (emphasising “sensitivity”)

The Study

903 patients who were stone-free after extracorporeal shock wave lithotripsy were followed every 6 months with history of recurrence plus a plain abdominal films and/or excretory urograms. Mean followup was 25 months.

The Evidence

There were 183 stone recurrences in 903 patients – a rate of 20% at an average of 25 months. “Survival curve” estimates showed rates of 6.7% at 1 year; 28% at 3 years and 48% at 5 years.

Appraised By

Paul Glasziou