On average, it is estimated that 1 in 11 Americans will suffer at least one episode of nephrolithiasis in their life time according to the most recent report from a cross-sectional analysis of large epidemiologic data from the National Health and Nutrition Examination Survey (NHANES) 2007–2010. These data clearly show an increase in the incidence and prevalence of the disease when compared to previous reports from the same database from the period between 1976 and 1980. Multiple factors including changes in diet and lifestyle, increasing epidemics of obesity and diabetes, migration from rural cooler settings to warmer urban areas, and even possibly changes in the global environment with warmer temperatures may all be contributing to this increase in kidney stones [1].

The risk of recurrence after a first kidney stone remains controversial. As early as 1919, Dr. Lamson in a speech before the Association of Residents and Ex-Residents of the Mayo Clinic mentioned a very wide rate of recurrence ranging from 10 to 48 % [2]. Nowadays, reported frequencies of kidney stone recurrence after a first episode range from 30 to 50 % at 5 years in uncontrolled studies and as much as 100 % recurrence in patients who form single stones if they were followed for longer than 25 years [3]. These data indicate the complex and heterogeneous natural history of nephrolithiasis. However, recent data from control groups in randomized, controlled trials suggest much lower rates, ranging from 2 to 5 % per year. The risk of recurrence increases with each new stone formed [4]. Therefore, the importance of prevention and assessment of the risk of stone recurrence is highly relevant to any patient and health care provider involved in their care, in particular for those patients with more complex and severe disease.

Some risk factors for stone recurrence cannot be modified; examples include gender, age, family history, gastrointestinal diseases that impact fluid balance and electrolytes, genetic conditions or urologic issues such as medullary sponge kidney or horseshoe kidneys. Other endocrine diseases, mainly related to management of calcium and phosphorus, such as primary hyperparathyroidism, may be modified and treatable [5].

Other independent factors that may increase the chances of recurrence as high as 10 % per year include a history of multiple relapses, increased levels of alkaline phosphatase, stones located in lower calyces as compared to the renal pelvis, multiple stones, stone size larger than 20 mm and younger age. The type of surgical treatment for the first stone event may also influence the recurrence rate and is an active field for research, although many confounding variables make retrospective observations inconclusive [6].

Although metabolic work-up and its possible effect to lower the risk of stone recurrence has not been thoroughly demonstrated, some individuals may benefit from counseling and management based on these results. Metabolic evaluation should then be offered specifically to patients with multiple stones or first stones among complicated cases, in single kidneys, transplant recipients, patients with known severe associated co-morbid conditions, and interested first-time formers [7].

Perhaps the most important aspect of the metabolic work-up is the volume collected during the 24 h collection. Lower urinary volumes have been recognized as a prominent risk factor for recurrence of kidney stones as demonstrated by a well-conducted study by Borghi et al. [8]. Hypercalciuria is the most common abnormality found in patients with kidney stones and urine metabolic work-up other than low fluid intake and low urinary output [9].