The lifetime risk of kidney stone disease is approximately 11% and stone recurrence risk can be as high as 50% in 10 years.2, 6, 12-16, 113-115 However, not all patients who experience a stone event warrant a comprehensive metabolic evaluation. A risk stratification approach based on an initial screening evaluation provides a rational approach to identify patients most likely to benefit from comprehensive metabolic testing. The Panel felt that stratifying patients according to risk (high versus low) provides an appropriate framework from which to guide the intensity of evaluation and treatment. Patients with recurrent stones and those with a first-time stone who have any high-risk features are considered high-risk (Table 3). In a comprehensive meta-analysis, Wang et al. found that younger age, higher body mass index (BMI), family history, certain stone compositions (e.g., uric acid, brushite, infection), the presence of bilateral/multiple stones, select comorbidities, and greater renal stone burden markedly increased the risk of stone recurrence regardless of whether a patient had a first-time stone or recurrent stone episodes. These high-risk features may be used to identify patients who will benefit most from metabolic testing to identify modifiable risk factors.116 Metabolic and systemic comorbidities including primary hyperparathyroidism, GI disease, and metabolic syndrome also contribute to a high risk of stone recurrence because the underlying pathophysiology (i.e., hypercalciuria, hypocitraturia, low/high urinary pH, hyperoxaluria) drives recurrence unless specifically addressed. Of note, patients with transplant nephrolithiasis, solitary kidney, CKD, and/or high-risk occupations (e.g., pilots, mine workers) should have a lower threshold for aggressive evaluation and preventative treatment regardless of other risk factors because of the implications of having an obstructing stone in these settings. Furthermore, population studies have linked stone history and recurrence to an increased risk of kidney disease progression, supporting proactive metabolic evaluation and targeted therapy in these groups.22