Background <p>Family history of kidney stones is a known risk factor for nephrolithiasis, but its specific association with metabolic abnormalities and stone types remains unclear. This study aimed to determine if family history predicts distinct metabolic profiles or stone compositions.</p> Methods <p>We retrospectively analyzed 101 patients from a specialized stone clinic (2022–2025), stratified by family history. Metabolic abnormalities (hypercalciuria, hyperoxaluria, hyperuricosuria, hypocitraturia, cystinuria, hypomagnesuria) and stone compositions were compared using chi-square tests. Logistic regression, adjusted for age, gender, body mass index (BMI), diabetes, hypertension, and metabolic syndrome, assessed independent associations.</p> Results <p>Patients with family history had higher prevalence of hypercalciuria (49.2% vs. 30.0%, <i>p</i> = 0.022) and hyperoxaluria (27.9% vs. 12.5%, <i>p</i> = 0.034). Among 90 patients with stone data, Calcium Oxalate (CaOx) monohydrate was more common with family history (65.6% vs. 47.5%, <i>p</i> = 0.036). Logistic regression confirmed family history as an independent predictor of hypercalciuria (OR 2.15, 95% CI 1.03–4.50, <i>p</i> = 0.041) and CaOx monohydrate (OR 2.05, 95% CI 1.01–4.17, <i>p</i> = 0.047), with a trend for hyperoxaluria (OR 2.62, 95% CI 0.99–6.92, <i>p</i> = 0.052). No significant differences were found for other abnormalities or stone types, with wide CIs for cystinuria (<i>n</i> = 4).</p> Conclusion <p>Family history of kidney stones is associated with increased risk of hypercalciuria, hyperoxaluria, and CaOx monohydrate stones, suggesting a genetic predisposition. These findings support using family history for risk stratification and targeted metabolic evaluations to prevent recurrence, warranting further genetic studies.</p>