FLUIDS by Jill Harris, LPN | Nov 22, 2015 | Q&A | 88 comments How much and what? We have already written a lot about this, but everyone has specific questions. This is the place to ask them. 88 Comments Stephanie on January 9, 2016 at 8:35 pm This post is not so much a question as it is a recommendation for a product that has dramatically helped me in my quest to drink more water. First off I should say that I am in no way linked to the company that makes this product. What follows is simply my humble opinion as someone with kidney stones that has struggled to maintain high fluid intake. The link below is for the Thermos water bottle with smart lid. This product connects to a mobile app and tracks all water that is consumed from it. It was easy to set up my personalized daily goal of 4 liters and the bottle sends me mobile alerts if I get off pace to reach my goal for the day. Custom reminders can be set for times when I know I struggle to remember to stop and hydrate. I also like being able to see my progress over a day, week, and month. It has really helped me to identify the parts of my day that I need to make a greater effort to get my water in. I find this product to be so helpful and motivating that it was well worth the money spent. If others are struggling to find a useful method to track and propel their water intake I highly recommend this product! Thermos 24 Ounce Hydration Bottle with Connected Smart Lid, Teal https://www.amazon.com/dp/B00ZQUNHO0/ref=cm_sw_r_cp_awd_ibCKwbCS7AKFR Reply jharris on January 10, 2016 at 10:05 am Dear Stephanie, What I love about this site is that it provides a space for all of us to suggest ideas, products, and revelations that have helped in the aid of kidney stone prevention. I am grateful that you wrote and suggested the above item. It IS very helpful and motivating to track progress when trying to get in all the required water one needs to prevent new stones. Thanks for the suggestion, I will be sending it off to my patients. Warmly, Jill Reply Meekah on June 22, 2016 at 8:09 am Hi Stephanie, Thank you for the recommendation, I’m going to order this! I’m currently using an app on my phone called Plant Nanny that sends me reminders to water my plant (by drinking water) throughout the day! I really like it and think it will work well with my new ‘smart’ water bottle! -Meekah Reply Ellen Key on January 11, 2016 at 9:30 am Water is not my problem. I take Potassium Citrate regularly (10mg 4 times a day) to prevent kidney stones. My stones are of Uric Acid> Is there an over the counter product or supplement that I can buy to take and cut the cost of my prescrition drug? Reply Fredric Coe, MD on January 11, 2016 at 7:26 pm Hi Ellen, Your stones form because of an excessively acid urine pH. Potassium citrate is ideal and will absolutely prevent stones. There is no OTC equivalent. Sodium bicarbonate would work but impose a large sodium load. A number of less expensive workarounds have been mentioned because of high cost. Crystal light lemonade will substitute – one liter is two of the pills you take. But be careful: Uric acid stones can grow rapidly and lead to surgery yet your present meds are a virtually perfect cure. Regards, Fred Coe Reply Michele Lewris on January 31, 2016 at 7:26 pm Dear Stephanie, How much lemon juice per day? I’m currently squeezing half a lemon in 16 oz of water three times a day. Also, can I use concentrated lemon juice or is fresh squeezed better? I’ve tried True Lemon, which is crystalized lemon but they say it doesn’t contain potassium citrate but does contain citric acid. Reply Jill on February 1, 2016 at 7:58 am Hi Michele, Please read the article on this site (http://kidneystones.uchicago.edu/price-of-potassium-citrate/) which will provide you with some help regarding your question. Very Best, Jill Reply John Kloepper on June 20, 2016 at 2:18 pm What is the medical “thought” on Chanca-Peidra” as a means of addressing kidney stones? I’ve read alot about it’s positive effects, but since it’s an herbal option there isn’t any clear discussion on how much and how often to take. Any thoughts there too? Reply Fredric Coe, MD on June 21, 2016 at 8:19 am Hi John, I cannot find even one entry for this material on PubMed which is the central repository for all published work in medicine and biology. Regards, Fred Coe Reply John Kloepper on June 24, 2016 at 1:48 am Dr Coe, The fact that you didn’t find anything nor have you heard of chanca-piedra doesn’t give me much confidence. However in the interest of peeking your curiosity here’s a brief yet informative link. There are others but that up to you to investigate. Seems to garner a lot of attention overseas, but not much here. http://www.globalhealingcenter.com/natural-health/benefits-of-chanca-piedra/ Reply Fredric Coe, MD on June 24, 2016 at 11:38 am Hi John, I know there is information and I was remiss in not mentioning that fact. Here is my issue. I am a physician scientist and a professor at a rather rigorous university, and my basis for doing things medically is formal science, by which I mean experiments carried out in what I might call the ‘scientific manner’. This site, although personal to me for the most part, carries the UC logo and because of that, and because of me, too, advocates for science as a basis for action in regard to medicine. I understand that professional science has its limitations, and grow as impatient as anyone else with certain aspects of that slowness in this country, but even so PubMed articles are my bible and roadmap. Every paper published in any peer reviewed journal makes its way into PubMed, and I make my way into it, too. While there, I could not find anything. If anything turns up I will be happy to read it and comment. Since the site is free and open to the world – as this one is – take a look yourself, and if you find something – I am not the most perfect scholar – I am pleased to try and be helpful. Warmest regards, Fred Reply Heather on December 16, 2016 at 3:59 am Hi Dr. Coe, Chanca Piedra is also called Phyllanthus niruri, and does indeed appear in PubMed under that name — between 8-12 articles related to kidney stones, depending on the precise search phrase I used. Here’s one specific link: https://www.ncbi.nlm.nih.gov/pubmed/16890682. I’d love to hear your comments on the research that’s been done. Thanks! Fredric Coe, MD on December 16, 2016 at 5:20 pm Hi Heather, I have read articles on this material, and If I did not say so in some prior comment I am sorry. This trial is more or less similar to those others I have read. In what appears to have been a non blinded and perhaps non randomized trial of stone free rates after shock wave lithotripsy there were no significant differences between those who used the material and those that did not except in the lower poles, and the effect was small. Here are the results: ‘Stone-free rate (stone-free defined as the absence of any stone or residual fragments less than 3 mm) was 93.5% in group 1 and 83.3% in group 2 (p = 0.48) at the end point of the followup (180 days). For lower caliceal stones (56 patients) the stone-free rate was 93.7% in the treatment group and 70.8% in the control group (p = 0.01). Re-treatment need for group 1 was 39.7% and for group 2 it was 43.3% (p = 0.2). No side effects were recorded with extracorporeal shock wave lithotripsy or P. niruri therapy’. They tested stone free rates – insignificant; they tested stone free rate only in the lower poles – significant; they tested retreatment rate, no significance. When you do this kind of multiple testing it is called fishing for a p value; the chances of getting a significant one increases with the number of tests. I suspect they found nothing and then saw that the lower poles were better with than without the drug. Perhaps the drug helps, perhaps not, but this is a very weak kind of trial. If the agent is safe and cheap why not use it? But I have little confidence so far. Regards, Fred Coe Jen Friday on January 28, 2017 at 9:22 am I have been increasing my water intake as suggested for prevention, however I am concerned about my well water. It has a high mineral content. Could this be a contributor to my forming. Reply Fredric Coe, MD on January 28, 2017 at 5:15 pm Hi Jen, Possibly it could if extreme. The mineral would be calcium, so is your urine calcium high? If so, perhaps you might do a month of bottled water and recheck. This seems easier than elaborate water testing. I would bet it is not the well, however. Regards, Fred Coe Reply Laura on April 23, 2017 at 8:01 pm Vitamin Water Zero has calcium phosphate and calcium lactate. Is there any correlation with this fluid and the creation of CaP stones? Reply Fredric Coe, MD on April 24, 2017 at 10:50 am Hi Laura, I read a bit on the web and do not find the filter is known to add calcium and certainly will not add lactate. But many people have had problems with the cost etc. Regards, Fred Coe Reply Ha on May 1, 2017 at 3:05 pm I have read the literature from the UW Hospital Metabolic Stone Clinic and have found it to be extremely helpful, Dr. Coe’s responses to the questions raised, especially so. Since Dr. Coe strongly recommends the product Crystal Light, I ordered a large quantity from Amazon. The CL mixing instructions are for lemonade, but “lemonade” is not defined in terms lemon juice, that is, the equivalent concentration of lemon juice in water. To my question: the clinic recommends either 4 oz per day of lemon juice in 12 oz water (for a total of 1`6 oz), or 32 oz of prepared lemonade. CL advises dissolving one of their packets in 64 oz of water to make “lemonade.” Will 16 oz of prepared CL be equivalent in lemon juice concentration to the concentration recommended by the clinic or is it only half? Another question: It is mentioned in the publication* that “Of the commercially-available lemonade products, those that are ready-to-consume have more citric acid than those [such as Crystal Light?] that come as a powder.” Is there a more quantitative statement available? *Produced by Kristina Penniston Reply Fredric Coe, MD on May 2, 2017 at 10:12 am Hi Ha, The product was simply one of many we assayed. It contains 20 mEq of potassium citrate in a liter. The goal of using potassium citrate salts is that they produce bicarbonate when metabolized, and that alkali load reduces urine calcium losses and can increase urine citrate excretion via effects on the citrate transporter. – also raises urine pH with is specifically helpful for uric acid stones. Citrate is metabolized as citric acid, so each molecule metabolized removes one proton thereby producing bicarbonate in blood. Citric acid is already protonated and has no specific effect. It is metabolized without changing urine pH or citrate. So how much citric acid is present has no interest for our purposes. We concern ourselves with the amount of citrate, determined by the amount of total citrate species and the pH of the beverage. Regards, Fred Coe Reply Paula Burr on July 10, 2017 at 9:46 am My issue is idiopathic hypercalciuria. I am currently following the diet recommended on this website and drinking 2+ liters of water a day. However, our well water is filtered through a reverse osmosis system that removes all buffering minerals and results in very acidic water (pH 4.5). Can large volumes of this water be problematic? Should I be adding small amounts of potassium citrate powder to make it more alkaline? Reply Fredric Coe, MD on July 11, 2017 at 6:00 pm Hi Paula, The water has a low pH but almost no buffering capacity so it is aright. Remember, the low sodium is paramount for IH! Likewise, get 24 hour urines to monitor progress. Regards, Fred Coe Reply Sharla on August 28, 2017 at 10:23 pm Does apple cider vinegar help prevent or dissolve stones? I don’t know what kind of stones I may have, but I read that ACV alkalizes the urine and is helpful with calcium oxalate stones as well as uric acid stones. I’m wondering if I should add a few teaspoons to my water. Reply jharris on August 29, 2017 at 3:09 pm Dear Sharla, I know that ACV is all the rage right now from everything to stones to toe nail fungus. I wouldn’t waste my money on it. You know what does help? Do a 24 hour urine collection and find out what is causing them. Best, Jill Reply Fredric Coe, MD on August 29, 2017 at 3:18 pm Hi Sharla, You do not know what kinds of stones you form, and I gather that you have not as yet had the benefit of a full evaluation. Anything you try to do for prevention will be random, and at best – very best – simply without effect. At worst you could just raise risk. Take a look at this article about confusion, and how to make a better approach for yourself. Regards, Fred Coe Reply Danielle on October 5, 2017 at 2:22 pm Is there any data on alkaline water and kidney stones? I am a registered dietitian in general practice and had a client who was told by her doctor to not drink water filtered by her Brita type water pitcher but rather an alkaline water (Culligan in particular) Is there any evidence for this? Other alkaline waters have become popular in our marketplace – thoughts? Reply jharris on October 5, 2017 at 10:10 pm Hi Danielle, No data that I know of. Dr. Coe can add to this comment if he knows better. I think alkaline waters are just another marketing ploy. If one has acidic urine it might help a bit, but the problem with acidic urine is diet or disease or both, so if this is the case the alkaline additive in these waters won’t help much. So, I am not a fan, unless needed. Patients need to drink water and it doesn’t need to be expensive. That is my story and I am sticking to it. Thanks for writing- Jill Reply Fredric Coe, MD on October 7, 2017 at 11:33 am Hi Danielle, The Brita filter has no role in stones. This amusing review of some serious articles might be of interest. Most filtration systems like Culligan are either ion exchange column, reverse osmosis or a combination. The key is to use a system that does not substitute sodium for calcium and magnesium. As for alkaline water, some add alkali powders and I see no virtue in them. Regards, Fred Coe Reply Elizabeth on December 10, 2017 at 7:00 am I have had kidney stones for about 3 weeks. Also I had my gut bacteria analyzed by Ubiome and got the report about 2 weeks ago. There is a bacteria that helps prevent formation of kidney stones (oxalobacter formigenes) which I am very very low in. This bacteria produces an enzyme (Oxalyl-CoA decarboxylase) which helps dissolve oxalate which is one of the primary substances in kidney stones. I have searched the web and out of many probiotics and enzymes I have looked at, none contain these items. Can anyone direct me to a place where I can buy either of these two substances, preferably the bacteria. Reply Fredric Coe, MD on December 10, 2017 at 4:31 pm Hi Elizabeth, No one has as yet been able to improve gut flora and prevent stones. But evaluation and prevention of stones is very efficient. Instead of following this rather speculative literature, why not just get evaluated and begin efforts at prevention. For example, are you sure you have excessive oxalate in your urine? Above all, do not jump to a conclusion because of gut flora studies, and miss out on well established if less exciting benefits. Regards, Fred Coe Reply Diego on January 10, 2018 at 4:06 am Just came from my appointment to go over the Litholink study results and everything looks great except for my urine calcium. Normal serum calcium, very high Uribe calcium (670). Waiting for Parathyroid Hornone Test. Hoping to get some feedback on what can I do in the meantime to improve my situation. Just increase urine output? What about dietary calcium intake? Should it be restricted? Also, can you offer any information on this normal serum calcium – high urine calcium result? I can’t quite understand how that’s possible. Thank you so much for this terrific website. This is by far the most complete resource on the internet for kidney stones. Reply Fredric Coe, MD on January 11, 2018 at 7:24 pm Hi Diego, If serum calcium is indeed normal, below 10.1, the parathyroid hormone test is important if suppressed. Here is a good article on the problem. Primary hyperparathyroidism is always a state of high serum calcium. If no other cause is found, you have idiopathic hypercalciuria. Read the long involved article because IH is itself really complex. Low calcium diet can cause bone disease. The trick is low sodium diet, and here is an article about people like who you probably are. Your physician needs to be sure, so do nothing until he/she finishes. This last article fills in all of the exclusions. Regards, Fred Coe Reply Ben Silverwater on January 27, 2018 at 8:54 pm I’m in my sixties and new to kidney stones (oxalate). How does one handle the increased need to urinate when out of the house with the consumption of one half to a gallon of water a day? Reply jharris on January 28, 2018 at 9:17 pm Hi Ben, I am not going to lie. It can be cumbersome to say the least. But kidney stones are worse, no? The goal is to do this most of the time. Understandably, some days might be tough if you are out all day. Do your best, perhaps you don’t need to drink as much as you think. Drink as much as you need to produce at least 2.5 liters of urine a day. This will help lessen your stone risk. Thanks for writing- Jill Reply Jan Young on February 8, 2018 at 3:41 pm Dr. Coe: Is your practice only to prevent and treat kidney stones? I have Chronic Kidney Disease with a history of two kidney stones. My last stone was about one and a half years ago. I am a female who is 67 years old. I want to do everything to prevent the kidney disease from getting worse. Would it be possible to make an appointment to see you? Thank you for your response. Reply Fredric Coe, MD on February 10, 2018 at 8:37 pm Hi Jan, My main purposes are stone prevention, but stones can lead to kidney disease so one has to do more than just one thing. I am easy to get to – my secretary is Kathleen Dineen 773 702 1475. Regards, Fred Coe Reply Carl Hammel on March 5, 2018 at 11:08 am I posted a question about a week ago in the Foods section and, seeing no answer, thought that perhaps it was because I had posted it in the wrong section, as it involved a fluid. My question was: are the benefits of cranberry juice to overall kidney/bladder health an old wive’s tale or is there value in a glass or more of cranberry juice per day? FYI – had my second stone in 5 years a few weeks ago; did not find the stone, but did find the previous one and it was 80% calcium oxalate monohydrate, 10% uric acid and 10% calcium oxalate dihydrate. Reply Fredric Coe, MD on March 5, 2018 at 12:16 pm Hi Carl, Sorry it took so long! I did answer you, but just today. Regards, Fred Reply Earline on March 5, 2018 at 11:16 am I read on another’s list that Ovaltine is rated High Oxalate but it doesn’t give the Mg amount. They only include it in the category shown as High Oxalate. I don’t find Ovaltine on the list you recommend. Can you provide me with the High Oxalate for Ovaltine? Reply Fredric Coe, MD on March 5, 2018 at 1:07 pm Hi Earline, I expect Jill Harris will want to answer this one. Regards, Fred Coe Reply jill harris on March 5, 2018 at 1:37 pm Hi Earline, I don’t have reputable numbers on Ovaltine, but I do suspect it would have higher oxalate bc of the cocoa powder it contains. I would have it as a treat, once a week, and leave it at that. Be well, Jill Reply Melissa Howard on May 18, 2018 at 5:07 pm Dr. Coe and Jill Harris, I’ve been drinking approx. one liter of Crystal Light every day for the last 6 mos to raise the citrate level in my urine. I’ll be going over my recent 24 hr urine results with my urologist next month. In the meantime, is there anything comparable citrate-wise to Crystal Light I can continue to include in my fluids that doesn’t have artificial sweetener as an ingredient? How much pure lemon juice would I need to add to my water to get the same amt of citrate? Thank you. Reply Fredric Coe, MD on May 20, 2018 at 1:55 pm Hi Melissa, Actually I have a good thought for you. If you eat the 5 servings of fruits and veggies that is in the kidney stone diet and also recommended for all Americans, you will get 110 mEq of potassium anion, which should make quite a difference and may even make potassium citrate tablets unnecessary. In general the kidney stone diet is the foundation of all treatment, and for reasons like this. Regards, Fred Coe Reply Jason on July 12, 2018 at 3:20 pm What about coconut water? Is it high/low in oxalate? Reply jharris on July 13, 2018 at 1:33 pm Hi Jason, Although avocados are listed as “high” you can certainly safely incorporate them in your diet. Look at the milligrams, not the adjective describing it. 19 mg for a whole avocado is not high. Best, Jill Reply jharris on July 13, 2018 at 1:36 pm Hi Jason, You can have it. Best, Jill Reply Rebecca Ramey on September 4, 2018 at 3:49 pm Do you need someone else as a study I’m willing. I need help Reply Fredric Coe, MD on September 6, 2018 at 8:06 pm Hi Rebecca, I do not believe we need anyone right now. But if you need help perhaps you could say what it is you need and I might try to point you in the right direction. Regards, Fred Coe Reply lesley on September 28, 2018 at 10:51 pm Is lime juice a good substiute for lemon juice to get more citrate? Reply Fredric Coe, MD on September 29, 2018 at 3:31 pm Hi Lesley, Please see my answer to this on your other post. Regards, Fred Coe Reply Dan M on October 15, 2018 at 7:40 pm Does the high calcium diet apply to uric acid stones as well? Reply Fredric Coe, MD on October 15, 2018 at 7:43 pm Hi Dan, High calcium diet has nothing to do with uric acid stones. It is healthy for your bones just in general. For UA stones treatment is with potassium alkali. Regards, Fred Coe Reply Mary Young on January 17, 2019 at 11:12 am What can I do to stop my chronic uric acid kidney stones? I have to be on limited fluid due to my heart. I heard potassium citrate can dissolve the stones however my stones are 80% uric acid and 20% oxalate. Can potassium citrate still dissolve these stones? What else can I do since I can’t drink a lot of fluid? Reply Fredric Coe, MD on January 20, 2019 at 11:13 am Hi Mary, Potassium citrate stops uric acid stones and can dissolve them. Here is the right article. But you also need high fluids because of the calcium oxalate part, and perhaps other treatment as well. Be sure and get proper 24 hour urine testing. Regards, Fred Coe Reply Kathleen Spielvogle on August 6, 2019 at 7:35 pm Everything I’m reading here suggests that this test is to prevent any additional stones after having one. My doctor ordered a test, but I have never had a stone. I had a 24 hr. urine test less than a month ago with all good results. but am being told that this test will cover area that the first didn’t. I’m thinking about a second opinion, but was wondering what your thoughts are on this subject. Reply Fredric L Coe on August 8, 2019 at 7:43 pm Hi Kathleen, If you have never had a stone, I am confused. If you had one stone and she/he wants to prevent another, I would agree it is a good idea because stones do recur. If you have never had a stone, I am confused altogether. Let’s assume you had one, and here is a good article on treatment. If it does not clarify things here is one on confusion. Regards, Fred Coe Reply Joann Whitney on September 13, 2019 at 11:19 am Hi, I have a family history of stones and have passed 1 at age 42. A CT Scan revealed that I have 1 more in my kidney that I have yet to pass. Although I have made drastic dietary changes which I believe to have helped (your Food List is my Bible), I fall short on hydration despite my best efforts. I was wondering if there have been any studies showing that IV therapy is shown to help stone sufferers who suffer from chronic dehydration? There are lots of medical clinics that now offer different ‘boosts’ (saline, B12 etc.), but I am cautious as I do not want to introduce anything that would compound my problem. Thank you. Reply Fredric L Coe on September 16, 2019 at 7:53 pm Hi Joann, IV fluids are not part of long term stone prevention, as what matters is the hour by hour – or even minute by minute balance between urine flow rate and excretion of stone forming salts. You do not mention 24 hour urine studies or blood studies. You need them. If you have them, what do they show? Diet is a fine thing but the causes of the stones needs be known, and the stone analysis likewise. Regards, Fred Coe Reply Skip Shimer on October 8, 2019 at 9:38 am I have had three 24 hour urine collections analyzed by Litholink. My normalized Ca 24/Kg is 4.3-4.6 and I weigh 80 kg. This is the only normalized value that is higher than recommended levels. My urine volume is between 3.2-3.5 L. Litholink present normalized values based on body weight. If stones are caused by supersaturation why do they not normalize to concentration? As a Ph.D. biochemist, this does not make much sense to me. Thank you for your time. Skip Reply Fredric L Coe on October 8, 2019 at 6:11 pm Hi Skip, SS is calculated from the concentrations of the main stone salt ligands, pH, and ionic strength. There are 24 complexes formed between calcium oxalate phosphates, citrate, and the rest and the solution is obtained in the usual way by extracting the matrix of coefficients and calculating the activity products, in this case for calcium oxalate and brushite. Normalizing excretions is to adjust for size – extensive variables, all. SS are intensive variables, and independent of size. Regards, Fred Coe Reply Skip Shimer on October 8, 2019 at 2:46 pm I have completed one 48 hour and one 24 urine analysis by Litholink. I have five stones in 30 years, starting at 35, drink 3 quarts of water and additional liquids daily, and try to eat a low oxalate, although it is difficult during the summer with all the fresh vegetables. I have two questions concerning the normalized values and calcium in my diet. I have high total Ca 24 (338-360), elevated oxalate (42-46), and my Normalized Ca 24/Kg is 4.3-4.7. My excreted volume is high at 3.1L/24 hours. The values are normalized to body mass, which as a Ph.D biochemist seems odd to me. If stones are formed by salt saturation in the urine why aren’t the values normalized to the urine volume? I am also confused by the dietary recommendation to ingest more calcium when eating oxalate rich foods. Since my Ca 24 is so high should I follow this guideline when eating oxalate rich foods? Thank you for your time. Best, Skip Reply Fredric L Coe on October 8, 2019 at 6:16 pm Hi Skip, I already mentioned the SS issue. SS can be put against urine volume, of course, and here is what it looks like. Because volume affects all of the ligand interactions, as well as ionic strength, and the latter controls activity coefficients, volume effects on SS are not simple. As for calcium, when you eat it it blocks oxalate absorption. The higher diet calcium can be controlled by reduced diet sodium, because of how kidneys work. Here is the way things seem to be, and the kidney stone diet rationale all in one article. Here is a practical guide to evaluation and treatment. Regards, Fred Reply Skip Shimer on October 8, 2019 at 6:43 pm Thank you for the quick reply. I will dig through the linked information and have a follow up conversation about the path forward with my urologist. Best, Skip Reply Frank Martinez on November 12, 2019 at 8:01 am Hello. I wanted to ask whether any research has yet been done into the citrate content of the new generation of “lite” orange juice and lemonade drinks that have become available within the past few years. I am both overweight and I suffer from kidney stones. As a result, I am always looking for ways to incorporate more citrus beverages into my diet while limiting the number of calories from those beverages. These new “lite”, low-calorie, artificially sweetened citrus beverages seem like a good compromise, but I have read from previous research that the contents of compound juice-based beverages can impact the availability of citrate to the body, and thus the efficacy of the beverage in helping to reduce stones. I wonder, in this case in particular, whether there is any interaction between the artificial and/or non-caloric sweeteners (aspartame, acesulfame potassium, stevia leaf extract, etc.) and the citrate present in the (often concentrated) fruit juice that is used to prepare these juice beverages commercially. Reply Fredric L Coe on November 16, 2019 at 2:06 pm Hi Frank, One only knows from measurements of citrate and pH – the latter to distinguish citrate alkali from citric acid in the beverage. We do not have measurements, and I have not seen any in recent papers. But a study of coconut water shows a marked increase of urine pH and citrate even though the actual citrate content of the product is modest. The reason is a high content of other alkali, mainly malate. Coconut water has modest calorie content and could be useful as an additional source of alkali. Remember, alkali intake signals kidneys to release citrate into urine, and the intake need not be of citrate itself. Also note, alkali raises urine pH, so one should not add it unless your testing results indicate that low urine citrate is a cause of stones, this is for your physician to discuss with you. Regards, Fred Coe Reply William P Dobbins on December 13, 2019 at 8:23 pm Greetings, I’ve had 2 calcium oxalate stones; The first in 1992, 5 mm, which was stuck in the ureter and had to be extracted via catheter interventionally. Cause was acute dehydration. The second In 2017 was an incidental finding in the kidney and blasted/removed via acoustic lithotripsy. Since the second stone I’ve done several 24 hour collections and I am getting good numbers but I have not been able to get my citrate value up to spec. using fresh squeezed lime juice (4.0 oz diluted in 24 oz. of water) then recently have been using bottled lime juice. I’m considering using food grade, anhydrous citric acid with the same concentration as lime/lemon juice (4.0 oz. water with about 1.5 grams/oz of citric acid crystals) diluted in 24 ounces of water. Is this a suitable way to improve my Citrate/24 hr, URN value and is it safe? Also, can I modulate this method by increasing the acid concentration or the frequency of consuming it? Thanks in advance for your answer. Reply Fredric L Coe on December 15, 2019 at 2:17 pm Hi William, Somehow this query seems familiar as if I had encountered it before and answered it, but I cannot find either. I gather the stone was calcium and your urine citrate was low, so you are trying to raise it. Citric acid is the citrate molecule fully protonated – three proton binding sites. When ingested, it may be partly metabolized in the citric acid cycle or simply excreted in the urine but will not alter urine citrate or urine pH – except perhaps downwards for both. Potassium citrate is citric acid with all three protons replaced by potassium, so it can take up protons when metabolized, in other words acting as a base or alkali. Lime juice has a low pH between 2 and 3.. The article I have used is very inaccurate apart from the pH part so please do not use it beyond that. At the pK of 2 – 3 citric acid is fully protonated, so it will not produce any alkali in your body when metabolized. Lemon juice has a similar pH depending on the ripeness of the lemons and whether pH has been adjusted. Potassium citrate and other alkali raise urine citrate because they signal the kidney cells, via a higher blood pH, to permit filtered citrate to leave in urine instead of reabsorbing the citrate and metabolizing it for energy production. So whatever you do with lemon or lime juice of citric acid it will do no good for raising urine citrate. Regards, Fred Coe Reply William P Dobbins on December 19, 2019 at 11:25 pm Dr. Coe, Subsequent to the 2016 stone I submitted my first 24 hour urine collection for stone risk in December of 2016. I did 5 more collections (3 in 2017, 1 in 2018, and 1 in 2019) with the objective of bringing the key values into specified limits. Following are the values for the collections: (The following 5 collections; The test was developed and its analytical performance characteristics have been determined by Quest Diagnostics Nichols Institute Valencia.) December, 2016: Citrate – 270 mg ( >320 mg/day ) PH – 5.4 ( 5.5 – 7.0 mg/day ) Calcium – 283 mg (<250 mg/day ) Oxalate – 115 mg ( <45 mg/day ) Potassium – 152 meq ( 19 – 135 meq/day Volume 2.77 L February, 2017: Citrate – 242 mg PH – 5.5 Calcium – 177 mg Oxalate – 54 mg Potassium – 59 meq Volume – 1.18 L July, 2017: Citrate – 76 mg PH – 5.5 Calcium – 187 mg Oxalate – 53 mg Potassium – 70 Volume – 2.5 L September, 2017 Citrate – 76 mg PH – 5.6 Calcium – 106 mg Oxalate – 33 mg Potassium – 75 meq Volume – 2.5 L September, 2018 Citrate – 227 mg PH – 5.6 Calcium – 224 mg Oxalate – 39 mg Potassium – 84 meq Volume – 2.92 L August, 2019 (Performed by Mayo Clinic Laboratories – MN) Citrate – .3 mmol/24h ( 1.7 – 6.4 mmol/24h ) PH – not reported Calcium – 129 mg Oxalate – 19.4 mg Potassium – not reported Volume – 2.8 L For the low Citrate values I did not take Potassium Citrate tablets but rather was drinking lime juice (4.0 oz./day) and while my urine PH has stayed constant at 5.5 nominally it did not affect the Citrate value. My question is; Should I increase my Potassium intake to get the Citrate value into tolerance. Also, should I take any action on values other than Citrate. Thanks in advance for your reply. Bill Dobbins Reply Fredric L Coe on December 20, 2019 at 4:51 pm Hi William, Looking at your data, urine volume varies from good to low, so fluids matter – 2.5 liter or so a day is ideal. Urine oxalate varies from low to very high, clearly dietary, and that is some combination of low diet calcium and high diet oxalate which your physicians have to figure out. Citrate is low, and so is pH but lime juice – low pH drink with lots of citric acid buffer – may be lowering urine pH and citrate. Remember, citric acid when titrated fully is an important acid load, and limes are biologically low pH fruits. Potassium citrates have all of the proton acceptor sites on citric acid (3 sites) occupied by potassium, so the material behaves as an alkali. My suggestion is to stop the limes, and think about your diet – with your physician – in terms of calcium and oxalate, and see if potassium citrate might raise your urine citrate once the limes have departed. Regards, Fred Coe Reply Bob on February 12, 2020 at 5:56 pm I have had bariatric sleeve surgery 2 years ago, since the last year I have been getting relatively often kidney stone pain, though manage to get through the pain without hospital visit in most cases though I have had previous bouts of stones before the bariatric surgery 5 and 10 yrs prior, I have over the last year been using turmeric in capsule form and as golden padte to put in food and drinks, could this be why I have been getting the more frequent bouts of kidney stones? Thank You Bob in UK Reply Fredric L Coe on February 21, 2020 at 5:08 pm Hi Bob, Maybe, but I would not guess. You had stones before, and probably have a common cause for them that proper evaluation will easily identify. Get it done and then treat what is wrong. Regards, Fred Coe Reply Constance French on November 27, 2020 at 5:19 pm Is pomegranate (freshly squeezed) juice (sweetened, if necessary with SweetNLow) okay for one with a history of kidney stones? Eating fresh pomegranate seeds? Reply jharris on November 29, 2020 at 11:50 am Hi Constance, As we say, all fluids count so you can enjoy this juice. I wouldn’t make it an everyday thing as it is high in sugar (even if it is naturally occurring). Jill Reply DeeDee B on July 17, 2021 at 7:29 pm I have a friend who has (1) stone in left kidney in the crick and (1) stone in the right kidney in the crick. They have talked to a dietitian but their Dr will not give them any meds or prevention help. Says eat calcium foods, follow a low oxalate diet, push fluids. The stones are 8 mm and 9mm and may need to be surgically removed. They have been dealing with stones since 2014. Then in 2019 they ended up in the hospital for 4 days from sepsis from a infected kidney stone & UTI. They almost died. I have said to them that they need a new Dr. They also have a cyst on their left kidney besides. Nothing seems to help my friend get rid of the one’s they have or prevent more. Reply Fredric L Coe, MD on July 25, 2021 at 2:04 pm Hi DeeDee, stone prevention is a process. Here is my best by way of an introduction. See if she/he finds it useful. I do not know what the crick of a kidney is, but if the stones are not obstructing, or causing pain, bleeding or infection removal is elective. Regards, Fred Coe Reply Sally Rishel on August 3, 2021 at 1:01 pm Reading through your site there is no mention of medications adding to the formation of kidney stones. I’m 70 yrs old and since being diagnosed with RA 10 yrs ago have been taking Enbrel, Methotrexate, Celebrex, occasional steroid shots and now Lisinopril as HCT lead to raised uric acid levels and “Gouty Arthritis”. I have developed continuous kidney stones – had lithotripsy, ureteroscopy and 3 trips to the ER. Potassium Citrate was prescribed by a Nephrologist but caused extreme, unbearable body & leg cramps within a week of starting the script. Been a life long Water drinker – have an occasional tea and that’s it. Have stopped RA meds a couple of times and stone formation has slowed. I agree diet and water consumption is important – but it is hard to believe that medications can’t also be part of mix. Reply Fredric L Coe, MD on August 9, 2021 at 8:00 pm Hi Sally, You do not say what the stones are made of. The HCT will raise serum uric acid and can cause gout. Given continuous stones, their crystal composition is crucial and likewise for sleuthing which drugs might matter. Regards, Fred Coe Reply Kenneth Mantei on November 15, 2021 at 3:19 pm Had a stone recently, 5th I think in the last 30 years. Second one I had to have surgically removed. All have been Calcium Oxalate Stones. This is the first time thought it sent me to the ER, so this is the first time I have taken it far more seriously. After a fee 24 hour urine test I can say there are some issues Urine Calcium: 400-510 Calcium/Creatinine: 300+ Urine PH: High 6.5-6.8 Other good factors Citrate 700-800, Oxalate 20-25, Urine Volume 3-3.25ml. Urine Sodium around 150. My doc has me going low sodium (staying under 2000mg/day), and made changes to my diet. I am a 1g or protein per pound of body weight guy as I am a weight lifter. So i have dropped my protein down to 120-150 instead of 200+ grams per day. I normally eat a low fat, low processed food diet. I drink 170-200 ounces of water per day. I get 1000-1500mg of calcium from my food. Your website has been so incredibly helpful. Full of such detailed information. Is there anything else I can be doing to decrease my risk of forming another stone? Of getting my urine calcium down under the 250 level? Reply Fredric L Coe, MD on November 21, 2021 at 11:05 am Hi Kenneth, It is interesting to me the stones are calcium oxalate given the urine calcium is very high and the oxalate remarkably low. The pH is very high as well – so I would have expected calcium phosphate stones. Please be sure if that is not the case. Check the actual stone report yourself. I like the high calcium and reduced sodium, and that no one has suggested potassium citrate (urine citrate is high and so is the pH). You do not mention stones in your kidneys, so be sure and get a CT scan (no contrast, modern machines are very low radiation) to ascertain any risk from stones already present. Regards, Fred Coe Reply Richard T. on December 24, 2021 at 12:35 pm I have a recurrent problem with bladder stones related to chronic foley catheter usage. Are kidney stones and bladder stones two different conditions, or can your Kidney stone information and recommendations be used to treat bladder stones also? Thank you! Reply Fredric L Coe, MD on January 5, 2022 at 8:05 pm Hi Richard, They are different. But often abnormal urine chemistries play a role in bladder stones. Your physician will want to analyze the stones and see if there are any prevention options. Likewise she/he will want 24 hour stone urine chemistries for the same reason. Crystals are the same whereever they are and follow well known physical laws. Regards, Fred Coe Reply Karen Kolba,MD on June 11, 2022 at 7:31 pm Dear Dr Coe, The studies showing a change from high CT papillary density to nearly normal after a year of increased fluid intake is remarkable. Since the plaque is unlikely to change (ever), have you (or anyone) documented just how fast the change in papillary density happens? You suggested it might be a matter of weeks. This would be high motivation for us stone-formers. Also, has anyone documented less or smaller stone formation in patients who showed the decrease in papillary density? References appreciated. Reply Fredric L Coe, MD on June 12, 2022 at 3:33 pm Hi Dr Kolba, Thanks for being interested in this matter. I am but no one else I know! I have no data beside what is in the article. Frankly I think the high density is from high papillary calcium concentrations – not crystals – but how to prove that?? Plaque certainly will not change in a year with fluids- our repeat URS cases show it is very stable over even a decade. No one has done a shorter interval hydration study like the one in the article. Warm regards, Fred Reply Ron Z on August 17, 2022 at 5:53 pm Dr. Coe, Do you have an opinion on the highly advertised Kidney C.O.P. supplement which touts some 99+% reduction in calcium oxalate stone formation? The primary ingredient is citric acid but it also contains inositol hexakisphosphate to inhibit calcium absorption in the intestines. Working in the drinking water industry, I am familiar with the chemical process of sequestering certain minerals in the distribution system to prevent binding ( using sodium hexametaphosphate), so a similar concept with those substances that cause kidney stones seems to makes sense. Any thoughts? Thank you. Reply Fredric L Coe, MD on August 28, 2022 at 1:23 pm Hi Ron, I started an article on this and its associates but never went on to finish it. Much hype and in my opinion misleading advertising to the public. The material can – they say – alter growth of crystals in vitro by 99%; this has no clear relationship to a change in human kidney stone production. At most the products – this one included – provide alkali, and therefore act like potassium citrate. Reduction of calcium absorption, if it in fact happens, would threaten bone and act like low calcium diet, a much undesired outcome. Here is a good review of current products by the Dallas group more or less showing how much alkali they provide, and pricing – more or less all there is to say about them. Regards, Fred Coe Reply Patricia V on December 26, 2022 at 11:51 pm Hello I recently took 24 hour urine test with Quest and calcium levels were 334 the first time then 300 the second in April and May of this year. I had Jill analyze my results and I had also informed her that I was taking over the counter potassium citrate, she advised me that taking this unnecessarily could cause calcium phosphate stones, so I immediately went off of it since I did not need it. From March to November I formed yet another stone. I recently just completed a third test with Litholink Labcorp and shockingly my urine calcium was 444. I am dumbfounded as I have done ALL the right things to get my numbers better including all the recommendations as it pertains to sugar, salt, calcium thru diet,, water and low oxalates eating more fruits and veggies. Recently I implored my doctor to get me on Thiazides but now I have concerns that it may solve one issue but then cause problems in another area such as hypercalcemia as I have provided in the article website above. Aside from some kidney stones I am a very healthy 55 year old woman and am becoming increasingly concerned that taking medication is going to create additional problems down the line. Can you please advise? Reply Fredric Coe, MD on January 4, 2023 at 9:40 am Hi Patricia, Possibly the higher urine calcium with the switch between vendors reflects their different approach to sample collection, but clearly you have very high urine calcium levels. I presume your urine sodium is indeed well controlled – 100 or less mEq/day. In general stubborn high urine calcium has a reasonable liklihood of arising from specific causes, such as primary hyperparathyroidism and, with recent advances in technology, specific gene variations. I would advise your physicians consider such possibilities. Reards, Fred Coe Reply Chad McInroy on June 26, 2023 at 6:31 pm I’m curious about the Plaques and Plugs. After everything i have been through I have to think that is the root cause of my problem. I have had my right kidney removed, and i produce large stones in my left kidney. Calcium Oxalate Mostly, had a large Struvite stone once, 29mm. I recently went into renal failure due to two stones blocking the ureter. These are small, approx. 8×10 and 10×10. I have lost count of the number of surgeries I have had and stents put in. I cannot get past the story of Randall and his theories, I am nearly sure that’s the root cause of my stone retention. I have used 3 different methods to help dissolve and pass stones, but how do I know when the plaque is gone? I have even passed stuff that looked like a tubule plug. I have a very hard time getting a Dr. of anything to even look at this theory, any advice on that also? Thank you. Reply Fredric Coe, MD on June 30, 2023 at 1:53 pm Hi Chad, Plaque and plugging is commonly observed during stone surgery and certainly promote stones. But having either one does not obviate stone prevention. I would advise you seek out a physician who has expertise in stone prevention – usually at university medical centers. Regards, Fred Coe Reply Submit a Comment Cancel replyYour email address will not be published. Required fields are marked *Comment * Name * Email * Save my name, email, and website in this browser for the next time I comment.