CLINICAL FINDINGS
A man in his fifties formed his first stone in the early 2000’s and his last 6 months ago. There was a single passage event a year or two after the first stone at which time he was 
given hydrochlorothiazide 25 mg daily. A right SWL procedure was performed 1.5 years ago because of a stone attack, and potassium citrate 10 mEq twice daily was added in treatment. A right sided URS procedure was performed 8 months later but was not completed because of bleeding. A right URS 6 months ago is said to have left his right kidney stone free, but some stones were seen on the left. I did not have images to review when I saw him. He believes that all of his passage events were on the right. Stone analysis of material removed at his last procedure showed 60% COM and 40% COD.
Apart from hepatitis A at age 13 and a disc injection he had no significant medical history. But, oddly, at a routine screening colonoscopy there were signs of Crohn disease which is said to have been verified at biopsy. He was and is devoid of any symptoms or other signs of this disease.
His mother has stones but not his father or three brothers. His father has adult onset diabetes. He has an extremely high level position that requires 10 hour working days, many working weekends, and meetings that occupy perhaps half of every working day. He need not become dehydrated during these meetings which he runs. But if he ‘forgets’ he does become dehydrated, and forgetting is not rare. Prior to the stone attack 1.5 years ago he believes he was frequently dehydrated during work. He flys 20 – 30 times a year for his work and is away from home at night but the trips are mostly domestic.
Breakfast is oatmeal with yogurt and pumpkin seeds. About two days a week, lunch is for business and at a restaurant. The other days he ‘grabs a sandwich’ at McDonalds or another local takeout place. Supper, at home with his family, is typical US cuisine with a lot of meat. He avoids spinach and nuts but in the past was a heavy user. He eats a lot of sugary foods if they are handy.
LABORATORY FINDINGS
Outside routine blood measurements from 2 months ago showed normal values except glucose was 141 mg/d; but he may have been not fasting. On review of this finding be mentioned that some prior HbA1c levels have been around 6 or so.
His 24 hour urine studies were performed at Litholink and are dated in months before my visit with him – to protect confidentiality. All three were performed while taking hydrochlorothiazide 25 mg daily, the most recent with potassium citrate, 10 mEq twice daily, as well. Because of the high urine oxalate, he was placed on pyridoxine prior to the most recent urine collection.
| Mo. | SSCaOx | SSCaP | SSUA | Creat | VOL | Ca | Na | CIT | Ox | pH | UA | SO4 | NH4 | PCR |
| -3 | 6.7 | 0.30 | 0.69 | 2429 | 4.3 | 283 | 204 | 1070 | 94 | 5.7 | 900 | 64 | 51 | 1.4 |
| -9 | 8.3 | 0.59 | 0.35 | 2519 | 3.6 | 242 | 198 | 1177 | 100 | 6.1 | 800 | 65 | 52 | 1.3 |
| -13 | 6.2 | 0.17 | 1.5 | 2211 | 3.2 | 147 | 97 | 841 | 92 | 5.5 | 1107 | 71 | 78 | 1.4 |
All values apart from SS are mg/24hr, mEq/24hr Na, SO4 and NH4, or l/24 hr, VOL.
INTERPRETATION
General Principle
I follow what I have called the fundamental premise of stone prevention: The urine supersaturations of an active stone former are too high in relation to the crystals in stones forming. Lower them.
Application to This Patient
Is my patient an active stone former?
I do not know. His surgeries were complicated and presumably aimed at a stone passage event and the reducing his renal stone burden. As is not rare, I did not have his CT images at this first visit, but even if I could it would have taken many serial images to decide if he had been active within any one period. I do not care anymore about that period of time, except in an academic way. Since his last surgery there may have been new stones in the right kidney, a question I will have to take up when I next see him. Clearly he had active enough disease in the past to amass a considerable stone burden, but he knows he was more prone to dehydration then than now and he stopped eating high oxalate foods, as well.
He is someone in whom it is important to determine stone activity, yet CT scans involve considerable radiation. I will presumably have to rely on renal ultrasounds from his urological surgeon. My decades of reading tens of thousands of simple flat plate radiographs have made me a powerful sceptic; much of the time I could not tell if stones were present or not.
Do we know the crystals in stones forming?
No.
We know the crystals in stones that formed in the past, and they are calcium oxalate mono and dihydrate with no reported calcium phosphate.
Do we know his urine supersaturations?
We know them in his altered state of awareness – by which I mean his urine volumes are very high and yet he tells me he was not rarely dehydrated during the years before his present stone burden. I can guess, and I can extrapolate, but I cannot know what his supersaturations were when he was an active stone former. His samples were obtained during working days according to my calendar – I know the real dates.
Laboratory Analysis
Supersaturations. All three CaOx SS are high enough to support crystallization, and would be very high if his urine volume were in the more common range of 2 liters/d instead of 3 – 4 liters as they are now. But that is meaningless in that the values are not related to active stones. CaP SS are trivial and would remain low even if urine volume were lower. Uric acid SS are low apart from the first one and not relevant to his stones.
Judging from the creatinine excretion, urines are consistently collected.
Urine Volumes are consistently high, far above the common risk level of below 2.5 liters.
Urine calcium excretion is high enough to pose risk of stones, and is crudely correlated with urine sodium as one expects. As there is no systemic cause, it is surely idiopathic hypercalciuria, and his mother may well have the same.
Urine citrate is very high, far above the risk level, and is not much higher in the most recent urine, when he took potassium citrate, than in the other two when he did not take the drug. Diabetes is associated with increased urine citrate, although some have found insulin resistance is associated with reduced urine citrate (and also) and suggested here by his borderline blood glucose and HbA1c levels. I must say I have often found that early diabetes is associated with high urine citrate excretion but have not published the observation.
Urine oxalate is remarkably high, in the range of primary hyperoxaluria or enteric hyperoxaluria. Nothing in his history suggested this finding except the odd note about symptomless Crohn disease found incidentally during a routine screening colonoscopy. His physicians suspected a possible pyridoxine sensitive version of PH1, perhaps, but he showed no response to the drug – dose unknown at the time.
Urine uric acid, sulfate and PCR values are consistent with his high intake of protein and purines from meats.
Urine pH varies in the low normal range, and with the high uric acid excretion rates causes variable UA SS. Urine pH of CaOx stone formers whose stones contain little or no CaP run a bit low – usually around 5.8.
CLINICAL SUMMARY AND TREATMENT
Summary
In many ways this man could seem to be a commonplace kind of idiopathic calcium oxalate stone patient with mild sodium dependent idiopathic hypercalciuria complicated by a demanding career that imposed intermittent but significant dehydration over many years. As such, like his physicians before me, I would have recommended marked diet sodium reduction, reduction of high sugar foods, and hydration with a reasonable likelihood of successful prevention. If that was not enough to prevent new stones I would have used a low dose of a long acting thiazide like drug like chlorthalidone or indapamide.
But given that his stone activity is as yet unknown, only hydration and reduced diet sodium are suitable. Bone mineral loss occurs in idiopathic hypercalciuria and lower diet sodium may well confer protection against this.
I would not use potassium citrate at this point. His urine citrate is very high, far above usual risk levels. His stones contain no uric acid, and his urine pH, though modestly low, is high enough that risk of uric acid stones would not move me to use a second drug. If I needed to supplement with potassium because of losses from thiazide I would use potassium citrate, but generally I try to avoid supplementation by controlling diet sodium and by using amiloride 5 – 10 mg daily. (The review in this reference points out that this class of sodium channel blocker has independent benefits in blood pressure lowering for which they are under-utilized).
All of this is set to the side by the startling and unexpected high urine oxalate. His diet does not seem a likely cause by history and dietary hyperoxaluria is not usually this marked. A reasonable possibility is primary hyperoxaluria, which can present in adults. Another is enteric hyperoxaluria because of his diagnosis of Crohn disease. Essentially pursuit of the correct cause and treatment for the oxalate excess is the clinical business here.
Any number of approaches can be justified, from genomic studies to GI malabsorption studies. My thought, for better or for worse, was to see if calcium supplementation, an excellent way to lower urine oxalate in enteric hyperoxaluria, might reduce the urine oxalate. To prevent increase of risk from calcium I thought to couple it with reduced diet sodium.
Treatment and Follow up
For all of these reasons, I recommended using one TUM with lunch and supper taking care the pill is used directly with the meal. I pointed him to the oxalate lists on this site, which are as reliable as any presently available, and asked him to reduce diet oxalate as much as possible. I left the potassium citrate in place for the moment as doing no obvious harm, and with the intent to make as few changes as possible.
If the urine oxalate falls significantly that will point to bowel disease or perhaps an unsuspected diet peculiarity. If not, PH is a good bet and genetic analysis the most obvious and direct approach.
Our own work points to proximal tubule crystallization as an important mechanism for kidney damage in PH1, and that crystallization is fostered by increases in proximal tubule reabsorption. Reduced diet sodium and thiazide diuretics will increase proximal tubule reabsorption. Therefore leaving him on thiazide and asking for less sodium intake – to balance the increase of urine calcium and SS CaOx from adding TUMS – is a calculated, or shall I say an intuitive choice. Followup measurements need to be fairly soon, not later, as we need to know. Even though things have gone well in terms of renal function – his is normal, PH1 is capable of producing rapid and severe kidney damage. Because the crystallizations are in the proximal tubule, fluids and other factors that reduce urine supersaturations are not likely to be protective.
I will update this case report as we get more information.
Lists of high and low oxalate foods contradicts each other as I am finding on the internet and from my doctor. Can you comment and send me a reputable list?
Hi Lauren, Here is an article on the subject with many lists. These lists have been curated by an expert (Dr Ross Holmes) and are as accurate as we can make them. Regards, Fred Coe
Hi Dr. Coe,
Read your idea of a TUM with meals with interest. Sounds like a very practical solution.
My oxalate output was good (30) when I was taking in about 1200 mg of calcium daily, mostly from dairy divided between breakfast and dinner. Then I had to reduce dairy for other medical reasons.
So I switched to yogurt with breakfast, and 200 mg calcium lactate caps at the start of both lunch and dinner to begin covering all three meals and to give about 1000mg total. (I chose calcium lactate capsules to avoid unwanted antacid effects of TUMs.)
Unfortunately my oxalate increased over 50%. Maybe calcium lactate was a poor choice. Please – Any thoughts on what went wrong or how to get back to good?
Hi Kenny, The problem is always timing. The dairy products have a long dwell time as they are absorbed, the Tums come in and are absorbed right away and therefore ineffective. If possible time the pills into the early 1/3 of each meal. Even then they may not match the food calcium. Regards, Fred Coe
Very helpful, thanks much!
I could have some milk… As a rule of thumb, might say 4oz be real help with oxalate, or just a drop in the bucket?
Hi Kenny; 4 ounces with each meal would be a start – 140 mg. You would need a lot more. Regards, Fred Coe
Hello Dr. Coe,
I have been reading your articles non-stop since discovering them yesterday in regards to kidney stones. If possible, I would like to give you a little hx about my son and get your input. He is a 19 y.o. division 1 long distance runner. His problems began the end of his high school senior year (May 2017). He had severe pain in bilateral thighs the final month of track and was dx with bilateral femoral stress fx in July of 2017. He rested the rest of summer, rehabbed in the fall once at college and was looking to be fully recovered by the end of year. It was thought that these stress fx’s were caused by common distance runner issues; overtraining, increased mileage, etc. Ortho dr. told him to start taking a Ca supplement of 1200 mg and 1000 i.u. vitamin D daily. His return to training seemed to be going well over the fall, but then in early Jan 2018 he sustained 2 sacral stress fx and was then out for rest of season. This was devastating news for all of us. The school ortho dr. then referred him for a bone density test in February and he has since been referred to an internal med dr. I will give you the results we have to date:
Bone density: Z scores were lumbar spine -0.9, normal; femoral neck -1.0 early osteopenia; proximal femur 0.1 normal
Blood work/24 hour urine 3/30/18: All blood results came back WNL, including PTH, ionized Ca, Na, testosterone
In urine abnormal results include: Vit D 25-OHD3 was 27, Creatinine/24 h 2,257, Calcium 396. BP was also 146/84
*At this point, dr. told him to stop calcium supplement as he may be overdosing on Ca and to start taking 2000 i.u’s of Vitamin D and a recheck would be done in 3-4 months.
6/30/18: Lab work was redone inc. 24 hr urine (urorisk), calcium ionized, Comp metabolic panel, PTH, Mg, P and Vit D
All blood work came back normal with exception of SGOT (AST), which was 72, Vitamin D increased to 38.9 (averaging taking 1000 i.u’s of vitamin d supplement daily, plus he is lifeguard for summer job…lot of sun)
Result for 24 urine as follows:
Ca urine 332
Oxalate 45
Uric Acid urine 939
Citrate urine 756
PH urine 6.1
Total urine volume 1.57 L
Sodium urine 247
Sulfate urine 39
Phosphorus urine 2222
Magnesium urine 252
Potassium urine 91
Creatinine urine 2430
Calcium oxalate 2.43
Brushite 5.04
Sodium Urate 6.33
Uric acid 1.99
As you can see, most of his urine results are abnormal and suggest kidney stones. I would so appreciate your input on his situation. We see the dr. on 7/12 and I want to make sure we proceed in best way. I am curious your thoughts on diet/medication use given his age and being endurance athlete (concerned about dehydration, loss of K) Also, how quickly once changes are made, can we expect improvement in bone strength? (concerned about stress fx’s) He has returned to running and is up to 35+ miles, is lifting several times wkly and feels good and wants to continue to progress to prepare for season. Please keep in mind he is a division 1 competitive runner. Also, safe to assume he will need an ultrasound/CT scan of kidneys to see if stones are present and how to proceed. Thank you so much in advance for your input. It is so hard to try to navigate these medical issues, especially with an otherwise healthy active young person who wants to return to his life as he knew it.
Hi Tracy, His results indicate idiopathic (genetic) hypercalciuria as a likely diagnosis. His urine calcium is elevated even allowing for his muscle mass. Bone mineral loss is commonplace in this condition, and things can be worsened by high sodium low calcium diets – his urine sodium is very high. Stress fractures have not been studied in this condition, but bone disease is very well established. His blood pressure seems very elevated; it is high for even an older person, and remarkably so for a young athlete. This needs to be followed up by more measurements – at home is fine. The combination of hypercalciuria and high blood pressure may point to an more complex underlying disease, so his physicians need to be thoughtful. From this distance I can of course offer only this general level of advice. regards, Fred Coe
Hello Dr..
i love your website…and I would like to ask about PH myths,,that is that true that if your blood PH reveals, you have Alkalosis then your urine will be .Acidic….? if yes ,,,,,,,,,,,,,then would you please explain how?
Secondly what is the best treatment for 70 years old woman if she has been diagnosed with Mild hydronephrosis in her left kidney with 2.3 cm stone in her ureter ….? she is also taking Pure encapsulation Potassium citrate 200 mg per day for about one month,she is now feeling better then before and her overall symptoms specially urinary excretion and her BP has been normalized without any other medication …would you please suggest the right dose in mg or does she need to add any more supplement to treat her stone?
I would greatly appreciate if you help me for this awful condition with my mom……!
please reply…
Hi Princess, Blood pH is not measurable in routine testing panels; instead one measures total CO2 content. When that is high – from alkali loads, or diuretics, as examples, urine is usually at its neutral point or alkaline. When it is low, and urine is alkaline, one may have the very uncommon renal tubular acidosis. That condition arises from kidney damage that prevents kidneys from acidifying the urine so acid accumulates in blood. Frankly, in usual stone formers, changes in serum CO2 are very uncommon. As for your mother, her surgeon no doubt is balancing damage from obstruction against risks from surgery in waiting for the stone to pass. So large a stone probably will not, so s/he no doubt plans removal to protect the kidney – ideally ureteroscopy will be used. Potassium citrate has no real effects for stone prevention below 1080 mg twice a day or more, and only then if 24 hour urine testing shows a need for it. The stone already there requires surgery, and nothing else can help unless it is thought to be uric acid. These can dissolve given alkali, and her physician can guess it might be from radiographic density on CT scan. Regards, Fred Coe
Hi Dr Coe. I have read pretty much all of your information on this site. Very comprehensive. Yet I’m confused. I’m sure that is normal. I am a stone former. I had a Lithotrypsy 11 years ago and 1 two months ago and am having one next week with atleast one more to follow. I have another 7 on one side and 8 on the other. I usually pass one stone each year. Obviously calcium oxylate. Since reading your studies and others, I’m trying to cut down on sodium, sugar and drinking more water and adding lemon. I have had 24 hour urine text, but frankly I didn’t read your article first and filled the tank to 4ML. So the reading came back great. Keep doing what you are doing, which is unreasonable unless I stay at home every day. I clean windows. I can improve on intake of fluids though and I will take that more seriously. I’m increasing my calcium intake taking 250 mg capsules of cal citrate with each meal and one with in between meals = 1000 mgs. Is that too much if I’m consuming calcium in my diet. I noticed you said take a TUM with a meal. Would that be better for binding with the oxalate? thank you
Hi Mike, The diet is great. If urine calcium, oxalate, citrate, and your supersaturations show no increased risk, you should be fine. If not, meds are not unreasonable. This article is my very best on treatment strategy. As for tums, I prefer food, with tums only to bring the total up high enough. Calcium, food or tums, needs to go where the oxalate will be – larger meals, and urine sodium has to be lowered below 100 meq (2300 mg) or less so urine calcium will not rise. It is all in the article. Regards, Fred Coe
Hello Dr Coe, I am a member of Jill’s Diet Prevention Program and am delighted to have found it. I’ve been creating stones since I was 25, (I’m now 66). About 5 years ago I began having infection problems associated with the stones. My last stone analysis showed them to be ‘mainly struvite’. I have had 4 laser lithotripsies and 1 PCNL done in the last 3 years. In June of this year I had the left kidney cleared and at the end of October the right kidney was cleared of stones. I was free of infection type symptoms for 3 weeks post-surgery, but they have now returned. What can a struvite sufferer do? I’m now fully engaged with Jill’s diet program and exercise regularly. In the first couple months after the left kidney was cleared in June I wasn’t completely on board with the diet program. Could new struvite stones be created that quickly? More importantly, what can I do? Thank you.
Hi Glenn, bacteria form struvite stones that can grow rapidly and have nothing to do with diet. I imagine you once formed calcium stones for a set of abnormalities that no longer much matter and were infected along the way, perhaps via one or another surgery. The infection caused your present stones. Management of infection stones is a complex medical/surgical affair in which your surgeons strive to remove all of the infected particles and your physicians use antibiotics to try to sterilize the urinary tract. Acetohydroxamic acid can inhibit the enzyme bacteria use to create struvite but the drug has very many unfortunate side effects. All of this relies totally on your physicians. If you have 24 hour urine abnormalities that can cause new calcium or even uric acid stones it is worthwhile to correct them – Jill can be helpful here – but unless stopped the infection stones will remain a real risk. Regards, Fred Coe
Dear Dr. Coe,
I am impressed by your deep knowledge in kidney stone formation.
I had my first kidney stone attack at age of 19. In past 28 years my both kidneys developed multiple calcium oxalate phosphate stones. I had 2 x ESWL, 3 x ureteroscope and 1 x PCNL. The end result of today is my stone count has been increased from 1 to 9. I have newly formed 9 stones in both of my kidneys at this moment. I have been drinking lemon water everyday, having low oxalate, low sugar, low salt, low protein diet. I exercise regularly, not overweight. I even changed drinking water system to RO water as in Netherlands water is hard. My 24 hours urine analysis is normal. Is there anything missing according to you? I am living in Netherlands. If I visit your office is it possible to find the root cause of my kidney problem and subsequently forming a kidney stone prevention strategy? I am getting desperate. Thanks in advance. Christina
Hi Christina, I believe I already answered to this. My secretary should be able to help arrange matters. Regards, Fred Coe
Hi Dr Coe, I am told I have calcium oxalate crystals in my urine. I am 52 female. Medications are vitamin D with vitamin K. Drinking 2 litres a day. Making sure I have 1200mg calcium a day (porridge x 2 with dairy) My urologist said to reduce salt that’s all he said, no diagnosis. Medical history, gestational diabetes. Onset of menopause from age 40 onwards, very dehydrated and thirsty, I did not realise until I went to hospital. I could not drink enough I was still dehydrated. Dry eyes, burning throat, reflux, rash on neck, cannot digest Fats, gallbladder pain happens especially if I have low calcium levels. Yellow stools, bladder constantly vibrating (Spasms) pressure, urgency, bladder gets worse if I have sugar. Recently started HRT still the same symptoms but feel lot better now having dairy (Calcium) Since started HRT and I get big pieces of white particules in my urine. Blood sugar result is 5.5 (UK) creatinine is very high and GFRis 65. Pain in kidneys. I have had scans and ultrascans they say the kidneys look normal.
Hi Sheri, In the UK 24 hour urine testing is spotty so I am not sure what physicians can do for you. The crystals may reflect high urine calcium since use of higher diet calcium (I infer that higher diet calcium is recent). As for poor fluid intake, you can solve that yourself, and should. As for the other symptoms, I am not in a position to help as that would require a lot more information about your medical condition. The white material in the urine should be collected (one can urinate through a filter) to see if there are crystals. They do that work in UK. If you can get 24 hour urine calcium (with creatinine) measured it will at least tell if that might be causing the crystals. Regards, Fred Coe
Hi Fredric,
I hope you’re well and I’m impressed by your vast knowledge.
I do apologise for contacting in this manner, I hope you don’t mind, after stumbling across your article from 2016 regarding causes and prevention of Calcium Phosphate stones.
I’m reaching out as I’m unsure what the best protocols are for me moving forward.
I had a ureteroscopy 30th April 2024.
8mm stone was stuck in my left ureter, with one smaller stone in each lower pole of both kidneys.
Surgeons said the ureteroscopy went well and they cleared out my left side completely (ureteroscopy + lithotripsy)
Lab results said the stone sample was 70% phosphate and 30% oxalate.
In theory I should now only be left with a small stone in the lower pole of my right kidney only.
Since surgery, on two occasions I’ve had pulsating cramping pain in the kidney of where I had the ureteroscopy. I’m waiting for a further CT scan to be completed.
I’m very confused on what sort of protocol I should be following to decrease my chances of further stone formation.
How much water, dietary changes, any supplements. I’m hopeful you might be able to shed some light on this for me and nudge me in the right direction.
Just a brief health history below which might be beneficial to any advice you’re willing to offer
Ashley Darby
31 Years Old
5ft 10in
84 kilos
– Egg allergy
– Eczema from birth
– Gout Diagnosis May 2023 in right toe.
– April 2024 – ECG showed some irregularities with my heart, I have been suffering from palpitations and increased heart rate when sedentary. Echo was normal
– Complaints of morning and evening pain across my hands and forearms.
– Cellulitis in top of Abdomen June 2024 (3 weeks of antibiotics so far)
RECENT BLOODS (10th May 2024 – 2 weeks after ureteroscopy surgery)
Adjusted Calcium 2.47
Serum Calcium 2.54
Serum Alanine transaminase 81 (out of range)
Serum Albumin 51 (out of range)
Serum ferritin 580 (out of range)
Serum triglyceride 2.6 (out of range)
Serum urate 272 (in range after being out of range for nearly a year)
I am due for further bloods but unable to have them done accurately whilst I’m treating this cellulitis with the anti-biotics
I drink 2 litres of water each day.
300mg allopurinol for gout
I also mix in Potassium & sodium bicarbonate & magnesium carbonate into water each morning ( I thought this might help with my stone formation if my uric acid levels were high)
I drink alcohol very rarely, and my diet is fairly balanced with the inclusions of some treats now again, like any human !
Many thanks
Ashley
Hi Ashley, I answered your personal email to me separately. Let me add here you need proper 24 hour testing to determine what is causing your stones. I already mentioned stopping the alkali as that may raise urine pH and foster phosphate stones. As for diet, there is a general sense this is a good one against stones. Best, Fred Coe