How much and what? We have already written a lot about this, but everyone has specific questions. This is the place to ask them.

72 Responses to “FLUIDS”

  1. Constance French

    Is pomegranate (freshly squeezed) juice (sweetened, if necessary with SweetNLow) okay for one with a history of kidney stones? Eating fresh pomegranate seeds?

    • jharris

      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).

  2. Bob

    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

  3. William P Dobbins

    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.

    • Fredric L Coe

      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

      • William P Dobbins

        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

        • Fredric L Coe

          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

  4. Frank Martinez

    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.

    • Fredric L Coe

      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

  5. Skip Shimer

    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

  6. Skip Shimer

    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.


    • Fredric L Coe

      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

  7. Joann Whitney

    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.

  8. Kathleen Spielvogle

    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.

    • Fredric L Coe

      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

  9. Mary Young

    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?

  10. Dan M

    Does the high calcium diet apply to uric acid stones as well?


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