The most common kind of stone former has no systemic disease as a cause of stones – ‘idiopathic’ stone former means that. Being most common, their treatments rank highest for all physicians who treat stone formers.
These articles include the treatment trials.
This charming Kitchen Scene by Joachim Beuckelaer (1533 – 1573) is oil on wood panel and hangs in the Louvre.
Fluids
Patient Q&A page about fluids – Underused; we answer questions
How to drink enough water – Tips and day plans
How to get a variety of fluids – Which fluids cause which prevent stones
Fluid prescription for kidney stones – A serious article about how much you need
Does water prevent stones; What’s your bet? – The water trial, evidence fluids work
Web apps and smart bottles – A poll of users and list of what is available
The low flows – People who do not like fluids
ACP Guidelines: Fluids – Defective review that can mislead physicians and patients
Kidney Stone Diet
What is it?
Three Essentials – Out of the welter of the diet, three essential steps that do most of the work if used exactly right
Canary in the mine shaft – Stone forming may signal abnormal risk from diet for kidney, vascular and bone disease
Our diet promotes stones, bone disease and hypertension – What is wrong with what we eat
Something Special Women Do – Women selectively absorb alkali from their food, protecting themselves from acid loads
The kidney stone diet – Less sodium and sugar, more calcium and potassium; control protein and oxalate
The science of the kidney stone diet – The Evidence behind the kidney stone diet
How to eat the kidney stone diet – Resources and links
Recipes for the kidney stone diet – A book of 31 recipes that accord with the diet requirements
Sodium
How to lower diet sodium – How to achieve the kidney stone diet sodium intake
Control your salt for fewer stones and stronger bones – Importance of sodium reduction
Salt – Detailed review of how sodium causes stones, bone disease, and hypertension
Case 3: A success story – How a wife and husband managed low sodium diet and hydration (for him)
Calcium protein and potassium
How to Eat a High Calcium Low Sodium Diet – How to achieve the kidney stone diet calcium intake
Diet protein and potassium – Animal protein hardly raises stone risk unless extreme; veggies lower it
Does too much protein increase stones or damage bones? – Yes for stones, no for bones; how much to eat
Oxalate
Why eat a low oxalate diet? – When do you need to control diet oxalate
How to eat a low oxalate diet – How to control diet oxalate intake; oxalate lists
Sugar
How to wean off sugar – Tips and alternatives
Science and politics of the US diet guidelines – Sugar scandals and the myth of the low fat diet
Against sugar – Gary Taubes’ reporting on the sugar scandal and sugar as poison
Consumer Reports Recommend Low Diet Sodium and Sugar – Experts recommend this
Sugar: The end of our love affair – My personal story about ending sugar addiction
More help
Food Q&A page – Questions answered
Online education course reduces stone risk factors – Preliminary data from online diet education course
Kidney stone prevention course – Online course by Jill Harris to help with diet
Take charge of your kidney stone prevention – Inspirational and practical advice by Jill Harris
Meds
Thiazide diuretics for stone prevention – Types, how they work, how to use them, the trial data links
Citrate to prevent calcium and uric acid stones – The citrate trials
Price of potassium citrate – Ways around the over pricing scandal (check out comments)
How potassium citrate pills work – Deep biology of citrate
Citrate and the Ostwald limit – Highly technical science
Calcium binding by citrate – Highly technical science
Potassium citrate: The contributions of Dr. Charles Pak – Review of classic research papers
ACP Guidelines on Medications – Defective review that can mislead physicians and patients
Diet and Meds Together
Treatment of idiopathic calcium stones – All the trials, and diet, how to use them together: Key article
Chapter 5: Idiopathic calcium stones – A lighter version of the prior article
Chapter 6: Why delay prevention? – Even one stone is enough to begin diagnosis and treatment
An expert rebukes ACP guidelines – Defective guidelines need serious critics like this one
Remedies
The coke treatment is useless – Seemingly without a reason to exist
24 Responses to “Fluids, Diet, and Meds for Common Stones”
Gary Sparks
Dear Dr. Coe,
I had ca 40 bladder stones removed mid December. The urologist then prescribed potassium citrate. I had a terrible reaction to that medication. My heartrate dropped to between 35 and 45 bpm, I stopped the potassium citrate and my heart rate largely returned to normal in a day, completely in three days. (I have never had heart issues, a trip to the ER to make sure I was OK yielded negative results (EKG, cardiac blood markers, X-ray)). I thought for sure I found a page on your website where you talked about alternatives to potassium citrate. If I am remembering correctly, could you kindly point me to that page … or to any other page that talks about alternatives to potassium citrate. I would like to be informed when I meet with my urologist in a few weeks. Thank you. Gary
Fredric L Coe, MD
Hi Gary, I wonder why the drug was used. Were the stones uric acid?? If so, there are other ways. If they were calcium oxalate, that is something else, too. Can you tell me what the stones were made of. If you do, I will try to do more. But absent that, I cannot imagine why K citrate would be helpful. Regards, Fred Coe
Jill
Hi Dr. Coe –
I have dealt with kidney stones for the past 23 years. When analyzed, they were determined to be 100% calcium oxalate stones. I see on the oxalate food list that coffee creamer is considered low oxalate, which is wonderful for those of us who enjoy creamer in our coffee. I had a dietician tell me that I shouldn’t be drinking creamer in my coffee due to the phosphates in it. Can you help me to understand what it may be in phosphates that would deter me from drinking coffee creamer while it falls in the low oxalate level category? I appreciate your help!
Fredric L Coe, MD
Hi Jill, phosphate is part of most food and is not of itself a cause of calcium oxalate stones. So go ahead and use it. But for prevention of these stones, you do want an ample diet calcium intake. Here is our best on a good diet for stone prevention. But also, one needs to be sure about the cause of the stones so be sure you have been properly evaluated.
Diane
How soon after someone drinks Crystal Light does it take for the urine PH to rise? Also for how long would it stay higher till it begins to drop again?
Fredric L Coe, MD
Hi Diane, Urine pH will rise in an hour or so and remain elevated afterwards as the citrate is metabolized. I do not have any information about the latter but I suspect some hours after drinking the beverage. However, as this is extra alkali it will neutralize acid from diet and metabolism, so as you use it daily urine acid excretion will fall and urine pH rise on average on a 24 hour basis. Regards, Fred Coe
Debbie Jeter
Dr. Coe,
I have had a recent litholink study. I have several stones in each kidney between 3 and 5.5mm. I have not passed any to my knowledge. Here is a summary of my numbers from the 24-hour litholink report. My kidney stones, based on ultrasounds and CTs between 2009 and 2020, seem fairly stable. They appear likely to be calcium phosphate.
SS CaOx 2.68
Urine Calcium 197
Urine Oxalate 23
Urine Citrate 380
SS CaP 1.90
24 Hour Urine pH 7.266
SS Uric Acid 0.02
Urine Uric Acid 0.362
I am not tolerating the HCTZ that my local kidney doctor prescribed. My side effects include persistent headaches, and severe tinnitus. I have some hearing loss already, and tinnitus. However, it is exacerbated on days I take HCTZ and starts earlier in the day and drives me crazy. Although there is no established association with hearing loss, there have been case studies indicating a possible causal link between HCTZ and irreversible hearing loss. Should I try a different thiazide? My BP is good with or without meds.
My urine calcium is mildly elevated. I have a lot of calcium in my diet. The litholink report stated: “Our records do not show the use of calcium supplements, confirm clinically as calcium supplements can cause hypercalciuria.” This was a mistake, as Dr. Tanner (my bone density physician) did prescribe calcium supplements for bone density. Would you recommend 200mg, 400mg or none?
Litholink report reads: “Urine pH remains very high. Risk of calcium phosphate stones is elevated. Although our records do not report prescription of alkali, this should be confirmed clinically.” I sometimes take a teaspoon of baking soda in water for acid reflux. Should I stop? What else is recommended?
The report reads: “Calcium phosphate stone risk is persistently high.” The dietician told me my urine oxalates were low, so she didn’t seem overly concerned about changing my diet except to drink more fluid. I eat a lot of fruit, which is consistent with elevated urinary pH. Are there diet recommendations for calcium phosphate stones?
Would you recommend that I do or do not take calcium citrate or magnesium citrate for low urine citrate? The report says potassium citrate may not be ideal at this point.
I like to add a tablespoon or two of white or apple cider vinegar to my water. Is this helpful, harmful, or neutral for kidney stones?
Thanks,
Debbie Jeter
Fredric L Coe, MD
Hi Debbie, I suspect your stones are indeed calcium phosphate, because your urine pH is remarkably high. Perhaps you are taking calcium carbonate supplements which can raise urine calcium and pH. I have a few suggestions but as I do not have complete information they are intended for your physicians to consider as they are in charge. You might want to take your calcium supplements with meals to avoid surges of calcium into urine. Your should try to keep diet sodium as low as possible so as to lower urine calcium that way, and perhaps that will permit reduction in the thiazide. You may better tolerate chlorthalidone 12.5 mg as it is another form of the drug and may not disturb your ears. Given the high pH in the urine, is your serum comletely normal – is your serum TCO2 perhaps low? Reduced hearing and dRTA do occur together. Regards, Fred Coe
Debbie Jeter
Thanks for the prompt response. I will see if I can find out my serum TCO2. I am not taking calcium carbonate supplements. I’ve only taken calcium citrate. If I take the calcium supplement with a meal, which form of calcium is better for calcium phosphate stones?
Robert Wells
Hello Doctor Coe, Thanks for the wonderful information you provide! However, I am confused on types of protein that seemed to be best… It seems I have a recollection of you not recommending soy protein sources and in other writings, I think that I’ve seen it recommended.. should one focus on animal and dairy products as primary sources of protein, or are plant-based (other than soy) ok? Thanks Robert Wells
Fredric L Coe, MD
Hi Robert, the problem has been settled, and it seems that protein is so trivial a risk you can ignore all but great excesses of protein. Safety lies in variety, to plants, animals, and milks all seem like good parts of a diet. Regards, Fred Coe
Robert Wells
Thank you, Sir!
Jenny
Dear Dr. Coe,
Thank you so much for this blog. Your knowledge and effort are much appreciated! My mother passes a stone or two every 10 years or so, each time quite painful. When she found out they’re calcium stones, she actually avoided calcium intake for a long time (and I believe she was deficient to begin with although they never checked her!). I’ve added a couple of 200 mg calcium citrate tablets to her meals, and am thinking of adding in a bit of K citrate as well. What is your opinion on cranberries/cranberry extracts? I’ve read totally contradictory “research” on their roles on stone formation; some say they prevent formation and clears uric acid while others say they can promote growth. We also regularly consume foods like tahini (usually black whole seeds) and amaranth grains. I understand that these foods are relatively high in oxalates, but most of them are in insoluble calcium oxalate form. Am I correct to assume that most of this will not end up in the urine and cause issues? Thank you!
Fredric L Coe, MD
Hi Jenny, For calcium it is either dairy products or supplements or some mixture of them. There is no useful calcium from veggies – poorly absorbed. What your mother needs is proper 24 hour urine and serum testing to figure out why she forms stones, and then to direct diet and or meds to those causes.Instead of guessing what is in the urine, lets measure, and then take steps to alter things in her favor. Regards, Fred Coe
Michael Fox
Hi Dr. Coe,
I am a calcium oxalate stone former (ideopathic/genetic hypercalcuria with high urine oxalate) and have a few questions regarding treatment/prevention over & above diet changes already in place:
– as there seems reasonable support for the benefits of lemon juice by reputable sources (eg. https://www.uwhealth.org/files/uwhealth/docs/pdf/kidney_citric_acid.pdf), why do you abhor its use as a therapy?
– would it be safe/effective to consume a low-dose of calcium citrate (eg. 100-200mg) with meals to help bind oxalate and inhibit absorption?
– can potassium citrate therapy still be of benefit where there is no indication of hypocitraturia?
– is consuming non-timed release potassium citrate supplements (eg. OTC, 4 x 99mg elemental K/tab = 10.12mEq) as safe/effective as timed-release (eg. Rx, 1 x 10mEq)?
Thank you.
Fredric L Coe
Hi Michael, Very astute questions. If your urine citrate is normal, I cannot imagine a reason to take citrate. As for lemons, they contain considerable citric acid but much of it is in the acid form – all proton acceptor sites protonated – so it will provide no new bicarbonate and therefore not raise urine citrate. The citric acid will be excreted unchanged in the urine or metabolized as such without benefit. Only the citrate – partially unprotonated citric acid – will provide new bicarbonate and raise urine citrate, but we already agreed this seems of no importance for you. As for reputable, no doubt, but exacting is another matter altogether. Lemons have a rather low pH, so their citrate is most the acid. I have never seen a reason to promote them for treatment. As for calcium supplements with meals, they will reduce urine oxalate – if it is high, but also raise urine calcium. The way to do this is complex: lower diet sodium and raise diet calcium. Here is the kidney stone diet. Regards, Fred Coe
Michael Fox
If I understand correctly, high diet calcium will lower urine oxalate, and low diet sodium will control urine calcium. In that scenario, would not potassium citrate be better apt to lower urine calcium further and raise urine pH?. You say the consumption of calcium supplements with meals will raise urine calcium, but how do you distinguish this from calcium obtained via diet? In digestion, logic would suggest that the body cannot differentiate calcium ingested from diet vs. supplements (when consumed at meals), and therefore would not calcium from diet be just as apt to increase urine calcium which is counter to the intended goal? If calcium, irrespective of source, is intended to bind oxalate when taken at meals, is it not then excreted from the body thereby not impacting urine calcium? The intent with utilizing low-dose supplementation is to ensure the presence of calcium at meals where one cannot be certain of both the calcium content of the food consumed at that meal, nor the level of oxalate. Low dose calcium supplementation (eg. 150-200 mg) is meant to mimic/mirror amounts that might be found in food (eg. 1/2 cup milk = 150 mg), and would seem a reasonable strategy particularly where one may wish to avoid dairy products (which represent a large source of higher calcium foods), and/or where other high calcium foods may also concurrently be higher sources of oxalate (eg. leafy greens). Is this line of thinking flawed? Thank you.
Fredric L Coe
Hi Michael, Calcium absorption by the intestines is regulated, so excess will not be absorbed into the blood. Using a TUM – 500 mg – with each meal that contains oxalate will lower oxalate absorption – we have data on that. Foods with calcium, like milk, will do as well; a glass of milk is 300 mg, a decent amount. Low diet sodium will reduce urine calcium no matter how much calcium is actually absorbed, and the extra calcium goes into bone. Regards, Fred Coe
Kim Rogers
Hi, My 13 year old son has been struggling with anxiety which lead us to consult with a nutrition specialist who recommended the Organic Acids Test – Nutritional and metabolic profile. This nutrition person just today referred to pediatrician for his oxalate levels. This OAT urine test revealed my son’s values of Glycolic 210 (Range 18-81), and Oxalic 232 (Range 8.9-67). He is generally healthy, no medication, just dietary supplements. He may be lactose intolerant and we have been avoiding dairy. Celiac negative. He has been underweight since he has been 4 years old. He weighs 70 lbs. I have been busy reading everything with your name on it and my question is how at risk are his kidneys ? What levels of oxalate determine hyperoxaluria? How do we safely get rid of this oxalate? I suspect it is diet related. We thought we were eating well but it turns out most of foods I now have discovered are high in oxalate. Regards, Kim
Fredric L Coe
Hi Kim, If the lab is accurate and urine oxalate is really 232 mg/d, this needs to be corrected immediately. As you can guess, eliminate all high oxalate foods and recheck. If it is all diet, then the diet must be extreme in both low calcium and high oxalate because a value so high is beyond anything I have ever seen from diet alone. Move quickly! Regards, Fred Coe
Katie Gorman
Dr Coe
I find your articles very informative and interesting, thank you. I am a calcium phosphate stone former and have type 1 renal tubular acidosis and medullary sponge kidney on both sides. In my 24hr urine tests despite being on potassium citrate I still show 0mg in a 24hr period. My nephrologist has told me to stop taking them as they aren’t working. I also take sodium bicarbonate but it has only been a month so do not yet know if it is effective. Do you have any advice for someone in my position? I drink 4L of water a day, low sodium and low animal protein as well. I feel a little discouraged as I currently have 12 stones between 3mm and 9mm. My last stone landed me in the hospital with sepsis for three weeks. Thank you for any advice you my offer.
Fredric L Coe
Hi Katie, I gather you have both a high urine pH and low urine citrate AND low serum bicarbonate. If so, the many calcifications in your kidneys are not MSK but rather tubule plugging. MSK patients form calcium oxalate stones. If your blood bicarbonate is normal, then you just have CaP stones. If your urine calcium is over 150 mg, I would consider low sodium diet and even chlorthalidone to lower it along with ample potassium chloride so you do not get potassium depleted. Your physician is entirely responsible for your care, I have not seen your actual data, so all you can do with my comment is ask him/her if it is at all useful. Regards, Fred Coe
t. jo
Dear Dr. Coe, I’d like to try a stone breaker product (active ingredient is CHANCA PIEDRA) for my stones. What to you advise on this ingredient? My last stone breakdown was as follows.
20% calcium oxalate monohydrate,
60% calcium oxalate dihydrate, and
20% calcium phosphate (hydroxy- and carbonate- apatite).
Thanks so much.
Fredric Coe, MD
Hi t.jo, I have read about this stuff and see little real evidence and a lot of hype. Your stone is not uncommon, and this stuff is promoted as a way to ‘dissolve’ them. I doubt it does anything but enrich the people who sell it. I have long meant to write about it, but it is a wearying thing to take on commercial stuff like this and show how mediocre the underlying data are. So negative a way to spend time! As for my advice, I know of no harm, and suspect it is without value. Regards, Fred Coe