Citrate and recurrent idiopathic calcium urolithiasis. A longitudinal pilot study on the metabolic effects of oral potassium citrate administered over the short-, medium- and long-term medication of male stone patients

HydroZitLa inhibits calcium oxalate stone formation in nephrolithic rats and promotes longevity in nematode Caenorhabditis elegans

Low fluid intake, low urinary citrate excretion, and high oxidative stress are main causative factors of calcium oxalate (CaOx) nephrolithiasis. HydroZitLa contains citrate and natural antioxidants and is developed to correct these three factors simultaneously. Antioxidants theoretically can prolong the lifespan of organisms. In this study, we preclinically investigated the antilithogenic, lifespan-extending and anti-aging effects of HydroZitLa in HK-2 cells, male Wistar rats, and Caenorhabditis elegans. HydroZitLa significantly inhibited CaOx crystal aggregation in vitro and reduced oxidative stress in HK-2 cells challenged with lithogenic factors. For experimental nephrolithiasis, rats were divided into four groups: ethylene glycol (EG), EG + HydroZitLa, EG + Uralyt-U, and untreated control. CaOx deposits in kidneys of EG + HydroZitLa and EG + Uralyt-U rats were significantly lower than those of EG rats. Intrarenal expression of 4-hydroxynonenal in EG + HydroZitLa rats was significantly lower than that of EG rats. The urinary oxalate levels of EG + HydroZitLa and EG + Uralyt-U rats were significantly lower than those of EG rats. The urinary citrate levels of EG + HydroZitLa and EG + Uralyt-U rats were restored to the level in normal control rats. In C. elegans, HydroZitLa supplementation significantly extended the median lifespan of nematodes up to 34% without altering feeding ability. Lipofuscin accumulation in HydroZitLa-supplemented nematodes was significantly lower than that of non-supplemented control. Additionally, HydroZitLa inhibited telomere shortening, p16 upregulation, and premature senescence in HK-2 cells exposed to lithogenic stressors. Conclusions, HydroZitLa inhibited oxidative stress and CaOx formation both in vitro and in vivo. HydroZitLa extended the lifespan and delayed the onset of aging in C. elegans and human kidney cells. This preclinical evidence suggests that HydroZitLa is beneficial for inhibiting CaOx stone formation, promoting longevity, and slowing down aging.

Preventive treatment of nephrolithiasis with alkali citrate—a critical review

Using the keywords "urolithiasis and citrate treatment", "nephrolithaisis and citrate treatment", "kidney stones and citrate treatment", a Medline search revealed 635 articles published between 1 January 1966 and 1 December 2004. For the present analysis, only studies meeting all of the following criteria were included: (1) publications in English or German, (2) studies on preventive alkali citrate treatment in patients with calcium oxalate, uric acid and infection stone disease, (3) clinical studies including at least ten subjects, and (4) treatment phases of at least 1 week duration. A total of 43 studies met the inclusion criteria and were further subclassified according to intermediate or ultimate endpoints as well as to study design. With stone recurrence as the ultimate endpoint, 21 uncontrolled studies in almost 1,000 patients demonstrated a reduction in stone forming rate by 47-100%. In four randomized controlled trials including 227 patients, 53.5% on alkali citrate vs 35% on placebo remained stone-free after at least 1 year of treatment (P<0.0005). Similar values (66% vs 27.5% for alkali citrate vs placebo, P<0.0005) were obtained in 104 patients from two randomized trials with dissolution/clearance of residual stones as endpoint. Unfortunately, up to 48% of alkali citrate treated patients left the studies prematurely, primarily due to adverse effects such as eructation, bloating, gaseousness or frank diarrhea.

Effect of acute load of grapefruit juice on urinary excretion of citrate and urinary risk factors for renal stone formation

The effect of citrus fruit juice ingestion on the risk of calcium oxalate stone formation is still debated. The present study was undertaken to investigate changes in urinary stone risk factors after administration of a soft drink containing grapefruit juice. Seven healthy subjects, with no history of kidney stones, were submitted to an acute oral load (20 ml/kg body weight over 60 min) of a soft drink containing grapefruit juice diluted (10%) in mineral water. After a 7-day wash-out period, each subject underwent an oral load with mineral water alone under the same conditions. Urine specimens were collected before (for 120 min) and after each oral fluid load (for 180 min). Urinary flow was significantly increased after both grapefruit juice (46+/-26 vs 186+/-109 ml/h, p = 0.01) and mineral water (42+/-16 vs 230+/-72 ml/h, p=0.001) compared to baseline. Compared to mineral water, grapefruit juice significantly (p=0.021) increased urinary excretion of citrate (25.8+/-9.3 vs 18.7+/-6.2 mg/h), calcium (6.7+/-4.3 vs 3.3+/-2.3 mg/h, p=0.015) and magnesium (2.9+/-1.5 vs 1.0+/-0.7 mg/h, p=0.003). Citrus fruit juices could represent a natural alternative to potassium citrate in the management of nephrolithiasis, because they could be better tolerated and cost-effective than pharmacological calcium treatment. However, in order to obtain a beneficial effect in the prevention of calcium renal stones a reduced sugar content is desirable to avoid the increase of urinary calcium due to the effect of sugar supplementation.

Dietary manipulation with lemonade to treat hypocitraturic calcium nephrolithiasis

PURPOSE

Pharmacological treatment of hypocitraturic calcium nephrolithiasis requires as many as 12 tablets, or numerous crystal packages or liquid supplements taken throughout the day. In addition to added cost, this cumbersome regimen decreases patient compliance, which may increase stone recurrence rates. We evaluated the urinary biochemical effects of dietary citrate supplementation in hypocitraturic calcium stone formers in an attempt to decrease or eliminate the need for pharmacological therapy.

MATERIALS AND METHODS

A total of 12 patients who were either noncompliant with or intolerant of pharmacological citrate therapy supplemented their routine diet with citrate in the form of lemonade, consisting of 4 ounces of reconstituted lemon juice (5.9 gm. citric acid) mixed with tap water to a total volume of 2 l. and consumed at uniform intervals throughout the day. Urine specimens (24-hour) were obtained for biochemical analysis after 6 days of lemonade therapy and compared to pre-lemonade baseline values.

RESULTS

Of the 12 patients 11 had increased urinary citrate levels during lemonade therapy (average 204 mg. per day). Average levels increased from 142 mg. daily (range less than 10 to 293) at baseline to 346 mg. daily (range 89 to 814) after treatment (p < 0.001). Daily total urinary volumes were similar (2.7 versus 2.9 l.). Seven of 12 patients became normocitraturic while consuming lemonade. Urinary calcium excretion decreased an average of 39 mg. daily, while oxalate excretion was unchanged. The lemonade mixture was well tolerated. Two patients complained of mild indigestion that did not require cessation of therapy.

CONCLUSIONS

Citrate supplementation with lemonade increased urinary citrate levels more than 2-fold without changing total urinary volume. Lemon juice, which contains nearly 5 times the concentration of citric acid compared to orange juice, is an inexpensive and well tolerated dietary source of citrate. Lemonade therapy may improve patient compliance, and may be useful as adjunctive treatment for patients with hypocitraturic calcium nephrolithiasis.

Transport of citrate across the brush border and basolateral membrane of rat small intestine

It was the aim of the present study to investigate the transport of tricarboxylates (citrate, tricarballylate) across the basolateral membrane (BLM) of the small intestine. Experiments were performed using BLM vesicles isolated from the jejunum of rats. For comparison, some experiments with brush border membrane (BBM) vesicles were also performed. Finally, transfer of citrate and tricarballylate across the intestinal wall was investigated using sacs of everted small intestine. Uptake of citrate by BBM vesicles occurs by a Na+ gradient-driven transport mechanism specific for tri- and dicarboxylates. The partially protonated forms of citrate seem to be much better transported than the completely dissociated form, since lowering the extravesicular pH from 7.8 to 5.6 resulted in a marked stimulation of Na(+)-dependent citrate uptake. In contrast to citrate uptake across the BBM, uptake of citrate across the BLM was neither influenced by Na+ nor by pH changes. Neither structurally related tri- and dicarboxylates (tricarballylate, succinate) nor other organic and inorganic anions (e.g. lactate, p-aminohippurate, sulfate, chloride, bicarbonate) significantly influenced citrate uptake by BLM vesicles under cis-conditions. Uptake of citrate as a function of the extravesicular substrate concentration was linear over a concentration range from 0.1 to 10 mmol/l. Thus, citrate uptake under these conditions seems to be Na(+)-independent and not to be mediated by a carrier. However, preloading the BLMV with citrate clearly trans-stimulated the uptake of citrate and tricarballylate, respectively. Furthermore, citrate significantly inhibited tricarballylate uptake into BLMV preloaded with citrate. These results indicate uptake of tricarboxylates across the BLM by an exchange mechanism. Using sacs of everted small intestine, no transfer of intact citrate against a concentration gradient occurred, but some evidence for metabolization of citrate within the intestinal wall was obtained. In contrast, the non-metabolizable tricarboxylate tricarballylate was significantly accumulated in the serosal compartment of everted intestinal sacs.

Studies on calcium oxalate monohydrate crystallization: influence of inhibitors

A simple model to study calcium oxalate monohydrate (COM) crystallization on different substrates is presented and the action of different potential inhibitors is evaluated and discussed. COM heterogeneous nucleation was assayed on solid surfaces as calcium phosphate, mixtures of mucin with calcium phosphate, and wax. In the presence of a non-protected non-renewed solid surface in contact with normal urine, COM crystal formation could be detected at short intervals (3 h). The most active heterogeneous nucleation capacity corresponded to calcium phosphate. In the presence of 10% mucin, owing to the renewal of the surface layer no COM crystal were detected on the pellet's surface. The study of citrate and pentosan polysulphate (a semisynthetic polysaccharide) on COM heterogeneous nucleation demonstrated some important inhibitory effects when concentration increased and time decreased. Maximum effects were selectively manifested on calcium phosphate surfaces. Only phytic acid at adequate concentration exhibited a total inhibitory capacity of COM formation, even during longer intervals (15 h).

Impact of sodium-potassium citrate on the diurnal variations in urinary calcium oxalate and calcium phosphate saturation levels in normal individuals

OBJECTIVE

To study the effects of treatment for 5 days with sodium-potassium citrate (1 g three times a day (t.i.d.), 1 g four times a day (q.i.d.), or 3 g three times a day (t.i.d.)) on the diurnal variations of urinary calcium-containing lithogenic substances.

SUBJECTS AND METHODS

Five healthy men participated in the study, in which the calcium oxalate (CaOx), octacalcium phosphate (OCP), hydroxyapatite (HAP), and brushite (Bru) urinary saturation levels in fractional urine samples were determined before and during treatment.

RESULTS

The CaOx and Bru saturation levels, as estimated from the AP(CaOx) and AP(Bru) indices (Tiselius) respectively, peaked between 05.30 and 08.00 hours, and the peaks were blunted by each treatment regimen in comparison with the control day. In particular, the 1 g q.i.d. regimen significantly decreased the CaOx saturation level between 05.30 and 08.00 hours. The OCP and HAP saturation levels, as estimated from the AP(CaP) index (Tiselius), peaked between 08.00 and 10.30 hours, and the levels were increased by each regimen. In particular, the OCP level exceeded the formation product between 08.00 and 10.30 hours on day 5 in all regimens.

CONCLUSION

An evening dose of sodium-potassium citrate in addition to the conventional t.i.d. regimen may reduce the early-morning urinary CaOx and Bru saturation levels whilst keeping OCP and HAP saturation within acceptable limits. In contrast, a morning dose may cause OCP saturation to exceed the formation product. Although the OCP saturation level during treatment was not significantly higher than the level before treatment, this slight increase might be critical.

Citrate and recurrent idiopathic calcium urolithiasis. A longitudinal pilot study on the metabolic effects of oral potassium sodium citrate administered as short-, medium- and long-term to male stone patients

In male patients with idiopathic recurrent calcium urolithiasis (RCU) the effects of oral potassium sodium citrate (PSC) on acid-base, citrate and mineral metabolism were investigated. There were 17 normocitraturic and 15 hypocitraturic patients. The examination time points in our clinical laboratory were prior to medication and after 3, 6 and over 12 months of medication. Urine collection periods were over 24 h, 2 h--after an overnight fast--3 h postprandially. Acceptance by the patients was poor, a large number refusing to take PSC for 12 months. Compliance of the patients continuing with the study was adequate as assessed by the urinary excretion of potassium and sodium. No unwanted side effects were observed. After 3 months of PSC medication a compensated metabolic alkalosis developed; in the urine calcium was decreased, while citrate, pH and oxalate were increased, as were hydroxyapatite supersaturation and calcium phosphate particles. After more than 12 months of PSC medication, citrate and pH tended toward the pretreatment baseline values, while hydroxyapatite supersaturation and calcium had already returned to pretreatment values. Despite ongoing PSC intake, patients with pre-existing hypocitraturia had lower urinary citrate than patients with previous normocitraturia, while the concomitant pH and hydroxyapatite supersaturation in the urine of the former remained at levels close to those of the latter. Under the influence of PSC, parathyroid gland function remained unchanged, but serum levels of bone alkaline phosphatase and osteocalcin were low, and urinary hydroxyproline was high.(ABSTRACT TRUNCATED AT 250 WORDS)