Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Prevention of recurrent calcium stones in adults

Gary C Curhan, MD, ScD
Section Editor
Stanley Goldfarb, MD
Deputy Editor
Albert Q Lam, MD


Prevention of recurrent calcium stones (which are usually composed primarily of calcium oxalate) is aimed at decreasing the concentrations of the lithogenic factors (calcium and oxalate) and at increasing the concentrations of inhibitors of stone formation, such as citrate.

Achieving these goals may require both dietary modification and the administration of appropriate medications. Medical therapy (and metabolic evaluation) is usually undertaken in individuals who have formed more than one stone. Even if a patient has only passed one stone, it is important to review the imaging studies to determine if other stones are present in the kidney since stone passage does not equal stone formation. At a minimum, those with a single kidney stone are encouraged to increase their fluid intake and should consider undergoing a metabolic evaluation and periodic monitoring (usually by renal ultrasonography) for evidence of new stone formation (image 1). (See "The first kidney stone and asymptomatic nephrolithiasis in adults".)

The management of patients with recurrent calcium stones will be reviewed here. The management of patients with other types of stones including those of unknown composition, and risk factors for recurrent calcium stones are discussed separately. (See "Evaluation of the adult patient with established nephrolithiasis and treatment if stone composition is unknown" and "Risk factors for calcium stones in adults".)


A variety of dietary modifications and drug therapies can reduce the likelihood of recurrence of calcium oxalate stones, but specific recommendations are based upon the 24-hour urine results. Thus, the 24-hour collections should be performed before dietary modification is attempted.

Dietary modification — From the viewpoint of diet, increasing the intake of fluid, dietary calcium, potassium and phytate may be beneficial. In addition, decreasing the intake of oxalate, animal protein, sucrose, fructose, sodium, supplemental vitamin C, and supplemental calcium (as opposed to dietary calcium) may reduce the risk of stones [1] (see "Risk factors for calcium stones in adults"). The role of vitamin D intake in stone formation remains unclear.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Oct 2017. | This topic last updated: Jul 25, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Taylor EN, Curhan GC. Diet and fluid prescription in stone disease. Kidney Int 2006; 70:835.
  2. Hosking DH, Erickson SB, Van den Berg CJ, et al. The stone clinic effect in patients with idiopathic calcium urolithiasis. J Urol 1983; 130:1115.
  3. Qaseem A, Dallas P, Forciea MA, et al. Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014; 161:659.
  4. Borghi L, Meschi T, Amato F, et al. Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized prospective study. J Urol 1996; 155:839.
  5. Strauss AL, Coe FL, Deutsch L, Parks JH. Factors that predict relapse of calcium nephrolithiasis during treatment: a prospective study. Am J Med 1982; 72:17.
  6. Gettman MT, Ogan K, Brinkley LJ, et al. Effect of cranberry juice consumption on urinary stone risk factors. J Urol 2005; 174:590.
  7. Shuster J, Jenkins A, Logan C, et al. Soft drink consumption and urinary stone recurrence: a randomized prevention trial. J Clin Epidemiol 1992; 45:911.
  8. Ferraro PM, Taylor EN, Gambaro G, Curhan GC. Soda and other beverages and the risk of kidney stones. Clin J Am Soc Nephrol 2013; 8:1389.
  9. Breslau NA, Brinkley L, Hill KD, Pak CY. Relationship of animal protein-rich diet to kidney stone formation and calcium metabolism. J Clin Endocrinol Metab 1988; 66:140.
  10. Borghi L, Schianchi T, Meschi T, et al. Comparison of two diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med 2002; 346:77.
  11. Hiatt RA, Ettinger B, Caan B, et al. Randomized controlled trial of a low animal protein, high fiber diet in the prevention of recurrent calcium oxalate kidney stones. Am J Epidemiol 1996; 144:25.
  12. Curhan GC, Willett WC, Rimm EB, Stampfer MJ. A prospective study of dietary calcium and other nutrients and the risk of symptomatic kidney stones. N Engl J Med 1993; 328:833.
  13. Curhan GC, Willett WC, Knight EL, Stampfer MJ. Dietary factors and the risk of incident kidney stones in younger women: Nurses' Health Study II. Arch Intern Med 2004; 164:885.
  14. Curhan GC, Willett WC, Speizer FE, et al. Comparison of dietary calcium with supplemental calcium and other nutrients as factors affecting the risk for kidney stones in women. Ann Intern Med 1997; 126:497.
  15. Meschi T, Maggiore U, Fiaccadori E, et al. The effect of fruits and vegetables on urinary stone risk factors. Kidney Int 2004; 66:2402.
  16. Taylor EN, Curhan GC. Oxalate intake and the risk for nephrolithiasis. J Am Soc Nephrol 2007; 18:2198.
  17. Muldowney FP, Freaney R, Moloney MF. Importance of dietary sodium in the hypercalciuria syndrome. Kidney Int 1982; 22:292.
  18. Eisner BH, Eisenberg ML, Stoller ML. Impact of urine sodium on urine risk factors for calcium oxalate nephrolithiasis. J Urol 2009; 182:2330.
  19. Lemann J Jr, Piering WF, Lennon EJ. Possible role of carbohydrate-induced calciuria in calcium oxalate kidney-stone formation. N Engl J Med 1969; 280:232.
  20. Taylor EN, Curhan GC. Fructose consumption and the risk of kidney stones. Kidney Int 2008; 73:207.
  21. Bataille P, Achard JM, Fournier A, et al. Diet, vitamin D and vertebral mineral density in hypercalciuric calcium stone formers. Kidney Int 1991; 39:1193.
  22. Asplin JR, Donahue S, Kinder J, Coe FL. Urine calcium excretion predicts bone loss in idiopathic hypercalciuria. Kidney Int 2006; 70:1463.
  23. Jackson RD, LaCroix AZ, Gass M, et al. Calcium plus vitamin D supplementation and the risk of fractures. N Engl J Med 2006; 354:669.
  24. Massey LK, Liebman M, Kynast-Gales SA. Ascorbate increases human oxaluria and kidney stone risk. J Nutr 2005; 135:1673.
  25. Traxer O, Huet B, Poindexter J, et al. Effect of ascorbic acid consumption on urinary stone risk factors. J Urol 2003; 170:397.
  26. Taylor EN, Stampfer MJ, Curhan GC. Dietary factors and the risk of incident kidney stones in men: new insights after 14 years of follow-up. J Am Soc Nephrol 2004; 15:3225.
  27. Taylor EN, Stampfer MJ, Curhan GC. Obesity, weight gain, and the risk of kidney stones. JAMA 2005; 293:455.
  28. Parks JH, Asplin JR, Coe FL. Patient adherence to long-term medical treatment of kidney stones. J Urol 2001; 166:2057.
  29. Nijenhuis T, Hoenderop JG, Loffing J, et al. Thiazide-induced hypocalciuria is accompanied by a decreased expression of Ca2+ transport proteins in kidney. Kidney Int 2003; 64:555.
  30. Nijenhuis T, Vallon V, van der Kemp AW, et al. Enhanced passive Ca2+ reabsorption and reduced Mg2+ channel abundance explains thiazide-induced hypocalciuria and hypomagnesemia. J Clin Invest 2005; 115:1651.
  31. Coe FL, Parks JH, Asplin JR. The pathogenesis and treatment of kidney stones. N Engl J Med 1992; 327:1141.
  32. Ettinger B, Citron JT, Livermore B, Dolman LI. Chlorthalidone reduces calcium oxalate calculous recurrence but magnesium hydroxide does not. J Urol 1988; 139:679.
  33. Laerum E, Larsen S. Thiazide prophylaxis of urolithiasis. A double-blind study in general practice. Acta Med Scand 1984; 215:383.
  34. Escribano J, Balaguer A, Pagone F, et al. Pharmacological interventions for preventing complications in idiopathic hypercalciuria. Cochrane Database Syst Rev 2009; :CD004754.
  35. Fink HA, Wilt TJ, Eidman KE, et al. Medical management to prevent recurrent nephrolithiasis in adults: a systematic review for an American College of Physicians Clinical Guideline. Ann Intern Med 2013; 158:535.
  36. Alon U, Costanzo LS, Chan JC. Additive hypocalciuric effects of amiloride and hydrochlorothiazide in patients treated with calcitriol. Miner Electrolyte Metab 1984; 10:379.
  37. Pak CY, Peterson R, Sakhaee K, et al. Correction of hypocitraturia and prevention of stone formation by combined thiazide and potassium citrate therapy in thiazide-unresponsive hypercalciuric nephrolithiasis. Am J Med 1985; 79:284.
  38. Lemann J Jr, Gray RW, Pleuss JA. Potassium bicarbonate, but not sodium bicarbonate, reduces urinary calcium excretion and improves calcium balance in healthy men. Kidney Int 1989; 35:688.
  39. Sakhaee K, Nicar M, Hill K, Pak CY. Contrasting effects of potassium citrate and sodium citrate therapies on urinary chemistries and crystallization of stone-forming salts. Kidney Int 1983; 24:348.
  40. Preminger GM, Sakhaee K, Pak CY. Alkali action on the urinary crystallization of calcium salts: contrasting responses to sodium citrate and potassium citrate. J Urol 1988; 139:240.
  41. Ettinger B, Tang A, Citron JT, et al. Randomized trial of allopurinol in the prevention of calcium oxalate calculi. N Engl J Med 1986; 315:1386.
  42. Ettinger B. Does hyperuricosuria play a role in calcium oxalate lithiasis? J Urol 1989; 141:738.
  43. Curhan GC, Taylor EN. 24-h uric acid excretion and the risk of kidney stones. Kidney Int 2008; 73:489.
  44. Favus MJ, Coe FL. The effects of allopurinol treatment on stone formation on hyperuricosuric calcium oxalate stone-formers. Scand J Urol Nephrol Suppl 1980; 53:265.
  45. Coe FL. Treated and untreated recurrent calcium nephrolithiasis in patients with idiopathic hypercalciuria, hyperuricosuria, or no metabolic disorder. Ann Intern Med 1977; 87:404.
  46. Sakhaee K, Alpern R, Jacobson HR, Pak CY. Contrasting effects of various potassium salts on renal citrate excretion. J Clin Endocrinol Metab 1991; 72:396.
  47. Pak CY, Peterson R. Successful treatment of hyperuricosuric calcium oxalate nephrolithiasis with potassium citrate. Arch Intern Med 1986; 146:863.
  48. Barcelo P, Wuhl O, Servitge E, et al. Randomized double-blind study of potassium citrate in idiopathic hypocitraturic calcium nephrolithiasis. J Urol 1993; 150:1761.
  49. Wabner CL, Pak CY. Effect of orange juice consumption on urinary stone risk factors. J Urol 1993; 149:1405.
  50. Seltzer MA, Low RK, McDonald M, et al. Dietary manipulation with lemonade to treat hypocitraturic calcium nephrolithiasis. J Urol 1996; 156:907.
  51. Penniston KL, Steele TH, Nakada SY. Lemonade therapy increases urinary citrate and urine volumes in patients with recurrent calcium oxalate stone formation. Urology 2007; 70:856.
  52. Eisner BH, Asplin JR, Goldfarb DS, et al. Citrate, malate and alkali content in commonly consumed diet sodas: implications for nephrolithiasis treatment. J Urol 2010; 183:2419.
  53. Sumorok NT, Asplin JR, Eisner BH, et al. Effect of diet orange soda on urinary lithogenicity. Urol Res 2012; 40:237.
  54. Hamm LL. Renal handling of citrate. Kidney Int 1990; 38:728.
  55. Melnick JZ, Srere PA, Elshourbagy NA, et al. Adenosine triphosphate citrate lyase mediates hypocitraturia in rats. J Clin Invest 1996; 98:2381.
  56. Sakhaee K, Alpern R, Poindexter J, Pak CY. Citraturic response to oral citric acid load. J Urol 1992; 147:975.
  57. Levi M, McDonald LA, Preisig PA, Alpern RJ. Chronic K depletion stimulates rat renal brush-border membrane Na-citrate cotransporter. Am J Physiol 1991; 261:F767.
  58. Williams HE. Oxalic acid and the hyperoxaluric syndromes. Kidney Int 1978; 13:410.
  59. Lieske JC, Goldfarb DS, De Simone C, Regnier C. Use of a probiotic to decrease enteric hyperoxaluria. Kidney Int 2005; 68:1244.
  60. Hoppe B, Beck B, Gatter N, et al. Oxalobacter formigenes: a potential tool for the treatment of primary hyperoxaluria type 1. Kidney Int 2006; 70:1305.
  61. Goldfarb DS, Modersitzki F, Asplin JR. A randomized, controlled trial of lactic acid bacteria for idiopathic hyperoxaluria. Clin J Am Soc Nephrol 2007; 2:745.
  62. Parks JH, Coe FL. A urinary calcium-citrate index for the evaluation of nephrolithiasis. Kidney Int 1986; 30:85.
  63. Curhan GC, Willett WC, Speizer FE, Stampfer MJ. Twenty-four-hour urine chemistries and the risk of kidney stones among women and men. Kidney Int 2001; 59:2290.
  64. Laube N, Pullmann M, Hergarten S, Hesse A. Influence of urinary stones on the composition of a 24-hour urine sample. Clin Chem 2003; 49:281.
  65. Laube N, Pullmann M, Hergarten S, et al. The alteration of urine composition due to stone material present in the urinary tract. Eur Urol 2003; 44:595.
  66. Hyams ES, Shah O. Evaluation and follow-up of patients with urinary lithiasis: minimizing radiation exposure. Curr Urol Rep 2010; 11:80.
  67. Gault MH, Chafe LL, Morgan JM, et al. Comparison of patients with idiopathic calcium phosphate and calcium oxalate stones. Medicine (Baltimore) 1991; 70:345.