Dietary manipulation with lemonade to treat hypocitraturic calcium nephrolithiasis

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.

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.

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.

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.