The efficacy of citric

acid for dissolving

calcium oxalate

Tzu Miao Wang

BIO 494
27 August 2014

Mentor: Dr. Roger Shane Gold

Abstract

Calcium oxalate renal calculi are one of the most common types of kidney stones.
Research has shown that citric acid can prevent calcium oxalate crystallization and that
extracts of Bryophyllum pinnatum may be able to reduce the size of existing calcium
oxalate crystals in vivo. Bryophyllum pinnatum extracts contain a high concentration of
citric acid, which may contribute to its ability to dissolve renal calculi. The purpose of
this study was to determine the efficacy of citric acid for dissolving calcium oxalate.
Calcium oxalate powder, contained in dialysis tubing, was incubated in solutions of
water, citric acid or EDTA for ten days and the change in mass was measured. Citric acid
was shown to have no significant effect, compared with water alone and is unlikely to be
the component in Bryophyllum pinnatum extracts that are responsible for reducing the
size of calcium oxalate calculi.

Introduction

Renal calculi, also known as kidney stones, are a disorder caused by excessive

salt concentrations in urine (Coe et al. 2005). Common renal calculi may consist

of calcium oxalate, calcium phosphate, struvite (magnesium ammonium

phosphate), uric acid, cysteine, or ammonium acid urate; imbalances in these

salts can precipitate into insoluble solids that may cause extreme discomfort and

require invasive surgery to remove (Coe et al. 2005). While the cause of kidney

stone formation is largely unknown, the analysis of microRNA expression

profiles, which have been demonstrated to accurately predict susceptibility for

kidney stones, suggests that there may be a genetic component to kidney stone

formation (Wang et al. 2014). A recent analysis of renal calculi demonstrated the

presence of specific bacteria, including Escherichia coli, Enterococcus spp.,

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Klebsiella spp., Enterobacter spp., and Proteus mirabilis, that are commonly

embedded throughout the stone matrix, including the nidus (Tavichakorntrakoo

et al. 2012). Subsequent research has demonstrated that P. mirabilis and E. coli

actively promote calcium oxalate crystallization in vitro suggesting that bacterial

infections may be the cause of at least some kidney stones (Tavichakorntrakoo et

al. 2012, Ong 2014). Citric acid has been shown to inhibit the formation of

calcium oxalate kidney stones (Meyer and Smith. 1975, Ebrahimpour et al.

1991), and recent research has demonstrated that extracts of Bryophyllum

pinnatum, a plant traditionally used in many parts of the world to treat kidney

stones, are effective in reducing the size of existing kidney stones (Gahlaut et al.

2012). Extracts of this plant reportedly contain high levels of citric acid,

potassium malate, ascorbic acid, and malic acid (Okwu and Josiah 2006), raising

the possibility that citric acid may also play a role in dissolving calcium oxalate

stones. The purpose of this study was to investigate the efficacy of citric acid in

dissolving calcium oxalate crystals.

Materials and Methods

The ability of citric acid to dissolve calcium oxalate was determined by

placing 0.2 g calcium oxalate powder inside sealed packets of dialysis tubing

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(Spectra/Por Regenarated Cellulose 6-8KD MWCO 32 mm) and soaking in

solutions of deionized water, citric acid (1, 10 and 100 mM), or EDTA (1, 10 and

100 mM) for ten days at room temperature with vigorous stirring. Calcium

oxalate packets were dried and weighed before and after treatment and the

difference in mass was averaged for each treatment. The means of the

differences were analyzed by ANOVA.

Results

Following the 10 day incubation period the differences in mass of calcium

oxalate was determined for each treatment (Table 1). While 100 mM citric acid

was observed to reduce the mass of calcium oxalate by an average of 38.8%

grams, the values obtained were not significant relative to water alone (6.1%, p =

0.131). The ability of 100 mM EDTA, which, as a chelator, is known to dissolve

calcium oxalate crystals, was demonstrated to significantly reduce the mass of

calcium oxalate (56.6%, p = 0.006)(Table 1).

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Table 1. The average difference and p-value of each package of calcium
oxalate in each treatment solution.

Average Change Percent Change

Treatment P-value
(grams) (%)

Water 0.015 ± 0.001 g 6.12% n/a

1 mM Citric acid 0.014 ± 0.001 g 7.22% 1.000

10 mM Citric acid 0.015 ± 0.015 g 5.76% 1.000

100 mM Citric acid 0.126 ± 0.11 g 38.84% 0.131

1 mM EDTA 0.040 ± 0.044 g 19.22% 0.990

10 mM EDTA 0.087 ± 0.034 g 32.43% 0.237

100 mM EDTA 0.187 ± 0.017 56.63% 0.006

Discussion

Recent research has demonstrated that potassium citrate can prevent the

formation of calcium oxalate kidney stones both in vitro and in vivo

(Ebrahimpour et al. 1991, Ho et al. 2013). Reports that B. pinnatum extracts,

which are rich in citric acid, actively reduce the size of both calcium oxalate and

struvite kidney stones suggest that citric acid may also help dissolve pre-existing

calcium oxalate stones (Gahlaut et al. 2012). However, this study failed to

demonstrate the ability of citric acid to dissolve calcium oxalate, at

concentrations up to 100 mM. While EDTA, a chelator of divalent metals, is able

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to dissolve calcium oxalate crystals, this compound is not absorbed through the

epithelial cells of the intestinal tract; therefore, oral administration of EDTA is

unlikely to accumulate to appreciable levels in the kidney (Downes and

McDonald 1964). Further studies should be performed to determine if other

components of the B. pinnatum extract directly confer an ability to reduce the

size of existing calcium oxalate kidney stones or if components of the extract

mediate changes in host gene expression that affect stone integrity.

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