The drug is potassium citrate, sold under the brand name Urocit-K, and it can reduce kidney stone recurrence by up to 96 percent in patients who have low urinary citrate levels. That is not a typo. In the right patients — roughly one in three kidney stone sufferers — this medication is remarkably effective at preventing new stones from forming. Yet only about 13.6 percent of kidney stone patients on preventive monotherapy actually receive it, according to research published in PubMed. Instead, the majority are prescribed thiazide diuretics, a class of drugs that a landmark 2023 trial found may not work at all for this purpose.
If you or someone you care for has dealt with the searing pain of a kidney stone, that prescribing gap should alarm you. Kidney stones are not just painful — they are increasingly common, with U.S. prevalence rising from 3.8 percent to 8.8 percent over recent decades. For older adults, particularly those with cognitive decline or dementia, a kidney stone episode can trigger hospitalization, delirium, medication complications, and a cascade of problems that extend far beyond the urinary tract. This article covers why potassium citrate remains underused, why the most commonly prescribed alternative just failed a major clinical trial, and what new research from Stanford could change kidney stone prevention entirely.
Table of Contents
- Why Do Doctors Forget to Prescribe the Drug That Prevents Kidney Stones?
- The NOSTONE Trial and Why the Standard Treatment May Not Work
- How Kidney Stones Create Special Risks for Dementia Patients
- Should Your Doctor Prescribe Potassium Citrate — And What to Ask
- The pH Problem and When Potassium Citrate Can Backfire
- New Research That Could Solve the Citrate Dilemma
- Why Kidney Stone Prevention Deserves More Attention in Aging and Brain Health
- Conclusion
- Frequently Asked Questions
Why Do Doctors Forget to Prescribe the Drug That Prevents Kidney Stones?
The short answer is a combination of side effects, habit, and a genuine pharmacological trade-off. Potassium citrate causes gastrointestinal problems — nausea, stomach pain, diarrhea — that lead many patients to stop taking it. In clinical trials, withdrawal rates due to adverse effects were notable, though tablet forms are better tolerated than liquid or powder formulations. For doctors managing elderly patients who already take multiple medications, adding another pill that causes GI distress is not an easy sell. According to the American Academy of Family Physicians, tolerability remains the primary barrier to wider adoption. There is also a clinical catch. Potassium citrate works by raising citrate levels in the urine, which inhibits calcium stone formation.
But it simultaneously raises urine pH, and higher pH can promote a different type of stone — calcium phosphate stones. This pH trade-off makes some physicians hesitant to prescribe the drug, especially when a patient’s stone composition is unclear or mixed. It is a legitimate concern, not mere forgetfulness, though the net benefit for patients with confirmed low citrate levels is well established. Then there is the matter of medical inertia. For decades, thiazide diuretics were the default preventive treatment. Roughly 56.3 percent of kidney stone patients on monotherapy receive a thiazide, compared to that 13.6 percent figure for alkali citrate therapy. Doctors trained in older guidelines simply reach for what they know, even as the evidence base has shifted dramatically under their feet.
The NOSTONE Trial and Why the Standard Treatment May Not Work
In 2023, the new England Journal of Medicine published results from the NOSTONE trial that upended decades of kidney stone prevention practice. The trial tested hydrochlorothiazide — the most commonly prescribed thiazide for stone prevention — at doses of 12.5 mg, 25 mg, and 50 mg daily against placebo. The result was unambiguous: none of the doses performed better than a sugar pill at preventing kidney stone recurrence. This matters enormously for anyone managing a loved one’s medications. Thiazides are not benign drugs. The NOSTONE trial also found higher rates of new-onset diabetes and gout among patients receiving hydrochlorothiazide compared to placebo.
For older adults already at elevated risk for metabolic disease, continuing a medication that does not prevent stones but does cause diabetes is a poor trade. However, there is an important nuance: chlorthalidone, a different and more potent thiazide-type diuretic, may still be effective. Research published in Current Opinion in Nephrology and Hypertension in 2025 noted that chlorthalidone has a “more robust hypocalciuric effect” than hydrochlorothiazide, meaning it may reduce calcium in the urine more effectively. So the failure of one thiazide does not necessarily condemn the entire class — but it does mean that the most commonly prescribed version appears to be useless. If a family member is currently taking hydrochlorothiazide solely for kidney stone prevention, that prescription deserves a conversation with their doctor. The NOSTONE trial is not a preliminary finding — it was a rigorous, placebo-controlled study published in the most respected medical journal in the world.
How Kidney Stones Create Special Risks for Dementia Patients
Kidney stones might seem like a straightforward urological problem, but for people with dementia or cognitive impairment, they create a chain of complications that caregivers need to understand. An older adult with Alzheimer’s disease may not be able to articulate the location or severity of their pain. A stone that would prompt a younger person to rush to the emergency room might instead manifest as agitation, confusion, refusal to eat, or a sudden worsening of behavioral symptoms. Hospitalization for kidney stones brings its own dangers in this population. Anesthesia for surgical stone removal can accelerate cognitive decline. Opioid pain medications commonly used for acute stone episodes — drugs like hydromorphone or oxycodone — carry heightened fall risk and can worsen confusion.
Delirium, a state of acute disorientation that is distinct from dementia but often mistaken for it, occurs frequently in hospitalized older adults and can persist for weeks after discharge. Prevention, in other words, is not just about avoiding pain. It is about avoiding a hospitalization that could permanently alter the trajectory of someone’s cognitive decline. The recurrence statistics make prevention even more urgent. According to epidemiological data published in PMC, about 11 percent of kidney stone patients will form another stone within two years, and roughly 20 percent will recur within five years. For patients with a history of recurrent episodes, that five-year recurrence rate climbs to 60 percent. A dementia patient who has already passed one stone is statistically likely to face the same ordeal again without preventive treatment.
Should Your Doctor Prescribe Potassium Citrate — And What to Ask
Not every kidney stone patient needs potassium citrate. The drug is most effective in people with hypocitraturia — low citrate levels in the urine. A 24-hour urine collection test can determine whether this condition is present, and it is the single most important diagnostic step that often gets skipped. If you are a caregiver for someone who has had kidney stones, asking their nephrologist or urologist about a 24-hour urine analysis is the most actionable step you can take. According to University of Chicago’s Kidney Stone Program, approximately one in three kidney stone patients have low urinary citrate, which means they are candidates for the drug. Stanford researchers suggest the number may be even higher — up to 50 percent of kidney stone patients have abnormally low citrate levels. The comparison between potassium citrate and thiazides is now starkly different than it was before 2023.
Potassium citrate, in the right patients, reduces stone formation by up to 96 percent but causes GI side effects and carries the calcium phosphate stone risk from elevated pH. Hydrochlorothiazide, per the NOSTONE trial, appears no better than placebo for stone prevention and introduces risks of diabetes and gout. Chlorthalidone may be effective but has not been tested in as rigorous a head-to-head trial. For a patient with confirmed hypocitraturia, the risk-benefit calculation favors potassium citrate by a wide margin. Adherence, however, is a real problem across all kidney stone medications. Among approximately 8,890 patients studied on preventive therapy, only 51.1 percent remained adherent to their prescribed medication. For dementia patients, this challenge is compounded by cognitive difficulties with medication management. Caregivers who set up pill organizers, use reminder systems, or supervise medication intake will need to account for yet another daily tablet — and one that may cause enough stomach upset that the patient resists taking it.
The pH Problem and When Potassium Citrate Can Backfire
The most important limitation of potassium citrate is one that many prescribing guides understate. By raising urine pH — making it more alkaline — the drug creates conditions that favor calcium phosphate stone formation. This means a patient who initially forms calcium oxalate stones, the most common type, could theoretically switch to forming calcium phosphate stones instead. The clinical significance of this trade-off varies, and for most patients with genuine hypocitraturia, the net benefit is positive. But it is not zero-risk. This is especially worth knowing if a patient has mixed stone composition or a history of calcium phosphate stones.
In those cases, potassium citrate might not be appropriate, and a doctor who is aware of this nuance may reasonably choose not to prescribe it. The problem is that the opposite situation — a doctor simply defaulting to thiazides out of habit despite clear hypocitraturia — is far more common. The pH concern is valid in a minority of cases; the under-prescribing problem affects the majority. Patients on potassium citrate should have periodic urine pH monitoring and follow-up stone composition analysis if new stones form. This level of monitoring is not always maintained in primary care settings, which is another reason the drug tends to be prescribed more often by nephrologists and urologists than by general practitioners. If a family member’s kidney stone care is being managed solely by their primary care physician, a referral to a specialist may be warranted — particularly if stones keep recurring despite treatment.
New Research That Could Solve the Citrate Dilemma
Dr. Alan Pao at Stanford is developing a fundamentally different approach to the problem. His team is targeting a protein called NaDC1, or sodium-dicarboxylate cotransporter-1, which controls how much citrate gets reabsorbed from urine back into the body. By blocking NaDC1, the drugs would raise urinary citrate levels without raising urine pH — solving the exact trade-off that limits potassium citrate’s usefulness.
As reported in Stanford Medicine Magazine in February 2026, the team has identified two classes of compounds that work in lab-grown cells and is now testing derivative compounds in mice. This research is still preclinical, so no one should wait for it instead of pursuing available treatments. But if the NaDC1 inhibitors eventually reach clinical trials and prove safe, they could make kidney stone prevention far simpler and more widely prescribed. Separately, empagliflozin — a diabetes drug in the SGLT2 inhibitor class — showed promise for kidney stone prevention in nondiabetic individuals in a randomized phase 2 trial published in Nature Medicine in 2024. The repurposing of existing diabetes drugs for stone prevention is a promising parallel track, though larger trials are needed.
Why Kidney Stone Prevention Deserves More Attention in Aging and Brain Health
The rising prevalence of kidney stones — now affecting roughly 11 percent of men and 7 percent of women in the United States — intersects uncomfortably with an aging population increasingly vulnerable to the downstream consequences of acute medical events. Every preventable hospitalization matters when the patient has limited cognitive reserve. Every unnecessary medication carries extra risk when the patient is already on a complex drug regimen for dementia, hypertension, or cardiovascular disease.
Kidney stone prevention is, in a real sense, brain health prevention for older adults. The cascade from an untreated stone to an emergency room visit to opioid exposure to delirium to permanent cognitive setback is well documented and largely avoidable. If the medical community can close the prescribing gap for potassium citrate and develop next-generation options like NaDC1 inhibitors, the benefits will extend well beyond the urinary tract — particularly for the patients who can least afford another medical crisis.
Conclusion
Potassium citrate remains one of the most effective and most underused tools in kidney stone prevention. It reduces recurrence by up to 96 percent in patients with low urinary citrate, yet fewer than 14 percent of patients on preventive therapy receive it. The NOSTONE trial’s demolition of hydrochlorothiazide — the most commonly prescribed alternative — makes this gap even harder to justify. For caregivers of older adults and dementia patients, the stakes are compounded by the cognitive risks of hospitalization, pain management, and surgical intervention that recurrent stones can trigger.
The most important next step is simple: ask about a 24-hour urine collection test. If low citrate is confirmed, potassium citrate should be on the table as a first-line preventive option, with appropriate monitoring for pH changes and stone composition. New drugs targeting NaDC1 may eventually eliminate the pH trade-off entirely, and repurposed diabetes medications like empagliflozin offer additional hope. But the existing solution — imperfect as it is — already works for a large portion of patients. It just needs to be prescribed.
Frequently Asked Questions
What is potassium citrate, and how does it prevent kidney stones?
Potassium citrate (brand name Urocit-K) is a medication that increases citrate levels in the urine. Citrate binds to calcium and prevents it from crystallizing into stones. In patients with low urinary citrate — a condition called hypocitraturia — it can reduce stone formation rates by up to 96 percent.
How do I know if potassium citrate is right for me or my family member?
A 24-hour urine collection test can measure citrate levels and other relevant factors. Approximately one in three kidney stone patients have low citrate, making them strong candidates for the drug. A urologist or nephrologist is best positioned to interpret the results and recommend treatment.
Why was hydrochlorothiazide the go-to kidney stone drug if it may not work?
Older studies suggested thiazide diuretics reduced stone recurrence by lowering calcium in the urine. The 2023 NOSTONE trial, published in the New England Journal of Medicine, tested hydrochlorothiazide specifically and found it no better than placebo at all three doses tested. Chlorthalidone, a different thiazide-type drug, may still be effective but requires more rigorous study.
What are the side effects of potassium citrate?
The most common side effects are gastrointestinal — nausea, stomach pain, and diarrhea. Tablet forms are generally better tolerated than liquid or powder formulations. The drug also raises urine pH, which in some patients can promote calcium phosphate stone formation, a different type of kidney stone.
Are there new kidney stone drugs in development?
Yes. Researchers at Stanford are developing NaDC1 inhibitors that raise urinary citrate without raising pH, potentially eliminating the main drawback of potassium citrate. These are currently in preclinical testing. Separately, empagliflozin, a diabetes drug, showed promise in a 2024 phase 2 trial for kidney stone prevention in nondiabetic patients.
How does kidney stone prevention relate to dementia care?
Kidney stone episodes in dementia patients can lead to hospitalization, opioid exposure, delirium, and lasting cognitive decline. Patients with cognitive impairment may not be able to communicate their pain effectively, leading to delayed treatment. Preventing stones reduces the risk of these cascading complications.
