International Urology and Nephrology 32: 19–27, 2000.

© 2000 Kluwer Academic Publishers. Printed in the Netherlands.

19

Kinetic versus thermodynamic factors in calcium renal lithiasis

Felix Grases1 , Antonia Costa-Bauzá1 , Erich Königsberger2 & Lan-Chi Königsberger2

1 Laboratoryof Renal Lithiasis Research, University of Illes Balears, Palma de Mallorca, Spain; 2 Department of
Physical Chemistry, University of Leoben, Leoben, Austria

Abstract. Calcium renal lithiasis formation depends on the balance between thermodynamic (supersaturation)
and kinetic (inhibitors, nucleants) factors. In this paper, the importance of both groups was evaluated using
(a) the complete urine analysis data obtained from 32 healthy volunteers and 141 active stone-formers, and
(b) a comprehensive computer model to calculate the supersaturation values of calcium oxalate monohydrate,
hydroxyapatite and brushite in each urine sample. The results of this evaluation were used to assess the possible
effectiveness of a given pharmacological treatment.

Key words: Calcium calculi, Lithogen risk, Renal lithiasis

Introduction lization processes), (iii) the presence of pre-formed

Formation of renal stones requires production of solid
phases such as calcium oxalate or calcium phosphates.
The driving force for crystallization is supersaturation,
that is a thermodynamic factor [3, 8]. Nevertheless,
there are other factors enhancing (promoters) or delay-
ing (inhibitors) the crystallization, these are kinetic
factors. As a consequence, crystallization depends
on the balance between thermodynamic and kinetic
factors.
All human urine are supersaturated with respect to
calcium oxalate [3] and, depending on the pH values,
they are also supersaturated with respect to calcium
phosphates [6]. This means that in all urine, according
to thermodynamic factors, calcium salts would crys-
tallize in some short time. Fortunately the majority
of urine do not form crystals due to kinetic retard-
ation by some urine constituents which may decel-
erate the crystallization process by 10 to 100 times.
Thus, these inhibitors keep the urine in a metastable
supersaturation state.
In fact, kinetic factors play an important role in all
crystallization processes [1, 4]. The time necessary to
generate a crystal mainly depends on: (i) the nature
of the crystal, (ii) the supersaturation of the solution
(thermodynamic driving force that pushes the crystal-
solid particles (the so called heterogeneous nucleants),
and (iv) the presence of crystallization inhibitors [4,
12].These time dependent processes can be delayed
for seconds up to years. Thus, the development of
renal uroliths requires the unfortunate combination of
thermodynamic and kinetic factors in such a manner
that crystals would be generated and retained in the
upper urinary tract for long enough to produce a solid
concretion.
The aim of this paper is to evaluate the import-
ance of both thermodynamic and kinetic factors using
clinical urine composition data and a comprehensive
computer model to calculate supersaturations in urine.
Moreover, the results of this study are used to assess
the possible effectiveness of a given treatment.
Materials and methods
Urine samples
Urine of 32 healthy volunteers and 141 active oxa-
localcic stone-formers with non-infected urine were
studied. Complete sets of urine analysis data were
available for all subjects who were on free diet at the
time of urine collection. None of the stone-formers
20
Table 1. ULR test results and the supersaturation values of COM, HAP, and DCPD obtained from
the urines of healthy people

ULR Absorbance pH log S (COM) log S (HAP) log S (DCPD) Individual No.

+ 0.562 5.5 0.484 0.612 0.076 93

– 0.198 4.9 0.513 0.118 –0.178 94
– 0.182 5.2 0.442 0.183 –0.209 95
– 0.155 5.4 0.458 0.424 –0.061 96
+ 0.464 6.6 0.444 1.147 0.138 97
– 0.161 5.4 0.555 0.551 0.015 98
– 0.162 5.5 0.355 0.315 –0.164 99
– 0.220 6.0 0.445 0.909 0.174 100
– 0.152 5.9 0.144 0.407 –0.144 101
– 0.185 6.2 0.320 0.775 0.003 102
– 0.180 5.4 0.556 0.516 –0.020 103
– 0.250 5.2 0.344 0.075 –0.269 104
+ 0.823 6.1 0.436 0.891 0.110 105
– 0.158 5.4 0.470 0.428 –0.064 106
– 0.136 6.2 0.184 0.594 –0.115 107
– 0.142 6.0 0.182 0.392 –0.228 108
– 0.135 5.2 0.297 –0.054 –0.378 109
– 0.191 5.9 0.362 0.696 0.042 110
– 0.149 5.5 0.351 0.444 –0.026 111
– 0.137 5.9 0.194 0.325 –0.256 112
– 0.153 5.4 0.484 0.445 –0.055 113
– 0.286 5.5 0.459 0.525 –0.001 114
+ 0.739 5.8 0.564 0.833 0.115 115
– 0.196 5.6 0.399 0.457 –0.088 116
+ 0.722 6.2 0.408 0.917 0.106 117
– 0.187 5.8 0.443 0.475 –0.185 118
– 0.180 5.4 0.411 0.322 –0.141 119
+ 0.320 5.7 0.560 0.792 0.122 120
– 0.164 5.4 0.148 –0.109 –0.449 121
– 0.180 5.1 0.340 0.006 –0.291 122
– 0.172 5.1 0.541 0.280 –0.119 123
– 0.173 4.9 0.459 –0.044 –0.315 124

was undergoing any type of pharmacological treat-
ment. Urine samples were collected under standard-
ized conditions in a sterile container without additives
or preservatives. No centrifugation or filtration of
the samples was carried out. The urinary lithogen
risk (ULR) to develop calcium stones was determined
using a test developed and validated for this purpose
[2, 5]. Samples were tested as soon as passed so that
they did not cool before being introduced into the
reaction unit. Most of the ULR test results used in
this study were already reported in [5]. The methods
to determine the pH value, the concentrations of cal-
cium, phosphorous, uric acid, citrate and creatinine in
each sample were described in detail by Grases et al.
[5].
Supersaturation calculations
Since calcium oxalate monohydrate, CaC2 O4 ·H2 O
(hereafter COM), hydroxyapatite, Ca5 OH(PO4 )3
(HAP), and brushite, CaHPO4 ·2H2 O (DCPD) are fre-
quently found as components of the most common
urinary stones, the supersaturation values of these
calcium salts (log S as defined in [6]) were deter-
mined for each urine sample. Considering the indi-
vidual urine analyses, the Joint Expert Speciation
 21
Table 2. ULR test results and the supersaturation values of COM, HAP, and DCPD obtained from the
urines of stone-formers

ULR Absorbance pH log S (COM) log S (HAP) log S (DCPD) Individual No.

+ 0.587 6.0 0.423 0.822 0.069 33

– 0.176 6.0 0.383 0.802 0.049 34
– 0.180 6.5 0.111 0.759 –0.123 35
– 0.308 6.0 0.419 0.823 0.073 36
– 0.162 5.5 0.419 0.479 –0.056 37
+ 0.815 6.5 0.508 1.119 0.146 39
+ 0.328 6.0 0.446 0.769 0.040 40
– 0.289 6.0 0.377 0.797 0.091 42
– 0.210 6.45 0.246 0.949 0.050 43
+ 0.597 6.0 0.569 0.911 0.139 44
+ 0.367 5.5 0.601 0.631 0.044 45
+ 0.328 5.5 0.620 0.697 0.122 46
– 0.276 6.0 0.540 0.876 0.098 47
+ 0.462 6.0 0.526 0.892 0.140 48
+ 0.331 6.5 0.076 0.761 –0.118 49
+ 0.343 5.5 0.320 0.466 –0.064 50
+ 0.406 6.0 0.337 0.771 0.028 51
– 0.265 6.0 0.201 0.617 –0.086 52
+ 0.387 5.5 0.619 0.670 0.077 53
– 0.260 7.45 –0.006 1.126 –0.124 54
– 0.231 5.5 0.010 –0.008 –0.435 55
– 0.194 7.0 –0.050 1.037 –0.021 56
+ 0.341 6.5 0.304 0.985 0.039 58
+ 0.365 5.5 0.312 0.450 –0.073 59
+ 0.550 6.0 0.637 0.981 0.167 60
+ 0.620 7.5 0.280 1.460 0.049 61
+ 0.476 6.0 0.520 0.889 0.133 62
– 0.236 5.5 0.328 0.460 –0.046 63
+ 0.455 7.5 0.308 1.378 –0.001 64
– 0.283 5.5 –0.032 0.053 –0.353 65
– 0.279 5.5 0.191 0.332 –0.153 66
+ 0.410 5.5 0.622 0.637 0.046 67
+ 0.386 5.5 0.556 0.569 0.001 68
– 0.261 6.5 0.267 0.834 –0.090 69
+ 0.322 5.5 0.550 0.590 –0.004 84
+ 0.541 5.4 0.689 0.738 0.167 91
+ 0.460 5.6 0.662 0.765 0.112 92
– 0.165 5.2 0.165 0.121 –0.197 93
+ 0.406 5.5 0.327 0.286 –0.191 160
– 0.158 5.6 0.403 0.418 –0.143 161
+ 0.348 5.6 0.392 0.286 –0.271 162
– 0.167 5.4 0.536 0.559 0.024 163
+ 0.302 6.0 0.423 0.895 0.159 165
– 0.126 5.9 0.470 0.838 0.118 167
– 0.160 6.7 0.212 0.865 –0.093 171
– 0.283 5.5 0.307 0.273 –0.197 172
– 0.180 6.4 0.370 0.997 0.107 173
– 0.235 6.3 0.347 0.974 0.140 174
– 0.251 5.6 0.421 0.477 –0.089 175
– 0.173 6.6 0.127 0.713 –0.161 176
22
Table 2 (continued)

ULR Absorbance pH log S (COM) log S (HAP) log S (DCPD) Individual No.

+ 0.439 6.6 0.209 0.990 0.093 192

+ 0.405 5.4 0.327 0.238 –0.194 193
+ 0.437 5.8 0.413 0.764 0.123 204
– 0.222 6.7 0.262 0.986 0.010 213
– 0.200 6.6 0.496 1.187 0.137 215
+ 0.329 7.1 0.182 1.252 0.143 216
+ 0.342 5.7 0.453 0.765 0.150 217
+ 0.349 6.3 0.355 0.908 0.065 227
– 0.181 5.5 0.263 0.252 –0.195 228
– 0.259 6.7 0.342 1.075 0.062 237
+ 0.603 7.8 0.326 1.547 0.051 239
– 0.240 5.9 0.307 0.593 –0.048 244
+ 0.493 6.1 0.334 0.858 0.123 245
+ 0.559 6.8 0.260 1.120 0.106 247
– 0.177 5.7 0.443 0.573 –0.047 248
+ 0.330 6.3 0.413 0.927 0.056 252
– 0.267 7.1 0.122 0.963 –0.129 254
– 0.183 6.0 0.414 0.725 –0.015 267
+ 0.381 5.5 0.606 0.681 0.060 272
+ 0.362 7.3 0.324 1.353 0.083 273
+ 0.471 7.7 0.282 1.498 0.068 277
– 0.258 5.8 0.390 0.638 0.001 281
+ 0.776 6.8 0.341 1.138 0.081 282
+ 0.339 6.5 0.286 0.914 0.016 283
– 0.239 5.9 0.216 0.418 –0.181 284
– 0.257 6.5 0.092 0.697 –0.110 285
– 0.273 5.8 0.298 0.497 –0.098 286
– 0.266 5.2 0.427 0.262 –0.130 287
+ 0.642 5.0 0.443 0.095 –0.220 288
+ 0.676 6.8 0.223 0.936 –0.071 289
+ 0.334 6.1 0.523 1.009 0.171 290
– 0.265 5.0 0.555 0.311 –0.060 291
– 0.291 6.4 0.277 0.777 –0.078 292
+ 0.671 6.4 0.305 0.890 0.027 293
+ 0.358 7.3 0.122 1.027 –0.152 294
+ 0.323 6.4 0.427 1.037 0.114 295
+ 0.349 5.8 0.474 0.705 0.024 296
+ 0.337 5.9 0.349 0.610 –0.055 297
– 0.287 5.8 0.131 0.334 –0.179 298
+ 0.537 7.1 0.331 1.230 0.041 299
+ 0.742 7.0 0.258 1.072 –0.032 300
+ 0.687 6.4 0.293 0.915 0.063 301
+ 0.713 6.6 0.321 1.001 0.041 302
+ 1.000 6.5 0.349 0.871 –0.060 303
+ 0.308 5.6 0.230 0.255 –0.216 304
+ 0.311 5.1 0.433 0.039 –0.318 305
+ 0.300 6.1 0.361 0.689 –0.062 306
– 0.294 5.3 0.353 0.133 –0.269 307
+ 0.483 5.4 0.523 0.522 –0.008 308
+ 0.670 6.1 0.523 1.015 0.175 309
 23
Table 2 (continued)

ULR Absorbance pH log S (COM) log S (HAP) log S (DCPD) Individual No.

+ 0.768 6.8 0.355 1.085 0.017 310

+ 0.681 5.3 0.414 0.220 –0.211 311
+ 0.318 5.8 0.390 0.671 0.037 312
+ 0.482 5.9 0.277 0.536 –0.086 313
– 0.251 6.6 0.275 1.014 0.084 314
+ 0.471 6.3 0.403 0.890 0.021 315
– 0.251 6.7 0.261 0.850 –0.131 316
+ 0.629 5.2 0.636 0.562 0.055 317
+ 0.767 5.6 0.477 0.508 –0.089 318
+ 0.756 5.6 0.500 0.550 –0.058 319
+ 0.305 7.6 0.267 1.418 0.040 320
+ 0.309 7.4 0.050 1.029 –0.158 321
– 0.288 6.4 0.322 0.942 0.077 322
– 0.258 5.8 0.446 0.708 0.042 323
+ 1.000 6.3 0.501 1.097 0.183 324
+ 0.406 6.2 0.583 1.041 0.122 325
+ 0.480 5.7 0.527 0.638 –0.030 326
+ 0.459 5.1 0.513 0.060 –0.338 327
+ 0.788 5.8 0.474 0.726 0.047 328
+ 0.701 7.5 0.276 1.433 0.096 329
+ 0.307 5.4 0.127 –0.108 –0.448 330
– 0.295 5.7 0.313 0.403 –0.155 331
– 0.294 6.0 0.178 0.526 –0.100 332
+ 0.691 6.1 0.053 0.416 –0.198 333
+ 0.732 5.6 0.513 0.624 0.013 334
+ 0.311 5.5 0.093 0.008 –0.362 335
+ 0.704 5.7 0.535 0.771 0.104 336
+ 0.814 7.0 0.343 1.224 0.073 337
+ 0.391 5.4 0.467 0.459 –0.040 338
– 0.271 6.2 0.195 0.588 –0.138 339
– 0.224 6.3 0.216 0.710 –0.067 340
+ 0.548 7.5 0.206 1.252 –0.053 341
– 0.287 5.8 0.485 0.616 –0.074 342
+ 0.566 5.3 0.501 0.282 –0.194 343
+ 0.578 7.3 0.242 1.237 0.003 345
+ 0.716 7.3 0.230 1.287 0.064 346
+ 0.712 6.5 0.318 0.965 0.052 347
+ 0.620 6.4 0.375 0.847 –0.053 348
+ 0.314 5.9 0.485 0.707 –0.027 349
+ 0.305 5.6 0.473 0.390 –0.202 350

System (JESS) package of computer programs [9,
10, 11] and the urine model employed previously
[7] were used to calculate the supersaturation val-
ues related to COM, HAP, and DCPD. All possible
complexes formed amongst Ca2+ , Mg2+ , oxalate, cit-
rate, phosphate and other inorganic components in
urine were considered and their formation constants
were taken from the JESS thermodynamic database.
The solubility products of calcium oxalate hydrates
determined recently by [13] were incorporated in the
model.
24
Figure 1. Absorbance of ULR test versus the supersaturation values of DCPD for healthy people (solid symbols) and stone formers (open
symbols).
Results
Results of the ULR test (related to the positive or
negative risk of urinary calcium stone formation) and
the supersaturation values of COM, HAP, and DCPD
obtained from the urine of healthy people and stone-
formers are summarized in Tables 1–2. It can be seen
clearly from these tables that all human urine are
supersaturated with respect to calcium salts, especially
HAP and COM, which is in accord with [3] and [6].
The absorbance of the ULR test results versus
the supersaturation values of DCPD, COM and HAP
for healthy and stone-formers are represented in Fig-
ures 1–3. In the case of healthy people (solid symbols),
as expected, most of the urine give negative ULR test
results, i.e. the absorbance A is less than 0.3; this value
has been established as the borderline between normal
and lithogenic urine (5). There are six samples from
this group giving positive results and their log S values
were employed to establish a region called ‘threshold
area’ for each of the crystallization of DCPD, COM
and HAP. These threshold regions are shown as the
shaded areas in Figures 1–3. In general, the lower limit
of the threshold area is denoted as χ and the upper as
y; the corresponding values for DCPD, COM and HAP
are 0.07 < log S < 0.18, 0.40 < log S < 0.57 and 0.80
< log S < 1.19 respectively. It should be noted that
no data from the healthy group and only positive ULR
test results from the stone-former group were found
beyond the threshold areas, i.e. for log S > y.
Discussion
The crystallization potential of urine is related not
only to the concentration of any particular compound
but also to the presence or absence of others, such
as complexing agents, inhibitors or promoters of the
crystallization of the compound in question. While
complexing agents allow higher total concentrations
of calculi compounds by increasing their solubility,
crystallization inhibitors frequently cause the actual

Figure 2. Absorbance of ULR test versus the supersaturation values of COM for healthy people (solid symbols) and stone formers (open
symbols).
concentration products to exceed the corresponding
solubility products. In this way, urine is supersaturated
(metastable) with respect to some substances and kine-
tic factors play an important role. As supersaturation
increases, a threshold is reached at which urine can
hold no more salt in solution, and kinetic factors are
no longer effective.
Thermodynamically, positive supersaturation val-
ues of a salt indicate the possibility of its crystalliz-
ation from the solution. However, a negative risk of
stone formation (A < 0.3) for positive supersaturation
values means that kinetic factors prevent or delay the
precipitation of the substance. In general for each cal-
cium salt, there are five cases corresponding to the
control of thermodynamic and kinetic factors either
alone or in combination. These cases are presented as
regions I, II, III, IV and V in Figures 1–3.
(i) In region I, 0 < log S < χ and A <0.3 mean
that kinetic restrictions effectively keep calcium
ions in solution. Most of the data obtained
25
from healthy people are found in this region.
This observation implies the absence of hetero-
geneous nucleants and/or the presence of some
natural crystallization inhibitors in urine. How-
ever some data obtained from the stone-formers
are also found in this region. The existence
of these indicates that although having nor-
mal urine, these patients suffer some abnormal
renal morphoanatomy, e.g., papillary necrosis or
strongly disordered urodynamic conditions [5].
(ii) In region II, 0 < log S < χ but A > 0.3 implies
that an alteration of kinetic factors is mainly
responsible for the stone formation. Only data
from stone-formers are found in this region
indicating the absence or insufficiency of crys-
tallization inhibitors in their urine. In fact, clin-
ical observations have shown that treating these
patients with some inhibitors effectively pre-
vent the formation of calcium stones in their
urine. It should also be noted that the presence
26
Figure 3. Absorbance of ULR test versus the supersaturation values of HAP for healthy people (solid symbols) and stone formers (open
symbols).
of too much heterogeneous nucleants may also
cause the crystal formation in the urine of these
patients.
(iii) Region III or the threshold area consists of data
with χ < log S < y. The width of this region
depends on the uncertainties involved in the ana-
lyses of the samples. This region is controlled
by the combination of both thermodynamic and
kinetic factors. As stated earlier, the upper
limit of this region is the furthest stretch of the
effectiveness of kinetic factors. Six lithogenic
samples from the healthy group found in this
region signal that these people have excellent
renal morphology so there are no stones formed
in their urinary tracts in spite of calcium salts
crystallizing in the ULR test [5].
(iv) Region IV starts at log S > y, in this area the
thermodynamic factor is in absolute control and
kinetic factors do not have any effects even if
inhibitors were present at the normal level in
the tested urine. Obviously the supersaturation
values are abnormally high so the only result
here is the crystallization of calcium salts. This
is confirmed by the fact that only data from act-
ive stone-formers with positive ULR test results
(A > 0.3) are found in this region.
(v) Region V (log S > y and A < 0.3) does not
contain any data since inhibitors are no longer
effective at such high supersaturations. In Fig-
ures 1–3, region V clearly establishes the upper
limits of the threshold areas for DCPD, COM
and HAP respectively.
It is noteworthy that DCPD crystallization has the
lowest threshold area and no data in region IV (Fig-
ure 1). This means that the DCPD formation in real
urine is clearly influenced by kinetic factors, its crys-
tallization is favorable in the presence of adequate
amounts of heterogeneous nucleants and/or deficit of
crystallization inhibitors.

For COM and HAP, calcium crystal development
in urine of stone-formers is also mainly caused by a
failure in kinetic inhibition. However, about 10% of all
data from the stone-formers and none from the healthy
groups are found in region IV, which is exclusively
governed by thermodynamic factors (Figures 2–3).
This result shows that in some stone-formers abnor-
mally high supersaturation values can lead to COM
and HAP crystal development. Especially in the case
of HAP, the data in region IV are associated with high
urinary pH values, therefore its crystallization could
be avoided if the pH is adequately decreased.
Moreover, a consequence for pharmacological
treatment using crystallization inhibitors can be
deduced. Obviously for urine belonging to region IV,
inhibitors are not at all effective so that it would be
necessary to decrease the supersaturation before the
administration of such substances.
As a final conclusion, it can be pointed out that
the calcium salt crystallization in urine is controlled
by both kinetic and thermodynamic factors. The bor-
der between these two groups can be described by
the term threshold area, which can help to design a
proper method to treat urinary stone formation. Below
the threshold areas, kinetic factors are in control so
that pharmacological treatments such as the introduc-
tion of some inhibitors can effectively prevent the
crystallization. Beyond the threshold areas, where the
thermodynamic factors take the key role, the reduction
of the supersaturation values is a top priority. This can
be achieved by decreasing the urinary pH values or
administrating some complexing agents to make the
log S values fall below the threshold areas.
Acknowledgments
The financial support by Acciones Integrades Austria
– Spain (Project 10/98) is gratefully acknowledged.
This work was encouraged by the EU-COST Project
D8/0002/97.
27
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Address for correspondence: Prof. Dr. F. Grases, Laboratory of
Renal Lithiasis Research, Faculty of Sciences, University of Illes
Balears, Ctra. de Valldemossa, km 7.5, 07071 Palma de Mallorca,
Spain
Fax: 34-71-173426
E-mail: dqufgf0@ps.uib.es