Am J Physiol Renal Physiol 317: F65–F72, 2019.
First published April 24, 2019; doi:10.1152/ajprenal.00066.2019.
RESEARCH ARTICLE
Mechanisms for falling urine pH with age in stone formers
Cameron J. Menezes,1 Elaine M. Worcester,1 Fredric L. Coe,1 John Asplin,2 Kristin J. Bergsland,1
and Benjamin Ko1
1
Department of Medicine, University of Chicago Medicine, Chicago, Illinois; and 2Litholink, Laboratory Corporation of
America Holdings, Chicago, Illinois
Submitted 12 February 2019; accepted in final form 22 April 2019
Menezes CJ, Worcester EM, Coe FL, Asplin J, Bergsland KJ,
Ko B. Mechanisms for falling urine pH with age in stone formers. Am
J Physiol Renal Physiol 317: F65–F72, 2019. First published April 24,
2019; doi:10.1152/ajprenal.00066.2019.—One of the main functions
of the kidney is to excrete an acid load derived from both dietary and
endogenous sources, thus maintaining the pH of other fluids in the
body. Urine pH is also of particular interest in stone formers, since it
determines the presence of either calcium phosphate or uric acid
content in stones. Others have noted in epidemiological studies a rise
in incidence of low pH-dependent uric acid stones with age, coincid-
ing with a decrease in the incidence of high pH-dependent phosphate
stones. Taken together, these trends are suggestive of a longitudinal
decline in urine pH in stone-forming patients, and, if true, this could
explain the observed trends in stone incidence. We studied 7,891
stone formers, all of whom collected a 24-h urine sample and
matching serum. Multivariate modeling revealed that urine pH did
indeed fall with age and particularly between the ages of 20 and 50 yr
old in both men and women. We sought to explain this trend through
the inclusion of traditionally understood determinants of urine pH
such as urinary buffers, estimates of glomerular filtration, and dietary
acid load, but these, taken together, accounted for but a small fraction
of the pH fall. Gastrointestinal anion absorption was the strongest
predictor of urine pH in all age groups, as we have previously reported
in middle-aged normal men and women. However, we found that,
despite a decreasing urine pH, gastrointestinal anion absorption in-
creased monotonically with age. In fact, after adjustment for gastro-
intestinal anion absorption, urine pH declined more markedly, sug-
gesting that bicarbonate-producing anion absorption is regulated in a
manner that offsets the decline of urine pH.
acid base; kidney stones; urine pH
INTRODUCTION
Systemic acid-base balance and renal acid excretion have a
special importance among stone-forming patients. Urine pH
governs whether the stone mineral will be calcium phosphate
or uric acid as opposed to the most common calcium oxalate
crystal, which forms independent of urine pH. Because both
calcium phosphate and uric acid stone formers plug terminal
nephrons more than calcium oxalate stone formers do, the
stone mineral phase affects the potential for kidney tissue
damage (5, 40).
Elsewhere, we have presented evidence for a higher urine
pH in normal women versus men (42). With age, especially
among women, the abundance of calcium phosphate stones
Address for reprint requests and other correspondence: B. Ko, Univ. of
Chicago Medicine, Nephrology Section/MC 5100, 5841 S. Maryland Ave.,
Chicago, IL 60637 (e-mail: bko@uchicago.edu).
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falls while that of uric acid stones rises (4, 22). Given that
alkaline urine pH fosters the former and acid pH the latter,
these epidemiological data suggest that urine pH falls with age.
Indeed, in a cohort of recurrent calcium oxalate stone formers,
Otto et al. (28) found that urine pH fell with age, although this
has not been studied in other groups.
Such a fall in pH could, in turn, reflect changes in systemic
acid-base balance, renal acidification mechanisms, or both. It is
known that urine pH falls with glomerular filtration rate (GFR);
however, phosphate stone prevalence falls between early adult-
hood and young middle age (4, 22, 31) while GFR declines
later in life (31), suggesting that the mechanism for falling
urine pH is not a decline in renal function. Obesity and diabetes
also lower urine pH (3, 21), the prevalence of both rise with
age, and both are higher among uric acid stone formers than
other stone formers (39). Although diabetes and obesity cer-
tainly occur even in early middle age, one might have expected
more effects from both a decade later. In other words, the
mechanism for this presumed urine pH change is not apparent.
Therefore, we undertook an analysis of urine pH, renal
acidification, and dietary acid-base contribution with age
using cross-sectional 24-h urine data from a large popula-
tion of stone formers ranging from 18 to ⬎70 yr of age. In
particular, we sought to determine the effects of body mass
index, GFR, ammonia production, and gastrointestinal anion
absorption (27).
We found that urine pH fell with age and, indeed, most
rapidly in the years in which stone phosphate content falls most
steeply. As one might expect given their higher prevalence of
phosphate stones, women produced urine of higher pH than
men at all ages. Straightforward multivariable analysis re-
vealed that age itself, separate from body mass index, renal
function, and gastrointestinal anion absorption, had a large and
independent association with urine pH. Gastrointestinal anion
absorption had a strong positive correlation with urine pH, but
gastrointestinal anion excretion increased with age as if in
compensation as opposed to cause.
METHODS
Subjects and Data
We used a large United States national data set of stone former
pretreatment collections (Litholink, a Division of LabCorp). Each
patient contributed one set of serum and 24-h urine data. The data set
included 12,839 patients (5,586 women and 7,253 men) from which
we excluded 4,948 (1,981 women and 2,967 men) because of missing
height, weight, or serum data, ammonia excretion ⬎ 100 mmol/day,
citrate excretion ⬍ 30 mg/day, or body surface area ⬍ 1 m2. The
remaining 7,891 cases were divided into hexiles by age (Table 1).
F65
F66 URINE pH AND GASTROINTESTINAL ANIONS WITH AGE

Table 1. Characteristics of age hexiles

Age Hexiles, yr

⬍33 33–42 42–49 49–56 56–64 ⬎64

Number
Women 821 681 559 568 525 452
Men 413 644 688 779 881 880
Age, yr
Women 26.0 ⫾ 0.2 37.0 ⫾ 0.1 45.2 ⫾ 0.1 51.9 ⫾ 0.1 59.2 ⫾ 0.1 70.4 ⫾ 0.3
Men 26.2 ⫾ 0.2 37.3 ⫾ 0.1 45.2 ⫾ 0.1 52.1 ⫾ 0.1 59.3 ⫾ 0.1 70.2 ⫾ 0.2
Weight, kg
Women 69.3 ⫾ 0.6 74.6 ⫾ 0.8 77.4 ⫾ 0.9 80.1 ⫾ 1.0 78.9 ⫾ 0.9 77.6 ⫾ 0.9
Men 83.9 ⫾ 0.8 91.8 ⫾ 0.8 93.6 ⫾ 0.7 93.8 ⫾ 0.7 94.6 ⫾ 0.7 88.9 ⫾ 0.6
Body mass index, kg/m2
Women* 25.9 ⫾ 0.2 27.9 ⫾ 0.3 28.7 ⫾ 0.3 30.1 ⫾ 0.3 29.8 ⫾ 0.3 29.8 ⫾ 0.3
Men* 26.4 ⫾ 0.2 29.1 ⫾ 0.8 29.2 ⫾ 0.2 29.5 ⫾ 0.2 29.7 ⫾ 0.2 28.2 ⫾ 0.2
Serum potassium
Women* 4.21 ⫾ 0.02 4.24 ⫾ 0.02 4.22 ⫾ 0.02 4.27 ⫾ 0.02 4.32 ⫾ 0.02 4.26 ⫾ 0.02
Men* 4.29 ⫾ 0.02 4.30 ⫾ 0.02 4.30 ⫾ 0.02 4.34 ⫾ 0.02 4.36 ⫾ 0.02 4.41 ⫾ 0.02
Serum total CO2
Women* 24.5 ⫾ 0.1 24.8 ⫾ 0.1 25.0 ⫾ 0.1 25.5 ⫾ 0.1† 25.7 ⫾ 0.1 25.7 ⫾ 0.1
Men 25.9 ⫾ 0.1 25.7 ⫾ 0.1 25.7 ⫾ 0.1 25.6 ⫾ 0.1 25.7 ⫾ 0.1 25.5 ⫾ 0.1
Values are means ⫾ SE. Trend analysis was undertaken for body mass index, potassium, and total CO2. *Significant linear trend, P ⬍ 0.001. Adjacent
difference analysis was undertaken only for serum analytes. †Significant difference (P ⬍ 0.001) from the previous hexile.

They were reasonably balanced with regard to sex ratio, age, weight,
and body mass index.
For each patient, we had available serum calcium, phosphorus,
magnesium, sodium, potassium, total CO2 content, chloride, uric acid,
and creatinine as well as the corresponding 24-h urine values for
volume, pH, calcium, phosphorus, magnesium, sodium, potassium,
uric acid, creatinine, oxalate, citrate, chloride, ammonium, and sulfate.
Analytes were measured using techniques previously described else-
where (29, 30).
Calculations
2
Urine excretions were calculated per 24 h per 1.73 m of body
surface.
We calculated titratable acidity (TA) as previously described (9).
Briefly, TA was calculated with the following equations derived from
the Henderson-Hasselbalch relation, referring to the physiologically
active pKa of the phosphate anion:
antiph ⫽ 10共uph⫺6.8兲 (1)
HP1 ⫽ 共antiph ⫻ p24M兲 ⁄ 共1 ⫹ antiph兲,
calculating the charge on phosphate at urine pH (2)
HP2 ⫽ 共3.98 ⫻ p24M兲 ⁄ 4.98,
calculating the charge on phosphate at blood pH (3)
TA ⫹ HP2 ⫺ HP1 (4)
where antiph is the antilog of pH, uph is urine pH, and p24M is
molality of phosphate in the 24-h urine collection. TA was expressed
in millimoles per liter.
The value calculated from Eq. 4 is the concentration of titrated
protons, and multiplying by volume adjusted per 1.73 m2 body surface
area returned the daily excretion of TA.
Gastrointestinal anion levels were calculated as follows: 冱Na⫹ ⫹
K ⫹ Ca2⫹ ⫹ Mg2⫹ ⫺ 冱Cl⫺ ⫹ 1.8 ⫻ P, where all solutes were in
⫹
milliequivalents per liter except for P, which was in millimoles per
liter; multiplying by 1.8 converts P to milliequivalents per liter at
blood pH. Gastrointestinal anion levels in milliequivalents per liter
were then multiplied by the 24-h urine volume adjusted for body
surface area. This composite variable represents gastrointestinal alkali
absorption and has been shown to correlate closely with anion ab-
sorptions measured in a total body balance study (27).
In the absence of urine total CO2 (TCO2), we were unable to
calculate net acid excretion (8). However, we performed some anal-
yses using the sum of ammonia and TA, which we termed “acid
excretion” (AE).
Creatinine clearance (CCr) was calculated as follows:
CCr ⫽ 共UC ⁄ serum creatinine兲 ⁄ 1, 440共ml · min⫺1 · 1.73 m2兲 (5)
where UC ⫽ urine creatinine (mg/dl) ⫻ body surface area-adjusted
volume [ml(1.73 m2) ⫻ body surface area].
Statistical Analysis
Comparisons across age hexiles by sex used fixed-effects multi-
variable ANOVA, since each person had only one 24-h urine sample
and paired serum. The significance of age effects was gauged using
post hoc polynomial contrast testing of the ANOVA models (Systat
13.2, San Jose, CA).
Contrast testing assesses for the existence of a relationship across
multiple levels of a variable with a specified polynomial form (linear,
quadratic, cubic, etc.) and returns an estimate of the coefficient of the
highest-order polynomial of the equation defining the relationship
between these levels. The null hypothesis is that the coefficient is
equal to zero, and a significant result demonstrates that the coefficient
is nonzero. When adding adjusted variables to the ANOVA model, it
is instructive to compare the magnitude of linear coefficients in
particular, since these are a multivariate proxy of the slope of the
effect.
In our analysis, hexiles of age were ordered from youngest to
oldest, and variables of interest were tested with linear (order 1)
polynomials with the exception of CCr, which was additionally tested
with a quadratic (order 2) polynomial.
Figures 1– 6, displaying age hexiles, use dashed lines connecting
adjacent hexile values for visual clarity.
RESULTS
Urine pH With Age
In men and women, urine pH fell with increasing age hexile
(Fig. 1). pH decrements by hexile were significant (P ⬍ 0.01)
for all but the transitions between hexiles 3 and 4 and hexiles
5 and 6 (men) as well as hexiles 4 and 5 and hexiles 5 and 6

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 URINE pH AND GASTROINTESTINAL ANIONS WITH AGE
Fig. 1. Urine pH versus age hexiles in men and women. Triangles, men; circles,
women. Values are means ⫾ SE. pH fell progressively in both sexes (linear
contrast for pH over age, F ⫽ 144 and 71, men and women, respectively, P ⬍
0.001 for both). Dashed lines are for visual clarity only and imply no
interposed information.
(women). In other words, the older age hexile transitions were
not generally significant for either sex. The linear contrast for
pH versus age was highly significant (F ⫽ 145 and 71, men
and women, respectively, and 208 for both sexes combined,
P ⬍ 0.001 for both; linear slope ⫽ ⫺0.227 and ⫺0.170, men
and women, respectively, and ⫺0.198 for both sexes com-
bined).
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F67
Effect of Rising Body Mass Index
We (24) have previously shown the urine pH of stone-
forming patients falls with weight adjusted for urine creatinine,
a proxy for body mass index when height is not recorded. In
addition, Taylor and Curhan (38) have shown an inverse
association between urine pH and body mass index itself in
non-stone-forming patients. Therefore, increasing body mass
index with age could account for the fall in urine pH. Body
mass index rose with age (Fig. 2, top left, and Table 1) in both
men and women (linear contrast F ⫽ 146, both sexes com-
bined, P ⬍ 0.001). In ANOVA containing body mass index,
sex, and age hexile, all three factors were significant, but
adjusted urine pH fell with age with little change in the contrast
slope (Fig. 2, top right, and Table 2) compared with the
unadjusted slope for both sexes combined (Table 2).
Effect of Falling Glomerular Filtration
As expected, CCr fell with age (Fig. 2, bottom left). Unlike
urine pH, decrements for both sexes were not significant
between the youngest three hexiles, in which urine pH most
markedly fell. Even so, the contrast trend was significant (F ⫽
114 and 58, men and women, respectively, order 2, and F ⫽
925 and 585, men and women, respectively, order 1, all P ⬍
0.001). When added to body mass index (Table 2), CCr had no
significant effect on the fall of urine pH with age. The adjusted
urine pH values were therefore practically identical with those
Fig. 2. Body mass index (BMI) versus age hexile,
BMI-adjusted (Adj) urine pH, creatinine clearance
(CCr) versus age hexile, and BMI ⫹ CCr-adjusted
urine pH. Triangles, men; circles, women. Dashed
lines are for visual clarity only and imply no inter-
posed information. Values are means ⫾ SE. Linear
contrast F ⫽ 146, both sexes combined, P ⬍ 0.001.
F68 URINE pH AND GASTROINTESTINAL ANIONS WITH AGE

Table 2. ANOVA models

Model 1 Model 2 Model 3 Model 4

F Effect F Effect F Effect F Effect

Constant 6.47 6.42 6.55 5.9

Body mass index, kg/m2 295* ⫺0.14 294* ⫺0.14 364* ⫺0.15 170* ⫺0.08
Sex 99* Men ⫽ ⫺0.054 102* Men ⫽ ⫺0.056 73* Men ⫽ ⫺0.045 8* Men ⫽ ⫺0.012
Age, yr 32* ⫺0.167 25* ⫺0.186 25* ⫺0.159 113* ⫺0.266
Creatinine clearance 4 186* 0.04 19* 0.01
Urine ammonia 659* ⫺0.12
Urine sulfate 839* ⫺0.1
Gastrointestinal anion 6,299* 0.16
Serum total CO2 25* 0.09
Age ⫻ sex 3 † 3 † 4 † 4* †
Multiple R2 0.084 0.085 0.156 0.498
*Significance at P ⬍ 0.01; all effects except age were per 10 units of the variable; effects for age were the linear contrast slope. †Many cross products use
sex, not shown for lack of important contribution to the model.

from model 1 in Table 2 and the unadjusted value (compare
Fig. 2, right, top and bottom, vs. Fig. 1).
Estimated GFR (eGFR) falls consistently with age (data not
shown; changes between each hexile P ⬍ 0.001) because the
CKD-Epi eGFR algorithm has 0.993age as a multiplier (20).
Likewise, by design, eGFR was nearly identical for the sexes
within a given hexile, as the equation demands. For this reason,
we do not offer a formal trend analysis.
Renal Acid Excretion With Age
Ammonia. Urine ammonia excretion rose (in women) or was
stable (in men) over the first three hexiles of age (Fig. 3, top
left) and then declined over the latter three hexiles. In both
sexes, linear contrast tests showed a highly significant relation-
ship between ammonia excretion and age (F ⫽ 191 and 173,
men and women, respectively, order 1, all P ⬍ 0.001). When
added to the ANOVA (Table 2), urine ammonia excretion had
a large effect, and its addition improved the significance of the
model (multiple R2 ⫽ 0.156). Urine pH still fell significantly
with age, albeit with a reduced contrast slope (Table 2).
Titratable acidity and acid excretion. TA rose and then fell
(Fig. 3, top right). The behavior of TA with age is complex
because falling urine pH would increase it, whereas falling
urine phosphate excretion (Fig. 3, bottom left) would decrease

Fig. 3. Urine ammonia (NH4), urine titratable acid-

ity (TA), urine phosphate (Phos), and urine acid
excretion (AE), all versus age hexile. Triangles,
men; circles, women. Dashed lines are for visual
clarity only and imply no interposed information.

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 URINE pH AND GASTROINTESTINAL ANIONS WITH AGE F69

Fig. 4. Urine sulfate and urine gastrointestinal (GI)

anion levels versus age hexile. Triangles, men; cir-
cles, women. Dashed lines are for visual clarity only
and imply no interposed information.

it. Being the sum of ammonia and TA, AE (Fig. 3, bottom
right) rose and then fell. We do not offer a formal analysis of
urine pH as a function of TA or AE, since TA was calculated
using urine pH as an exponent (METHODS).
Dietary Acid-Base Contribution
Urine sulfate. Urine sulfate, taken as the dietary acid load
(8), rose in men and women between the first two hexiles (Fig.
4, left) and then remained more or less stable until the last
hexile, when it decreased significantly. Despite the modestness
of changes between hexiles, there was a significant linear
relationship between age and sulfate excretion in both sexes
(F ⫽ 16 and 27, men and women, respectively, P ⬍ 0.001),
mainly because of the decline in the terminal hexiles. At all
ages, values for men far exceed women despite normalization
for body surface area. This is well known within the United
States population (28a).
Gastrointestinal anion levels. Gastrointestinal anion levels
(METHODS) rose with age (linear contrast, F ⫽ 42 and 23, men
and women, respectively, P ⬍ 0.001; Fig. 4, right). Notably,
whereas the overall trend of increase was significant in both
sexes, in women there were no differences between adjacent
hexiles, whereas in men there was a significant increase (P ⬍
0.001) between hexiles 3 and 4. Mean gastrointestinal anion
values for women exceeded those for men in the youngest
hexile (P ⫽ 0.007), but the difference disappeared with age
such that the sex difference in the second hexile was of
borderline significance (P ⫽ 0.015). In all other hexiles, the
sexes did not differ.
Role of urine potassium. Notably, all of the constituents of
gastrointestinal anions (Fig. 5) were constant or decreased with
age with the exception of potassium, which increased with age
(linear contrast, F ⫽ 84 and 53, contrast slope ⫽ 7.06 and 5.49,
men and women, respectively, P ⬍ 0.001 for all comparisons).

Fig. 5. Urine excretion of the components of gastrointestinal anion levels versus age hexile. Triangles, men; circles, women. Filled symbols are urinary sodium
(UNa), urinary phosphate (UPhos) ⫻ 1.8, and urinary calcium (UCa); open symbols are urinary chloride (UCl), urinary potassium (UK), and urinary magnesium
(UMg). All values are in meq·day⫺1·1.73 m⫺2 body surface area. Dashed lines are for visual clarity only and imply no interposed information.

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F70 URINE pH AND GASTROINTESTINAL ANIONS WITH AGE
In men, there were increases between hexiles 1 and 2 and
hexiles 3 and 4, whereas in women, there was an increase
between hexiles 1 and 2 (all P ⬍ 0.001). It is this increase in
urine potassium that drives the increase in calculated gastro-
intestinal anion values.
Serum Measurements
Serum potassium. In addition to the notable increases in
urinary potassium excretion, serum potassium also increased
with age (linear contrast, F ⫽ 28 and 17, men and women,
respectively, P ⬍ 0.001; Table 1). There were no significant
differences between adjacent hexiles in either sex despite
highly significant overall trends.
Serum TCO2. Serum TCO2 also displayed age-related
changes (Table 1). In women, there was a significant upward
trend (linear contrast, F ⫽ 128, P ⬍ 0.001) and an increase
between hexiles 3 and 4 (P ⬍ 0.001). In men, no such changes
were seen (linear contrast, F ⫽ 6, P ⫽ not significant).
Final ANOVA Model of Urine pH
The addition of gastrointestinal anions, urine sulfate, and
serum TCO2 (Table 2) almost fully accounted for the sex
difference (Fig. 6). The decline of urine pH with age remained
highly significant. Indeed, after full adjustment, the fall in urine
pH with age was monotonic, and, except for the final hexile in
women, every hexile was significantly lower than the previous,
and the contrast slope was higher than the unadjusted value
(Table 2, compare model 4 with the unadjusted value of
⫺0.198, both sexes combined). The overall regression now
accounted for a highly significant fraction of the total variation
of urine pH with age (multiple R2 ⫽ 0.498). The effect size of
gastrointestinal anions was particularly notable.
Interactions Between CCr and Urine Ammonia
Ammonia was not included in model 4 because of its close
correlation with CCr. Inclusion of ammonia drastically reduced
the value of the F statistic of CCr (19 – 0.1) and did not greatly
improve the variance explained by the model (multiple R2 ⫽
0.498 vs. 0.505). Taken together, this implies that ammonia
Fig. 6. Fully adjusted urine pH versus age hexiles from model 4. Triangles,
men; circles, women. Dashed lines are for visual clarity only and imply no
interposed information.
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and CCr covary and thus are not independent predictors of
urine pH.
DISCUSSION
Urine pH Falls With Age
In this study of 7,891 stone-forming individuals, urine pH
fell with age, most dramatically between the ages of 18 and 55
yr old. The decline echoes that seen in calcium oxalate stone
formers in a cohort that includes calcium oxalate, calcium
phosphate, and urine acid stone formers (28). This finding
likely explains why phosphate content in kidney stones de-
creases with age while uric acid content rises (4, 13). Indeed,
the fall in kidney stone phosphate content occurred most
between the ages of 18 and 50 yr old, coinciding with the
decline in urine pH we observed. Similarly, the higher urine pH
of women throughout all age groups probably explains their
higher kidney stone phosphate content versus men (22).
Our Data Exclude Certain Potential Mechanisms
Body mass index, CCr, urine ammonia. While consistent
with our understanding of kidney stone formation, the physi-
ological mechanisms of the age decline in urine pH are less
clear. We (24) have previously shown that, in two separate
stone centers, urine pH fell with body weight adjusted for urine
creatinine. In the present study, body mass index indeed
correlated inversely with urine pH, but this explains only a
small fraction of the pH decline with age. Although CCr and
urine ammonia excretion strongly correlate with urine pH,
these measures accounted for only a small fraction of the age
effect.
Diabetes lowers urine pH (10), and its prevalence rises with
age. Most of our pH decline occurred between the ages of 30
and 50 yr old, whereas one would expect diabetes prevalence
to rise continuously after 50 yr old, as well. We cannot explore
this possibility further with the information available except to
mention that a defect of renal ammonia production has been
identified as an important contributor to low urine pH in
diabetes (35) and was not important as an explanation for what
we found here.
Urine sulfate and gastrointestinal anions. Although urine
sulfate excretion correlated negatively with urine pH, it rose
very little between the ages of 30 and 50 yr old and actually fell
thereafter. In our models, its addition accounted for little of the
fall in pH. Gastrointestinal anion levels had a preponderant and
powerful positive correlation with urine pH. However, gastro-
intestinal anion levels rose with age, and, as currently under-
stood, this increase would tend to offset a fall in urine pH. In
fact, adjusting for gastrointestinal anions and urine sulfate
caused pH to fall more steeply and consistently.
Sex differences. Adjusting for gastrointestinal anion and
sulfate removed the majority of the urine pH difference be-
tween sexes. A diet consisting of greater amounts of fruits and
vegetables could contribute to the higher urine pH in women.
However, the fraction of diet gastrointestinal alkali absorbed
might also differ between the sexes. We have previously
shown in nonstone formers that higher urine pH in women is
entirely related to their higher urine gastrointestinal anion
excretion even though both sexes ate identical diets (42). Here,
the adjustment for sex differences arose from both the higher
 URINE pH AND GASTROINTESTINAL ANIONS WITH AGE
gastrointestinal anion levels in women and higher sulfate in
men.
Urine Potassium Rises With Age
This is the immediate arithmetic cause of the increase in
gastrointestinal anion levels. All of the other constituents of the
urine charge difference from which gastrointestinal anion level
is calculated (Na⫹, Mg2⫹, Ca2⫹, Cl⫺, and PO1.8 ⫺
4 ) either
remained steady or declined with age. Although declines in the
excretion of either Cl⫺ or PO1.8 4
⫺
could account for the change
in calculated gastrointestinal anion levels, in our data set
changes in urinary potassium excretion accounted for ⬎90% of
the changes in gastrointestinal anion levels. In addition to the
increased urinary excretion of potassium, we also observed an
increase in serum potassium. Taken together, these phenomena
suggest that potassium intake, gastrointestinal potassium han-
dling, or perhaps both are subject to aging effects.
Diet. The increasing urine potassium could perhaps be diet
driven, caused by a move away from meats and toward fruits
and vegetables, favoring increased potassium alkali absorption.
However, while some dietary changes occur through adult-
hood, it is unlikely that shifts in diet could cause the monotonic
and isolated increase of potassium (12a). Our data cannot allow
us to pursue this matter in more detail.
Transport selectivity. Selective net absorption of potassium,
perhaps with food anions, rather than age-driven changes in
food intake might play a major role in raising gastrointestinal
anion absorption with age. Absorption of potassium has long
been known to occur primarily in the small intestine (1), and
the colon is the principal site of potassium secretion (36). A
large number of potassium channels have been identified in the
gut (12); however, regulation of the transmembrane potassium
transport events leading to gut net potassium absorption is not
well elucidated, nor are any potential effects of age. This
represents an important area for future study.
Anion Absorption
Gastrointestinal potassium and alkali absorption could be
coupled or could occur independent of each other. Although
our data cannot test the possibility, gastrointestinal anion absorp-
tion might increase in compensation for the factors reflected by
a falling urine pH. In other words, gastrointestinal alkali
absorption might be regulated in response to rising systemic
acid retention, for example. Such potential renal-gastrointesti-
nal cross talk could act to offset increasing acid loads and
prevent metabolic acidosis. Such regulation could be because
of increased gastrointestinal transporter in situ activity or
abundance, as is seen with organic anion transporters (19).
Alternatively, age-related changes in the microbiome could
affect gastrointestinal alkali absorption, as has been proposed
by Maalouf et al. (11, 23).
The Fall of Urine pH With Age Is Not Fully Accounted For
Multiple potential mechanisms exist that may explain the
remaining decline in urine pH with age. For instance, endo-
thelin-1 levels rise with age (37), and Wesson and Dolson (41)
have demonstrated that endothelin-1 stimulates proton secre-
tion in the collecting duct. Alternatively, the fall of urine pH
may represent a consequence of the previously described
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F71
increase in steady-state acid serum H⫹ in older individuals (6).
A detailed examination of bicarbonate balance across multiple
data sets is necessary to explain this finding and is worthy of
further study. Experiments targeted at explaining this phenom-
enon will need to include urine collections to preserve TCO2
and likewise direct measurement of total urine organic ions
(33, 34).
Potential Limitations of This Study
The study sample comes from a testing laboratory popula-
tion, so it is possible that uric acid stone formers are selectively
enriched in our data set. Their urine pH would be particularly
low and would downweight the average urine pH with age.
However, in a similar laboratory testing population (22), uric
acid stones were only ~8% in women and 12% in men from the
ages of 50 –59 yr old, by which point most of the decline in
urine pH has occurred.
The decrease on average from a urine pH of 6.2–5.9 appears
a clinically modest one, since the median pH of 24-h urine
collections is ~6. However, this decrease of 0.3 pH units
represents approximately two times the concentration of free
protons in urine, which likely arises from a combination of
decreased urinary buffers and increased proton excretion, since
AE only falls by 25% over the same time period. Although not
of apparent clinical significance, these observations indepen-
dently could account for the clinical observations of decreasing
calcium phosphate stone content in aging (2).
In our study, the gastrointestinal anion level was estimated
via Oh’s formula (27), which has been confirmed to match that
determined in total body balance studies. It is possible that
Oh’s relationship does not hold with aging, since the original
paper introducing the concept is based on a review of Lemann
and Relman’s research performed largely on young men (7,
14 –18, 27, 32). However, Oh’s method is based on physical
chemistry, molar balance, and conservation, which are unlikely
to vary with age.
Although our work does not elucidate the mechanisms for
the fall in urine pH with age, even in this selected population,
it does falsify the leading hypotheses concerning these mech-
anisms based on present knowledge of acid-base physiology.
This was our intent, since it offers to other investigators
opportunities for experiments concerning alternatives such as
abnormal conversion of diet anion to bicarbonate or perhaps
inadequacies of contemporary calculations of gastrointestinal
anions.
Finally, and importantly, this data set is limited to a stone-
forming population. Therefore, it is unclear whether this phe-
nomenon is limited to stone formers or is more generalizable to
a larger population.
Summary
In conclusion, this work provides an explanation for the
decreasing prevalence of phosphate-based kidney stones seen
in aging by demonstrating a progressive decline in urine pH in
stone-forming individuals. This decline seems ameliorated by
an increase in gastrointestinal alkali absorption with age. Both
of these findings need further investigation in the form of direct
experiments to fully elucidate the underlying mechanisms.
DISCLOSURES
No conflicts of interest, financial or otherwise, are declared by the authors.
F72 URINE pH AND GASTROINTESTINAL ANIONS WITH AGE
AUTHOR CONTRIBUTIONS
C.J.M., E.M.W., F.L.C., K.J.B., and B.K. analyzed data; C.J.M., E.M.W.,
F.L.C., and B.K. interpreted results of experiments; C.J.M., E.M.W., F.L.C.,
and K.J.B. prepared figures; C.J.M., E.M.W., F.L.C., and B.K. drafted man-
uscript; C.J.M., E.M.W., F.L.C., J.A., and B.K. edited and revised manuscript;
C.J.M., E.M.W., F.L.C., J.A., K.J.B., and B.K. approved final version of
manuscript; E.M.W. and F.L.C. conceived and designed research.
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